20 years of nutrition progress in Nepal
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This presentation by Kenda Cunningham, Helen Keller International was shown at the Transform Nutrition - Evidence for Action regional meeting in Kathmandu, Nepal on 8 July 2017. This one-day event shared Transform Nutrition evidence on key issues related to nutrition policy in Nepal, Bangladesh and India, lessons on strategies for change from other contexts and discuss the relevance and applicability of the research findings to policies/programmes that aim to address nutrition in South Asia.
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20 years of nutrition progress in Nepal
- 1. 20 Years of Nutrition Progress in Nepal By: Kenda Cunningham, Akriti Singh, Derek Headey, Pooja Pandey Rana, and Chandni
- 2. Stories of Change in Nutrition • Overall objective: To document experience on “how” (versus “what”) nutritional change has and can happen in an initial set of 6 countries: Bangladesh, Nepal, India, Senegal, Zambia and Ethiopia • Nepal study objectives: • To identify drivers of reductions in undernutrition in Nepal using both quatitative and qualitative techniques • To examine how these drivers vary by nutrition indicator and agro-ecological zone • Outputs • Book chapters • Policy briefs • Videos • Peer-reviewed journal articles http://www.transformnutrition.org/stories_of_change/stories-of-change- special-issue/
- 3. Methods • Quantitative drivers: 1996 to 2011; DHS data; stunting (<2y), wasting (<5y), and maternal underweight; decomposition techniques • Mother’s perspectives: 1996 to present; qualitative open- ended interviews; life-history approach by 5 year birth periods • Policy perspectives: document review; net-mapping of stakeholders; qualitative key informant interviews from MSNP stakeholders • Ethical approval: Nepal Health Research Council and IFPRI’s Internal Review Board
- 4. Nutritional outcomes over time (%) 48 16 28 41 12 26 34 13 2627 11 20 0 10 20 30 40 50 60 70 80 90 100 Stunting (0-24m) Wasting (0-59m) Maternal underweight 1996 2001 2006 2011
- 5. Underlying determinants over time: nutrition specific (%) 80 61 18 7372 71 20 88 79 62 18 86 0 10 20 30 40 50 60 70 80 90 100 Exclusive breastfeeding (0- 5.9m) Fed any solid foods yesterday (6-8.9m) Fed foods from 4 of 7 food groups yesterday (6-23.9m) Fed 3 or more times yesterday (6-23.9m) 2001 2006 2011
- 6. Changes in Underlying Determinants: 1996-2011 3.4 2.7 1.7 0.8 0.7 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Asset index (1-10) Maternal education (years) Paternal education (years) Birth order (rank) Birth interval (years)
- 7. Changes in Underlying Determinants: 1996 to 2011 (%) 23 59 33 25 33 11 7 10 0 10 20 30 40 50 60 70 80 90 100 4 or more ANC visits Iron supplements Born in health facility All vaccinations Open defecation Water source: tube well Water source: piped Maternal empowerment
- 8. Drivers of change in undernutrition
- 9. Maternal perspectives: nutrition- specific changes over time • Maternal nutrition: Diets during pregnancy & lactation were poor: resource constraints and decision-making compound knowledge gaps. • Breastfeeding: Mothers across all time periods were aware that breast milk was best for her child and all mothers breastfed for at least the first few months. However, exclusive breastfeeding for 6 months was unusual. • Complementary feeding: timely initiation of complementary foods, particularly animal source foods was uncommon. “Yes, immediately after delivery it is milk in our village. Later on some feed something they buy in the market.” - Chitwan, 2005-2010 “I fed only my milk for about 1 or 1.5 years. Till then just my milk was sufficient for my baby.” -Chitwan, 1990-1995
- 10. Maternal perspectives: nutrition- sensitive changes over time • Health: Mothers who given birth in the last 5 years were more likely to have received care during pregnancy, had ANC check-ups, and delivered at a health facility compared to mothers who gave birth earlier. • WASH: The majority of the mothers shared that they had a toilet in their household but that this was not the case in the past • Education: all mothers expressed the importance of sending both sons a& daughters to school, even those who had never gone to school themselves • Infrastructure and Migration: Road progress and other community infrastructural projects noted, as was a shift in labor-migration from India to the Middle East and Malaysia with varying consequences “Now it is very clean. There is a toilet in the school. We have a toilet at home. Now all houses are clean. All houses have a toilet.” - Rupandehi, 1990-1995 “Some boys will study. Some will go to work. Some will go abroad. Others will stay at home. [But] girls will go to study.” – Chitwan, 2010-2015 “...earlier the walls used to be made of mud, the roof made of mud and dried grass. Later we had tiles, now cyadar; it is improving.” - Rupandehi, 1995-2000
- 12. Key policies over time: Health and Nutrition
- 13. Key policies over time: WASH, Ed, Agri, Mig, Etc. Pre-1990 1990-1994 1995-1999 2000-2005 2005-2009 2010-2014 2015 onwards Nepal National Sanitation Policy & Guidelines for Planning and Implementati on of the Sanitation Program (1990) School Sanitation & Hygiene Education Program (2000) School Led Total Sanitation (SLTS) (2006) Sanitation and Hygiene Master Plan (2011) Sector development plan (drafted) Rural Water Supply and San National Policy, Strategy and Action Plan (2004) Urban Water Supply and Sanitation Policy (2009) MSNP-PA (2013-2017) Total Sanitation Guideline (drafted) Community Led Total Sanitation (CLTS) (2004) National Education System Plan [1971-1976] Education For All National School Health and Nutrition Strategy (2006) MSNP-PA (2013-2017) Education Act [1971) National Plan of Action (EFA/NPA) (2001) Girls Education Including Early Childhood Development (2009) National Plan of Action for Nutrition (NPAN) (98- 99) National Agricultural Policy (04-05) Local Governance and Community Development Program (LGCDP) Phase I (08- 12) National Agriculture Sector Development Priority (NASDP) (10-15) Ministry of Livestock Development constituted (2016) Local Self Governance Act (LSGA) (99) Area Development Program (01) Nepal Agriculture & Food Security Country Investment Plan (10-15) Agriculture Perspective Plan (03) Food and Nutrition Security Plan of Action (12-23) Agriculture Development Strategy (ADS) (13-23) Nepal Agriculture and Food Security Program (NAFSP) (13-17) MSNP-PA (13-17) Local Governance and Community
- 14. MSNP Weaknesses • Lack of clarity for how each sector should engage nutrition • Ambiguity as to whether coordinated action or sectoral nutrition-sensitive actions are needed • Implementation challenges including lack of scale up to all districts • Capacity and leadership gaps Strengths • Governmental prioritization of nutrition and nutrition architecture • Common goal across multiple-sectors • Focus on community level needs
- 15. Discussion Points • Variation in: – progress on nutritional status & determinants – which determinants contribute to different reductions – sub-national level • What is measured (and not) matters! • Much work remains – in nutritional indicators but also in IYCF, education, health services, WASH, and so on. Economic growth will be insufficient! • New/unaddressed challenges: over-nutrition,
- 16. Recommendations • Expand coverage and target disadvantaged for high-impact interventions. • Ensure the MSNP promotes open dialogue re: weaknesses and has M&E with feedback cycles to improve the policy and its implementation • Continue to build strong collaborations across sectors, but also stakeholder groups • Prioritize other equally important nutritional burdens, such as anemia and food hygiene. • Address data gaps and prioritize research, to enable evidence-based policies & programs
- 17. THANK YOU! • Co-authors • Government of Nepal • Nutrition stakeholders • Suaahara/HKI • IFPRI (Transform Nutrition) • CIFF • NIL (Tufts/JHU) • Global Food Security
Editor's Notes
- In recent years there has been a major upswing in global attention and political momentum to the challenge of addressing undernutrition. There is now demand for learning that comes directly from countries on not only what works and why, but how we get there. The Stories of Change project was led by IFPRI with various partners, and was a quick research project meant to engage local and global experts to quickly synthesise available evidence and complement it when necessary to TELL A STORY in six countries, including Nepal. It applies research approaches in selected countries to better understand, engage with, influence and evaluate multisectoral action to reduce undernutrition. Quantitative analysis seeks to document and disentangle the key drivers of positive change in rates of undernutrition, through in-depth statistical analyses of DHS data over multiple years. Then qualitative work to analyzes the political economy of nutrition, investigating policy-relevant challenges, constraints, incentives, trade-offs, opportunities relating to operationalizing, scaling up and sustaining plans for multisectoral action on nutrition. Additional qualitative work was done to complement the numbers by triangulating this with viewpoints of those most frequently living in conditions ripe for malnutrition – mothers in rural Nepal.
- Improvements in all 3 indicators over time. Stunting shows most drastic reductions Wasting Maternal underweight (<18.5 BMI)
- LITTLE to NO movement on any IYCF indicators over time.
- We next look at trends in several broad sources of nutritional change available to us in the DHS data. HUGE improvements in asset index and parental education (more so among mothers than fathers) Birth order shows number of children so small declines and interval between children increasing --- good indicators for progress on Health Timing and Spacing of Pregnancies Maternal height is missing because scale is different but increased from 150 to 151.5 cm – good sign of maternal nutrition progressing
- All went in the direction you’d expect HUGE movement in WASH (particularly access to toilets) and health indicators – showing access to and use of service improvements
- These are the results of the analysis of drivers of stunting change from the DHS data, for all children, and then split into under- and over-one year, because different factors affect younger or older children more. An important finding of the analysis is that the model using available variables explains approximately 60% for stunting and 85% for maternal underweight but all (actually a little more than all) for wasting. of the actual changes observed over this period. The grey area at the top of the bars shows how much is left unexplained due to the limitations of the DHS dataset, which doesn’t cover everything relevant to stunting. (ex; nothing about food security/agricultural production/etc. and women’s empowerment data is very weak and only about d-making. Most striking is the contribution of health services (in dark blue at the bottom), accounting for a significant % of the reduction in each nutritional outcome indicator Water and sanitation issues also drive some of the stunting story: having a private toilet is important particularly for older children, and not having piped water is a drag on change particularly for younger children. Both water and sanitation appear to require not only individual households to have access to improved facilities, but entire communities; it is only when we start to approach zero open defecation or 100% improved water sources that children stop being exposed to pathogens and HAZ improves. Health service use has also driven some of the change in stunting here: Being fully vaccinated is important particularly for older children, being born in a medical facility is important to younger children, and mothers not attending enough antenatal visits is detrimental to younger children. So we can start to understand some of the drivers of stunting reductions, and start to build on these.
- Still progress is needed – most hoped for change involved roads, particularly black tops and ability to get between villages. 2nd most hope for change was health facilities. Better education and jobs were also mentioned Current programs focus on women but need to include men in intervention programs also mentioned
- Netmap exercise among sampling of stakeholders – 1 shot in time of something that is not static in reality but gives a good picture. Size of circle = degree of influence Color is type of stakeholders - Government of Nepal (GoN), development partners (including donors and international NGOs), academia, local NGOs and civil society, and others including individuals who shape and influence the nutrition-related discourse in Nepal. - 42 linked stakeholders, and has high centralization, meaning that a few stakeholders have many links while most have few, and not all are connected to each other Lines show linkages: 89 total links comprised of 42 funding links, 32 technical links and 15 advocacy links Lots of actors but concentrated work with the MOHP and NPC even though nut is now specified as MS in Nepal
- FCHVs – 1988 Vit A supplementation - 1994 IFA during pregnancy – 98, along with iodized salt strategy Anemia control for pregnant women – 2000 and again 2006 Safe delivery incentive program – 2005 MSNP – 2011 IYCF strategy - 2015
- Education for all – 2000 onwards a real push to make education accessible and address gender gaps CLTS and SLTS Ag Development Strategy
- The interviews complemented the policy process data gathered from the document review. Rather than being used to gather greater detailed information on how the policy change for the MSNP came about, the degree and ways in which evidence has been used in decision-making, whether particular individuals served as nutrition champions during this time, how resource allocation decisions were made, or other related policy dimensions, these interviews focused almost exclusively on the MSNP and generated rich discussions on its strengths and weaknesses.
- Variation in progress on nutritional indicators at a national level – greater reduction in stunting than maternal underweight for ex. Why? Variation in which determinants contributed to the reductions seen. – Sanitation played a bigger role for weight among women and children, whereas health services played a bigger role for stunting as did education. Variation in progress on nutritional indicators and contributions by determinants at the sub-national level – points at importance of sub-national analysis to go next mile in Nepal. Lots not measured and complex multi-sectoral, nationally representative datasets are needed and should shed additional light --- Thanks NIL! UNICEF MICS, National Nut Surv System, etc.