SISNERI, Nepal – Sanu Maya, Biri Maya Tamang’s fourth child, was born months after the country’s devastating April 2015 earthquake.
Tamang and her husband are subsistence farmers, dependent on the maize, millet and radishes they are able to grow. The quake damaged their mud house in Sisneri, about 25 miles (40km) southwest of Nepal’s capital, Kathmandu, and they were still living in a makeshift shelter when Sanu Maya was born. Facing these hardships, farming became difficult and the family’s diet rapidly deteriorated.
In June 2016, when Sanu Maya was seven months old, a female community health volunteer visited the family as part of a routine government service. One of her tasks was to check children for malnutrition. She quickly determined that at 9.7lb (4.4kg) Sanu Maya was undernourished. If the infant were to be left untreated, she might become stunted.
The volunteer gave Tamang several months’ worth of energy-dense Ready-to-Use Therapeutic Food packets to feed Sanu Maya and followed up regularly to make sure the girl was improving. More than a year later, Sanu Maya is an active and healthy two-year-old weighing more than 23lb (10.4kg).
“I had lost hope,” Tamang said. “But after the treatment, her condition has improved.”
Sanu Maya is one of the thousands of Nepalese children who have benefited from a range of interventions successfully introduced by the government over the past decades to reduce all forms of undernutrition, but particularly the catastrophic numbers of stunted children.
Using a combination of approaches, including specific healthcare interventions to address stunting, and by encouraging collaboration among sectors – including the ministries responsible for agriculture and sanitation – the country has roughly halved what was consistently one of the worst rates of stunting, at times climbing to above 70 percent. By 2016 the rate had fallen to 36 percent, according to government surveys.
A global effort to reduce the number of stunted children worldwide from the current estimate of at least 155 million to fewer than 100 million by 2025 has fallen behind, putting the broader Sustainable Development Goal of ending all forms of malnutrition by 2030 in jeopardy. Nepal’s experience holds lessons that could help guide that effort, even as the country looks to build on its own success.
In the late 1970s, Nepal’s first national study on nutrition found that more than 70 percent of its children suffered from the irreversible condition of stunting. Experts say this was the result of diets too dependent on just a few nutrient-limited foods, irregular meals and high infection rates that could be traced to limited access to clean water.
Stunting rates would remain persistently high over the next two decades, even as the country introduced basic interventions, including efforts to address deficiencies in vitamin A and iodine. By the late 1990s, though, the government had committed to making malnutrition reduction – particularly stunting – a top priority.
“The government gathered that families with well-nourished children will eventually lead to the country’s economic prosperity,” Geeta Bhakta Joshi told News Deeply. Joshi is a member of the National Planning Commission, which guides government development policy. “A healthy young generation will grow to become a capable human resource.”
Rather than starting from scratch with a series of discrete interventions, the government added more coverage for malnutrition onto a rapidly improving healthcare system. The country’s cadre of female health volunteers, who had been introduced in 1988 in a bid to promote reproductive health services, saw their responsibilities expand in the mid-2000s to include monitoring for malnutrition. And by the late 2000s, the government had established more than 15,000 primary healthcare outreach clinics able to provide treatment for undernutrition within a continuum of care stretching from pregnancy through early childhood.
Embedding nutrition services into the healthcare system was a critical decision, according to a 2015 paper from the International Food Policy Research Institute (IFPRI) evaluating Nepal’s success between 2001 and 2011. Reductions in stunting rates are “strongly associated” with the use of prenatal and neonatal care, the researchers noted.
At the same time, the Nepalese authorities understood that stunting is not a health sector issue alone.
“Children are malnourished because they suffer from diarrhea,” said Pooja Pandey Rana, the deputy chief of party at Helen Keller International’s Suaahara program, which addresses undernutrition in parts of Nepal. “The health ministry can treat diarrhea, but it can’t prevent diarrhea. To prevent diarrhea, you have to work with the ministry of water, sanitation and hygiene.”
Over time, six ministries in addition to health – including water, sanitation and hygiene and education – have been brought in to help coordinate and oversee the implementation of the country’s nutrition strategy. Raj Kumar Pokharel, the chief of the nutrition section within the health ministry, said that such collaboration encouraged ministry officials to think about how their policies might aid nutrition and helped the executive promote those efforts that seemed to be delivering results.
There is clear evidence that some of the actions emerging from those other ministries were critical to Nepal’s overall success. While the IFPRI researchers found that improved assets and better healthcare were the most important factors in reducing stunting, better sanitation and parental education were among the top five contributors.
These results may point to a model of policy collaboration that could be replicated by other countries.
Maintaining the Momentum
While officials tout Nepal’s success, they are also eager to see the country’s stunting rates continue to fall. A new, five-year Multi-Sector Nutrition Plan (MSNP), at an estimated cost of $470 million, aims to reduce the stunting rate to 24 percent by 2025, meeting the global targets set by the World Health Organization.
“The second phase of MSNP captures the gaps and unaddressed issues of [the first stage] MSNP I, such as evidence-based interventions,” health minister Deepak Bohara said at the mid-December launch of the plan in Kathmandu.
The new plan is more granular than its predecessor, with strategies to reach communities that earlier efforts have missed – particularly in the country’s midwestern region, where rates were as high as 55 percent, and in rural areas across the country.
Overall, though, the plan looks set to build on what is already working in Nepal – integrating more services for malnutrition into primary healthcare and collaborating across ministries to amplify efforts that already appear to be working to reduce stunting.