In this article I tried to stress how complex it is for Nepal to tackle malnutrition because its causes are tightly linked to other factors such as education status and poverty. Despite great progress in the past couple of decades it looks unlikely that the government will meet the global malnutrition targets for 2025.
The article was published on Nepali Times as Food for thought for Nepal’s nutrition planners.
‘Young children suffering from undernutrition have poorer school achievement, diminished cognitive and language ability, and more behavioural problems… Adults who were malnourished in childhood have less economic productivity and increased incidence of health problems.’
Malnutrition has long been identified as a major barrier to development in Nepal, and other low-income countries. The solution seems obvious: ensure that children eat enough of a balanced diet so they get the needed proteins, vitamins and minerals.
Two recent projects set out to do just that. The first provided animal source foods (meat, fish, eggs and dairy), vegetables and a diverse diet to children in low-income farming households in Nepal’s Banke district, the second helped women in Bajura to grow vegetables in kitchen gardens. Both succeeded, but would have done even better if the target families didn’t face so many other obstacles to success.
Access to water, land and time are key
In Bajura, researchers found that ‘structural barriers’ prevented some women participants, all of who were pregnant or had children two years old or younger, from committing fully to the garden. ‘Participants demonstrated high levels of knowledge about the program’s nutrition messages and expressed interest in and motivation to engage in the program,’ wrote the study’s authors. ‘However, access to water, land, and time determined the extent to which their full participation in the program was feasible.’
That finding was not surprising, says Pooja Pandey Rana, deputy chief of party for the Suaahara nutrition program, the operational arm of the Government of Nepal’s multisector nutrition plan. Based at the international non-government organisation Helen Keller International, which carried out the garden project, Rana was a co-author of the study, ‘Navigating structural barriers to the implementation of agriculture-nutrition programs in Nepal,’ published in the journal Food Security in April 2020.
“We’ve made massive progress on stunting, on the nutrition indicators. But on the underlying barriers, you know access to food, to all these resources, I think we can do a lot more and not one project can do everything”
— Pooja Pandey Rana, Deputy Chief of Party, Suaahara nutrition project, USAID
“We’ve made massive progress on stunting, on the nutrition indicators. But on the underlying barriers, you know access to food, to all these resources, I think we can do a lot more and not one project can do everything,” said Rana in a telephone interview.
“It also raises the broader question of what are the broader interventions we can do in a nutrition program and are donors ready to support them? They have their own targets, their own agenda and theory of change,” added Rana.
The study notes that difficulties accessing water were raised in nearly every conversation researchers had with participants and staff and in focus group discussions with female community health volunteers. In some cases, the barrier was the time required to fetch water, in others it was a ban on Dalit villagers using taps or scarcity of water overall.
The research suggested solutions to overcome such barriers, at least in the short term. For water, that included ‘micro-irrigation’ equipment (sprinklers and hoses). ‘Enabling households to access such equipment, possibly by subsidizing it or through community sharing schemes, could ease access to water and substantially reduce the work burden associated with kitchen garden cultivation for many participants.’
Some solutions in place in Bajura
Rana says that phase two of the project has incorporated some such ideas. These include training women farmers on wastewater management and forming village farmer networks so women growers can better negotiate with traders.
Overall, she is optimistic, partly because of interest from local governments. “Most of the municipal leaders we’ve interacted with, we’ve worked with, they want to do really good, impactful work. But they need support on strategic things, for example who to contact for poultry vaccination. They need these sorts of networks and connections and capacity-building.”
In Banke, researchers found that over four years ‘the evident contributions of diet to developmental status were striking: Even small changes in dietary intake were associated with impressive improvements in child developmental performance’, wrote the authors of the article, ‘Diet quality over time is associated with better development in rural Nepali children,’ published in the journal Maternal & Child Nutrition in January.
But that impact was tempered by household wealth, mother’s education and ‘home environmental quality’, report researchers. The latter includes such things as availability of toys, dolls, and books; interactive activities mother such as mothers and children reading together, telling stories, and playing; and how often the child was left alone or under the supervision of another child.
‘Limited resource environments present many potential hazards to growing children, including poor nutrition, lack of medical care, increased exposure to infections, physical and emotional neglect, stress, and lack of stimulation for cognitive development… Lower educational levels of the parents (particularly the mother) are one of many additional risk factors in impoverished households.’
‘We found that child developmental scores were significantly associated with household wealth, maternal education, and the home environmental quality’, the authors concluded.
Those findings echo the analysis in another recent study, which concluded that Nepal’s poorest families are 50 years behind its richest households in terms of newborn health. Key risk factors for neonatal mortality were a mother’s lack of a tetanus vaccination, her education status, giving birth before the age of 20, household air pollution, poverty, and having no toilet at home.
Rana says she sees hope in the next generation of women, who are much different than their mothers. “Almost 60% to 70% of them have access to cell phones in Bajura. How do we use that technology to empower them? They want to do more, study more… The progress we’ve made is tremendous in terms of nutrition indicators but adolescence and youths is a missed opportunity — we need to do more.”