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Municipal budget allocation and utilisation for nutrition in Nepal

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By Shraddha Manandhar, Pramila Shrestha, Bishow Raman Neupane, Satya Narayan Acharya, Harendra Bahadur Chand and Pooja Pandey Rana

Shraddha Manandhar is Data Analyst Manager for the Suaahara II programme at Helen Keller International in Nepal. She has a Master’s degree in International Public Health, a postgraduate degree in Women’s Studies and over six years of experience in mixed-methods research.

Pramila Shrestha was Programme Documentation Assistant for the Suaahara II programme. She has a Master’s degree in Public Health and over four years of experience in project management and research in several areas mainly in nutrition.

Bishow Raman Neupane is Multi-sector Governance Director for the Suaahara II programme. He has more than 32 years of experience working as a teacher, project manager, training and development facilitator, advocate, motivational speaker and writer.

Satya Narayan Acharya is Monitoring, Evaluation and Research Senior Manager for the Suaahara II programme. He is a programme monitoring, evaluation and learning expert with over 17 years of public health experience.

Harendra Bahadur Chand is Governance Manager for the Suaahara II programme. He has over 20 years of hands-on experience from field-level extension supervisor to governance manager.

Pooja Pandey Rana is Deputy Chief of Party for the Suaahara II programme. She has a Master’s degree in Public Health and has over 20 years of experience in public health and nutrition programming.

The authors acknowledge the generous support of the American people through the United States Agency for International Development (USAID) to the Suaahara II programme which made this article possible. The contents of this article are the sole responsibility of the authors and do not necessarily reflect the views of USAID or the United States government. The authors would also like to thank all the participants from the study districts for providing their time and information for this study. Finally, we would like to thank Dr Kenda Cunningham, Senior Technical Advisor for the Suaahara II programme, for guiding the lead author in the writing process.

Location: Nepal

What we know: The new constitution of Nepal in 2015 facilitated the transfer of greater decision-making power and control over budgets to local government across the country.

What this article adds: A qualitative study was undertaken by Suaahara II (SII) to explore factors affecting the allocation and utilisation of local budgets, particularly those affecting investments for nutrition. The study was conducted in four districts of Nepal across seven municipalities, through stakeholder focus group discussions and in-depth interviews, non-participant observations and a document review. Clear process guidelines are in place for local-level budget allocation, and utilisation and findings show that external development partners (EDPs) such as Suaahara have helped sensitise local government on the importance of investing in nutrition. However, barriers to budget allocation and utilisation remain, including perceptions that existing federally and provincially funded nutrition programmes are enough, political tendency to only invest in programmes that show ‘immediate effects’, and limited plans proposed by lower levels, partly due to lack of knowledge on how to develop nutrition-related plans. Findings highlight the need to sensitise and orientate health stakeholders and municipal, ward and community levels to ensure that nutrition plans are demanded and to increase support to health stakeholders to understand local budgetary processes, analyse community nutrition needs and plan responses. Nutrition-sensitive planning must also be strengthened through coordination with other sectors. Timeliness in releasing authority for budget allocation and monitoring and supervision of budget utilisation are areas that also need to be improved. EDPs must support local-level budgetary processes to ensure long-term ownership and sustainability of local nutrition programmes.

Introduction

Nepal’s government structure

The 2015 Constitution of Nepal specifies three tiers of government (federal, provincial and local (municipality and ward)) (Figure 1) and promotes social democracy at municipality and ward levels. Municipal governments have power to prepare and implement long-term and short-term periodic plans, including annual, strategic and sector-wide plans for local development, with direction from federal government towards meeting the Sustainable Development Goals.

There are 753 local government units in Nepal that govern municipalities in remote, rural locations (with populations of <25,000) through to urbanised, metropolitan areas (with populations of >300,000), under which are 6,743 wards. Budget is allocated by municipalities with support from wards to different sectors such as infrastructure, health and agriculture from total funds available from internal sources (taxes and service-user fees) and external sources (provincial and federal government and donor funding). Municipalities are led by locally elected representatives (ERs), namely chairs and vice-chairs, who lead a team of non-elected government staff. The major sector units under municipal governments are shown in Figure 1.

Figure 1: Nepal’s government structure

Nutrition situation in Nepal

Nepal faces a triple burden of malnutrition: undernutrition, micronutrient deficiency and overnutrition. According to the 2016 Nepal Demographic Health Survey, 36% of children under five years of age are stunted, 10% are wasted and 27% are underweight. Eleven per cent of women aged 15-49 are short (less than 145 cm) and 17% are thin (body mass index (BMI) less than 18.5). Twenty-two per cent of women are overweight or obese (BMI greater than or equal to 25.0). Among men, 17% are thin and 17% are overweight or obese. The Government of Nepal (GoN) acknowledges the problem of malnutrition, particularly undernutrition, and the need for multi-sector efforts to improve the nutrition of its citizens.

The Nepal Multi-sectoral Nutrition Plan (MSNP) II for 2018-2022 takes a multi-sector approach to tackling malnutrition and sets out guidance for the integration of both nutrition-specific and nutrition-sensitive interventions. Several national nutrition programmes are implemented country-wide by the Ministry of Health (MoH), funded by conditional budget1 allocated from federal and provincial levels, including programmes on maternal, infant and young child feeding; integrated management of acute malnutrition (IMAM); and adolescent iron and folic acid (IFA) supplementation. In addition, guided by the MSNP, the Partnership for Improved Nutrition (‘Poshan Ko Laagi Haatemalo’) project, which is government-owned and funded by the United Nations Children’s Fund (UNICEF) and the European Union (EU), conducts nutrition-specific programmes through Nepal’s MoH, and nutrition-sensitive programmes through the Ministry of Federal Affairs and General Administration (MoFAGA), in coordination with relevant ministries. This programme is currently implemented in 28 districts of Nepal, with a view to wider phased rollout across Nepal.

To tackle the problem of undernutrition in Nepal, it is crucial that local governments take ownership and mobilise existing budgets to complement national- and provincial-level nutrition efforts and those of external development partners (EDPs). The MSNP-II mandates that integrated nutrition2 is included in local, provincial and federal government policies and plans, guided by Nutrition and Food Security Steering Committees (NFSSCs) that meet regularly at national, provincial and local government (municipality and ward) level. Municipal-level NFSSCs bring together nutrition stakeholders to advocate and lobby for needs-based nutrition activities with the community and local governments to encourage the allocation and proper utilisation of local budget for nutrition.

Suaahara II ­– working with municipal governments for integrated nutrition

Suaahara II (SII) (2016-2021) is a USAID-funded, multi-sector nutrition programme that works to improve the nutritional status of women and children through a multi-sector approach in all municipalities (389) and wards (3,353) of 42 of Nepal’s 77 districts, in line with MSNP II. Led by Helen Keller International (HKI), SII is implemented by a consortium of seven organisations: HKI; Cooperative for Assistance and Relief Everywhere, Inc. (CARE); Family Health International 360 (FHI 360); Environmental and Public Health Organization (ENPHO); Digital Broadcast Initiative Equal Access (DBI EA); Nepali Technical Assistance Group (NTAG); and Vijaya Development Resource Center (VDRC). At the district level, SII partners with 40 local non-government organisations (NGOs) technically supported by SII district sub-offices. At the community level, SII activities are implemented through SII frontline workers in close coordination with  government female community health volunteers (FCHVs), Nepal’s cadre of community health workers, which is particularly active in maternal and child health.

The SII programme has four intermediate aims: 1) improved household nutrition and health behaviours; 2) increased use of quality nutrition and health services by women and children; 3) improved access to diverse and nutrient-rich foods by women and children; and 4) accelerated rollout of the multi-sector nutrition plan through strengthened local governance. SII has several cross-cutting themes, including gender equality and social inclusion (GESI); social and behavior change communication (SBCC); public-private partnerships (PPP); monitoring, evaluation and research (MER); and disaster preparedness and emergency preparedness and response plan (EPRP). Under intermediate aim 4, the SII team coordinates with national and sub-national actors to create a favourable policy environment, increase investments in nutrition and support the formation and functioning of NFSCCs at all levels.

Objectives of the study

In 2018, internal monitoring data revealed that, across 30 SII districts,3 although 173 out of 277 (62%) municipalities reported allocating USD 8.46 million to implement integrated nutrition activities for women and children, utilisation of budget was only USD 3.5 million; not even half (41%) of total allocated funds (SII, 2018). Suaahara is interested in ensuring that activities it has initiated in the communities are sustained by local governments to ensure continuous progress in nutrition, even after SII phases out. Therefore, SII planned a qualitative study to explore the factors affecting allocation and utilisation decisions of local budgets, particularly those which affect investments for nutrition, to gain insight for project improvements in future.

Study methodology

The study was carried out in four geographically diverse districts of Nepal: Achham (mountain), Dang (plain), Nuwakot (hill) and Sindhupalchowk (mountain). Seven municipalities (one in Nuwakot and two in each of the other three districts) and seven wards (one ward per municipality) were purposively selected. Seven focus group discussions (FGDs) and 46 in-depth interviews (IDIs) were undertaken with municipality and ward-level government stakeholders, community informants and EDP representatives working on nutrition at local level. In addition, 12 non-participant observations (NPOs) were undertaken of budget allocation and utilisation-related meetings that took place during the data collection period, and key documents related to budget allocation and utilisation were collated from municipality and ward levels and analysed. Audio-recordings of FGDs and IDIs were transcribed verbatim and observation notes from NPOs elaborated into detailed transcripts, which were later translated into English, coded in NVivo 12 and analysed using thematic analysis approach.

Findings

Budget allocation process

Nutrition plans can be proposed to municipalities either via community members during public community meetings; the Health Facility Operation Management Committee (HFOMC4), which can propose needs-based health (and nutrition) related plans directly to the ward or municipal health committee; or via wards or municipal sector committees, which can propose health or nutrition plans that they feel are important or needed. The GoN guideline is clear that all municipalities must follow a seven-step planning process for the allocation of budget (Figure 2), ending in approval by the municipal assembly if successful.5

Figure 2: Seven-step process for allocation of budget for nutrition and health

Budget utilsation process

As per the GoN guideline, an integrated implementation plan is prepared by municipalities after approval by the municipal assembly. Regarding health and nutrition plans, municipal health sections formulate and implement programmes via HFOMCs. Required documentation, including a workplan, expenditure bills and programme-completion reports, are forwarded to the municipality for payment. Nutrition-specific activities are implemented by the health section, while nutrition sensitive-activities are implemented by the respective sections (e.g. distribution of vegetable seeds by agriculture section). Health plans are monitored periodically by municipalities and wards. This process is described in Figure 3.

Figure 3: Budget utilisation process

Facilitators of budget allocation and utilisation in nutrition

An important facilitator of budget allocation identified was good coordination within the municipality, between municipality and ward, and between municipality and international and national non-governmental organisations (NGOs), leading to integrated planning. Other important facilitators were a sense of responsibility among ERs towards their community; national/ municipality guidelines and acts outlining the allocation and utilisation process; and awareness and participation among the community regarding the planning process. Facilitators of implementation/budget utilisation identified were capacity-enhancement trainings on budget utilisation, and adequate monitoring and supervision of plans during implementation. Facilitators of budget allocation and utilisation for nutrition specifically were awareness among municipality and ward leaders of the importance of health and nutrition, as well as involvement of Suaahara in advocacy and lobbying for allocation of budget to nutrition, technical support and joint monitoring with municipalities. A best-case scenario of budget allocation and utilisation for nutrition was observed in Achham. Findings triangulated from FGDs, IDIs, NPO and document review showed that the strongest facilitator for Achham was the government-led MSNP (Poshan ko laagi haatemalo) programme (See Box 2).

Box 1: Quotes from study participants on facilitators of budget allocation and utilisation

Government had opened forms for proposal and requested for demands for agricultural materials, vegetable blocks, etc. When we received this information from the municipality, we [SII] immediately informed them [community groups] and gave them instructions as well. At that time, only two groups were registered. I facilitated this process. I registered the groups myself and filled the grant form on the same day for one group. We received a grant amount of 19 lakhs (USD 19,000). I am very happy.

Suaahara Field Supervisor, Nuwakot

We ‘launched’ a programme named ‘Flag in the house and eggs in the hands of pregnant women’. We launched the programme … we conducted municipality-level orientation in the presence of all ERs, other stakeholders, different NGOs working in the field of nutrition like Suaahara.”

Municipality health staff, Nuwakot

 

Box 2: Achham case study

In Achham, the government MSNP programme was being implemented jointly by the municipality and UNICEF/EU; as a result, nutrition budget allocation and utilisation was substantially better in the two sampled Achham municipalities. For example, in one of the municipalities in Achham, USD 3.1 million was allocated for MSNP activities where the budget was shared between the municipality (51%); EU/UNICEF (40%) and the federal/provincial government (9%). The government MSNP programme has specific activities for which this budget must be spent, including dissemination of nutrition information using media; conducting of municipal and ward NFSSC meetings; distribution of vegetable kits (pumpkin, carrot, beans, fenugreek, coriander, green leafy vegetables, etc.) to poor ‘1,000-day’ families; demonstration of plastic-house vegetable production for non-seasonal vegetable production; orientation on water purification and distribution of filters to ultra-poor pregnant and post-partum families; men-women interaction programmes on topics including care of pregnant women, reducing gender-based violence, reducing women’s workload and nutrition; and programmes where pregnant women/new mothers gather to celebrate this significant milestone in their lives and interact with one another. Additionally, in coordination with the government MSNP programme, SII also implements activities with its own budget in Achham district.

Most participants mentioned that EDPs and the municipality are working collaboratively to implement approved nutrition plans. For instance, EDPs provided technical support to sector units (e.g. health and agriculture) to formulate and implement workplans and, in some cases, EDPs conducted joint monitoring with municipalities. EDPs were also checking if municipalities were spending budget as per the allocated heading or not to reduce budget transfer to other activities and budget freezing.

Facilitators: Owing to the government-led MSNP programme, NFSSCs were established and functioning more actively compared to other districts. Municipal and ward-level participants were more aware not only of the importance of investing in nutrition, but the budget allocation and utilisation process as well. In addition to setting budget for nutrition, SII also supported in the functioning of NFSCCs. Monitoring and supervision of implementation/utilisation was more regular and was often conducted jointly by municipalities and EDPs, leading to successful implementation of approved plans.

Barriers: Compared to other districts, fewer barriers were noted in Achham. Reported barriers included: absence of ERs/staff (vacant positions) resulting in additional responsibilities for existing ERs/staff; inexperience and/or lack of awareness among ERs/staff as federalism is relatively new; lack of community awareness and participation; political influence; and insufficient coordination between stakeholders. While budget is allocated from government MSNP activities, like other districts, needs-based demands from community and ward levels were also lacking in Achham. Some participants in Achham explained how delayed conditional budget from EDP for the MSNP programme had impacted implementation of nutrition programmes, whereas others reported that budget was transferred from one heading to another due to political influence. 

Barriers to budget allocation and utilisation for nutrition

Barriers to budget allocation and utilisation processes identified were: insufficient experience and skills of ERs in the new context of municipal planning; insufficient staff in municipality and ward offices; no or less involvement of sector committees; insufficient community awareness and participation; insufficient coordination between stakeholders (within government, such as ERs/government staff/thematic committees or municipality/ward, and with EDPs); and unfair influence (corruption and nepotism). Insufficient budget allocated to plans and insufficient monitoring and supervision led to problems during utilisation.

Box 3: Quotes from study participants on barriers to budget allocation and utilisation

While running the local government, there is shortage of staff. At present, we have eight wards and there is not a single secretary in any of the eight wards. A health worker is doing the work of a secretary. You can imagine how effective the local level is. A staff [member] working in veterinary is doing the work of registration. How effective will his work be? So, the current local level is not in the situation to run fast, despite efforts.

Municipality chief, Achham

During plan collection, there is participation from active and interested members, as well as those from lower ‘level’, illiterate and from backward communities. They [people from backward communities] don’t show interest and usually don’t attend the community-level meeting and, even if they attend, they don’t realize the importance of the meeting. They just attend and do not say anything.

Ward Chairperson, Dang

We are busy and we have many projects. We have altogether 52-54 projects; last year it was 94-95. Some plans are of 20,000 rupees [USD 200], while some are of 2 lakhs [USD 2,000]. To reimburse these amounts, we had to face many problems.

Ward Secretary, Dang

Regarding barriers specific to nutrition, many participants mentioned lack of community awareness on nutrition, resulting in no nutrition demands, lack of awareness and priority of nutrition among ERs, and ERs prioritising visible plans with immediate outcomes, such as roads and bridges. Some also mentioned lack of skills of community, ward and municipality members to formulate nutrition-related plans as a barrier. A few participants cited perceptions among ERs that the conditional budget for nutrition (under health) is enough as another barrier. Speaking about specific barriers to utilisation in nutrition, some participants mentioned budget being allocated as a lump sum to health without segregation of line items, and insufficient skills among ERs/government staff to implement nutrition activities. This lead to delayed or failed implementation, budget freezing, or transfer of nutrition budget to other headings.

Box 4: Quote from study participant on barriers to budget allocation and utilisation for nutrition

What community demands most are roads, bridge, water, electricity and community building, and graveling road, pitching road, boreholes and pump sets, grants for seeds. These are the issues raised at the community-level meetings, and health-related issues are raised less. The need is not felt … If we invest in health, then it takes time for result. If a road is dug, then everyone can see it.

Municipal staff, Dang 

Discussion

There is a huge potential for Nepal to reduce undernutrition through the addition of municipality programmes to national to meet the specific needs of citizens in local contexts. Realising the significant roles that local governments could play, this study was conducted to explore how the newly assembled local governments are allocating and utilising budget in general and for nutrition in particular.

As reported by municipality and ward participants, EDPs such as Suaahara have helped sensitise local government on the importance of investing in nutrition. However, while awareness is there, other barriers to budget allocation and utilisation are present, such as the perception that conditional budgets are enough, political motivations to invest only in programmes that show “immediate effects”, and lack of plans proposed by lower levels, in part due to lack of knowledge on how to develop nutrition-related plans. In the light of these findings, we suggest that awareness activities continue, but with revised content to address identified barriers, covering general allocation and utilisation process, analysis of community nutrition needs, and the formulation of plans to address them.

For budget allocation in nutrition, one of the most critical findings is the need to sensitise/orient health stakeholders at municipal and lower levels (health coordinators, HFOMC members, health workers, FCHVs, and HMG members and the community in general), as the analysis shows that few nutrition plans are demanded. Although health stakeholders are expected to be the strongest advocates of nutrition for budget allocation and are in the right position to put forward nutrition demands, they are not currently doing so. Nutrition-sensitive planning also needs to be strengthened in agriculture, livestock and other related sectors; therefore coordinated efforts with all these sectors is important. Other recommendations are to ensure timeliness in releasing authority and budget for implementation, and adequate monitoring and supervision of budget utilisation.

Suggestions or action points that EDPs could consider to support budget allocation and utilisation for nutrition include the provision of technical assistance to municipal and ward levels to formulate nutrition-sensitive, long-term strategies and plans; technical assistance for better and more accountable utilisation; development of strategies to increase the visibility of nutrition and advocate to ERs to invest in nutrition; and to formulate, test and recommend nutrition plans that government can replicate. Finally, EDPs such as Suaahara should gradually take a step back to increase accountability and ownership by municipalities.

Findings of this study have been circulated to all study districts. Our field teams are now targeting efforts towards health stakeholders at different levels and conducting sustainability workshops in all 389 SII municipalities where the study recommendations are being implemented.

For more information, please contact Shraddha Manandhar at SManandhar@hki.org 

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Endnotes

1 Conditional budget is the budget received for national programmes that cannot be spent on anything else.

2 According to the MSNP II, integrated nutrition comprises six sectors: health; education; women, children and social welfare; water supply, sanitation and hygiene; agricultural development; and livestock development.

3Data from 12 districts missing as some municipalities were reluctant to provide data on budget allocation and utilisation and others did not have an official budget document to submit on time.

4Each government health facility has an HFOMC consisting of health workers, community leaders and government leaders.

5Municipal assembly is the most powerful municipal body, consisting of all elected leaders from municipality and ward levels. The municipal assembly’s decision on budget allocation is final.

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Shraddha Manandhar, Pramila Shrestha, Bishow Raman Neupane, Satya Narayan Acharya, Harendra Bahadur Chand and Pooja Pandey Rana (2020). Municipal budget allocation and utilisation for nutrition in Nepal. Field Exchange 62, April 2020. p44. www.ennonline.net/fex/62/municipalbudgetnutritionnepal

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