93525 Achieving Results through Partnerships Nepal’s Scaling-Up Nutrition Initiative Technical Assistance (SUNITA) highlights • The SUNITA trust fund started in 2011 at the suggestion of Government of Australia’s Department of Foreign Affairs and Trade (DFAT) to provide technical support in the form of analytical work, evaluations of interventions and technical assistance to target actions that effectively address gaps in nutrition interventions in Nepal. • SUNITA complements the South Asia Food and Security Initiative (SAFANSI) trust fund, which was established to address the South Asian Enigma—how chronic malnutrition remains intractable despite high economic growth. • SUNITA’s key contributions and achievements include: the Food and Nutrition Security Thematic Report; a review of the infant and young child feeding program; the implementation of a community-based behavior change for nutrition improvement project; training of social mobilizers and coaches; October 2014 and the development of district profiles of determinants of food insecurity and malnutrition. South Asia Region OVERVIEW Over the past two decades, Nepal has The Nepal’s Scaling-Up Nutrition Initiative achieved economic growth and improvements Technical Assistance (SUNITA) fund in social and health indicators. However, started at the suggestion of Government of the poor nutritional status of first, women, Australia’s Department of Foreign Affairs and manifested in a low body mass index, and Trade (DFAT) to provide technical support second, children, seen in low birth weights, in the form of analytical work, evaluations underweight, stunting1 and wasting, has not of interventions and technical assistance to shown much improvement over this period. target actions that effectively address gaps in nutrition interventions. The immediate causes of chronic malnutrition in Nepal include poor feeding and care SUNITA complements the South Asia Food practices, insufficient nutrient intake, high and Security Initiative (SAFANSI) Trust Fund, rate of infection, and teenage pregnancy. which was established in 2010 to address Underlying these causes are issues of the South Asian Enigma —how chronic poverty and food availability, access to safe malnutrition remains intractable despite high drinking water, environmental hygiene and economic growth—. The ultimate objective sanitation, low literacy, gender inequities of SAFANSI is to increase the commitment and cultural factors that affect household of governments and development partners food handling and use. in pursuing more effective and integrated food and nutrition-related policies and The inherent complexity of under-nutrition investments. in Nepal, and across South Asia, requires the design and implementation of a more SUNITA has successfully achieved its comprehensive approach to nutrition objective through key activities such as: across multiple sectors, which involves government officials, civil society, and development partners. Reviewing National Direct Technical Entitlement Analysis on Planning and Support at the Programs for Determinants Strategy Community Efficiency and of Malnutrition Development Level Efficacy 1 challengE Chronic under-nutrition remains in Nepal of birth, 70 percent are exclusively a critical area in which past development breastfed during the first six months, 65 efforts have not made that much of an impact: percent are provided with appropriate complementary foods at six month, • Nepal is among the ten countries in and only 24 percent of children 6-23 the world with the highest stunting months of age are able to meet the prevalence, and one of the top twenty recommended minimum acceptable countries with the largest number diet (DHS, 2011). of stunted children (UNICEF, 2009). Twelve percent of babies have low birth The Government of Nepal (GoN) has been weight, and under-nutrition contributes delivering nutrition interventions as part of its to more than one third of child mortality. health sector program, some of which have After two years of age, 41% of pre- been successful and some which have yet school children are found to be stunted to scale up. The GoN recognizes the need (Demographic and Health Surveys - for: 1) a more comprehensive approach to DHS, 2011). address the direct and underlying causes of under-nutrition in women and children; and • The consequences of stunting are 2) technical assistance to overcome some profound and irreversible, and all too capacity constraints that limit the planning, often, the cycle continues for their monitoring and delivering of its nutrition children. Children who survive under- interventions. nutrition are most likely to lead a diminished life due to impaired brain and physical development, and to lowered economic productivity leading to the perpetuation of inter-generational poverty. • During the last decade maternal micronutrient status has somewhat improved; however, 18 percent of women are still thin or undernourished, and 35 percent are anemic. Almost a quarter of expecting mothers (23 percent) give birth before the age of eighteen, while about half have given birth by age of 20. In terms of both pre-natal and post-natal care, mothers are not provided for as much as they should (DHS, 2011). • Infant and young child feeding practices are far from optimal. A little less than half (46 percent) of babies are initiated with breastfeeding within one hour 2 approach In 2009, the Government of Nepal carried- With the support from World Food Program out a Nutrition Assessment and Gap Analysis (WFP), UNICEF, and the World Bank, a (NAGA) which identified the need for a Nutrition Secretariat within the National multi-sectoral approach and institutional Planning Commission (NPC) has been architecture to address the issues of established to coordinate the implementation malnutrition in the country. of the MSNP. The Secretariat is also supporting the government with technical The NAGA recommended nutritional assistance for periodic plans, draft policies interventions in the areas of health, and facilitated coordination. agriculture, education, economic activity, gender, social welfare, and finance. In this context, the main focus of the SUNITA Subsequently the GoN, approved the “Multi- trust fund is carrying out analytical work that sector Nutrition Plan” (MSNP), which involved will enable the relevant government ministries all the relevant government ministries. The to contribute significantly to improving MSNP has not only created the foundation nutrition indicators in Nepal through the for increased and cross-cutting investment implementation of their sections of the multi- in nutrition across the country, but has also sectoral plan of action. This analysis will ensured a wide berth for sustained technical complement the support provided by the stewardship on Food and Nutrition Security World Bank through SAFANSI.2 issues across a variety of ministries. 3 partnerships results SUNITA was launched in 2011, at the All SUNITA activities have successfully suggestion of the Government of Australia’s been able to support, as envisaged, the Department of Foreign Affairs and Trade development and implementation of the (DFAT) with a total contribution of (AUD Nepal Multi-Sectoral Nutrition Plan, which is 1,946,800). the corner-stone for enabling the country to address the problem of perennial malnutrition. In line with the 2005 Paris Declaration Contributions and achievements of the Plan on Aid Effectiveness, SUNITA works with include: Development Partners as well as other organizations to streamline efforts and • The Food and Nutrition Security increase collaborative effectiveness by Thematic Report updates the status of improving the coordination of Technical Food Security and Nutrition in Nepal, and Assistance and Technical Support. analyzes key food security trends over the past 15 years. It is based primarily Led by the Nepal Nutrition Group, a on the findings of the Nepal Living Technical Assistance/Technical Cooperation Standards Survey (NLSS) 2010/11, matrix and a Draft Joint Technical Assistance which covered 5,988 households and Arrangement were agreed upon between included anthropometric data collected the GoN and the Development Partners. All from approximately 2,500 pre-school SUNITA activities follow the principles and children under 60 months (5 years) arrangements described under these two of age. The report was produced as instruments. a joint effort by the National Planning Commission, the Central Bureau of Statistics, WFP, UNICEF, United Kingdom’s Department for International Development (DFID), Australia - DFAT, the European Community (EU), and the World Bank, and represents a comprehensive and reliable source of information on the status of national and regional food security and the nutritional status of Nepal’s population. • A Review of the Infant and Young Child Feeding (IYCF) Program was conducted to assist the GoN in planning future actions to improve child nutrition. Following the recommendations stated in the Nepal Nutrition Evidence Review, conducted by the World Bank in 2011, fragmented Infant and Young Child Feeding practices in different parts of the country were identified, and the need for a comprehensive IYCF 4 program was confirmed, with a view to government’s Operational Manual for developing a set of practical, action- the best approach identified to address oriented and specific recommendations deficiencies in nutrition. Additionally, for improving the quality of IYCF-related the project is also aimed at sensitizing interventions in Nepal. communities and building the readiness to engage in the program both at the • The Community-based Behavior local community and government Change for Nutrition Improvement levels. The project completed piloting Project provided support to the the Rapid Results for Nutrition Sunaula Hazar Din (SHD) - Community Initiatives (RRNIs) in four communities Action for Nutrition Project (this project during the 100-day pilot cycle. The focuses on community mobilization project has resulted in a massive for improved nutrition by addressing scale-up of these initiatives and now the key risk factors during the first involves over 800 new initiatives as of thousand days from conception the beginning of June 2014. The photo through the first two years of life). The below shows an event launch for one of project introduced a multi-sectoral, the nutrition initiatives in a community results-based, community mobilization outside Kathmandu. approach with the expectation that the lessons learned would inform the 5 • Training of social mobilizers stakeholders, including the National and coaches in a results-based, Planning Commission. Based on this community driven approach to deliberation, the need and desire to reducing malnutrition provides scale this activity to other districts, will technical assistance to the SHD - be determined. Community Action for Nutrition Project • Small Area Estimation of Food by preparing training materials, work Security and Nutrition provides plans, and methodology to train social estimates (including prevalence, gap mobilizers and coaches in a results- and severity), at the sub-district level, based, community-driven approach which contribute to programming and to reducing malnutrition. Phase II of targeting assistance, and formulating training is expected to commence in evidence-based policies to attend the late 2014. most food insecure and malnourished • District Profiles of Determinants of population. Specifically, the study Food Insecurity and Malnutrition will generate small area estimates gathers nutrition-relevant information of the following key indicators of as well as stimulates discussion on the food insecurity: under-nourishment multiple determinants of malnutrition (measured by kilo calorie intake); among different stakeholders at the and food poverty (measured by the district-level, to better understand the monetary value of consumption intake district-specific nutrition situation. A expressed in local prices). The task is tool to determine the district profile was a joint effort undertaken by the WFP, developed and tested in two districts of the World Bank and the GoN’s Central Nepal - Parsa and Okhaldhunga (Hill Bureau of Statistics. The results were and Terai). The project’s task team has achieved and a final report will be recently shared and discussed this tool- completed by 2015. kit and recommendations with relevant 6 moving forward With help from DFAT, the second phase of SUNITA will continue doing various analytical work, evaluations of interventions and providing technical assistance to target actions that effectively address gaps in nutrition interventions. This includes more collaboration with external agencies and more testing of actual approaches to improve the food and nutrition security situation throughout Nepal. Moving forward, SUNITA will increase the commitment of governments and development partners to more effectively integrate food and nutrition- related policies and investments. partners SA FANSI Administered by: DFAT 1 Stunting is a primary manifestation of malnutrition in early childhood, including malnutrition during fetal development brought on by the malnourished mother. This irreversible process affects the child during the first two years of life. 2 In Nepal, SAFANSI has used multiple approaches to address food and nutrition insecurity and has focused on building national commitment to the these issues through: 1) Gaining commitment through government and development partners; 2) Strengthening national capacity and programming; and 3) Building evidence, analysis and awareness of food and nutrition security. Photo credits: World Bank Front cover image, page 3 and 7: Aisha Faquir; Page 2 and 4: Simone D. McCourtie; Page 5: Curt Carnemark; Page 6: Maria Fleischmann Achieving Results through Partnerships highlights development results, operational innovations and lessons emerging from the Trust Funds and Partnerships program of the World Bank South Asia region. This results series is produced by the Trust Funds team of the South Asia’s Development Effectiveness unit. Disclaimer: The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive Directors of the International Bank for Reconstruction and Development / The World Bank or the govern- ments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank con- cerning the legal status of any territory or the endorsement or acceptance of such boundaries.