In bad shape

Nutrition is crucial to both individual development and by extension, national productivity. The ‘Golden 1000 days’ is a term used by nutrition advocates to refer to a critical period, beginning with pregnancy until the first two years of life, that decides children’s personal and economic productivity based on their access to proper nutrition. Children, if undernourished during the Golden 1000 days, are at high risk of stunted growth and impaired cognitive development, as well as predisposed to increased risks of obesity, diabetes, and a myriad other diseases during adulthood. In the majority of children, this damage is irreversible. According to the The Lancet, a premier global medical journal, under-nutrition during the first two years of life reduces a nation’s economic advancement by at least 8 percent as a result of direct productivity losses as well as losses resulting from poorer cognition and reduced schooling.

Nepal ranks amongst the worst in the world for levels of stunting (height for age), an indicator of chronic undernutrition and wasting (weight for height), an indicator of acute undernutrition. At 41 percent stunting (a figure that represented global stunting levels 20 years ago) and 11 percent wasting, Nepal’s nutrition figures are comparable to those of Ethiopia and Somalia, countries that, for most Nepalis, conjure up images of hunger and starvation. Although these figures have witnessed marked improvement from a decade ago, Nepal still surpasses figures that are considered an emergency. Furthermore, the distribution varies significantly along wealth quintiles and ecology—the poorest and those living in the mountains are the hardest hit. Surprisingly, wasting also affects those living in the Tarai the most (cultural practices may be offsetting high productivity and access to food).

Leading the way

Nepal is recognised globally as a leader in innovative investments to improve maternal and child nutrition. Our country was recently awarded the USAID Pioneers Prize and recognised as one of the “early adopters” of the Scaling Up Nutrition movement—a global movement founded on the principle that all people have a right to food and good nutrition. Nepal’s National Vitamin A Programme, which provides capsules twice a year to roughly 90 percent of the country’s women and children, is often highlighted as a highly cost-effective programme. The  country’s Female Community Health Volunteers—a 70,000- strong cadre providing basic health services at the community level—is similarly lauded.

That said, the government is not resting on past laurels, despite making important gains in tackling poor nutrition in the last decade. Whereas nutrition investments in the past were limited to providing relief during emergencies, the 2008 world food crisis reenergised the movement to adopt a holistic, integrated, multi-sectoral approach to nutrition and agriculture and frame it as a development agenda. Nepal is at the forefront of this new territory.

Nepal is leading by example through the National Multi-Sectoral Nutrition Plan (MSNP), a multidimensional approach to tackling undernutrition, involving five key government sectors—health, agriculture, education, water and sanitation, and local development—and coordinated by the National Planning Commission in collaboration with external development partners. This plan offers a package of interventions, which, over a period of 10 years, will contribute to a reduction in more than 20 percent of current rates of chronic malnutrition. In addition, the government works with development partners to address and resolve current nutrition challenges, including through programmes such as the USAID’s Suaahara (implemented by Save the Children, Helen Keller International, and 6 other non-governmental organisations), KISAN programmes (implemented by Winrock International in collaboration with several non-governmental organisations), the World Bank’s Sunaula Hazar Din, and UN agencies, Unicef, World Food Programme, and World Health Organisation. Astutely, the government also recognises the importance of empirical evidence and supports research through initiatives such as the Nutrition Innovation Lab (a consortium of US based universities—Johns Hopkins, Harvard, Purdue, and Tuskegee, led by Tufts University—collaborating with local academic and government partners.

Coordination challenges

While the national commitment to improving nutrition is strong, challenges still lie ahead. The National MSNP is an impressive step toward improving maternal and child nutrition and reducing chronic malnutrition. But even if we achieve the 20 percent reduction Nepal is currently pursuing, 1.5 million stunted children will remain untreated—equivalent to countries like Haiti and Iraq.

Vertical and horizontal coordination between and within ministries, as well as with external partners, have historically proven to be formidable foes in a multi-sectoral fight against malnutrition. There are differences in working culture, procedures, power structures, methods of delegation,  and financial distribution, among other peculiarities. It has practical as well as technical implications. Technical capacity is also lacking. There aren’t enough health sector personnel with formal nutrition training, let alone the limited capacity of personnel in other sectors, who are now expected to work on improving nutrition. Tackling nutrition challenges takes vision, drive, and extra effort for those traditionally not accustomed to working multi-sectorally to collaborate with one another to achieve these goals.

Despite the coordination challenges, Nepal is traversing a new path. The country is making progress in rolling out the MSNP from pilots in six districts—Accham, Bajura, Jumla, Kapilvastu, Nawal-parasi, and Parsa—to national scale-up. At times, problems can seem insurmountable, but Nepal and its many development partners are unusually committed to tackling them head-on through an approach that engages a multiplicity of stakeholders across civil society, academia, and various government agencies. The world looks to Nepal for best practice evidence and lessons on strategically tackling nutritional challenges. An opportunity to provide global leadership beckons once again.

Sapkota is Country Representative for Tuft University’s Nutrition Innovation Lab-Asia and holds a Masters in Public Health