Atul Upadhyay, PhD

On September 1, Bill Gates, co-founder of Bill & Melinda Gates Foundation, in his blog, GatesNotes, write why some countries excel at saving lives. He further explains in a short video about the exemplary activities performed by Nepal to reduce stunting from 57 per cent in 2001 to 36 per cent in 2016. The credit, as per Gates, goes to few key interventions - investment in health system that increased births in health facilities, improved sanitation practices like open defecation free areas, thereby reducing diarrheal diseases, increasing school attendance and improving richer diets.

Large-scale reforms
It is evident that Nepal reduced stunting through large-scale reforms in health care, education, sanitation, and improved diet. Resolving remaining challenges – increasing inequality, high out-of-pocket payments, and dependence on donors and NGOs – will enable Nepal to continue building on the progress it has made over the last two decades.
The Nutrition Analysis and Gap Assessment conducted in 2009 identified strength, weaknesses and gaps in nutrition programming and primary determinants of under nutrition. The assessment revealed that lack of availability, accessibility, and affordability of diversified foods, poor water, sanitation and hygiene and care related behaviours, inadequate consumption of nutrient dense and quality, and high prevalence of infection contributed to malnutrition. These identified determinants of malnutrition reflected the need for a multi-sector approach. This led to the formulation of the first Multi Sector Nutrition Plan (MSNP) 2013 – 2017, which engaged diverse sectors through a national coordination mechanism under the National Planning Commission (NPC). With encouraging results, the government has endorsed the second phase of MSNP (MSNP II) in the country.
A study conducted in 2017 in the Kathmandu Valley revealed that the consumption of unhealthy snack and beverage are pushing out nutritious foods, and may have contributed to the child stunting. The study further exhibited that mothers and caregivers, although aware of the unhealthiness of most processed foods, still fed their child with these unhealthy foods primarily due to the convenience, child preference, availability and affordability. Thus, the existing multiple and conflicting drivers of food choices are influencing caregiver behaviour. Therefore, the country needs regulations and improved capacities on monitoring of these unhealthy foods.
According to Nepal Demographic Health Survey 2016, about 36 per cent of children under five years of age are stunted, with 12 per cent severely stunted, whereas 10 per cent are wasted, and two per cent severely wasted, 27 per cent underweight, five per cent severely underweight and one per cent overweight. Similarly, the prevalence of anemia among children under the age of five years is 53 per cent. Forty-one per cent women of reproductive age suffer from anemia as per NDHS. Children, adolescent and mothers are affected by major micro-nutrient deficiencies. Malnutrition increases the risk of mortality in the early stages of infancy and childhood, impairs cognitive function of those who survive, and hinders efforts to enhance national social and economic development goals and great loss for the nation in terms of human capital and productivity.
Despite significant achievement in nutrition there is still a marked disparity in stunting by gender, wealth quintile, and level of maternal education, geographical areas and caste/ethnicity. For example, the children who are from the poorest wealth quintile are three times more likely to be stunted (49.2 per cent) than the children from the richest quintile (16.5 per cent). The children from the mothers who are not educated are twice more likely to be stunted (45.7 per cent) than the children from the educated mothers. As per the federal structures, state 2, Lumbini, and Karnali have prevalence of stunting above the national average.
Nepal has taken innovative and proactive momentum to attain the World Health Assembly (WHA) targets for 2025 and the SDG targets for 2030. Nepal aims to reduce stunting to 24 per cent by 2025 and 15 per cent by 2030 to meet the WHA and SDG targets, respectively. Moreover, the NPC formulated and developed Multi Sector Nutrition Plan II (MSNP II) aimed at achieving the Sustainable Development Goals by 2030. Forging partnership with the private sector is one of the novel interventions of MSNP II to alleviate nutrition related issues. Similarly, the government has shown political commitment towards the Scaling Up Nutrition (SUN) Movement. As per the 2030 agenda, leaving no-one behind in the fight against malnutrition in all its forms, Nepal has committed to graduate from LDC and have prioritised nutrition in the 15th Periodic Plan. These commitments are expected to be instrumental in creating healthy and competitive human capital and breaking the cycle of inter-generational poverty and under-nutrition in the long run.
Impact of COVID-19 on the food and nutrition insecurity along with reduced disposable income at household levels is evident. Reports suggest that Sudurpaschim, Karnali and state 2 are the worst affected regions with inadequate food consumption. Similarly, Lumbini is the most struck region regarding household income loss. The UN World Food Programme has predicted that the present pandemic crisis might be the cause to 15 – 30 per cent increase in malnutrition and food insecurity, and hence nutrition insecurity, particularly among household engaged in informal labour, precarious labour, service sector and daily wage work, as well as household with return migrants and income losses.
Furthermore, slowdown in all major sectors of the economy, viz. tourism, service and manufacturing sectors, has increased the inflation and unemployment, affecting the nation’s most vulnerable and food insecure populations, who are not only in the high food and nutrition insecure region, but also do not have sufficient disposable income to buy safe and nutritious foods to feed themselves and their family members.

Private sector’s role
Addressing malnutrition requires a multidimensional effort ranging from the government interventions to the private sector’s involvement. MSNP II has recognised the importance of private sector in improving the nutrition. The increasing consumption of processed foods has certainly stressed the roles and importance of private sector in the food-based nutrition intervention movement in maintaining the demand and supply of healthy but affordable food is very crucial.
Private sector has massive roles in improving the nutrition situation by delivering healthier and affordable options. On the other hand, creating demand for nutritious and affordable foods through aspirational campaigns for the demand side needs out-of-box approach. The conundrum of supply/demand of nutritious foods needs to be addressed through a new identified role that requires partnerships among all stakeholders, including public, civil society and private sector by using avenues from food- to non-food sectors. This will shift the consumption behaviour and thus increase the demand for nutritious and affordable foods, which in turn, would shift the supply side to manufacture and deliver healthier options at affordable rates.

(Upadhyay is CEO of Baliyo Nepal Nutrition Initiative and chair of Nutritionist and Dietitian Association of Nepal.)