How did Nepal implement?
- A pro-poor policy environment:
The pro-poor ideology underpinning the Maoist insurgency influenced a succession of governments to address the needs of historically marginalized citizens.
- Donor involvement:
Multilaterals, bilaterals, and NGOs have actively contributed both financing and technical support to major initiatives that have impacted childhood nutrition.
Decentralization of authority from the central government to local government and local organizations (e.g., Village Development Committees, Mothers’ Groups) have helped to adapt development programs to the needs of diverse, often remote communities.
- Women’s empowerment:
The elevated status of and attention paid to women has led to significant improvements in women’s health, reduced fertility, higher levels of education, and an increased role in making household decisions.
Development momentum picked up after 1990, when the autocratic monarchy was replaced by the mostly democratic constitutional monarchy. This is not a coincidence. With the pro-democracy movement, all the major development infrastructure was updated to reflect the reality of life in Nepal. Although the violence of the Maoist insurgency interfered with progress, the pro-poor ideology underpinning it pushed a succession of governments to try to address the needs of historically marginalized citizens.
Multilaterals, bilaterals, and NGOs have been extremely active in Nepal, providing both technical assistance and financial support for a range of development programs. In 2016, donor money accounted for 14 percent of all health spending in Nepal. Compare that to eight percent in Bangladesh, seven percent in Pakistan, and just one percent in India.1 There is, however, some disagreement over how much control the government of Nepal has maintained over its development strategy as it responded to donors’ priorities.
Nepal has addressed the challenge of providing services to an exceedingly diverse population living in difficult terrain by decentralizing authority. A range of local organizations - Village Development Committees, Mothers’ Groups, etc. - help manage development programs based on the needs of the community. The FCHV program links far-flung communities to the health system through local volunteers. The 1999 Local Self Governance Act created a legal structure to match the policy-making principle that key decisions should belong to communities by transferring power from the central government to local governments closer to the people. Even the decentralization of passport issuance set the stage for international labor migration.
Though Nepal’s health and education systems continue to face the challenge of limited local capacity, decentralization has unlocked access to health information, health services, and primary schools. It has been an effective implementation strategy for a range of social policies in a country of diverse and remote communities where centralized authority was a challenge.
Every analysis we conducted showed that stunting reduction went hand in hand with women’s empowerment.
In line with other developing countries, Nepal’s gender equity indicators improved substantially between 2000 and 2016. The gender inequality index decreased from 0.670 to 0.497, and the gender development index increased from 0.769 to 0.925. Despite this improvement, Nepal’s ranking on the gender inequality index is still relatively low - 116 out of 160 countries - suggesting that there’s more progress to be unlocked as women continue to gain power and status in society.2
The four factors highlighted in our narrative - health care, education, sanitation, and poverty reduction - all demonstrate how fundamentally life has changed in the past 20 years for girls and women. The health system, once inaccessible to Nepalis in rural areas, now reaches into every community by way of more than 50,000 female volunteers. The typical Nepali woman used to go through pregnancy and childbirth without ever seeing a skilled practitioner. Now, most have four prenatal visits and give birth in a facility. Girls are now universally enrolled in primary school, more than 80 percent are literate, and more than half finish secondary school.
As a result of these changes in the health and education system, women are choosing to marry later, start having children later, space their births further apart, and have fewer children. The decline in fertility has been particularly noteworthy. In a single generation (1990-2016), the number of births per woman had gone down from 4.6 to 2.3.3 Women were able to effect this change with help from a health system that provided education about and access to contraceptives, and from a government that was the first in a low-income country to fully legalize abortion for pregnancies up to 12 weeks, in 2002.4
Our qualitative analysis, however, makes perhaps the most compelling case for how women’s roles have changed - and how those changes have contributed to the stunting decline. As one mother summarized it, “Twenty years back solely male were only the breadwinner of the family and female used to fully depend on male. But now the time has changed. Male and female are almost in the same level. They are equal. Female are also educated now and they are employed. They also earn, look after the family. If we have money we can spend more on child care, buying varieties of nutritious food like meat, fruits, legumes etc. on our own. We should not wait our husband to buy anything.” One of the FCHVs we interviewed agreed: “Now, females are also ahead in decision-making. In [the] past most of the female[s] were uneducated and men used to dominate them. But now females are also educated and they are doing well.”
One interesting data point that supports these quotes about women’s changing role in society is the number of women’s groups meetings, in which village women come together, sometimes with FCHVs, to discuss health and other challenges and solutions. In 2001, mothers’ groups held an average of 53 meetings per 10,000 people. In 2016, that number had more than tripled to 171.5
These transformations are also reshaping society at the highest levels of government: World Bank data shows an increase in female representation in Parliament from 6 percent of all members in 2006 to 30 percent by 2017.6 In 2018, national election laws instituted gender quotas in local government. One Ministry of Health official said that as a result of these increases in the presence of women in politics, “I believe that things will start changing very fast.”
External health expenditure (% of current health expenditure). World Health Organization Global Health Expenditure database. http://apps.who.int/nha/database. Updated 18 February 2019. Accessed 19 February 2019.
Table 5: Gender Inequality Index. United Nations Development Programme Human Development Reports. http://hdr.undp.org/en/composite/GII.; Table 4: Gender Development Index (GDI). United Nations Development Programme Human Development Reports. http://hdr.undp.org/en/composite/GDI. Accessed 19 February 2019.
Nepal Demographic and Health Survey 1996. DHS Program. Kathmandu, Nepal; 1997; Nepal Demographic and Health Survey 2016. DHS Program. Kathmandu, Nepal; 2017.
Wu, W. J., Maru, S., Regmi, K., & Basnett, I. (2017). Abortion Care in Nepal, 15 Years after Legalization: Gaps in Access, Equity, and Quality. Health and human rights, 19(1), 221-230.
Nepal District Health Information System repository.
Proportion of seats held by women in national parliaments (%) - Nepal. World Bank Data. . Accessed February 1, 2018.