2017 Study of Operational Strategies to Reduce Malnutrition in Nepal MANAV BHATTARAI, CHHITIJ BASHYAL AND ABEYAH A. AL-OMAIR Health, Nutrition & Population GOVERNMENT OF JAPAN b STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 2017 Study of Operational Strategies to Reduce Malnutrition in Nepal MANAV BHATTARAI, CHHITIJ BASHYAL AND ABEYAH A. AL-OMAIR Health, Nutrition & Population GOVERNMENT OF JAPAN This work is a product of the staff of The World Bank with external contributions. The findings, interpreta- tions, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments 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 concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. Because The World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publi- cations, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Acknowledgements T his qualitative study reviews operational strategies of some major nutrition and food security projects/programs implemented in Nepal. The study team was led by Manav Bhattarai who has also authored this report with Chhitij Bashyal and Abeyah A. Al-Omair. E. Gail Richardson (Practice Manager, GHNDR South Asia), Rekha Menon (Practice Manager, GHNDR South Asia); and Takuya Kamata (Country Manager, Nepal) provid- ed overall guidance to the study team. Jaya Karki, Martha P. Vargas and Ajay Ram Dass provided timely and helpful administrative support. The study was financially support- ed by the Japan Trust Fund for Scaling Up Nutrition administered by the World Bank. The study team met and held invaluable discussions with the project managers and im- plementers of some nutrition and food security projects including government officials and Development Partners and International/Non-Governmental Organizations (I/ NGOs) and academia. The New ERA Nepal team and their field researchers provided excellent data collection work. The study team is grateful to the following list of colleagues who shared their insights and provided substantial feedback on the final report, including Dhushyanth Raju (for also being a peer reviewer), Pooja Pandey Rana and Pradiumna Dahal. Additional writ- ten comments were provided by Tej Bahadur Subedi, Indra Bahadur Bhujel and Dhan- anjaya Paudel. Finally, the study team expresses deep gratitude to relevant agencies in Nepal, including the National Planning Commission, Ministry of Federal Affairs and Local Development, Ministry of Agriculture Development and the Ministry of Health, Development Part- ners, I/NGOs as well as the District, Village, and Ward-level officials and stakeholders involved in the qualitative interviews and focus group discussions. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL iii Abbreviations ACF Action Contre La Faim ADB Asian Development Bank AFSP Agriculture and Food Security Project BMI Body Mass Index CBS Central Bureau of Statistics CEDAW Convention on the Elimination of all Forms of Discrimination Against Women CEPRED Center for Environmental and Agricultural Policy Research, Extension and Development CHD Child Health Division CRC Convention on the Rights of the Child CSANN Civil Society Alliance for Nutrition, Nepal DADO District Agriculture Development Office(r) DAG Disadvantaged Group DDC District Development Committee DFAT Australian Department of Foreign Affairs and Trade DFID Department for International Development DFTQC Department of Food Technology and Quality Control DHO District Health Office(r) DPHO District Public Health Office(r) DLO District Livestock Office(r) FAO Food and Agriculture Organization FCHV Female Community Health Volunteer FGD Focus Group Discussion GDP Gross Domestic Product GON Government of Nepal HKI Hellen Keller International IDI In-Depth Interview IFAD International Fund for Agricultural Development INGO International Non-Governmental Organization JT/JTA Junior Technician/Junior Technical Assistant LDO Local Development Officer iv STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL v MDG Millennium Development Goal MI Micronutrient Initiative MICS Multiple Indicator Cluster Survey MOAD Ministry of Agricultural Development MOE Ministry of Education MOF Ministry of Finance MOFALD Ministry of Federal Affairs and Local Development MOH Ministry of Health MOWCSW Ministry of Women, Children and Social Welfare MOWSS Ministry of Water Supply and Sanitation MSNP Multisector Nutrition Plan NAGA Nutrition Assessment and Gap Analysis NDHS Nepal Demographic and Health Survey NFS Nutrition and Food Security NFSSC Nutrition and Food Security Steering Committee NGO Non-Governmental Organization NPC National Planning Commission RRNI Rapid Results Nutrition Initiative SAARC South Asian Association for Regional Cooperation SABAL Sustainable Action for Resilience and Food Security SAPPROS Support Activities for Poor Producers in Nepal SHD Sunaula Hazar Din (Golden Thousand Days) SPRING Strengthening Partnerships, Results, and Innovations in Nutrition Globally SUN Scaling Up Nutrition VDC Village Development Committee VNFSSC Village Nutrition and Food Security Steering Committee UNICEF United Nations Children's Fund USAID U.S. Agency for International Development WASH Water, Sanitation and Hygiene WFP World Food Program WHO World Health Organization Table of Contents Acknowledgements iii Abbreviations iv Executive Summary vii 1. Introduction 1 1.1 Malnutrition in Nepal 1 1.2 Existing Nutritional Interventions and Organizations in Nepal 3 1.3 Prospects and Challenges for Effective Operation of Nutrition and Food Security Strategies 5 2. Study Purpose and Design 7 2.1 Rationale 7 2.2 Key Questions 8 2.3 Methodology 9 2.4 Challenges and Limitations of the Study 11 3. Key Findings and Thematic Discussions 13 3.1 National Policy and Priorities 13 3.2 Developing Technical Approaches for Nutrition and Food Security Projects 15 3.3 Investment Mechanism 21 3.4 Institutional Modality 25 4. Conclusion 39 5. Bibliography 41 6. Annexes 43 vi STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Executive Summary M alnutrition is a serious problem in Nepal. Malnutrition negatively affects human and economic development and the country’s overall prosperity. Malnourishment during childhood results in a lifetime of lost earning poten- tial and consequently the perpetuation of intergenerational poverty (Alderman, 2006). Chronic malnutrition and micronutrient deficiency decrease gross domestic product (GDP) by an estimated 2–3 percent annually (World Bank, 2011). It is impressive to note that Nepal has made a credible achievement in reducing stunting from 57 percent in 2001 to 40.5 percent in 2011. However, these rapid reductions in stunt- ing rates have plateaued more recently. For example, the stunting rate among children under five decreased from about 49.3 percent in 2006 to 40.5 percent in 2011, which is a drop of 8.8 percentage points in five years (2006 to 2011). By 2016, however, the stunting rate declined to 35.8 percent, a five-year decrease of only 4.7 percentage points (Ministry of Health, Nepal; New ERA; and ICF, 2017). Maternal malnutrition is also a major problem in Nepal. In 2016, about 17 percent of women aged 15–49 were undernourished, as defined by a body mass index (BMI) of less than 18.5 (Ministry of Health, Nepal; New ERA; and ICF, 2017). At the same time, a growing problem for Nepalese women is overweight; 22 percent of women were overweight or obese according to the 2016 Nepal Demographic and Health Survey (NDHS), up from 9 percent in 2006. Anemia continues to be a significant problem for women and children in Nepal. In 2016, 53 percent of children and 41 percent of women were anemic. Nutritional outcomes vary across the country’s geographical regions and by wealth and educational status. Despite the challenges, Nepal’s prospects for improving the population’s nutritional profile are promising. The Government of Nepal (GON) has committed to reducing malnutrition by cultivating the proper investment climate for nutrition interventions and donors have committed to financing nutrition programming. The Government has made nutrition and food security a national priority by undertaking the Nutrition As- sessment and Gap Analysis (NAGA, 2011), preparing the Multisector Nutrition Plan (MSNP, 2012), and creating the National Nutrition and Food Security Secretariat under the umbrella of National Planning Commission (NPC). The Government’s challenge is to best utilize the resources that are available in the country. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL vii viii STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Reducing malnutrition is a challenge. The causes of malnutrition are many, and they interact differently in different locations. A package of interventions might work well at one place but not at another. Rigorous evaluations of the implemented interventions are lacking and the causative factors affecting overall nutrition status have not been determined. The lack of monitoring and evaluation to provide data results for nutrition programming with many interventions and sometimes the same interventions as well as crowding-in of resources, might not be an efficient and effective way of utilizing scarce resources to reduce malnutrition. Currently, different nutrition projects and programs are aimed at reducing malnutrition in Nepal. Some are implemented by government agencies with technical and financial support from donors, and some are implemented mainly by International Non-Govern- mental Organizations (INGOs), but financed by donors. Lessons have emerged from the interventions, which could positively guide future nutrition interventions and help to anticipate as well as address the risks, bottlenecks, and challenges that have arisen in those projects. The World Bank conducted this study to identify and understand the bottlenecks to effective implementation of nutrition operations in Nepal and to provide strategies and recommendations to overcome those challenges to achieve more effective and sustain- able nutrition outcomes. It is a qualitative study in which in-depth interviews (IDIs) were conducted with project and program managers and implementers of government and nongovernmental partners’ nutrition interventions at central and local levels. Fo- cus group discussions (FGDs) were conducted at the communities. The preliminary ev- idence was further analyzed and discussed during an Evidence Synthesis Workshop (ESW) with key stakeholders from ministries, the NPC, the Child Health Division (CHD) of the Ministry of Health (MOH) and academia. The feedback and additional insights on emerging trends and findings helped to enhance the analysis, a process culminating in this report. Research Findings Current nutrition and food security policies in Nepal are conducive to investment in nutrition. The Government is finalizing the MSNP 2. It must start to tap the potential of the private sector, which can use its social marketing skills to promote fortified foods, produce the different therapeutic foods locally, and support water, sanitation, and hy- giene interventions. Simultaneously, the country should execute the provisions it has to restrict the promotion of harmful practices like the use of infant formulas as a substitute for breastfeeding and children friendly-advertisement of processed junk-food, which are regarded as empty calories. Malnutrition is caused by a complex interplay of issues requiring specific nutrition in- terventions for different areas. Every nutrition program or project must gather evidence to determine the causative factors for the prevalence of malnutrition in the particular STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL ix geographical area in order to apply an effective nutrition intervention. Although there are data for regions and nation as a whole, often data specific to particular localities where interventions are being planned are lacking. Due to the dearth of such data, pri- or formative research should be undertaken in the targeted area of high malnutrition to identify the cause(s) of malnutrition so cost-effective specific nutrition interventions can be implemented. The nutrition interventions implemented for the Suaahara Project, financed by USAID, were based on prior formative research. Although multisector planning is key to reducing malnutrition, it is essential that ac- tivities are implemented sectorally. All identified nutrition interventions should be im- plemented by the sectors with a comparative advantage by having previously imple- menting the activities as well as having the capacity to do so. For example, the MOH has a comparative advantage in promoting breastfeeding and complementary feeding, whereas, the Ministry of Agriculture has expertise in promoting homestead kitchen gardens. Cash transfers to improve nutrition are best coordinated by the Ministry of Federal Affairs and Local Development (MOFALD) with the collaboration of the MOH. This study found that the Sunaula Hazar Din (SHD) Project implemented by the MO- FLAD included activities usually carried out by other line agencies e.g., breastfeeding, complimentary feeding, chicken rearing, iron/folic acid supplementation, etc), and the activities were not implemented effectively. Whereas the Agriculture and Food Securi- ty Project (AFSP) implemented by the Ministry of Agricultural Development (MOAD) collaborated with the MOH for delivering nutrition specific interventions. Since MOH already had the capacity to implement nutrition specific interventions, nutrition compo- nent of this project was effectively implemented. While operating in a resource-constrained environment, due consideration should be given to the targeting mechanism to avoid the risk of omitting the poor and those who cannot afford the program conditions. Targeting not only means bringing interventions where they are needed but also entails efficiency and costs of screening. Sometimes, for the ease and cost effectiveness of implementation, it is appropriate for a project to cover the entire boundary of an administrative unit rather than a sub-set of the unit. For example, selecting further a small area within a local government boundary for project interventions would entail an additional cost of screening which might be high- er than implementing the project in the entire administrative unit. Within a particular framework of beneficiary selection, e.g., interventions for “1,000 days” households or households with under-five children, or adolescents or pregnant and lactating moth- ers, conflicts and challenges can be avoided if targeting is universal at certain autono- mous administrative units and universal at the communities’ beneficiaries, irrespective of their income status or whether they are marginalized or non-marginalized. Nutri- tion-specific interventions of the Suaahara Project were implemented district-wide and a targeted approach was used to reach Disadvantaged Group (DAG) households with nutrition-sensitive interventions. The SHD Project, on the other hand, covered only 25 percent of the village development committees in a district and provided amenities only to the poorer households, which created conflicts in the communities. x STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Approvals and funds that must pass through various administrative layers before reach- ing the intended targets can delay implementation and provide avenues for rent-seek- ing behaviors. Community-driven projects like the SHD Project seems to have suffered such issues, delaying implementation. Financial accountability should be the responsi- bility of the units receiving the spending authorization. For a community-driven project, it is essential that a central unit approves the proposals and releases the funds directly to the communities. Communities have very minimal capacity to follow bureaucratic pro- cesses of documenting technical and financial reports. Such processes at the community level generate exhaustion and disinterest for the project. Communities need to be made accountable for the money they receive but not at the cost of complying with complex bureaucratic processes. To ensure effective collaboration from various sectors, a project or program should ini- tially define shared responsibilities with clear provisions for authority and resources to execute those responsibilities. It is essential to give adequate authority and resources to different sectors if their input is required in certain nutrition interventions. Collabo- ration between sectors without empowering them with proper authority and required resources does not produce desired results. Each sector should have adequate human resource and relevant technical expertise to monitor nutrition interventions. If the necessary capacity does not exist, the required services should be procured as soon as possible. Annual work plans should be detailed and implementation should be regularly monitored to reflect progress and achieve- ments on a dashboard for everyone to see. This ensures transparency, accountability, and the early identification of issues for the management team to address in a timely manner. If implementation and monitoring functions are outsourced to nongovernment partners, whether NGOs or private firms, their accountability can be ensured by paying for verified results. Targeted project beneficiaries in some cases received benefits late into the project be- cause of the evaluation design. While rigorous impact evaluation is necessary to gen- erate evidence, this should be done without compromising project implementation as was seen in some projects where beneficiaries had to wait to be included in the project in order to fulfill the requirement of evaluation design. 1. Introduction 1.1 Malnutrition in Nepal M alnutrition is a serious problem in Nepal, which negatively affects human and economic development and the nation’s overall prosperity. Malnourish- ment during childhood leads to lifetime losses in earning capacity and the perpetuation of intergenerational poverty (Alderman, 2006). Nepal loses an estimated 2–3 percent of gross domestic product (GDP) annually from high rates of malnutrition and micronutrients deficiencies (The World Bank, 2011). It is impressive to note that stunting in Nepal declined from 57 percent in 2001 to 40.5 percent in 2011. As per the WHO/UNICEF/World Bank joint monitoring estimates 2015, Nepal with stunting at 37.4 percent has similar position compared to India (38.7 percent), Myanmar (35.1 percent), Bangladesh (36.1 percent) and Indonesia (36.4 per- cent) in the South East Asia Region. Those with better stunting rates in the region are Thailand at 10.9 percent, Sri Lanka at 14.7 percent and Maldives at 20.3 percent (World Health Organization Regional Office for South-East Asia, 2016). Since 2012, Nepal has been exemplary in its nutrition policy. In 2011, the Government and its partners started joining forces to improve the country’s nutritional status. They jointly produced the NAGA report. The NAGA emphasizes that a concerted and coordi- nated effort by the nation’s various sectors is necessary to reduce malnutrition and that a central coordination body needed to be established to design a MSNP and to oversee the implementation of sectoral plans. The GON was actively involved in the global Scal- ing Up Nutrition (SUN) Movement and has been recognized for its efforts in nutrition policy. It is now well understood “what” needs to be done to address malnutrition- a life cy- cle approach with a special focus on the “window of opportunity” from conception to two years of life (first 1000 days). Such interventions would be related to activities which support: improved nutrition of adolescents, pregnant and lactating mothers and children; multisectorality; promotion of accountability and commitments from govern- ments, donors and civil societies; and nutrition governance with political commitment STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 1 2 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL guided by relevant sectoral policies, regulatory framework and evidence informed ac- tions. Even though the GON’s efforts have generated increased investments in nutrition by the Government and donors, Nepal has not yet made rapid progress in reducing stunt- ing. The stunting rate among children under five decreased from about 49.3 percent in 2006 to 40.5 percent in 2011, which is about 8.8 percentage points in five years (2006–11). By 2016, however, the stunting rate was at 35.8 percent, indicating that stunting had declined by only 4.7 percentage points from 2011 to 2016. Even though Nepal has made progress in reducing poverty from 42 percent between 2003–04 to 25 percent in 2011, malnutrition has not decreased. Nepal also missed the target of reducing the stunting rate to 28 percent by 2015 to meet the Millennium Development Goal (MDG) malnutri- tion target (see Annex 1, Table 1). The cost of malnutrition and micronutrients deficiency to Nepal remains unacceptably high. Nepal’s nutritional outcomes have been poor from other perspectives. In 2016, 27 per- cent of children were underweight and 10 percent were wasted. Moreover, about 2 per- cent of children under five were overweight (Ministry of Health, Nepal; New ERA; and ICF, 2017), which is a concern especially in urban areas. Nutritional outcomes also vary by geographical regions, development levels, class, wealth, education, and caste status. Regional variations in poverty rates, malnutrition, and food insecurity problems also roughly correlate. The poverty rates in the mid-west and far-west regions of Nepal are very high. The overall development problems are also severe in those regions, including infrastructure, access to health, sanitation, and education (Adhikari, 2008). Disaggregat- ed data for 2001, 2006, 2011, and 2016 are presented in Annex 1, Table 1. Maternal malnutrition is a major concern in Nepal. In 2016, about 17 percent of women in the 15–49 age group were undernourished—as defined by a BMI of less than 18.5 (Ministry of Health, Nepal; New ERA; and ICF, 2017). In 2011, 18 percent of women were undernourished (Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc., 2012). Overweight is also a growing problem for women; 22 percent are overweight or obese according to the 2016 Nepal Demographic and Health Survey (NDHS). The 2006 NDHS showed that only 9 percent of women were overweight, indi- cating an increasing trend. Anemia continues to be a significant problem for women and children in Nepal; 53 percent of children and 41 percent of women were anemic in 2016. The Nepal Living Standard Survey (NLSS) III data shows an interesting relationship between food security and nutritional status. If food security is considered as consump- tion of adequate food, then food security status has been improving. For example, the percentage of households reporting less than adequate food consumption has been con- sistently declining at a fast rate—from 50.9 percent in 1995–96 to 31.2 percent in 2003–04 to 15.7 percent in 2010–11. Only 7.5 percent of households in 2010–11 reported food shortages at any time in the last 30 days, with many households meeting the shortages through various means (see Annex 1, Table 2). Nutritional improvement over the period is very slight in the last decade until 2011, but improvement is drastic in food consump- STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 3 tion status. This finding indicates that food consumption alone is not a good indicator of nutritional improvement. The food consumed must be nourishing, diversified, as well as protein and micronutrient rich. The average food consumption in Nepal was adequate by 2010–11, as shown above. The national average calorie intake is more than the requirement of 2,536 Kcal per capita against the requirement of 2,220 Kcal per day, which defines the GON’s poverty line. However, the problem of poor diet diversity in Nepal remains. More than 84 percent of households in rural areas have a high staple diet, that is more than 60 percent of the households’ total calories are from staples, and more than half (52 percent) have a very high staple diet, that is more than 75 percent of their total calories are from sta- ples (Central Bureau of Statistics, National Planning Commission, World Food Program, World Bank, AusAID and UNICEF, Nepal, 2013). This finding indicates that production patterns should change to produce good food—rather than just food. The agricultural sector also faces problems in producing diversified and nutritious foods. Other factors linked to malnutrition need to be addressed. For example, sanitation ser- vices are still inadequate, with 38 percent of the population defecating in the open (Min- istry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc., 2012). The 2014 Multiple Indicator Cluster Survey (MICS) shows that household members with E. Coli risk levels in their household water are 82 percent and from the source of water are 71 percent. Even though access to drinking water (piped water) has increased to 93 percent in Nepal—96 percent in urban area and 93 percent in rural area—the qual- ity of water is very poor. Only 48 percent children’s stools (0–2 years) were disposed of safely, and 73 percent of households have a designated place for handwashing with soap. Just 60 percent of households have improved sanitation facilities. Only 82 percent of households take iodized salt. The smoking and tobacco use prevalence rate is 9 per- cent and the alcohol use prevalence rate is 10 percent among women (15–49 years), the use of which are known to have adverse consequences for maternal and child nutrition. 1.2 Existing Nutritional Interventions and Organizations in Nepal In the past, nutrition interventions were regarded solely as the responsibility of the MOH, and specifically, the Nutrition Section under the Child Health Division of the Department of Health Services of the MOH. The Nutrition Section budgets for nutri- tion-specific interventions, including prevention and treatment services related to nutri- tion. Following the 2011 NAGA and the development of the MSNP, the entire GON has been active in efforts to reduce the population’s malnutrition. The MSNP is implement- ed by the MOAD, the MOH, the Ministry of Education (MOE), the Ministry of Water Supply and Sanitation (MOWSS), the MOFALD, and the Ministry of Women, Children and Social Welfare (MOWCSW), each with their various programs and activities. A sec- retariat in the NPC oversees and coordinates the nutritional interventions undertaken by all the ministries. Nepal’s Ministry of Finance (MOF) has been financing the imple- mentation of the MSNP for last two years with the contributions by various donors. 4 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL The World Bank has provided financial and technical assistance for Nepal’s nutrition and food security interventions for the following projects. The Nepal Agriculture and Food Security Project (AFSP) 2013–18 (World Bank, 2013), Sunaula Hazar Din– Com- munity Action for Nutrition Project (SHD) (World Bank, 2012), and the Rural Water Supply and Sanitation Improvement Project (2014–19) (World Bank, 2014). The AFSP, implemented by MOAD, supports nutrition-sensitive agricultural activities to promote the production and consumption of nutritious foods in marginal regions. MOFALD im- plemented the SHD Project, which is a demand-driven community-led project imple- mented at the ward level by community teams. The Rural Water Supply Project aims to improve access to quality drinking water and sanitation, which is a major component of nutrition-sensitive interventions. The World Bank also provides technical support through the South Asia Food and Nutrition Security Initiative (SAFANSI), a program financed by the Department for International Development (DFID) and the European Commission. Other international organizations with nutrition programs in Nepal include UNICEF, the World Health Organization (WHO), the World Food Program (WFP), the Food and Agriculture Organization (FAO), and the International Fund for Agricultural Develop- ment (IFAD). UNICEF provides a wide range of financial and technical support for the GON to develop policy and to implement nutrition activities. UNICEF’s activities cov- er health, water and sanitation, nutrition, child friendly local governance, social poli- cy, child protection, education and adolescent development. It aligns its activities with the Health Sector Wide Approach (SWAp) Program to support maternal, neonatal, and child health, the micronutrient program, community management of acute malnutri- tion, and school sanitation (UNICEF, 2013). UNICEF has remained one of major partners for the GON to support scaling up of implementation of MSNP in Nepal. The WFP has partnered for decades with the GON to provide food transfers to reduce vulnerability in Nepal. The WFP has embraced a safety net approach with a focus on children by promoting mother-child health nutrition (MCHN), school meals, and for adults through asset creation activities. The FAO and IFAD work through government channels to im- prove food production. WHO mainly supports the GON in the areas of food safety, chemical safety, and capacity building of government staff. USAID has been financing food and nutrition and food security programs implemented by competitively hired international organizations, such as Save the Children and Helen Keller International (HKI). Among other projects, USAID finances the Suaahara Project, with a focus mainly on nutrition, Sustainable Action for Resilience and Food Security (SABAL) Project with a focus on livelihood, health, and nutrition, and Feed the Future or the KISAN Project with a focus on food security, markets, and the private sector. The Swiss Agency for Development Cooperation has programs to improve livelihood and food security through business activities. The European Commission has supported the GON’s Agricultural and Nutrition Extension Program. The Asian Development Bank (ADB) has financed the project Reducing Child Malnutrition through Social Protection in districts of the Karnali Zone and supported Flour Fortification in the Chakki Mill Projects to address micronutrient deficiencies. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 5 INGOs involved in food and nutrition in Nepal include Care Nepal, HKI, Micronutrient Initiative (MI), Oxfam, Plan Nepal, Heifer International, Save the Children, and Action Contre la Faim (ACF) (Action Against Hunger). HKI’s activities include essential nutri- tion actions, homestead food production, local multisector governance, and improved nutrition interpersonal communication. The INGOs work with local NGOs and commu- nity-based organizations to achieve social mobilization of targeted population. Often, they are also able to reach pockets of marginalized communities. Of the many NGOs working in Nepal, the Center for Environmental and Agricultur- al Policy Research, Extension and Development (CEPRED), the Support Activities for Poor Producers in Nepal (SAPPROS), and the Forum for Rural Welfare and Agriculture Reform for Development (FORWARD) are NGOs involved in nutrition and food secu- rity. They work with farmers’ groups to increase income and food consumption by the commercial cultivation of vegetables and other high value crops. The three NGOs cover a wide geographical area of Nepal. Several civil society organizations are also active in food and nutritional security. They include the Civil Society Alliance for Nutrition, Nepal (CSANN), the National Network on Right to Food Nepal (RtFN), comprising more than 50 national and international NGOs, the NGO Federation, the Federation of Community Forest Users Nepal, the Irri- gation Water User Federation, Drinking Water and Sanitation Federation, human rights networks, women rights networks, peasants’ federations, and youth organizations. The National Alliance for Food Security in Nepal (NAFOS) and Food-First Information and Action Network (FIAN) Nepal are involved in food rights. 1.3 Prospects and Challenges for Effective Operation of Nutrition and Food Security Strategies Nepal has very good prospects to reduce malnutrition. The country has the proper in- vestment climate for nutrition interventions and is receiving donor financing for the interventions. With the MSNP and National Nutrition and Food Security Secretariat under the umbrella of the NPC, the nutrition and food security agenda has gained mo- mentum in Nepal. Besides the GON’s own revenue, resources from donors are also flowing into the country to reduce malnutrition. The GON’s challenge is to make the best use of available resources to reduce malnu- trition. There are many causes of malnutrition and they differ from place to place and require different solutions. A package of interventions might be effective in reducing malnutrition in one place but not in another. Rigorous analysis of the problems and solutions that are specific to each issue are lacking. Without data about outcomes, pro- gram interventions may be pouring resources into ineffective and inefficient interven- tions that underutilize available resources. 6 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL The Government must better harmonize the various nutrition programs underway by numerous organizations. Many different projects are operating in the same localities. For example, the SHD Project and the government-financed MSNP work in the Par- sa District, and the SHD Project and the USAID financed SABAL Project work in the Makwanpur, Sindhuli, Ramechhap, Khotang, Okhaldhunga, and Udayapur Districts. Some of the districts where the Suaahara Project is being implemented overlap with the districts with the government’s MSNP interventions. Some projects have focused on a district-wide approach, such as the Suaahara Project. Other projects only have programs in some of the districts’ village development committees (VDCs), for example SHD proj- ect and the AFSP. The variations increase the likelihood of resource duplication in some places and a lack of funding and attention in other places that need nutrition interven- tions. To ensure necessary coverage where required, all government and partners’ nutri- tion activities must be harmonized. The GON needs to assume a strong leadership role in directing where and how nutrition investments are made in the country. 2. Study Purpose and Design 2.1 Rationale M ost studies in the relevant literature discuss the design of various interven- tions to address malnutrition (that is, how a program should work), while other studies simply examine whether interventions worked or not. For example, convergence approach where both nutrition-specific and nutrition-sensitive interventions are jointly targeted to vulnerable geographical populations worked well in Peru to reduce stunting by four percentage points per year in the districts reached (Levinson & Balaranjan, 2013). According to an extensive literature review done by the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project, there is a document- ed evidence that nutritional intervention during pregnancy and early childhood can increase offspring size and adult stature of women. The study also documents that improvements in girls’ early nutrition have led to increased years of schooling and to delays in age at first pregnancy and delaying age at first pregnancy enhance maximal attainment of height (Caulfield & Elliot, Program in Human Nutrition, the Johns Hopkins Bloomberg School of Public Health, for SPRING, 2015). Very few studies dig into what implementation-related factors aid or impede the suc- cess of interventions. Effective implementation of any intervention is a global challenge. There can be several crucial and unknown factors that interplay to hamper implemen- tation. This study has attempted to shine light into the “black box” of implementation, based on qualitative information. Based on the overall findings, the study has narrowed down the potential factors to be considered into certain thematic areas as detailed under the Key Findings section. This study did not delve into generating evidence of effects of any nutrition-specific or nutri- tion-sensitive interventions but was conducted to identify and understand the bottlenecks in nutrition operations in Nepal and to provide strategies and recommendations to over- come them to achieve more effective and sustainable nutrition outcomes. The findings of the study will help guide future operational support to reduce malnutrition in the country. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 7 8 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL This study sought to generate rigorous evidence for decision makers for three areas of intended impact: (a) Matching supply and demand of nutritional responses for greater technical effec- tiveness. (b) Investment modalities for nutrition and food security programs. (c) Identifying effective program design and engagement strategy for future nutrition programs. 2.2 Key Questions The following table explains in detail the abovementioned impact goals of the study, the key decision evidence sought, and the guiding research questions to gather such evidence. Study Impact Areas Key Research Questions and Learning Objectives (a) Matching supply and demand of • Understanding the demand side of inter- nutrition responses for greater ventions and matching it with supply. technical effectiveness. The study • Gathering evidence of effectiveness of var- particularly seeks answers in the ious beneficiary targeting approaches. following areas. (b) Generating evidence for effec- • How have some investment modalities, tive investment modalities for input-based versus results--based, condi- nutrition and food security pro- tional versus unconditional cash transfers, grams. The study seeks to gather and in-kind transfers worked for different evidence that will help guide in- interventions? vestments in future nutrition pro- • What sort of challenges have nutrition and grams, particularly by generating food security projects/programs faced the following answers. when they were financed through govern- ment systems versus outside-of-govern- ment systems? (c) Effective program design and • Determine strengths, key bottlenecks, and engagement strategy for future positive deviances of various institutional nutrition programs. For this pur- modalities including partnership arrange- pose, the study will conduct a ments and monitoring and evaluation thorough operations research of mechanisms of nutrition and food security its current programs, particularly programs that sought to improve nutrition with the following goals. outcomes. • Determine pros and cons of various insti- tutional arrangement framework existing for some major nutrition and food security programs in the country. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 9 2.3 Methodology The research employs a multi-staged qualitative methodology to achieve the above-men- tioned objectives, as illustrated in the diagram below. The Preparatory Stage The Evidence Collection Stage The Evidence Synthesis Stage l Desk research to understand l In depth interviews (IDIs) with l Primary analysis nutrition and food security national, district & VDC officials l Evidence synthesis (NFS) strategies, priorities, l Focus group discussions workshop policies, and programs in (FGDs) with community l Final analysis Nepal beneficiaries 2.3.1 The preparatory stage The preparatory stage consisted of desk research to understand the landscape of nu- trition and food security (NFS) policies, priorities, and programs in Nepal. The back- ground developed from this stage helped to develop specific selection criteria to iden- tify key nutrition and food security (NFS) projects to explore at the central, district, village development committee (VDC), and local levels, in the second stage. 2.3.2 The evidence collection stage The second stage used in-depth interviews (IDI) with national, district, and VDC-level stakeholders, as well as focus group discussions (FGDs) with community-level benefi- ciaries. A purposive sampling of projects for IDI and FGDs were done with the follow- ing considerations: • The samples must represent a diversity of technical approaches, such as food and agriculture-based interventions, health systems-based interventions, communi- ty-driven development approaches or a combination of these interventions. • The samples must be large-scale across many districts and multi-year projects be- cause the lessons will be used to help implement projects at scale. This excludes any small-scale projects or pilots done by other entities. • The samples must also capture different investment or fund-flow mechanisms, such as through the government system and nongovernment structures. • The samples must also capture different operational modalities, such as through government line-agencies, autonomous government bodies, health delivery units, nongovernment project structures, and private sector engagement. The policy-level stakeholders and experts from the NPC and Child Health Division (CHD) were consulted at the central level to capture additional insights about the over- all policy environment and priorities. Data collection methods and sampling The sampling techniques used to identify respondents from the selected projects and the four study instruments used in data collection are described below (see Annex 1, Table 3). 10 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL • National-level IDI: The first component was national-level stakeholder consulta- tions with managers and experts to understand their perspectives about the tech- nical, investment, and operational aspects of their respective NFS projects and ac- tivities. Fifteen interviews were conducted. The consultations with national-level project managers from six selected projects helped to identify samples for IDIs at the district level. The national project managers were asked to provide the names of three project districts with high-performing and low-performing VDCs based on ease of implementation and project outputs. The purpose of selecting the two dif- ferent types of VDCs is to allow for a comparative assessment of challenges and op- portunities faced in those contexts, and to capture any positive deviances and local innovations in projects operating in their own political economic background. • District-level IDI: The district-level interviews were mostly conducted at the head- quarters of the seven districts selected through the national-level IDIs. The districts included in the terai (southern plains), Nawalparasi, Siraha, Saptari, and in the hills, Surkhet, Jumla, Dadeldhura, and Okhaldhunga. Sixteen interviews were conducted involving government officials stationed at the time of the interview in district head- quarters. They included the Local Development Officers (LDO),1 the District (Public) Health Officer (DHO/DPHO),2 and the District Agriculture Development Officer (DADO). • VDC-level IDI: The district-level officials helped further identify and coordinate with VDC-level stakeholders from selected high-performing and low-performing VDCs. Their identities are omitted from this report to maintain the confidentiality of the respondents and projects. Twenty-four IDIs were conducted with local-level facilitators called coaches of the SHD Project, VDC secretaries, Junior Technicians or Junior Technical Assistants of the AFSP, and the Female Community Health Volun- teers involved in the Suaahara, UNICEF, and MOH’s activities. • Community FGDs: Altogether, 17 FGDs were conducted with the beneficiaries of the selected projects. Beneficiaries included the Rapid Results Nutrition Initiative (RRNI) team of SHD Project, mothers’ groups (UNICEF, Suaahara), farmers’ groups of the AFSP, and KISAN. In each FGD, 8–10 members were selected from existing groups of beneficiaries from each of the respective projects for the discussion. Study Instruments All study instruments followed a standardized general content structure and modules. Such consistency across four different modules allowed for effective comparison of re- sponses by stakeholders at different levels and by stakeholders from different projects. The modules are described in detail below. • Module 1: Respondent Information. The purpose of this module was to understand the role, level, and nature of the respondent’s engagement in project preparation, implementation, and evaluation. • Module 2: Review of Project Implementation. The purpose of this module was to understand the respondents’ perspective of the overall project operations and In the absence of LDOs, persons who were acting for them were interviewed. 1 In the absence of DHOs/DPHOs, persons who were acting for them were interviewed. 2 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 11 to capture the lessons learned for eight categories, which are project acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, coverage, and sustainability. The module allowed for respondents to rate each indicator from 1–5 to sum up the discussion for each indicator. • Module 3: Review of Project-Specific Approaches. The purpose of this module was to discuss specific operational, technical or investment approaches to further eluci- date the process flow, and particularly to help identify key bottlenecks or constraints in three functional areas: (a) decision making, (b) execution, or (c) monitoring / ac- countability. The module also used a process map to probe respondents to point to constraints along the various interfaces from the national to the local-level stake- holders. 2.3.3 The evidence synthesis and analysis stage The data collected from the previous stage was transcribed and translated into English. All transcripts were then coded in NVivo, a qualitative data analysis computer soft- ware, from which emerging themes were developed within the broad categories of a project’s technical strategy, investment mechanisms, and operational modalities. The preliminary evidence was further analyzed and discussed during an Evidence Synthesis Workshop (ESW), which was held with key stakeholders from the ministries, NPC, the Child Health Division (CHD), and academia. The feedback and additional insights on emerging trends and findings helped to further enhance the perimeters of the analysis, a process culminating in this report. 2.4 Challenges and Limitations of the Study The research was intended to gather information and to draw lessons from the major nutrition and food security (NFS) projects in Nepal to guide future World Bank support to improve nutrition in Nepal. Given the diversity of NFS projects, the study attempted a non-probability and convenience sampling to capture various technical, investment, and operational dimensions employed in Nepal’s political-economic context. The first challenge was to ensure that the project diversity was captured adequately in the sam- pled projects and districts. This was accomplished by broad review of projects at the be- ginning followed by focused consultations with national level experts. The second chal- lenge was in sampling high-performing and low-performing VDCs in the absence of more objective performance metrics. Because the study focused more on the operational or process dimensions, rather than quantitative indicators of success, the second-best method was used to identify the samples, which was relying on the experiences and challenges managers faced in project implementation across different communities. Al- though such a grounded-approach can identify interesting positive deviances and their determinants, the selection process can be biased. The third challenge was to ensure the truthfulness of the responses by various actors. Although every effort was made to discourage interviewees from providing biased re- sponses by explaining the value of a truthful assessment of the projects and other actors’ 12 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL activities, it is very likely that some respondents were motivated to censor their honest assessments. Because the same assessments were collected from various actors, from national to local levels, the study did allow for some degree of triangulation of informa- tion to identify and investigate any data discrepancies. The final challenge is inherent to analyzing qualitative data, particularly in developing conceptual themes based on information from a non-probabilistic sample. To improve the reliability and validity of the findings, the specific context from which the information was derived is presented in the analysis. In sum, despite some of the inherent and practical limitations discussed above, the research team adhered to the highest standards of qualitative data design, collection, and analysis to meet the objectives of the study. 3. Key Findings and Thematic Discussions T his section highlights the key findings in relation to Nepal’s national policy and priorities to reduce malnutrition and to the project-specific operational assess- ment of six large-scale projects, which employ various modalities to deliver nu- trition and food security interventions. 3.1 National Policy and Priorities 3.1.1 Key policies and priorities The GON has been implementing the 2012–17 MSNP, which is expected to accelerate gains in nutritional outcomes to assist in meeting the MDGs for food and hunger, and to break the cycle of intergenerational poverty and undernutrition in the long term. The Government’s commitment to reduce malnutrition is visible in other policy documents including Agriculture Development Strategy (2015-2025), National Health Policy 2014, Food and Nutrition Security Plan of Action (2013-2023), Nepal Zero Hunger Challenge: National action Plan (2016-2025) and Nepal Health Sector Strategy (2015-2020). The GON’s commitment to food and nutrition is also demonstrated by maintaining and reaffirming food security or the right to food as a fundamental right in the Nepalese con- stitution in 2006 and 2015. Food sovereignty also has provisions in the constitution. The provisions in the constitution and in various laws and regulations are also supported by Nepal’s status as a signatory to various international covenants and agreements. They include the Convention on the Rights of the Child (CRC), the Convention on the Elim- ination of all Forms of Discrimination Against Women (CEDAW), the SUN Initiative, and the International Covenant on Economic, Social, and Cultural Rights (ICESCR). At the regional level, Nepal is party to the South Asian Association for Regional Cooper- ation (SAARC) Development Goals and the South Asian Regional Nutrition Strategy. Nepal’s current three-year periodic plan 2013/14 – 2015/16 aims to reduce the rates of infant, child, and maternal mortality through proven and cost-effective interventions. The current plan, as well as the forthcoming plan 2016/17 – 2018/19, focuses on 26 dis- STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 13 14 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL tricts of Karnali, which have been facing a long-term food crisis. The other key expected programs of the government include a national framework for social protection, which also aims to universalize child protection grants (cash transfers) to improve child nutri- tion and expand maternal services. In the health and agriculture sectors, nutrition and food security have been emphasized in strategies and plans. The National Nutritional and Food Security Policy is being prepared. The High-Level Nutrition and Food Security Steering Committee and the National Nu- trition and Food Security Coordination Committee under the NPC, which were estab- lished in 2012, are intended to ensure central coordination of nutrition and food security activities. For effective coordination of activities at the grassroots level, the Nutrition and Food Security Steering Committee exist at the district and VDC levels. 3.1.2 Current constraints Effective monitoring of the MSNP’s implementation has been a challenge due to a lack of an effective reporting mechanism. It appears that the institutional home within each line agency, except for a few, needs to be recognized and established to aggregate and report sectoral indicators identified by the MSNP. The Ministry of Federal Affairs and Local Development has been working on reporting tools to strengthen monitoring and reporting. The role of the private sector in improving malnutrition is important to highlight. It can use its social marketing skills to promote fortified foods, produce different therapeutic foods locally, and support areas such as water, sanitation, and hygiene. The country should execute the provisions it has to restrict the promotion of harmful practices like the use of infant formulas as a substitute for breastfeeding and children friendly-adver- tisement of processed junk-food, which are regarded as empty calories. The private sector’s involvement in food security and nutrition is limited. Although, the Breast Milk Substitute Act exists to regulate the private sector market, the consensus is that the act is not implemented effectively. The Chaudhary Group, a private company, developed a product called Instant Meal, which is the first fortified cereal-based blend- ed food. Its production facilities are recognized and approved to produce and distrib- ute fortified blended food in the South Asian region by UN agencies such as WFP and UNICEF. The Nepal Government’s Department of Food Technology and Quality (DFTQC) has innovated and developed various nutritious foods, but it lacks a private company to produce the products and introduce them in the market. Nonetheless, a few examples exist of private sector linkages with food processing. For example, Bel-Juice is produced through target groups co-operatives, and the Federation of Nepalese Chambers of Com- merce and Industry is helping market it. More research is required to develop local pro- duced varieties of therapeutic foods to reduce the costs of purchasing the same products internationally. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 15 3.1.3 Future directions Nepal’s nutrition profile has been raised at the central level, which is evident by nutri- tion’s coverage by journalists in quality news articles and its visibility in talk shows. The GON is currently drafting its second MSNP. As Nepal undergoes federalization, it is essential that advocacy for nutrition is replicated at the states and local government levels, since they will be autonomous and have authority over the resources to imple- ment development programs. Therefore, the next phase of the MSNP should be drafted to ensure that those who will lead the provinces will also have ownership and be ac- countable for outcomes. 3.2 Developing Technical Approaches for Nutrition and Food Security Projects Nepal implements a range of technical interventions to minimize key risk factors for malnutrition. Figure 1 illustrates the three-step process for developing a technical strate- gy, starting by identifying key risk factors for malnutrition and designing interventions, assessing demand and supply match, and finally, by developing a beneficiary targeting strategy. This study is not intended to review risk factors of malnutrition and identify nutrition specific and sensitive interventions. (Interested readers may refer to them in Annex 2). This section presents a systematic methodology for matching supply side in- terventions with demands in the community, the contextual best practices in identifying and engaging target groups, and a close analysis of selected interventions. Figure 1: Steps for developing a technical strategy Step 1: Identify the Key Risk Factors of Step 2: Assess demand and Step 3: Develop Targeting Malnutrition and explore interventions supply match Strategy l Identify objectives specific l Match demand and supply l Target beneficiaries to addressing the key risk sides of interventions through multiple levels of factors associated with governance malnutrition l Central level l Explore nutrition specific l District level and sensitive interventions l Local level l Consider positive deviances and considerations Step 1- See Annex 2. Step 2- Matching Demand and Supply Sides of the Interventions For an intervention to be successful, the demand and the supply sides of the interven- tions must be developed simultaneously. Therefore, while designing interventions, the next step is to thoroughly assess the constraints and prospects, first from the perspective of the community’s level of awareness and demand for a nutrition intervention (the demand-side), and second from the perspective of the health and nutrition systems, markets, and the socio-cultural and political environment (the supply-side). The follow- ing Demand-Supply Matching Matrix illustrates the keys areas of possible (mis)match in some projects in Nepal. 16 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL DEMAND Weak Strong Weak-weak scenario is created when the High-demand mismatch is created when the community is unaware or unconvinced community has accepted the need and even of the need for intervention and when demanded the intervention or a practice but the health systems or programs lack are limited by inadequate supply-side efforts or adequate effort or capability to provide the resources. intervention. Example: Households understand the need for Weak Example: Low awareness about the pregnant women to consume a high-protein diet, importance of exclusive breastfeeding but there is limited support to provide actual in communities (demand) and limited financial or technical resources to enable poor counseling capabilities in health facilities to households to raise poultry for eggs or animals for encourage the practice (supply). meat. S U P P LY Low-demand mismatch is created when Ideal matching is possible when both sides of emphasis is provided only on the supply the intervention are properly addressed. The side of the intervention and limited effort community or beneficiary should be convinced of is exerted to convince communities or the value of a given intervention and supply-side beneficiaries about the importance of actors must match the community’s expectations. intervention. Strong Example: To create demand, FCHVs provide proper Example: Construction of unused latrines counseling and encouragement to pregnant mothers for defecation through subsidies and to choose institutional deliveries over unsafe delivery grants is a most noted challenge in at home. This is matched by proper provision of addressing community-level risk factors for midwifery and referral services at local health facilities. malnutrition. Recommendations • Any nutrition operation needs to garner evidence of the prevalent causative factors for malnutrition in the particular geographical area of intervention. This will help one understand the demand side. If there is a lack of existing evidence, a prior for- mative research might be helpful to identify the cause(s) of malnutrition in the area and to plan particular interventions to improve nutrition for the area. • Always match the demand created—as identified through formative research or baseline surveys—with adequate supply-side interventions. For instance, a food in- secure household should be provided with the means to secure nutritious food, in addition to advocating for better nutritional behaviors in the household. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 17 Step 3 – Develop Beneficiary Targeting Strategy Another critical step of developing a technical strategy is ensuring that the intended beneficiaries adequately receive the interventions. The aggregate outcome of the project is determined by the success of the interventions in producing the anticipated changes in each beneficiary. Target Beneficiaries at Multiple Levels The review of various nutrition and food security (NFS) projects in Nepal reveals that the process of identifying beneficiaries occurs across multiple levels, from central to local. Each level is prone to structural and implementation constraints, as described in detail below. 1) First Level targeting: It is used to identify the regions and districts with poor nu- trition status using a range of data source and indicators (see Box 1). This process allows a project to quantify the need for engagement, prioritize malnutrition risk factors to address, design interventions, and estimate costs and resource require- ments. Some of the key constraints at this level of targeting include the following. • Reliability of data to infer true need or nutritional status: Most of the indicators used in target selection are derived at the level of ecological regions, such as the hills, terai or mountains, or at the aggregate level of administrative units, such as by districts or clusters of VDCs. Examples of commonly used sources for target selection include the Demographic Health Survey, the Multiple Indicator Cluster Survey, and the Nepal Living Standard Survey. While the information is useful for prioritization of project regions, the data are not adequate to select the VDCs or wards with the greatest needs. • Inability to customize interventions to economical, geographical or cultural differences: Given the inadequacy of information at the local level, the aggregate information only points to the problem, as represented by corresponding malnu- trition indicators. The problem might be the result of diverse root causes or risk factors depending on local-level factors arising from socio-economic, geographic or cultural differences. For instance, compared to the flat plains of the terai, the hills and mountains have scattered population across difficult terrain. Interven- tions and investments to address the same problem in the terai or in the hills and mountains can vary greatly. Similarly, in communities with a larger share of poor and food insecure households, interventions require greater logistic support until the communities are economically capable. In terms of cultural differences, women in the terai, especially daughters-in-laws, are often restricted from partic- ipating in community groups. In contrast, due to the high migration of men from the hills, women are often the active participants in community groups. • Reducing overlap with existing projects and interventions: Various nutrition programs in the country operate differently. Some programs operate within the government budget systems and others are outside the systems and are imple- mented at different times. The programs and the types of interventions may overlap geographically. 18 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Box 1: Data Sources Commonly Used to Select and Target Project Beneficiaries • Periodic Household Surveys: The interventions have to be implemented Demographic and Health Survey, the at a small scale with limited capacity Nepal Living Standard Survey, and the and resources. The data is produced at Multiple Indicator Cluster Survey are done ilaka level (a few VDCs) by combining periodically but generate disaggregated Nepal Living Standard Survey III data information at the ecological zones rather with auxiliary data derived from Census than by administrative units. 2011. The Nepal Small Area Estimates of • Routine Information Management Poverty 2011 was developed by the CBS System: A Health Information with support from the World Bank. Management System generates yearly • DAG Score: The DAG score is based on data from facilities. The data are generally the indicators comprised of (1) food supply side and based on population sufficiency of less than three months, (2) projections. the presence of marginalized groups, (3) • Small Area Estimation of Food Insecurity lack of access to basic services, (4) the and Undernutrition of Nepal (2014): lack of representation / participation Developed in collaboration with the Central of / by women, Dalits and Janajati in Bureau of Statistics (CBS), GON, World decision-making bodies, (5) the prevalence Bank, WFP, and UNICEF, this data can be of gender discrimination, and (6) the used to identify locations where nutrition presence of vulnerable groups. 2) Local level targeting: The second level of targeting occurs at the regional (or pro- vincial) or district (or local government) levels. The district-level authorities selected the VDCs and wards for the project. Because district-level officials would have a better understanding of the needs of the VDCs and wards in their districts, the central line agency decentralized the selection process to the district. For the AFSP and SHD Proj- ect, the central authority gave the project districts a set of criteria for project selection, which the latter used to rank prospective VDCs for projects. One of the criteria used by the districts was the DAG Score (see Box 1). For projects operated by nongovernment agencies, the selection of VDCs and wards rested with the project itself, but the imple- menters consulted with the government entities, e.g., KISAN Project. The decentralized targeting process faces a few constraints as described below. • Unreliability and utilization of data – For projects relying on DAG scores for selec- tion, one concern was whether the DAG scores might not truly represent the status of the VDCs. In addition, when VDCs have the same DAG scores, but only a limited number of VDCs are to be selected per project, how should the selection decision be determined? • External pressure in selection of VDCs – Decision makers often faced pressure from lobbyist to include their VDCs in a project. In such cases, decision makers often successfully convinced lobbyist of the objective criteria used in the selection process by sharing the criteria. However, district officials reported that interventions should STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 19 have been district-wide instead of being only in certain VDCs as there was a push- back from those VDCs not benefitting from the project despite being in the same districts. • Time consumption and delays – Even though the decentralized process helps to increase the ownership of district-level stakeholders and to leverage their expertise in the targeting process, it is nonetheless a time-consuming process. District officials are expected to consult with other district-level stakeholders, often by convening a district-level meeting to resolve any conflicts or concerns from different actors. They also face other logistical constraints, such as in communicating with central-level officials and the unavailability of VDC- level officials to provide inputs. 3) Community-level targeting: The third level of targeting is done by community groups or structures formed by the project to identify households and individuals who should receive project benefits. Some interesting approaches used for effective local-lev- el targeting implemented by the community members themselves are described below. • Household data collection by community teams: For the SHD project communi- ty-based teams implementing the project went door-to-door to identify households that fall within the selection criteria, and thus created a roster of beneficiaries for sub-projects. This approach provided teams with data to not only select beneficiaries more objectively but also to resolve any concerns from groups or individuals exclud- ed from the project. • Using health facility data to identify beneficiaries: In Suaahara, the project im- plementers obtained data from health facilities to select their beneficiaries and to identify Female Community Health Volunteers (FCHVs) for mobilization. While this process may exclude individuals not using the facilities or those who might not have access to FCHVs, the approach nonetheless provided extra tools to estimate the size of target groups and to assist in identifying individuals. Critical Considerations in Beneficiary Selection However, projects did face common challenges to ensure that only needy people were selected as beneficiaries. Some of the most prominent issues that should be considered during the selection process are as follows. • Possibility for elite capture: In introducing or starting projects that require strong community participation or formation of community groups, the projects must go beyond finding the “local champions.” It is important to conduct a more thorough assessment, instead of simply relying on such individuals, and to ensure a more inclusive channel of communication, such as the Ward Citizen Forum or existing groups such as mothers’ groups. “However, in my personal experience, in many of these programs, generally one contact person from the village is picked up. He is solely contacted and consulted for commu- nity group formation. In those community groups, favoritism and nepotism are highly practiced.” – VDC Stakeholder, AFSP 20 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL • Well-intended selection criteria often prevent effective inclusion: In some cases, interventions are designed with conflicting criteria that unintentionally exclude certain groups. For instance, when a certain intervention modality requires group members to have a certain level of literacy, but certain historically excluded groups, such as Dalits or women, do not meet the criteria, then such provisions defy the very goal of ensuring inclusion in interventions. “In my opinion, I haven’t seen any Dalits getting the opportunity of working as vol- unteer because there is no education among the backward groups... Volunteers are only from the educated family.” – VDC Stakeholder, AFSP • Marginalized groups may not participate or speak up due to socio-economic fac- tors: During the process of beneficiary selection, marginalized groups may not ac- tively participate or voice their opinions given their low-level of empowerment and economic opportunity costs. Therefore, extra effort must be taken to ensure margin- alized groups’ constraints are thoroughly considered in planning information ses- sions or beneficiary selection in villages. “… the poor people and marginalized are suppressed and silenced. They do not want to speak up. They don’t have enough to eat. They have bigger things to worry about; why would they want to go and listen to speeches?” – Coach from a terai district, SHD Project • Rollout of interventions in multiple phases can help increase coverage in areas with large or dense population. Such rollouts can be based on settlements, priority groups, or operational considerations and can help resolve possible conflicts or ob- jections from community members who are concerned about being excluded from the project. Targeting- Blanket Approach versus Selective Targeting One of the most contentious issues in beneficiary selection is the choice between a blan- ket approach (covering everyone in a project location) and selective targeting (covering only those people in-need in a project location). Malnutrition with multi factor causes and requiring interventions at various stages of human life cycle possesses a challenge while selecting beneficiaries. This issue arises especially when the project intends to pro- vide certain amenities (cash, in-kinds, etc) to people to change their behavioral practices for better nutrition. Selection of beneficiaries could depend on the nature of interventions. Blanket approach is appropriate to addresses risk factors that are community-wide, e.g., open defecation practices, or society-held misguided belief systems. Selective targeting is usually prac- ticed when a risk factor is concentrated in certain economic groups e.g. poor households which are food insecure. However, whether to adopt a blanket approach or selective tar- geting also depends on geographical spread of the risk factor for which an intervention is designed and marginal cost of operations. Selective targeting would involve the cost of identification of the beneficiaries and if the risk factor in consideration is spread over multiple locations, then the marginal cost of interventions might increase. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 21 In community-driven projects, like the SHD Project which provided amenities to peo- ple, there was a strong resistance from people such as those who were not poor or are from “higher” castes or who were not selected for the benefits. This sort of attitudes in the community hampers smooth implementation of activities. Sometimes it might be more convenient to include all the beneficiaries (like pregnant and lactating women, children under two years, etc) irrespective of their income status or castes considering the high opportunity cost of resistance from hostile community participants. Recommendations • Given the resource constraints, targeting should be strategically planned. One should make use of all the information available to narrow down the geographical location of intervention, and further identify spatial orientation of risk factors and risk groups within that location. In the dearth of relevant information at the inter- vention area, a prior survey or formative research will be helpful in designing an effective methodology for beneficiary targeting. • One can select beneficiaries within a framework, for example, intervention for the first 1,000 days, or for households with under-five children, adolescents, or preg- nant and lactating mothers. Conflicts and challenges can be avoided if interventions cover an entire autonomous administrative unit. For example, one should use a dis- trict-wide (or Local Government-wide) or province-wide approach and select bene- ficiaries irrespective of their income status or whether they are marginalized or not. If resources are limited, interventions should be implemented in phases in different autonomous administrative units. 3.3 Investment Mechanism 3.3.1 Financing Sources Nepal uses a range of financing mechanisms to implement nutrition interventions. The mechanism depends on various factors, such as the objective and type of nutrition inter- ventions, the number and nature of target beneficiaries, and the scale of coverage across geographic areas and districts. The four primary categories of financing mechanisms used in Nepal are described below. • Development partners financed large-scale interventions using the government’s financial system: The European Union through UNICEF finances nutrition-spe- cific interventions by partnering with the MOH and other all relevant ministries including MOFALD, MOE, MOWSS and MOWCSW and their line agencies. The World Bank had financed a separate nutrition project, the SHD Project, through the MOFALD. Other donors that have financed nutrition-related programs in Nepal are DFID, DFAT, WFP, FAO, and ADB. • Development partners financed large-scale interventions using their own finan- cial system. USAID has financed Suaahara, SABAL, Pahal, and KISAN (Feed the Future) Projects. Those projects are implemented through international NGOs, in- cluding Save the Children, HKI and FHI 360, which are selected through competi- tive bidding. 22 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL • Government financed large-scale interventions using its revenue resources: The GON has directly invested its own revenue in nutrition-specific and nutrition-sen- sitive activities through various line ministries and agencies. For instance, the Nu- trition Section of Child Health Division of Department of Health Services supports micronutrient supplementation, therapeutic feeding, supplementary feeding, op- timum breastfeeding, complementary feeding, and responsive feeding practices. Since 2015, the MOF has been contributing funds to implement the government’s MSNP through the MOH and MOFALD. • Other organizations financed small-scale interventions: Some small-scale, stand- alone interventions are financed by NGOs. ACF with the help of UNICEF has sup- ported Saptari District in managing acute malnutrition. Some projects directly contribute to the government’s budget and use government fi- nancing systems, as described above. Whereas some projects use partially separate or completely separate financing systems. Nutrition interventions implemented solely through government’s traditional line-item annual budgeting include the MOH’s own nutrition-specific activities, the World Bank financed Sunaula Hazar Din–Community Action for Nutrition Project, AFSP, Rural Water Supply and Sanitation Project, and the Government’s MSNP. UNICEF also primarily finances through on-budget programs which also includes direct payment method. Other donor-funded programs like Suaa- hara have also contributed through an on-budget direct funding modality to districts through relevant line agencies. Suaahara has funds for its project via off-treasury mech- anism too. Suaahara has channeled some of its funds through competitively selected NGOs and partner organizations. USAID projects, such as KISAN, adhere to USAID’s financial and procurement policies, and fund-flow occurs to competitively selected firms. Activities financed through government systems depend solely on the timing of the spending authorization received by the implementing units from the center to the local levels. If the implementing unit is a community, as happens in a community-driven project, it appears that the community receives funds only towards the latter half of the fiscal year. The delay in receiving funding can happen anywhere at various levels of government. Even if the budget is announced on time, the program approval takes time before the central implementing agency obtains the funds to spend. If donors have committed the funds, then the central government might not release the funds to the project if reimbursement by the donors has not been made to the treasury for the previ- ous fiscal year’s expenditures. Donors reimburse the expenditures only on the premise that financial transactions have been accounted for. At the local levels, frequent transfers of officials and inadequate attention could lead to delays in funding allocations. At the level of communities, if the financial transactions and reporting do not comply with the set standard, then a further delay of fund flows could occur. The more layers of approval within the government, the more delays in the funding flow. Projects like SHD suffered such setbacks due to funding delays. Nutrition projects that do not use the government financial system did not suffer fund- ing delays. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 23 Recommendations • It is essential to minimize the layers of funding flow for a project or any activity within the system. Financial accountability should be the responsibility of the units that receive the spending authorization. • It is essential that timely financial compliance is maintained by the implementing agencies to get reimbursement of expenditures committed by donors. • For a community-driven project, it is essential that a central unit approves the pro- posals and releases funds directly to the communities. Communities have very minimal capacity to follow bureaucratic processes of documenting technical and financial reports. Such processes at the community level generate exhaustion and disinterest for the project. Communities need to be made accountable for the money they receive but not at the cost of complying with complex bureaucratic processes. 3.3.2 Financing Modalities The nutrition and food security projects in Nepal employ a range of financing modali- ties to carry out activities and achieve the stated objectives. The modalities can be cat- egorized in three broad domains, namely input-based financing, safety-net financing, and results-based financing. The chart below illustrates each modality, with descrip- tions, assessments, and learning based on experiences in Nepal. Input-based financing Under this modality, the assumption is that the desired outcomes will automatically follow from providing better inputs and processes. How results are achieved depends on the correct sequence of activities elaborat- ed in the logical framework from inputs to outcomes, and provided no external unfortunate events occur that would negatively affect the results. Implementers are accountable for inputs but not results. For reporting, implementers use indicators such as coverage of inputs, e.g., households reached, mothers counseled on exclusive breastfeeding, number of children suffering from severe acute malnutrition receiving treatment. Examples: The funds have mainly financed Learnings: specific inputs to implement nutrition-specific • This modality is more suitable to finance interventions and nutrition-sensitive interventions, including with reliable assumptions of theory of change, i.e., spec- communications strategy, and monitoring and ified activities will result in certain outcomes. evaluation. Some examples include: • Since the fund is not contingent on the outcomes, the • Purchase micronutrients, complementary modality is less suitable for more complex implementa- food, supplementary and therapeutic food tion interventions or a change process. • Support homestead gardens to grow vita- min-rich food • Invest in health infrastructure to increase ac- cess to quality health services • Support initiatives in Water, Sanitation and Hygiene (WASH), reproductive health, and women’s empowerment 24 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Results-based financing In this modality, the financing decision is made based on the anticipated results or outcomes of the activities in a logical framework. Several types of this financing modality are implemented in Nepal. They can be cate- gorized as (a) conditional grants (b) semi-conditional grants, and (c) performance-based incentives. Some of the common conditions with results-based financing elements in Nepal are cited below. Conditional grants • Food / Cash for Work: The Additional Fi- Learnings: nancing of Social Safety Nets Project (SSNP) • There were recurring delays in the MOFALD’s funds implemented by the MOFALD sought (as release for the Social Safety Nets Project (SSNP). How- one of its objectives) to improve the pop- ever, in food/cash for work, such delays were not seen ulation’s access to nutritious food in food due to direct transfers to a WFP subsidiary to deliver insecure districts.  The main activity con- foods, thereby increasing efficiency. Similarly, in re- ducted to meet this objective was engaging mote areas, switching from food delivery to providing the community in infrastructure works such cash grants for labor work was easier to manage and as construction of rural roads, irrigation reduced logistics (World Bank, 2015). systems, flood control, soil conservation, • Globally, Conditional Cash transfers given to house- and by providing livelihoods and agricul- holds for adopting certain health care practices and ture-focused activities. Given the difficulty nutrition behaviour have generally shown good results of delivering food to remote areas, and the but are usually contingent upon the nature of “condi- recognition that in some food insecure dis- tioning” and the quality of services (Marie M. Gaarder, tricts, food was available in the market, the 2010) (Jef L. Leroy, 2009). modality switched from in-kind to a cash • Conditional grants provide a “check” on the quality grants modality (World Bank, 2010). and results of activities, which can have a positive effect when they incentivize a community to perform. • Strong monitoring and accountability mechanisms must be established to assess whether the conditions have been adequately met to approve grants. Semi-conditional grants for beneficiaries (demand-side) • Grants for awareness event attendance: Learnings: The World Bank’s pilot project Community • A randomized evaluation found that providing cash Challenge Fund provides cash transfers to grants to mothers who participated in nutrition infor- mothers for attending nutrition awareness mation sessions had substantially improved knowl- programs. The cash transfers are intended edge about practices to improve maternal and nutri- for the mothers to put into practice their tional health and resulted in small gains in children’s new knowledge about nutrition. The only cognitive development (Levere, 2016). condition for receiving the transfer is for the mother to attend the information session and not based on the actual result of change in nutrition practices or behaviors. • Small grants for agriculture: The AFSP pro- vided small grants to farmer groups with the goal of the farmers increasing their pro- duction of nutritious foods, such as by con- structing better irrigation systems. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 25 Performance-based incentives for health service providers (supply side) • Health facility incentives: Maternity incen- Learnings: tive Aama Program has provided perfor- • The lessons from the Aama Program can be used for mance-based incentives to health workers. nutrition-focused programs, with possible application Such incentives have been gaining popular- in malnutrition surveillance, treatment, raising aware- ity to improve access to health services, par- ness, and incentivizing agriculture and veterinary ser- ticularly by providing payments to health vice providers at the local level. facility workers for conducting institutional deliveries. • Community worker incentives: Instead of receiving a direct salary, FCHVs are often in- centivized to carry out their activities based on the number of referrals or by partici- pating in community health campaigns or learning events. Welfare Financing The modality seeks to provide welfare support to those most vulnerable to malnutrition. • Cash transfer: Since fiscal year 2010, MO- Learnings: FALD has been providing cash transfers to • An increase in the cash grant benefit would lead to de- children under five in the districts of Karnali cline in the prevalence of underweight and severe wast- zone and to poor Dalits all over the country. ing. Children under five—up to a maximum of • There are constraints and challenges to this modality, two per household—receive NPR 200 per such as the low level of benefit, low coverage among un- child per month. Although the cash grant is der-two children, and delay in cash delivery (UNICEF, unconditional, the objective of this program 2016). was specifically related to improving nutri- tion. • Unconditional in-kind transfer: Some com- munities vulnerable to food insecurity and malnutrition are provided with in-kind goods, such as agricultural tools, seeds, and fertilizers, to help grow vegetables to im- prove their dietary intake. Recommendations • While there is no one best modality, due consideration should be given to the capacity of the implementing agency and the existing accountability mechanism for the modalities to ensure that money is used for the purpose intended. 3.4 Institutional Modality 3.4.1 Institutional Arrangements in Government-Implemented Projects Even among Government-run projects, the institutional arrangements vary. The institutional modality to de- liver nutrition programs is contingent on the prior institutional structure and the additional infrastructure and human resources needed to implement certain activities. 26 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Some sectoral ministries may have the correct institutional structure from the central to the community levels to deliver nutrition-related interventions. For example, in Nepal, the MOH implements nutrition-specific interventions through its Department of Health Services and its divisions (CHD and FHD). The nutrition-specific services are delivered through the MOH’s health facilities, including hospitals, primary health care centers, and health posts. Female Community Health Volunteers (FCHVs) are also actively in- volved in the delivery process in the communities. Although the MOH’s health system is fairly equipped to deliver such services, donors like UNICEF, USAID, UNFPA, and WFP with their technical and financial support enhance its capacity. The MOAD operates agricultural programs through its various agencies, including the Department of Agriculture, the Department of Food Technology and Quality Control, the Nepal Agriculture and Research Council, and local structures, including the District Agricultural Development Office. There are also community extension workers called Junior Technical Assistants (JTAs). Other agencies, external to the Government’s struc- ture, like FAO, have also been involved in providing technical backstopping to imple- ment agriculture projects like the AFSP. The Ministry of Federal Affairs and Local Development implements its programs through District Development Committees (DDCs) and Village Development Commit- tees (VDCs). Under its Local Governance and Community Development Program, the ministry also has social mobilizers working in the communities to create awareness of civic rights and duties, to inform people about government services and facilities, and to help communities with economic development opportunities. In the following section, different institutional modalities are examined which are used across central, district, and local levels by three World Bank funded projects that use the Government’s structure. The chart below provides the general types of modalities in the Government system. Central District/Village/Municipality Local l Shared management unit District Offices Extension Workers l MOFALD: LDO, l Social mobilizers, Coaches l Dedicated management unit l MOAD: DADO, DLSO l JTA / JT l MOH: DHO / DPHO, l FCHV District Committees Community Groups l DDC l Mothers’ Group l DADC l Community-based l NFSSC organizations l Farmers’ Groups Village Committees l User Groups l VDC l VNFSSC STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 27 Central-Level Management Arrangement The institutional arrangements for a project management unit (PMU) at the central level can be classified into two categories: (1) shared implementation unit, in which PMU staff are engaged in multiple projects; and (2) dedicated implementation unit, in which PMU staff are engaged full-time in the project. The chart below compares the two cate- gories in more detail: Shared management unit The project is led by a PMU consisting of ministry staff, who share their time e.g., SHD Project, MSNP with other tasks. The SHD Project was implemented by staff from the Local Body Support Section of the MOFALD, which was also involved in imple- menting the MSNP. The Local Body Support Section has other responsibilities besides implementing nutrition projects. Points to consider: • PMU staff are often overburdened by their other shared responsibilities and may not provide the time required for the concerned project. • Such an arrangement in the PMU calls for hiring dedicated staff to oversee the project early during project implementation. To support MSNP imple- mentation, the MOFALD has recently been hiring technical expertise for the central government as well as in the districts, with UNICEF’s support. Dedicated management The project is led by a PMU or a section consisting of ministry staff who either unit or section, e.g., are hired full-time or are present full-time to oversee projects. In AFSP, the AFSP, Nutrition Section Joint Secretary led the project with officers supporting various project func- of Child Health Division tions, such as administration, M&E, finance, and so on. Another example is the dedicated staff of the Nutrition Section of the Child Health Division in the Ministry of Health, which has the sole responsibility of executing the nutri- tion-specific interventions per their mandate. Points to consider: • This allows the team to function with fewer interruptions, and they can therefore dedicate their time fully to the assigned project or activities. District and Local Implementation Arrangement It is essential that the central ministries have adequate infrastructure and human re- sources to implement their respective activities at the district and local levels, including among villages and the communities. In this section, different management arrange- ments are reviewed at the district and local levels for key government ministries in- volved in nutrition and food security interventions. The following chart assesses necessary capabilities for project implementation or Tri- ple-As, that is Ability, Authority, and Acceptance at various levels. 28 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Ability District level For new projects, the project implementers must receive proper orientation and institute a mechanism to transfer knowledge for new staff because district officials share responsibili- ties across multiple tasks. If districts have platforms working on similar issues, it is essential to use that platform for program implementation. AFSP used the collaborative platform of the District Agriculture Development Committee. The SHD Project utilized a newly created structure for implemen- tation, the District Nutrition and Food Security Committee, which was mandated by the NPC. The new structure created confusion primarily because of a lack of orientation, and secondly, due to the sheer number of members on the committee, it was difficult to convene. “…if there is a gap in the veterinary, then there is lack in one part. And if there is a gap in agriculture, then we will not have the expected outcome in nutrition; or if the health lags behind, then the outcome will not be as expected.” District Official, SHD project Dedicating time for project monitoring is a major challenge. Some of the reasons given include having limited time for field visits due to multiple meetings at headquarters, the remoteness and difficulty of reaching villages, and logistical and accommodation challenges in villages. Providing dedicated human resources helps to relieve the workload from existing district officials and allows for focused and efficient project implementation. In the AFSP project, such provisions were built into the project early by outsourcing to FAO. Whereas for the SHD Project, district coordinators and assistants were hired very late after the project was implemented. Village level Thoroughly assess the capacity and time availability of VDC staff to take on the project activities. Given the human resource constraints, members of one VDC are responsible for overseeing the work of multiple nearby VDCs. VDC secretaries are often absent from the village, thereby hampering the project implementation. In such cases, outsourcing the super- visory and monitoring functions would be essential from the start. Points to consider while outsourcing: The government should ensure outsourced firms/NGOs are accountable to contractual obligations and paid for verified results. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 29 Community Community workers, social mobilizers, and community groups act as a bridge between the level communities and the service providers. Their strong development capabilities are critical for the smooth operation of projects. The following points should be emphasized: (a) the initial training should be in a language familiar to the community groups, that is Nepali or local dialects should be used for instructions or discussions. And the training should engage participants in practical situations, for example demonstrations, group work, and expert observations; (b) inception field training should involve close observation and support by supervisors to ensure acceptable performance as the community groups begin to work in the field; (c) routine quality monitoring and refreshers should review the quality of proposals, reports, and process-level outputs of the individual workers; and (d) peer-to-peer learning between high-performing and low-performing workers can also help to boost practical skills and the confidence of the workers to improve their performance. If communities must follow strict government rules to spend their grant money, the com- munity members’ capacity should be built so they clearly understand the regulations. Com- munities were frustrated when they were unable to receive subsequent installments because they failed to follow government financial transaction rules. In SHD Project, accounting and record-keeping were insufficient, resulting in inefficient processing of proposals. Using existing community structures like farmers’ groups, mothers’ groups, FCHVs, and JTAs simplifies implementation. Although additional human resources may be necessary at times to supplement their activities. SHD project and AFSP hired coaches and JTAs re- spectively at some cost. There was some turnover of coaches in SHD project. In AFSP, a high turnover of JT / JTAs resulted in the project losing trained labor and therefore, additional time was devoted to re-recruitment of staff. A major reason for the high turnover of staff is the low salary paid to coaches or JTAs by the firms that selected them. The firms are selected by a competitive bidding process, which usually awards the contract to the firm with the lowest bid. With a low working budget, the firms pay low salaries to JT / JTAs to fulfill the terms of the contract. To resolve this problem, the contracting process should specify, and if possible enforce, a competitive salary for field staff. 30 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Authority District Level If the district officials are responsible for oversight and accountability, the project or program / Central level needs to dedicate more authority to the districts for decision-making and problem-solving. In AFSP, such provisions helped to resolve implementation issues and challenges more effective- ly. Even though such mechanisms were ensured in the SHD project, the ability of the authori- ties to make decisions were lacking. There are allegations at times of abuse of authority which might be difficult to prove but project should have some mechanism to address those risks. “When we went to collect money, officials at the DDC deducted 20 percent of the allocated fund and….” – RRNI Team Member, SHD If cross-sectoral collaboration is necessary, then a clear plan for cross-sectorial collaboration by the different line agencies needs to be established to increase ownership of the activities and shared objectives. The SHD Project had clearly missed it as at the level of communities, a com- prehensive plan for collaboration was not there. In AFSP, the MOAD had to collaborate with the MOH to deliver nutrition-specific programs. The MOH was clearly given authority and resources to provide such support throughout the project. Village level At the village level, issues of oversight and accountability are the same, but depends on what functions can be delegated to the village level based on the existing capacity. If the village level acts only as a “post-office” to channel funds to the communities, then there might be rent-seeking behavior as observed in the study. For instance, in some cases, govern- ment agencies allegedly sought a commission for approving proposals, advised against certain types of projects, or suggested adjusting the beneficiary selection. “Officials coming to the VDC said that they would not put any stamps on the paper if that 2 percent is not given to them.” – RRNI Team member, SHD Community For community-driven activities, it is essential that communities receive adequate resources level through direct channels and are given the authority to make course corrections in their work plan and to counteract unforeseen circumstances. People appreciate when the majority of re- sources goes directly the community’s bank accounts. They are given full authority to mobilize their funds based on project agreements. Local political parties sometimes interfere with communities’ authority to implement projects, but the interference can often be countered through broad-based community discussions and transparency in the decision-making process. “Local political parties demanded [money] from us, saying they want a share of the project fund.”– Com- munity member, AFSP STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 31 Acceptance District level Acceptance is increased if district implementers are involved in project prepa- ration, planning, and implementation. It seems that officials are comfortable working with existing structures, rather than creating a new one. The collaborative platform of the District Agriculture Development Committee (DADC) was valued by district stakeholders in the AFSP. DADC had repre- sentation from agriculture, forestry, irrigation, and livestock agencies, which collaborated to improve the planning and decision-making process. Acceptance is also enhanced if local level cross-sectoral agencies are engaged early in the project for effective collaboration and cooperation. The SHD Project suffered initial setbacks because sectoral agencies at the local levels were not accepting of the project. Village level / Proper orientation and explanations are required to counter initial skepti- Community level cism and reluctance by communities to participate. The sensitization session must clearly explain the benefits of the program and emphasize that the project is for the people from the GON. Incentives for participation must be balanced with objectives of participa- tion. In agricultural training programs, implementers indicated that farmers are often motivated by allowances and food, rather than the information that the project provides. They also emphasized the importance of considering the contextual differences to determine the amount of incentives, such as cost of food in remote versus urban areas. Most FCHVs expect to receive incentives for their support to health programs and for attending trainings and seminars. However, they also seem to value the learning opportunity and chance to help people in villages. “It would be great if they could provide one or two thousand rupees a month. It would be very helpful. We cannot ask for a 20,000 salary. It’s not easy for us. If the government could assist us a bit. We must roam around on an empty stomach. It would be really helpful if the government could provide us with lunch, at least.” – FCHV, Jumla “Even though there was no money in it, it was an opportunity to travel around my village, to serve the people and children, and learn new things. I thought this was more important than money. I learned so many things, new skills.” – FCHV, Dadeldhura 32 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 3.4.2 Nongovernment Partnerships Partnerships with nongovernment entities, such as INGOs, NGOs or private firms, are crucial for procuring services and support in implementing nutrition interventions. This study shows that nongovernment partnerships can be procured through the govern- ment system, from outside the government system, or with external resources. The World Bank funded projects, such as SHD and AFSP utilize the government pro- curement process to select NGOs and firms for delivering specific services during imple- mentation. SHD, for instance, partnered with three National Service Providers (NSPs) or NGOs, which were responsible for hiring coaches and district-level supervisors to support the project. AFSP also partnered with FAO to implement food security and nutrition interventions. The USAID funded Suaahara Project and SABAL Project sup- ported many nutrition interventions. Funding agencies’ systems were used to procure such services. The NGO selection process faced hurdles from political pressures, and the resulting delay in selection was more prominent when the government selected the services. The performance of some of the selected NGOs hired through the government system and partners’ systems was not acceptable since they were not paying their staff salaries and performing their required duties. It appeared that the NGOs had bid quite low to win the contracts and later they could not perform very well. USAID-financed nutrition projects, which are aligned to the government’s MSNP, are mainly delivered through various partner organizations that were competitively hired through a bidding process by consortiums of competitively selected international orga- nizations. A mix of local and national NGOs engaged for different purposes and exper- tise enhanced Suaahara’s implementation of activities. Although the MOH has an institutional structure to deliver nutrition-specific interven- tions, technical agencies like UNICEF and UNFPA support the MOH with budgetary and extra-budgetary allocations for human resources and with technical inputs for quality implementation. Partners like HKI and Save the Children receive funding from USAID for nutrition-related programs to support the MOH by strengthening the in- stitutional capacity of the ministry to execute nutrition programs with technical sup- port. Suaahara II nutrition and health related activities are also reflected in the red book (on-budget) of the MOF. 3.4.3 Cooperation, coordination, collaboration, and partnerships Successfully achieving multisectoral nutrition results depends on the effectiveness of cooperation, coordination, and collaboration of different line agencies working togeth- er towards a common goal. Ensuring mutual accountability for a multisector outcome depends on how responsibilities are shared and whether individual agencies have the authority and resources to execute their assigned tasks. The following research findings well illustrate this concept. The MOFALD implemented the SHD Project with the expectation that other line agen- cies would be coordinating and cooperating during the implementation of community STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 33 projects. While cooperation and coordination was deemed necessary for the success of the project, the communities could not garner the necessary support in the manner en- visaged. Firstly, the different implementing line agencies did not have the authority and resources to oversee the project. Secondly, many communities chose sub-projects related to small household constructions like latrines, chicken coops, bio-sand filters, improved cooking stoves, and handwashing and sanitation stations, which communities felt they could construct without consultations. Soliciting coordination for activities was left to the community level. At some places, the communities did consult local line agencies, such as the livestock office for vaccina- tion-related matters, and the FCHVs and local health workers for health-related matters. However, activities requiring innovative mechanisms from relevant line agencies con- cerning behavior changes related to breastfeeding and complementary feeding practic- es, adolescent and sexual reproductive health, early marriage, and delayed pregnancy were not effectively implemented. The SHD project incorporated a user group mechanism similar to the one used by the Rural Water Supply and Sanitation (RWSS) Project funded by World Bank and imple- mented by the Water Fund Board. The RWSS project community (users’ committees) participated in selecting and managing projects, and the Fund Board financed suitable projects. The SHD Project formed a new kind of user group known as the RRNI team, which dissolved after each subproject implementation. Intra-community coordination depended on social structure and social cohesiveness. In the terai, the level of trust among the communities was much lower than in the hills. As a result, more conflicts occurred in terai communities during project implementation. RRNI teams were new to the communities. The inhabitants viewed them with suspicion and feared they would steal the money that was allocated to the communities. The conflicts revolved around the targeting mechanisms and were also due to interference by the political parties. “There was some conflict, like why is it only focused on the poor people and not on the rich people. They are also pregnant, they are also the lactating mothers, but we tried and convinced them. The people from the party also created the conflict. They complained of selecting only some people; then we held a meeting calling the party representatives and ward citizen forum and convinced them that the program is for the targeted people, and the targeted people are not only the poor people.” – Coach, SHD “Objections do arise as there are several political parties involved. The parties complain that their people are not selected. The selection process is satisfactory; however, the polit- ical parties create problems if their people are not selected, which leads to shortcomings.” – VDC Official, SHD “It was difficult to convince the target group. This problem was much created by local political leaders. They have such a mentality that it [selection process] should be in their hands rather than in women’s. They were against this program because women were involved in it. Time and again they used to pressure the VDC.” – RRNI Team member, SHD 34 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL In contrast, the MOAD, which implemented the AFSP, received cooperation and coordi- nation from the MOH, and the relevant nutrition section of the MOH had the authority and resources to implement their share of activities. The MOH used its health facilities and human resources, including the FCHV, to implement nutrition-specific activities. The AFSP uses mothers groups’ forums and farmers groups’ forums to implement such activities at the community level. Those forums have existed for some time. The coordi- nation among the members of the groups was highly effective. Recommendations • To ensure effective collaboration with various sectors, a project or program should define upfront the shared responsibilities with clear provisions for authority and resources to execute those responsibilities. It is essential to give adequate authority and resources to different sectors if their input is required in certain nutrition in- terventions. Collaboration between sectors without empowering them with proper authority and the required resources does not produce the desired results. Results are better if sectors are tasked with responsibilities related to their own sectors and not otherwise, meaning nutrition interventions should be planned multisectorally but implemented sectorally. 3.4.4 Monitoring and Evaluation Monitoring nutrition interventions can be difficult without adequate human resource with optimal capacity. This study shows that various nutrition programs in Nepal have addressed human resources differently, indicating that monitoring in some programs was better than in others. Donor-financed and managed INGOs hired local NGOs to implement nutrition in- terventions for their programs. The Suaahara Project partnered with four INGOs and worked with 45 local NGOs. The project had a detailed annual implementation plan with fund flows and work plans that facilitated effective self-monitoring and reporting of the activities. Regular implementation support visits, including joint visits with gov- ernment’s relevant persons and feedback, also helped to solve problems. The project has a database of reporting mechanisms from the periphery to the center. The Suaahara Project manager hired International Food Policy Research Institute (IFPRI) to conduct baseline and end-line evaluations of the program. The MOAD implemented the AFSP and had active District Supporting Units as well as technical specialists. The ministry also contracted JTAs hired by NGOs, which were con- tracted by FAO, to monitor their project activities. Other supporting government agen- cies involved in AFSP, like the DFTQC and Nepal Agriculture Research Council, mon- itored their own activities and reported to the MOAD’s central project implementation unit. Approximately 450 additional staff were contracted for project implementation. In addition, Government staff were also involved in implementation. Joint supervision visits to the sites by the ministry were done together with the World Bank at least twice a year. AFSP staff worked on digitizing monitoring tools, but they are not yet quite oper- ational. The contracted NGOs paid lower level project staff inadequate salaries, leading to high staff turnover, which affected project implementation and monitoring. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 35 The World Bank is conducting a rigorous impact evaluation of the AFSP with a phased- in approach. Late starter VDCs waited two and a half years to participate in the project, which only lasted five years. The late starting VDCs acted as counterfactuals for the impact evaluation. There were field-level concerns as to why some VDCs were not in- cluded in the project. A midline survey had to be done before the late starter VDCs could be included in the project. Nonetheless, a delay in the MOH’s implementation of its nutrition component further delayed the project implementation with the late starting VDCs. The Government complained that the phased-in evaluation modality hampered disbursements and raised conflicts in the field since the beneficiaries were unaware of the evaluation design. Monitoring of The SHD Project appeared weak until the last year of the project. The project management team was composed of 4–5 government staff and three contracted staff at the central level, one of which one was a procurement specialist. The govern- ment staff was also involved in managing other projects. A civil servant in each district was designated as a focal person to help implement and monitor the project. However, the district focal person had many other responsibilities beside the SHD Project. Three NGOs hired to implement and monitor the project did not perform their duties as ex- pected. The project tried to digitize monitoring software, but it was not functional due to the lack of human resources. During the last year of the project, the ministry had an additional 35 contractual project staff, which strengthened the field-level monitoring and reporting. “...the structure in the district needs to look after a lot of projects simultaneously, moni- toring cannot be done, which you know. It is also weak from the monitoring aspect. We ex- pected the NSP to see all these [weaknesses] but the performance of the NSP wasn’t good.” The SHD Project also received a rigorous impact evaluation designed by the World Bank. It also had a phased-in approach with half of the project VDCs receiving benefits earlier (“early starters”) than the other half (“late starters”). The “late starters” VDCs were acting as counterfactuals for two and half years without the project. The concerns were similar to those of the AFSP as explained above. This research study shows that unless everyone involved in implementing the project is accountable for their areas of responsibilities and systematically monitoring outcomes, the project may not achieve its intended objectives. The Suaahara Project has established a dashboard to monitor every activity based on the annual work plan, and supervisors are actively engaged in monitoring. This monitoring system seems to work very well for timely implementation and response to issues. While rigorous impact evaluation is necessary to generate data, this should be done without compromising project implementation and making beneficiaries wait for ex- tended periods to be included during a five-year project while data is gathered. Project implementers and beneficiaries complained about the implementation delays for the SHD Project and the AFSP. 36 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Recommendations • Each sector should have adequate human resources and relevant technical expertise to design and implement effective monitoring and evaluation systems. If the neces- sary capacity does not exist, adequate services should be procured as soon as possi- ble. Annual work plans should be detailed and implementation should be regularly monitored to reflect progress and achievements on a dashboard for everyone to see. This ensures transparency, accountability, and early identification of issues for the management team to act on in a timely manner. • If implementation and monitoring functions are outsourced to nongovernment part- ners, whether NGOs or private firms, their accountability can be ensured by paying for verified results. • While rigorous impact evaluation is necessary to generate evidence, this should be done without compromising project implementation and making beneficiaries wait to be included in the project while data is gathered. 3.4.5 Institutional Arrangement Framework The table below provides an assessment of four different types of possible institutional arrangements, combining the operational aspects of implementing and financing nutri- tion interventions. Technical Financing Implementation Interventions Management Arrangement 1 One Project, Single Agency, Single Agency Pros Cons Multiple centrally (with local Financial Coordination Interventions financed coordination) management difficulty with project and reporting is different local- Example: less dependent line agencies at • MOFALD implemented SHD Project with 15 different on efficiency of the community interventions. other actors since level due to • MOFALD received budget from MOF and was accountability low incentives responsible for project’s technical and financial rests with including lack management. one single of authority • MOFALD implemented the project through its own implementing for resource local bodies, DDCs and VDCs, with the help of its agency. However, management grassroots’ platforms like ward citizen’s forums and the local bodies of citizen awareness centers. New community groups the implementing Technical quality were created to do projects around 15 areas. Funds were agency have to of interventions made available to the community groups. cooperate in the is compromised • Technical coordination anticipated with other line- entire process. due to lack of agencies. Locally, other agencies are consulted or sought cooperation as per need, e.g., coach and community groups seek from local line support from agriculture and livestock JTA or FCHV, agencies DHO, DADO, DLO. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 37 2 One Project, Multiple, Multiple Pros Cons Multiple centrally Agencies Individual line Financial Interventions financed (through local- agencies should management can project level units) supposedly be be challenging Example: well equipped when transfers • MOFALD and MOH implements Multi Sector Nutrition to implement happen to Plan, which has different sectoral interventions. activities related to different local • MOFALD and MOH receive budget from MOF and their own sector. agencies. are responsible for project’s technical and financial management. Technical quality Harmonization of • MOFALD transfers funds to its local bodies (DDCs) may be better activities might to use for their own local plans and through its local as individual be difficult at bodies to other local line agencies, except health sector, ministries and the community and helps to implement the district nutrition plans. agencies are doing level if one • MOH implements district plans through its local health what they are agency’s activity facilities. supposed to do is dependent on the other 3 One Project, Single Central Multiple Pros Cons Multiple agency, Agencies • Project man- One agency Interventions centrally (through local- agement which is financed, level units) accountability responsible but does rests on one for overall MOU with single agency management other central • Individual is always at agencies for line agencies risk if the other fund transfers should sup- agencies do Example: posedly be not cooperate • MOAD implements AFSP, which has both nutrition well equipped and coordinate specific and nutrition sensitive interventions. to implement properly • MOAD receives budget from MOF and is responsible activities relat- for entire project’s financial and technical management. ed to their own • MOAD does MOU with MOH for certain nutrition-spe- sector cific interventions and correspondingly transfers funds. • Technical • MOAD and MOH through their local units implement quality may their activities as laid down in the project. be better as individual ministries and agencies are doing what they are sup- posed to do 38 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 4 Multiple Projects, Multiple Multiple Pros Cons Multiple Agencies, Agencies Advantages of Easier to manage Interventions centrally (through local- individual complementarity financed level units) activities brought in by • MOH runs community management of Acute Malnu- package of trition; MOAD runs village model farm and homestead Technical interventions garden for diet diversity, or livelihood program. quality is better during the same • MOWSS runs a rural water supply program. as individual time frame in a • MOWCSW runs women’s empowerment and child ministries and locality is lost protection program. agencies are doing as different • MOE runs parental education and the school’s nutrition what they are interventions curriculum program, and the mid-day meal. supposed to do might come at • MOFALD runs cash or food transfer. different times of the year 4. Conclusion M alnutrition has multiple causes and requires multisectoral efforts to reduce it. To achieve the Sustainable Development Goal (SDG) of ending all forms of malnutrition by 2030—and in the context of scarce resources—due consider- ation should be given to the following: • Designing contextual interventions with matched supply-side and demand-side activities: It is important to thoroughly assess the demand-side considering com- munities’ level of awareness of food and nutrition situation and the cultural context. This might entail formative research in the geographical area of intervention. Sec- ond, the constraints and prospects also need be assessed from the perspective of sys- tems, markets and political environment to understand the supply-side readiness. Then one should design the best possible intervention which adequately matches the nutrition response to the demand of the communities. • Targeting methods: For geographical targeting, one should use all the available in- formation to select appropriate locations. For the ease of administration and avoiding conflicts, one needs to consider adopting a district-wide (or local government-wide) approach rather than only selecting some villages/areas within those administrative units. In the communities, to avoid resistance from rich and high caste people, espe- cially if there are in-kind or cash transfers, one might consider providing benefits to all beneficiaries irrespective of their economic or caste status. • Ensuring adequate financial compliance: One should consider minimizing the layers of approval mechanisms and fund flow to avoid rent seeking behavior. For community-driven projects, maintaining accounts with receipts and vouchers by the communities as per government norms might not be feasible given their limited capacity. However, communities can be made accountable by paying for verified results. • Financing modalities: One should consider various options-input versus re- sults-based, conditional versus unconditional transfers and in-kind transfers-de- pending on the type of interventions and the target groups. Due consideration STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 39 40 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL should be given to the capacity of the implementing agency and the existing ac- countability mechanism when selecting a financial modality to ensure that money is used for the purpose intended. • Capacity and resource needs of the implementing agencies: It is important to pro- vide adequate authority and resources to the sectoral agencies to implement activi- ties. If adequate resources are given to all the sectoral agencies as well as the author- ity, they are likely to cooperate and collaborate for producing a convergence effect (i.e. concentrating different kinds of support in a particular area). Nongovernment partners play an invaluable role by supporting the Government in program imple- mentation, supervision, and monitoring, and by bringing in the technical knowl- edge to reduce malnutrition in the country. Accountability for the proper use of funds can be ensured by having a system to design and track work plans with a mix of input-based and performance-based (results-based) financing. • Sectoral implementation: One should ensure that the sectors implement activities only for which they have a comparative advantage. By being engaged in such activ- ities in the past, respective sectors would have the required capacity to implement the interventions. For instance, the Ministry of Health is best at promoting breast- feeding and complementary feeding, and the Ministry of Agriculture has an ad- vantage in promoting homestead kitchen gardens. Whereas the Ministry of Federal Affairs and Local Development could best implement cash and in-kind transfers for food security and nutrition improvement. 5. Bibliography Adhikari, J. (2008). Food Crisis in Karnali. A Historical and Political-economic Perspective. Martin Chautari. Alderman, Harold; Behrman, Jere R.. 2006. “Reducing the incidence of low birth weight in low-income countries has substantial economic benefits”. The World Bank re- search observer. -- Vol. 21, no. 1 (Spring 2006), pp. 25-48. http://documents.world- bank.org/curated/en/348621468154166798/Reducing-the-incidence-of-low-birth- weight-in-low-income-countries-has-substantial-economic-benefits Caulfield, Laura E., Victoria Elliot, Program in Human Nutrition, the Johns Hopkins Bloomberg School of Public Health, for SPRING. 2015. Nutrition of Adolescent Girls and Women of Reproductive Age in Low- and Middle-Income Countries: Current Context and Scientific Basis for Moving Forward. Arlington, VA: Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project. Central Bureau of Statistics, National Planning Commission, World Food Program, World Bank, AusAID and UNICEF, Nepal. (2013). Thematic Report Food Security and Nutrition. Nepal Living Standard Survey III. Jef L. Leroy , Marie Ruel & Ellen Verhofstadt (2009). The impact of conditional cash transfer programmes on child nutrition: a review of evidence using a programme theory framework, Journal of Development Effectiveness, 1:2, 103-129, DOI: 10.1080/19439340902924043 Levere, Michael Benjamin; Acharya, Gayatri; Bharadwaj, Prashant. 2016. The role of information and cash transfers on early childhood development : evidence from Nepal. Policy Research working paper; no. WPS 7931; Impact Evaluation series. Wash- ington, D.C. : World Bank Group. http://documents.worldbank.org/curated/ en/788751483028902307/The-role-of-information-and-cash-transfers-on-early- childhood-development-evidence-from-Nepal Levinson, F. James, and Yarlini Balarajan, ‘Addressing Malnutrition Multisectorally: What have we learned from recent international experience?’, UNICEF Nutrition Working Paper, UNICEF and MDG Achievement Fund, New York, August 2013. Marie M. Gaarder, Amanda Glassman and Jessica E. Todd (2010). Conditional cash transfers and health: unpacking the casual chain. Journal of Development Effectiveness, 2(1), 6-50. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 41 42 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. (2012). Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Minis- try of Health and Population, New ERA, and ICF International, Calverton, Mary- land. Retrieved March 13, 2017, from http://dhsprogram.com/pubs/pdf/FR257/ FR257[13April2012].pdf Ministry of Health and Population (MOHP) [Nepal], New ERA, and Macro Internation- al Inc. (2007). Nepal Demographic and Health Survey 2006. Kathmandu, Nepal: Min- istry of Health and Population, New ERA, and Macro International Inc. Retrieved March 13, 2017, from http://dhsprogram.com/pubs/pdf/FR191/FR191.pdf Ministry of Health, Nepal; New ERA; and ICF. (2017). Nepal Demographic and Health Sur- vey 2016: Key Indicators. Kathmandu, Nepal: Ministry of Health. Retrieved July 10, 2017, from http://pdf.usaid.gov/pdf_docs/PBAAF667.pdf UNICEF. (2013). Country Program Action Plan 2013–2017. Nepal. UNICEF. (2016). Policy Brief. Benefits of Nepal’s Child Grant for current and future generations. World Bank. (2010). Project Appraisal Document. The Social Safety Nets Project, Nepal (Ad- ditional Financing). World Bank. (2011). Nutrition in Nepal: A National Development Priority. The World Bank. Retrieved July 10, 2017, from http://documents.worldbank.org/curated/ en/635951468124159285/pdf/683780WP0P1235000Nutrition0in0Nepal.pdf World Bank. (2012). Project Appraisal Document. Sunaula Hazar Din – Community Action for Nutrition Project Nepal. World Bank. (2013). Project Appraisal Document. Nepal Agriculture and Food Security Project. World Bank. (2014). Project Appraisal Document. Rural Water Supply and Sanitation Project. World Bank. (2015). 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Annexes Annex 1- Tables Table 1: Nutritional Status and Poverty in Different Regions of Nepal 2001, 2006, and 2011 and 2016 Stunting (percent) of Underweight (percent) Wasting (percent) of Poverty Group/Region under 5 children of under 5 children under 5 children rate 2011 2001 2006 2011 2016 2001 2006 2011 2016 2001 2006 2011 2016 Nepal 57 49.3 40.5 35.8 43 38.6 31.1 27 11 12.6 13.7 10 25.16 Urban 36.8 36.1 28 32 33.5 23.1 18.9 23 7.8 7.5 11.0 9 15.46 Rural 52.2 51.1 44 40 46.7 40.7 33.1 31 9.8 13.3 14.2 10 27.43 Ecological Regions Mountain 61.4 62.3 56 47 45.1 42.4 37.3 28 5.3 9.4 9.0 6 42.27 Hill 52.4 50.3 42 32 41.4 33.2 25.2 18 5.9 8.4 6.9 6 24.32 Terai 47.3 46.3 39 37 48.4 42.3 35.2 32 13.3 16.6 20.4 12 23.44 Development Regions Eastern 47.6 40.3 40 33 43.4 32.9 26.9 26 9.1 10.1 13.1 13 21.44 Central 50.0 50.0 38 35 44.7 38.2 33.3 28 10.8 13.8 16.8 10 21.69 Western 50.1 50.4 40 37 43.4 38.5 27.2 23 8.9 10.9 10.9 6 22.25 Mid-western 53.9 57.9 51 42 49.0 43.3 36.3 29 8.8 11.6 12.0 9 31.68 Far-western 54.0 52.5 41 36 48.9 43.7 30.5 28 8.8 16.7 12.2 9 45.61 Source: CBS, WFP, WB. 2006. Small Area Estimates of Poverty, Calorie Intake and Malnutrition in Nepal. Kathmandu: CBS/WFP/WB. USAID, New Era, MoHP, 2007. Nepal. Demographic and Health Survey, 2006. Kathmandu. CBS, 2012. NLSS III Survey Report. Kathmandu. CBS, 2012 Poverty in Nepal. Table 2: Food Shortages Reported by Households in Nepal Living Standard Survey 2010 1995-96 2003-04 2010-11 percent households reporting less than adequate consumption of food 50.9 31.2 15.7 percent households reporting food shortages at any time during the last 30 days NA NA 7.5 met the food shortages by ( percent household reporting) Borrowing food or money 68.4 Purchase food on credit 57.1 Eating less expensive food 50.9 Eating less for each meal 41.5 Skipping meals 33.4 Source: CBS. 2012. NLSS III. Kathmandu 100. STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 43 44 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Table 3: Sampled Projects and Sample Size by Study Instruments Used for Data Collection Project Associated Agency Sample size by Study Instruments National District VDC IDI Comm IDI IDI FGD Sunaula Hazar Din or World Bank; Ministry of Federal 3 3 6 6 Golden Thousand Days Affairs and Local Development Project Nepal Agriculture and Food World Bank; Ministry of 3 3 4 6 Security Project (NAFSP) Agriculture Development UNICEF support (MSNP – UNICEF 1 1 4 2 nutrition interventions) Feed the Future KISAN USAID, Winrock International 1 1 2 1 Suaahara Project USAID, HKI 2 3 4 2 SABAL Project USAID 1 - - - Nutrition-focused National Planning Commission 1 - - - secretariat (NPC) Nutrition policy and Child Health Division 2 - - - programs of Ministry of Health Total 14 11 20 17 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 45 Annex 2- Technical Approaches Step 1: Identify key risk factors and interventions Identify Key Risk Factors of Malnutrition to be Addressed To address key risk factors associated with malnutrition, Nepal has implemented a range of technical interven- tions in its nutrition and food security (NFS) programs. While there is limited evidence to rank risk factors based on their causal links to malnutrition, a comprehensive strategy against malnutrition must consider all risk factors and employ interventions to reduce some of the fundamental issues affecting malnutrition in Nepal. Fundamental Issues and Risk Factors Menu of Standard Interventions Inadequate diet of women and children • Improve dietary intake, 4–5 meals per day with protein during the “golden 1,000 days.” for pregnant and lactating mothers. The first set of challenges in reducing • Encourage exclusive and proper breastfeeding malnutrition is ensuring an adequate diet for • Maintain adequate weight of pregnant women and moth- pregnant women, and children under two ers and their mothers, which requires that the • Reduce excessive energy expenditure and workload of standard interventions are incorporated in pregnant women the activities. • Homestead food production of vegetables and fruits in kitchen gardens Early pregnancy and low empowerment of • Delay marriage and pregnancy of adolescent girls women. • Increase years of schooling for girls Some traditional beliefs and practices • Raise awareness about number and spacing of children in Nepal promote early marriage and • Empower women economically and in intra-household pregnancy, which can increase the risks decision-making for mother and child. To discourage household or societal-level risk factors, some technical interventions targeted towards empowerment of women are listed. Lack of clean, sanitary and hygienic • Use of safe and clean water environment. • End open defecation The third set of issues consist of community- • Handwashing practices and habits level risk factors, which can only be • Sanitation in schools and other public spaces addressed through community-wide • Reducing indoor smoke and air pollution interventions, such as those listed. Limited availability and utilization of • Vaccination of children preventive and curative health services. • Use of contraception The fourth set of issues must be addressed • Intake of micronutrients, including iron-folic acid (IFA) in collaboration with existing health and deworming medicines infrastructure and services, particularly • Timely seeking of health services to ensure health services that promote the • Service provision for and timely treatment of acute malnutri- following. tion 46 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL Identify Interventions Nutrition-Specific and Nutrition-Sensitive Interventions To address the above-mentioned risk factors for malnutrition, various projects have applied a range of interven- tions, which are either nutrition specific or nutrition sensitive as presented in the table below. Nutrition Specific Nutrition Sensitive • Micronutrient supplementation, i.e., vita- • Boost agriculture production by using improved mins, iron-folic acid tablets for mothers seeds and other technology • Therapeutic / supplementary feeding, i.e., • Bio-fortification of staple food such as wheat and ready-to-use therapeutic food rice • Optimum breastfeeding and responsive • Market-side interventions to lower prices feeding practices and simulation • Support livelihoods to increase income and • School meals, i.e., nutrition-enriched school purchasing power lunch • Cash or food transfers to support adequate dietary • Food fortification, e.g., addition of calcium intake—conditional or unconditional and vitamin in generally consumed food, • Support diet diversity such as biscuits; home fortification of food • Proper schooling, nutrition curriculum, early with multiple micronutrient powder childhood development • Provision of food and nutrition during • Timely treatment seeking and provision of emergency, e.g., in-kind distribution of services for adolescent and reproductive health food during periods of food insecurity • Women’s empowerment • WASH—provision of safe water, sanitation, and hygiene of households and communities STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL 47 48 STUDY OF OPERATIONAL STRATEGIES TO REDUCE MALNUTRITION IN NEPAL The World Bank Group Nepal Office P.O. Box 798 Yak and Yeti Hotel Complex Durbar Marg, Kathmandu, Nepal Tel.: 4236000 Fax: 4225112 Email: infonepal@worldbank.org www.worldbank.org/np www.facebook.com/WorldBankNepal