Stunting reduction in Nepal
Nepal reduced its stunting prevalence from nearly 70 percent to 36 percent over the last twenty years
In 1995, Nepal recorded a stunting rate of 68 percent, the highest in the world. This amounted to more than 2 million stunted children. By 2016, the rate had been cut almost in half, to 36 percent.
In the two decades that followed, however, Nepal made improvements across the board. Nepal, whose government shifted considerably toward pro-poor policymaking after 1990, invested heavily in its health and education systems and scaled up sanitation-related behavior change campaigns across the country. In concert with a steadily improving economic situation, these broad-based government efforts to reach more people with basic services cut the number of stunted children in Nepal in half in 20 years.
Investment in health infrastructure
Since the mid-1990s, health care spending in Nepal increased dramatically, leading to construction of health facilities, development of a nationwide community health worker cadre, and training of health workers.
Following the 1991 National Health Policy, Nepal, with support from donors, built thousands of health facilities, trained tens of thousands of health workers, and implemented evidence-based practices to address important priorities like maternal and child health. This led to improved health-seeking behavior among Nepalis, especially mothers, who received more skilled care during pregnancy and delivery and adopted new child care and feeding practices, ultimately resulting in lower rates of stunting.
Overall, health expenditure per capita more than doubled, from $64 in 2000 to $160 in 2015, but it is important to note that less than a quarter of that amount is spent by the government. After two decades of investments in the health system and evidence-based health programs, the health situation in Nepal had improved significantly. Stunting, of course, was down by 47 percent since 1995, child mortality rate was down by 70 percent and maternal mortality was down by 61 percent.
Investment in education infrastructure
Nationwide education programs significantly increased enrollment in primary and secondary school, particularly for girls and other disadvantaged groups.
In 1990, primary school enrollment in Nepal was less than 70 percent, and the youth literacy rate was under 50 percent; for girls, it was just 33 percent.
The Nepali government responded with a string of policies to decentralize and improve education. Beginning with the Basic Primary Education Program (BPEP) in 1992, donors and the government built new facilities, enrolled more than a million more children in primary school, achieved gender parity in primary enrollment and close to parity in secondary completion, and boosted literacy among all groups.
As of 2016, primary enrollment was at 97 percent and secondary enrollment at 55 percent. Furthermore, the gender parity index for primary school (the ratio of girls to boys) jumped from 0.45 in 1985 to 1.08 in 2016. Since many of these improvements, affected children who have yet to become parents, it is likely that we will continue to see the impact of these investments on stunting.
Sanitation-related behavior change
Community-Led Total Sanitation improved upon previous supply-oriented interventions to substantially decrease open defecation and disease transmission.
Improvements in sanitation address the burden of diseases like diarrhea and pneumonia that stunt children’s growth. Adapting Community-Led Total Sanitation (CLTS), an NGO-led method of generating demand for sanitation (instead of creating supply), Nepal has transitioned just since the turn of the millennium from three quarters of its people defecating outside to three quarters of its people using toilets. Partly as a result, diarrhea incidence declined from 20 to eight percent and acute respiratory infection incidence from 23 to two percent between 2001 and 2016.
In 2011, the government developed a National Sanitation and Hygiene Master Plan, which goes further than CLTS and adopts an approach known as Community‐Led Total Behavior Change in Hygiene and Sanitation or Total Behavior Change (TBC). TBC commits to the major tenets of CLTS but is different in some specifics, based on Nepal’s needs; it offers subsidies, for example, and operates on a much slower schedule more suited to a mountainous region with many remote villages where communication can happen only intermittently.
Market- and policy-oriented poverty reduction
Economic growth and remittances lifted ordinary Nepalis out of poverty and increased disposable household income, which was often used to purchase food and other essential consumables.
In Nepal, the rate of extreme poverty ($1.90/day) dropped from 62 percent in 1995 to 15 percent in 2010. Although the government of Nepal created plans with poverty reduction as a goal and invested in some programs to alleviate poverty, the driving force behind the rapid decline in poverty in Nepal had less to do with the government than market forces.
An influx of remittances from millions of labor migrants complemented the government’s increasingly pro-poor policies and investments, cutting the poverty rate dramatically.By 2010/2011, 53 percent of Nepali households had at least one member living outside the country for work. The total number of international labor migrants was almost 2 million.
The remittances they sent home, worth $5.2 billion, amounted to one quarter of Nepal’s GDP. This wealth improved life by increasing food security, diet quality, and health-seeking behavior, which contributed to population-level stunting decline.
Decomposition analysis methodology Nepal
Stunting reduction in Nepal
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South Asia has long been synonymous with unusually high rates of undernutrition. In the past decade, however, Nepal has arguably achieved the fastest recorded decline in child stunting in the world and has done so in the midst of civil war and post-conflict political instability. Given recent interest in reducing undernutrition–particularly the role of nutrition-sensitive policies–this paper aims to quantitatively understand this surprising success story by analyzing the 2001, 2006, and 2011 rounds of Nepal’s Demographic Health Surveys. To do so, we construct models of the intermediate determinants of child and maternal nutritional change and then decompose predicted changes in nutrition outcomes over time. We identify four broad drivers of change: asset accumulation, health and nutrition interventions, maternal educational gains, and improvements in sanitation. Many of these changes were clearly influenced by policy decisions, including increased public investments in health and education and community-led health and sanitation campaigns. Other factors, such as rapid growth in migration-based remittances, are more a reflection of household responses to changing political and economic circumstances.
This paper explores the drivers of Nepal's maternal and child nutrition success using document review, interviews with mothers, and quantitative analysis of DHS datasets. Our qualitative and quantitative analyses both highlight similar policy and community level changes but limited improvements in child feeding and care practices. Improvements in four key drivers of nutritional change emerged: health services, sanitation, education, and wealth. However, the relative contributions of each factor varied by indicator, with health services more important for linear growth among children, and sanitation more important for weight gain among both children and mothers. We conclude with a discussion bringing the qualitative and quantitative findings together into key lessons from Nepal's success.