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Addressing inequities in nutrition outcomes in Nepal: Integrating an unconditional child cash grant and infant and young child feeding programme

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Kedar Raj Parajuli is the Chief of the Nutrition Section in the Family Welfare Division of the Department of Health Services, Ministry of Health and Population, Government of Nepal.

Karan Courtney Haag is the Chief of the Nutrition Section, UNICEF Country Office, Nepal.

Anirudra Sharma is a Nutrition Specialist, UNICEF Country Office, Nepal.

Thakur Dhakal is a Social Policy Specialist, UNICEF Country Office, Nepal.

Sanjay Rijal is the Monitoring and Evaluation officer, UNICEF Country Office, Nepal

Introduction

Childhood stunting remains a major development challenge in Nepal, with 36% of young children affected1. Geographic and socioeconomic inequities persist, with children living in the mid and far-west hills and mountain areas in Karnali Pradesh and Sudurpashchim Pradesh provinces and those from poorer households and socially excluded caste and ethnic groups worse off. Sub-optimal infant and young child feeding (IYCF) practices are a contributing factor to the high stunting rates and other forms of child malnutrition in the country, with the diets of 55% of children aged 6-23 months failing to meet the minimum dietary diversity nutrition indicator1.

Significant financial barriers affect the ability of poor households to afford optimal diets in Nepal2. For example, children from households in the poorest wealth quintile have a greater likelihood of not consuming legumes, dairy products or flesh foods3. While poverty in Nepal has declined, an estimated 22% of the population still live below the poverty line and children under 10 years old constitute the poorest age sub-group4. Poverty lessens the ability of poor households to withstand shocks associated with natural hazards such as earthquakes, droughts and flooding, which worsen food security and reduce household nutrition resilience. Added to this, the country’s exposure to periodic global crises, such as the 2008 global financial and food price crises and the 2020 COVID-19 pandemic, further erodes the ability of chronically poor households to afford nutritious foods, compounding nutritional vulnerabilities. Evidence from a recent rapid assessment of the socioeconomic impacts of the COVID-19 pandemic in Nepal revealed that, among 20-25% of respondents, children were experiencing changes in dietary intake, such as reduced number of meals per day, less dietary diversity and reduced amounts of food consumed at mealtimes5.

Addressing poverty

The Government of Nepal (GoN) has a range of policies and programmes that address poverty, vulnerability, exclusion and malnutrition across the life cycle and among vulnerable and disadvantaged groups. Nepal’s Multi-Sector Nutrition Plan (MSNP) (2013-2017; 2018-2022) is a key policy instrument for multi-sector action to improve maternal and child nutrition, including health-system actions to improve IYCF; food-system actions to increase the availability and consumption of safe and nutritious foods; and increasing access to social protection interventions, such as child grants targeting households with children under the age of five.

Recognising the influence of social and behavioural determinants on child feeding and care practices, as well as the financial drivers, the GoN linked its social protection scheme aimed at young children with an existing IYCF programme. This article describes the lessons learned from the implementation of this joint approach and what is known about its impact. 

Origins of an integrated initiative 

In the wake of the 2008 global financial and food crisis, the GoN expanded its targeted social protection policies and programmes by introducing a social assistance allowance in the form of an unconditional social transfer, the child cash grant, in 2009/2010. The grant was targeted at all households with children under five years old in the geographically and economically isolated and chronically food-insecure Karnali zone and other districts that had low human-development index scores, and children from the Dalit caste across the country. Both target groups had high levels of child stunting.  

The policy and standard setting of the child grant is administered by the Department of National Identification and Civil Registration under the Ministry of Home affairs. Eligible households with up to two children under the age of five per mother or primary caregiver receive a monthly cash grant allowance of NPR 200 (approximately USD 1.60), which is disbursed every four months (three times a year). In addition, these households should also receive social and behavioural change communication (SBCC) interventions delivered by the Ministry of Health and Population, including counselling on IYCF practices and other key behaviours related to child nutrition, such as hygiene and sanitation, early stimulation, and utilisation of primary healthcare and nutrition services. The SBCC interventions are delivered by facility-based health workers and female community health volunteers (FCHVs) using a combination of approaches, including advocacy, interpersonal counselling, community mobilisation and mass communication. 

Development partners provided technical and financial support to the GoN for initiating the child cash grant/IYCF programme in five districts (Dolpa, Jumla, Kalikot, Mugu and Humla) of Karnali zone. The Reducing Malnutrition through Social Protection project, a partnership between the Asian Development Bank and the United Nations Children's Fund (UNICEF), was implemented between 2011-2016.

A mother belonging to the socially marginalized Dalit community receives the child cash grant on behalf of her young daughter. ©UNICEF/2015/Shrestha

Coordination mechanisms for joint programming

Inter-ministerial coordination mechanisms through district development committees (DDCs) and village development committees (VDCs) were put in place in these districts to facilitate policy coherence and coordination of implementation across involved ministries and development partners. District-level orientations, in which the secretaries of 127 VDCs participated, were organised at the beginning of the project to orient district stakeholders on the project objective and to draft the implementation plan. Review meetings were organised after one year of implementation in all five districts. Since 2017, district-level committees have been replaced with local government coordination and planning committees. The Multi-Sector Nutrition Plan (MSNP-II) nutrition and food security steering committees were established in the respective local governments within each of the five districts and continue to play an important role in coordinating among different sectors and ministries, and lead the process of planning and budgeting for MSNP-II.  

Building capacity to strengthen SBCC

To strengthen the SBCC component, capacities had to be built up across the health system for delivery of the programme interventions, including training and supervision of frontline workers, and for information monitoring and management. A total of 848 health workers and 2,309 FCHVs were trained on IYCF counselling between 2012-2015 and conducted mothers’ group sessions, including food demonstrations, to reach about 36,386 mothers and caregivers. Partnerships were established with local and community radio stations to raise awareness, mobilise communities and reinforce priority IYCF and care behaviours and practices. In addition to routine government monitoring, a three-wave household monitoring survey system was put in place to track progress and evaluate whether the priority actions and interventions were leading to improvements in child nutrition and to generating learning to inform the scale-up.

Evaluating programme impact

A number of studies and evaluations have assessed the impact of the child cash grant/IYCF programme on IYCF practices and child nutrition since it was set up. A 2013 survey showed that 83% of households reported receiving the child grant allowance at some point, while 78% had received the allowance in the preceding 12 months6. The midline survey also indicated that coverage of the grant was significantly low among children aged under 12 months, mainly due to the annual registration process. This finding was taken into account and the registration process was revised, making it ongoing rather than once per year. 

Most households reported using the grant to purchase nutritious foods for their children that they had learned about during food demonstrations given by FCHVs on preparing traditional complementary foods using locally available foods. Parental literacy rates affected the way in which the grant was used, with households with literate mothers more likely to purchase nutritious foods than those with illiterate mothers. 

The 2013 survey also found improved rates for several IYCF practices in comparison to the baseline 2009/2010 rates. For example, the proportion of children who were introduced to complementary food at six months of age increased significantly from 24% at baseline to 43%6. In addition, there were increases in the proportion of children receiving the recommended minimum meal frequency (47% to 91%) and minimum dietary diversity (17% to 27%)6

More recently, an evaluation of the impact of the child grant and IYCF interventions on child nutritional status over the period 2009-2015 found that child nutritional status improved, with reductions in stunting (a decrease of 9%) and wasting (a decrease of 5%), as well as improvements in water, sanitation and hygiene outcomes; care and health-seeking behaviours; and food availability7

Scaling up the programme 

Between 2009-2018, approximately 562,000 children under five years old in the Karnali zone and Dalit children nationally (about 20% children under five years old in the country) have benefited from the programme. Scale-up has evolved over several phases. In 2016 the government scaled up the child grant in three additional districts, following evidence of impact, and in 2018 the grant was expanded to a further six districts. UNICEF provided technical support to initiate identification and registration of eligible children and oriented about 1,500 local government officials in those districts. From September 2016, the size of the child cash grant allowance was increased to NPR 400 (about USD 3.50) per month. 

The enabling environment for universalising the child grant has also been strengthened. The 2018 Social Security Act formalises the government’s cash transfer programmes as legal entitlements. In line with the draft national Social Protection Framework, the government has developed a long-term expansion plan to expand the grant geographically in a phased manner for universal coverage across the whole country. The 15th National Development Plan (2014-2019) aims to achieve universal coverage within the plan period. The child cash grant is tax-financed and analysis shows that the expansion plan is within the government’s fiscal capacity. MSNP II (2018-2022) also carries the ambition to increase the number of local governments providing child grants to children under five years old from 203 (2018 baseline) to 372 by 2022.

Lessons learned and challenges in implementation 

Several design and implementation bottlenecks have affected the delivery of the programme and its impact on children’s diets and nutritional status. 

First, there were limitations in the size, frequency and coverage of the cash transfer. For many households, the size of the cash transfer (initially NPR 200 per month per child, which was subsequently increased to NPR 400) was likely too small to impact on dietary diversity; to optimise impact the size of the transfer needed to be equivalent to at least 20% of household expenditure7. The 2013 IYCF/Cash Grant survey revealed that the majority (79%) of households received the cash transfers just once in the last year and only 2% of households received the expected transfer three times a year6. Furthermore, coverage of the grant was lower among infants under 12 months of age (who are highly vulnerable to malnutrition); it is thought that, as birth registration is a prerequisite for the grant, delays in birth registration deprive households with qualifying infants from timely access to the allowances. This challenge is being addressed by raising awareness among target households of the need to register births promptly after delivery.

Second, the quality of individual and group IYCF counselling provided by FCHVs remained weak, diminishing the potential impacts of the cash transfers. To address this challenge, FCHVs have been retrained on interpersonal communication and counselling skills. Access to health and nutrition services is also a challenge in the mid and far-west hills and mountain areas owing to the difficult terrain and poor road transportation networks; efforts to strengthen community-based delivery systems are contributing to improved access in these areas.

Another important lesson learned is Nepal’s experience in making the child cash grant responsive to shocks. During the 2015 earthquake response an increase in the size of the cash transfer and the expansion of the targeting to all under-five children in the affected districts increased the resilience of households and helped to protect the diets and nutritional status of young children. The earthquake response piggybacked the existing child cash grant, whereby a one-off ‘top up’ of 4,000 NRP per child was added to regular payments. These top-up payments were stopped after the response.

Based on this experience, expanding coverage of the child cash grant in response to the COVID-19 pandemic could help buffer the impacts of the economic fallout on young children’s diets and their nutritional status. To this end, and despite losses in government revenue as a result of the pandemic, the GoN has announced an allocation of NPR 3.76 billion in the 2020/21 annual budget for scaling up the child cash grant to an additional 11 districts, which will reach approximately 400,000 children under the age of five. 

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Footnotes

1Ministry of Health, Nepal; New ERA; and ICF. (2017). Nepal DHS 2016. 

2Biehl et al. (2016). What Does It Cost to Improve Household Diets in Nepal? Using the Cost of the Diet Method to Model Lowest Cost Dietary Changes. Food and Nutrition Bulletin 37 (3): 247–60

3Baek, Y. & Chitekwe, S. (2019). Sociodemographic Factors Associated with Inadequate Food Group Consumption and Dietary Diversity among Infants and Young Children in Nepal. PLOS ONE 14 (3): e0213610.

4Ministry of Finance, Nepal. (2018).  Economic Survey 2018/19. https://mof.gov.np/uploads/document/file/compiled%20economic%20Survey%20english%207-25_20191111101758.pdf

5UNICEF Social and Economic Impact Survey (June 2020).

6Ministry of Health, Nepal; UNICEF, Nepal; ADB. (2014). A Cross-section Study on the Relations between Child Nutrition and Social Protection Measures in Karnali zone. Kathmandu, Nepal: Ministry of Health, Nepal.

7Renzaho, A.M.N., Chen, W., Rijal, S. et al. The impact of unconditional child cash grant on child malnutrition and its immediate and underlying causes in five districts of the Karnali Zone, Nepal – A trend analysis. Arch Public Health 77, 24 (2019). https://doi.org/10.1186/s13690-019-0352-2

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Kedar Raj Parajuli, Karan Courtney Haag, Thakur Dhakal, Sanjay Rijal, Anirudra Sharma (2020). Addressing inequities in nutrition outcomes in Nepal: Integrating an unconditional child cash grant and infant and young child feeding programme. Nutrition Exchange Asia 2, June 2020. p25. www.ennonline.net/nex/southasia/2/nepalchildgrants

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