The number of children in Nepal with acute malnutrition hovers near emergency levels, something that has not changed even after 15 years of efforts and millions of dollars invested, say local and international nutrition experts.
“The prevalence was the same in 1996. If we look at the number of children affected, the situation has even deteriorated due to the population increase,” said Nicolas Oberlin, deputy country director of UN’s World Food Programme (WFP).
Levels of wasting - acute malnutrition, or low weight-to-height ratio - hardly changed from 2006 to 2011, according to the Nepal Demographic and Health Survey 2011 (DHS).
Any global acute malnutrition rate- comprising both moderate and severe acute malnutrition-exceeding 10 percent is considered a nutrition emergency, according to medical experts. As of 2011, the Department of Health (DOH) estimated wasting affected nearly 11 percent of children under five years old, or 385,000 children. Some 2.6 percent of all under-fives – 91,000 – had severe acute malnutrition.
In Nepal, malnutrition plays a role in 60 percent of child deaths, according to UN Children’s Fund (UNICEF).
“We are concerned about making more children vulnerable if we don’t act fast,” Raj Kumar Pokharel, chief of the DOH nutrition section, told IRIN, acknowledging that the government, until now, has not paid enough attention.
While most children with wasting are in the remote hills of Midwest and Far West regions, considered the poorest areas nationwide, severe acute malnutrition, the situation is worse in the southern fertile plains bordering India, known as the western Terai. There, more than 15 percent of children are estimated to be acutely malnourished due to poor sanitation, contaminated water and water-borne disease outbreaks during monsoons, according to the government.
In addition, the rate of stunting (low height-for-age, also known as chronic malnutrition) in Nepal is among the world’s highest; UNICEF reported this year that Nepal has the sixth worst rate of stunting - 49 percent - among all countries that provided data.
Below, IRIN explores five reasons experts have identified as the main culprits behind Nepal’s stubbornly high malnutrition rates.
Acute respiratory infections and diarrhoea, Nepal’s leading causes of deaths among children under age five, are linked to acute malnutrition, according to the Ministry of Health and Population. Diarrhoea depletes children of critical nutrients and makes them more vulnerable to infection; infections, in turn, worsen their nutritional status.
In 2011, there were 2.7 million cases of acute respiratory infection reported to the government. Of the 1.7 million reported cases of diarrhoea, only 38 percent of the children saw a healthcare provider.
Of those who sought healthcare, half were treated with oral rehydration salts (ORS). In 2012, an independent evaluation of Nepal’s health system noted that zinc, recommended by the World Health Organization for diarrhoea treatment in conjunction with ORS and proven to cut diarrhoea-related deaths by some 40 percent, was not widely distributed.
More than three million of the country’s 30.4 million people do not have access to safe drinking water despite the country’s abundant fresh water resources. Nearly 19 million do not have access to “improved sanitation”-public standpipes, covered wells or springs, piped household connections or boreholes -according to the local NGO Forum for Water and Sanitation.
“A big cause of malnutrition is our poor health environment due to the poor hygiene practices, poor sanitation and…poor living conditions,” said nutrition expert Som Paneru, president of the Nepal Youth Foundation, which runs nutrition treatment centres nationwide.
Poor access to safe drinking water and sanitation facilities are associated with skin and diarrhoeal diseases, as well as acute respiratory infection.
Poor early childcare practices
“The critical period [for a child] is during the 1,000 days from pregnancy up to two years of age. Whatever damage is done to physical growth and brain development during the period is very difficult to reverse,” said Saba Mebrahtu, chief of UNICEF’s nutrition section in Nepal.
“Childcare practices are really poor, and usually we find that babies are not fed nutritious food, especially after six months,” explained government official Pokharel.
Breastfeeding within the first hour after birth and exclusive breastfeeding for the first six months can strengthen a child’s immune system for years. But only around half of babies are breastfed within the first hour -51 percent in urban areas and 44 percent in rural areas, according to the 2011 DHS. Fortunately, exclusive breastfeeding rates are improving - now 70 percent, up from 53 percent in 2006.
Still, mothers of malnourished children lack proper healthcare before and after birth. “Most of the time, they are expected to get back to household chores like working in the farm and the kitchen just a few days after delivery, and it affects the mother’s health and nutrition,” he added.
While 88 percent of urban mothers received antenatal care from a skilled provider, only 55 percent of rural mothers did so, according to the DHS. Additionally, some 23 percent of mothers nationwide gave birth before age 18.
Poor agriculture investments
A key challenge in fighting acute malnutrition is simultaneously addressing its many causes, said WFP’s Oberlin.
“Some of these factors weigh more heavily in certain geographic areas, or within certain social categories. For instance, food insecurity in remote areas is a serious contributing factor, where unavailability and lack of access to food, combined with poverty, have a dramatic impact on nutrition,” he added.
A quarter of the population lives under the national poverty line, and nearly 3.5 million people have difficulty getting nutritious foods, according to WFP.
“A lot of investment is needed now in the agricultural sector, but, unfortunately, the investment and funding by both the government and aid agencies have reduced a lot,” said Pitamber Acharya, director of Development Project Service Centre, a local NGO working on agriculture and food security.
According to the Ministry of Agriculture and Development, donor support to agriculture declined from 2002-2006. Overall government spending has more than doubled since 2006, but spending on agriculture has remained unchanged.
Until now, the central government has relegated malnutrition issues to a four-person nutrition unit, led by DOH’s Pokharel. The unit ranks low within health ministry’s hierarchy.
“The way that the nutrition section has not been given prominence shows the government’s negligence over the past years, and the small team is actually doing [its] best to reduce malnutrition. But that is really a herculean task for them to cover the whole nation,” said Paneru from the Nepal Youth Foundation.
Still emerging from a decade-long civil conflict that killed an estimated 18,000 civilians, the country has been without local government since 1997, leaving nearly 4,000 “village development committees” with only one person, appointed by the national government, to keep basic services going.
A new constitution that would lead to local elections has yet to be approved. Promised in 2010, draft approval has been delayed four times, most recently on 27 May.
Ongoing political squabbling also delayed the new fiscal budget by eight months, which held up money needed for development, said Chandan Sapkota, an economist at the South Asia Watch on Trade, Economics and Environment office in the capital, Kathmandu.
But agencies and the health workers are still hopeful. The government launched its first inter-ministerial national nutrition plan on 20 September. Donors have pledged close to 60 percent of the plan’s US$150 million 2014-2017 budget, while the government has set aside near $12 million for 2012-2013 nutrition interventions.
The National Planning Commission will monitor spending for the new nutrition plan, which is expected to create a national centre for nutrition and a “food security secretariat”.
DOH’s nutrition team anticipates this will translate into improved nutrition and has proposed hiring 35 staff for the national centre, nutrition supervisors for all of the country’s 75 districts, and nutrition officers for each of the five regional health offices.
“We have, however, yet to see how things will shape up,” said Pokharel, referring to the ongoing political deadlock.