Profiles in Nutrition: Suaahara II’s Pooja Pandey Rana

In 1995, Nepal had the highest rate of stunting prevalence in the world at 68%, due to extreme poverty and poor health, education, and sanitation systems. At the time, more than 2 million children in the country were stunted.

In the decades that followed, however, Nepal's governments undertook a series of sweeping reforms, including adopting a pro-poor outlook and investing heavily in health, education, and sanitation with the help of donors and international NGOs. The governments also decentralized power to local authorities over an extended period, which helped improve access to health care and other services for an exceedingly diverse population living in difficult terrain. Meanwhile, many Nepalese men had started migrated to Gulf countries and India for work and were sending back remittances, which helped relieve much of the extreme poverty.

By 2016, the Himalayan country's stunting rate had fallen by almost half to 36% despite several volatile periods, including a violent Maoist insurgency between 1996 and 2006 and major political instability between 2006 and 2015. The country's stunting rate continues to drop and now hovers around 32%.

Pooja Pandey Rana, who is Chief of Party of the USAID-funded Suaahara project implemented by Helen Keller International in Nepal and formerly Deputy Chief of Party and Director of Programs at Helen Keller International-Nepal, has been at the forefront of this dramatic improvement in the health of Nepal's children.

The Suaahara project – now in its second five-year phase – aims to improve the nutritional status of women and children within the 1,000 days from conception until the child reaches 24 months of age, in 42 underserved rural districts of Nepal. Suaahara II covers about half of Nepal’s population, reaching over two million children under five years, pregnant women, and breastfeeding mothers with a comprehensive, home-based program.

As part of a series highlighting people working to improve nutrition around the world to mark the 2023 Micronutrient Forum Global Conference, being held Oct. 16-20 in The Hague under the theme Nutrition for Resilience, Exemplars News spoke with Rana about the Suaahara II project and what lessons Nepal has to share with the other countries.

First, tell me a bit about your own journey. How did you come to focus on nutrition and why are undernutrition and stunting so important to you?

Rana: My nutrition journey started when I joined a local Nepali NGO in the late 1990s. As part of my work, I had to travel to some of the most remote parts of Nepal to do community-based nutrition surveys. I was a city girl and quickly realized that parts of Nepal were very different from where I grew up – and how much I had to learn.

While conducting community nutrition surveys, we found high rates of malnutrition. I saw many people die of very preventable diseases like diarrhea (and) pneumonia. It made me realize the scale and impact of malnutrition. I also realized that many nutrition interventions are very cost-effective. For the price of a cup of coffee, you can give vitamin capsules to hundreds of children. I learned that solutions existed – we just had to take these solutions to the communities. That motivated me to really get into the delivery and implementation aspect of nutrition programming.

Could you tell us more about the Suaahara II project and what you're doing to improve the health and nutritional status of women and children?

Rana: Suaahara translates into English as 'good nutrition.' It's a large-scale, multisector nutrition project that covers almost 60% of the country and targets marginalized communities, covering almost 2.2 million Nepali households.

What's unique about the project is the integrated approach, which includes the prevention and treatment of malnutrition, family planning, water and sanitation, and agriculture interventions for insecure communities. The other key approach for Suaahara is behavior change and gender and social inclusion – marginalized groups also get additional support on income generation, livelihoods, community mobilization, and women's empowerment.

We've partnered with more than 45 local NGOs across Nepal and have been working in 42 out of 77 districts since 2016. We're now in our second phase, which is being led by Helen Keller International, building on the multisector nutrition program of the first phase, which was led by Save the Children.

I also think the Suaahara project is unique in the sense that our programming approach is grounded on evidence. How do we adapt scientific intervention at community level and take it to scale? There's a strong learning component which has really helped us generate data on different implementation pathways. Why does this approach work? Why doesn't this work? How can we improve and also adapt the program to different programming contexts? Suaahara I looks different from Suaahara II, and I think given Nepal's change in political structure, federalism, COVID (and) the Ukraine war, the program has adapted well to new contexts.

Suaahara has shown that large‐scale integrated nutrition interventions can successfully influence nutrition‐ related knowledge and practices while simultaneously reducing inequities. Could you tell us more about how it has helped reduce Nepal's equity gap?

Rana: We've taken a very integrated approach and looked at the drivers of malnutrition within marginalized communities, including food and health care, and taken a tailored and targeted household approach. We recently completed an independent evaluation and the data shows that the project has improved multiple nutrition and health indicators and has closed the equity gaps as well, whether it's improving maternal and child diets or health-seeking behaviors. I think this targeted, nuanced, and integrated approach has worked.

For example, as part of our targeted approach we make sure frontline workers are from the same communities, and about 80% of these frontline workers are women. We do community mapping and wellbeing rankings to identify marginalized groups in the community, which could mean rich and poor, but it could also be marginalized based on caste systems. Nepal has a really strong caste system – there's so-called high caste and low caste. If you belong to a certain ethnic group or caste group, you are disadvantaged in so many ways. And once we identify them, they receive very targeted and tailored intervention packages based on the barriers they face.

The other thing we do is try to link marginalized households to the government's existing social protection programs. There were cash grants, but many people don't know about them. There was a lack of public awareness of their rights, as well. We've also looked at where they were going for healthcare-seeking behavior and asked ourselves – how can we bring the outreach clinics to their communities?

The other thing we did was use multiple platforms to reach marginalized households. We looked not only at interpersonal communication, but also mass media, because in Nepal almost 75% of households have access to smartphones and radio. So, we use these different technologies to reach them. We also have toll-free numbers they can call for one-on-one counseling.

It seems that nutrition-related projects such as Suaahara had a protective effect following the earthquake in Nepal in 2015. How do you build nutritional resilience?

Rana: During Suaahara's phase one, because of the earthquake, we had to drop our formal impact evaluation. In the current phase, COVID happened, but we still did an impact evaluation. We saw that whether it was an earthquake or COVID, the program did play a protective role.

I think one of the key reasons for that is the knowledge and skills the program has provided to participants. We did a lot of interventions to build marginalized groups' self-efficacy and self-confidence to raise their voice. They are now gender champions and social inclusion champions at the community level and actually go negotiate with local leaders such as mayors and deputy mayors. I think that's really helped increase their confidence to ask the local government for their rights.

Another way the program has improved resilience is that it's given smallholder farmers from really marginalized communities access to insurance schemes, including poverty insurance and crop insurance. Saving and credit groups were also formed, so they have emergency funds for rainy days. For instance, we work with almost 30,000 women's groups across the program area, and they all have savings and credit. I think that's been one of the key success factors.

You've said that one reason for Nepal's successes in nutrition and health has been the 'sense of sisterhood' and female community health volunteers. Could you tell us more about that?

Rana: If you're a woman in Nepal there are sheer logistic challenges to running a household, especially in the hills and mountains. For example, getting your water, getting your firewood, all that. It's a huge task. With male migration increasing in Nepal, almost 60% of the men are away. That's just the formal records. We also share an open border with India and we don't even know how many men are in India. The women are left on their own to take care of the families, so you have to create your own social support system.

The good thing is the men are sending remittances to the women. I think this has really empowered them to invest in things that work for them. Over the past 20 years, women have really organized themselves. They're part of different formal networks and groups, but also informal women's groups. They have their own savings and credit accounts. A lot of women now are in the running for local elections. They've figured out how to manage their homes, but also be financially empowered.

Because of our Hinduism and Buddhism, the culture also encourages you to do something for your community. Volunteerism is high in Nepal. When you talk about the 60,000 female community health volunteers across the country, they've been the backbone of Nepal's public health system since the late 1980s. They provide almost 15 preventive services, whether it's immunization or vitamin A distribution, or identifying malnourished children or pregnant women, or referring them for health care.

Despite rapid progress, millions of Nepalese remain undernourished. What do you think needs to be done to sustain the country’s progress?

Rana: We just finished a demographic health survey – a national survey that's done every five years – and what is really obvious is that if Nepal really wants to reduce malnutrition, we have to focus on the vulnerable groups. For example, it shows that you are marginalized based on where you live. Nepal has seven provinces and there is one province where the malnutrition rate is more than the WHO standard. There's another province where almost 70% of the households can't access a minimum affordable diet.

Because of this, I think we need a contextualized approach looking at geography, looking at your agro-ecological zones, looking at your equity quintile, and really focus on reducing the equity gap. Then linking those groups with social protection programs, social safety, and other programs to address underlying determinants of malnutrition.

The other thing I think Nepal needs to do is better implementation. We have a great policy environment, but we need to really focus on improving implementation rigor. We're seeing that breastfeeding rates are going down. We do have a lot of acts to support breastfeeding mothers, but they're not being implemented well. Service providers and the government should be more accountable. We need a results-based accountability framework. Somehow different ministries should be accountable for different indicators, and I think we need to do a better job of doing those assessments.

The other thing we're seeing is the double burden of malnutrition with rapid urbanization. Even though the poorest households are buying food from the market, we find that almost 80% of under-two children are already exposed to high- sugar, high-salt, high-fat foods because these foods are cheap and accessible. I think Nepal needs to look at the drivers of food choices and how we can make nutritious food more affordable.

What nutrition lessons from Nepal do you think should be shared with other countries?

Rana: When I think of Nepal, I think of the strong community-based networks. Despite COVID, the Ukraine war, and the earthquake, women's groups, the community health volunteers, all helped create a strong foundation at the community level. Once you have a strong foundation, you can deliver a lot of other interventions and services. The other thing that Nepal has done really well is look at evidence from the beginning. 'Where is the evidence for this intervention and how can we scale up?' has always been the top priority for the government. The government also didn't just scale up everything at once but took a very systematic phased approach. When you talk about vitamin A programs or antenatal care, it was very much, 'Let's start with five or 10 districts, learn from it, keep refining it.' Adaptive management has been part of the implementation culture, which I think really helped to refine national programs.

Another thing is the really good policy environment – we have a really progressive, decentralized structure now. Local governments have a lot of power and resources and, if they work well, you can really transform your community.

And the last thing has been keeping people and community at the center of everything.