Meeting the global nutrition targets 2025: Nepal’s unfinished agenda
Kiran Rupakhetee is Division Chief/Joint Secretary of the Good Governance and Social Development Division, National Planning Commission Secretariat in the Government of Nepal and the SUN Country Focal Point.
Manisha Laxmi Shrestha is a nutrition specialist working for the Suaahara II programme based in Kathmandu, Nepal.
Bishow Raman Neupane is Director of Multi-sector Governance for the Suaahara II programme, Helen Keller International, Nepal.
Introduction
Nepal, host country to the SUN Movement Global Gathering 2019, has seen marked progress in reducing hunger and improving nutrition through robust policies and programmes carried out by the government and key development partners. In the 1990s Nepal had the highest recorded rate of child stunting in the world, with around 60% of children under five years old (CU5) being stunted1. From 2001 to 2011, child stunting declined from 56.6% to 40%, a reduction of 1.66 points per year and the fastest recorded global reduction in child stunting1.
Meeting current global targets
The country is on track to meet the World Health Assembly (WHA) Global Nutrition Targets 2025 for CU5 overweight and exclusive breastfeeding, but is off course to meet the targets for all other indicators2. Today, the national prevalence of CU5 stunting stands at 36%, which is greater than the developing country average of 25%2. Moreover, the national prevalence of CU5 wasting of 9.6% is also high and greater than the developing country average of 8.9%1. The country’s current rate of reduction for prevalence of wasting is 1.82%, but an annual rate of decline of 7.41% is required to meet the global target of 5% by 2025 (see Figure 1). Nepal will have to accelerate its efforts in order to reach all the 2025 Global Nutrition Targets.
Key drivers of change
Nepal has implemented various strategies to improve the nutrition status of its population. Nutrition and food security are endorsed as a high-level political agenda for the country and is addressed in the government’s 15th periodic plan (2019-2024), and the adoption of the right to food is stated in the constitution. The adoption of a multi-sector approach to nutrition, whereby each stakeholder has a globally recognised and defined set of interventions through which to meet the WHA targets, is viewed as a key driver of positive change. The development of multi-sector nutrition plans (MSNP-I (2013-3017) and MSNP–II (2018-2022)) has been led by the National Planning Commission (NPC), with a Nutrition and Food Security Secretariat established at the NPC for coordination and advocacy on nutrition.
With its recent move to federalism, Nepal now has three tiers of government (federal, provincial and local) and there has been advocacy to include nutrition in local plans and policies. As a result, most of the provinces have mainstreamed nutrition into their development agenda, along with a dedicated budget. Moreover, local-level government has contributed to more than 50% of the costs of MSNP-II implementation.
MSNP-II interventions are being implemented in 610 out of 753 local governments and in 62 out of 77 districts, with plans for nationwide scale-up by 2022. Provincial-level Nutrition and Food Security Steering Committees have been established in all seven provinces and the process of establishing similar committees at the ward level (the smallest administrative unit in Nepal) are underway. All nutrition activities are tracked through a web-based reporting system, although accurate and timely reporting by all sector ministries remains a challenge.
Challenges and ways forward to accelerate progress
Inadequate funding for nutrition to meet WHA global targets
Although the government’s allocated budget for nutrition has increased over the years with MSNP implementation, Nepal still ranks low in terms of investment for nutrition and food security (152 out of 193 countries) and is low even for the region3. According to the World Bank, an additional cost of USD8.50 per child per year is required to meet the global nutrition target for CU5 stunting alone4.
Nutrition financial tracking for the previous three years is underway and supported by UNICEF, although country-level nutrition financing data are needed to support domestic resource mobilisation for nutrition and to help coordinate donor resources. It is hoped that the findings from the financial tracking will also encourage sector and sub-national level decision-makers to align allocations to priority nutrition activities. With continuous advocacy, local government has realised the importance of investing in nutrition and is allocating more budget for nutrition. However, such budget allocations need to be continuous to sustain the efforts and achievements made so far on nutrition.
Emphasising a ‘nutrition throughout the life-cycle’ approach
Adolescent nutrition is a second window of opportunity for improving nutrition and there is growing interest to think beyond the ‘Golden 1,000 days’ period (as it is known in Nepal) from conception to a child’s second birthday by addressing the social determinants of malnutrition through a life-cycle approach. Adolescent nutrition has received little priority to date but is crucial, since 17% of female teenagers (10-19 years old) in the country are pregnant or already have a baby5. The government has adopted adolescent nutrition as a priority activity in MSNP-II. Additionally, various intervention programmes have been implemented to improve the health and nutrition status of adolescents in some districts.
Need to strengthen governance at all levels
The country has developed legislation and policy for improving nutrition, with the appointment of designated personnel at different levels in relevant ministries to support implementation of MNSP-II. Nevertheless, challenges remain in the institutional arrangements with the transition to a federal structure. Concrete strategies for capacity building and system strengthening have to be developed and implemented to cope with the challenges of the newly-introduced federal system, with more ownership at local level and clear assignment of roles and responsibilities. Coordination among various stakeholders at all levels needs to be improved and strengthened with internalisation of nutrition as a priority issue and ownership of MSNP at federal, provincial and local levels.
Where to focus?
While CU5 stunting prevalence has declined over the years, the rate of decline is insufficient and needs to be accelerated to meet the global WHA targets for Nepal. To improve child nutrition, Nepal needs to scale up implementation of the MSNP-II in all 753 local government areas. Although municipalities have incorporated nutrition, it needs to be more widely discussed and more and continuous budget has to be allocated for nutrition. Targeted interventions for reaching the hard-to-reach, marginalised and vulnerable populations are also necessary.
Footnotes
1 Headey DD, Hoddinott J (2015). Understanding the Rapid Reduction of Undernutrition in Nepal, 2001–2011. PLoS ONE 10(12): e0145738. doi:10.1371/journal.pone.0145738
2 https://globalnutritionreport.org/media/profiles/v1.9.7/pdfs/nepal.pdf
3 NPC (2018) Towards Zero Hunger in Nepal. A Strategic Review of Food Security & Nutrition 2018. Kathmandu: National Planning Commission
4 http://pubdocs.worldbank.org/en/460861439997767818/Stunting-Costing-and-Financing-Overview-Brief.pdf
5 MSNP II document http://nnfsp.gov.np/PortalContent.aspx?Doctype=Resources&ID=330