STUNTING REDUCTION IN NEPAL - STUNTING
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T U NTI
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S T U N T I N G I N N EPA L 1
E T H I O PI A
K Y RGY Z R E P U B L I C
N E PA L
PE R U
S E N EG A L
STUNTING REDUCTION
IN NEPAL
May 2019
http://www.exemplars.healthS T U N T I N G I N N EPA L 2
EXEMPLARS IN GLOBAL HEALTH
E X E M PL A R S I N G LO B A L H E A LT H I S A PA R T N E R S H I P of funders, researchers, academics, and
in-country experts committed to harnessing rigorous data and evidence to better
understand how to replicate large-scale health successes around the world.
Our approach, building on both local and global insights, helps us better understand
well-known advances; incorporate lesser-known innovations; and spur progress on major
health challenges.
Exemplars in Global Health maintains a global platform of research and analytics on
leading examples of progress against these challenges. This platform ensures that learnings
and expertise are shared, and that successful practices may be adopted more widely.
The Exemplars in Global Health program has identified a small group of nations that
have made notable progress in curbing stunting rates among children under the age of
five. The stunting report seeks to identify the policies and practices that have made these
gains possible—and to determine which of them might be applicable elsewhere.
Stunting is a condition characterized by a reduced growth rate during childhood and
manifested in below-average height. Beyond shorter stature, stunted children suffer from
greater risk of illness and premature death, delayed mental development, and reduced
cognitive capacity. As a result, stunted growth is associated with substantial short- and
long-term consequences for population-level health, economic, and social outcomes.
The magnitude of global stunting levels is alarming. Stunting affects approximately
one-third of children in low- and middle-income countries. The Sustainable Development
Goals (SDGs) and the Decade of Nutrition include a target to reduce the total number of
stunted children globally to 100 million by 2025, down from 156 million (as of 2017). Based
on current trends, the world will only get about halfway to its goal (to 127 million stunted
children). One challenge in reaching the target is that more needs to be learned about
which determinants cause stunting in the first place and which packages of interventions
are most effective for addressing it.
In spite of the complexity and difficulty involved in reducing stunting, success stories
do exist. Countries that have significantly reduced their stunting prevalence in the recent
past have employed a combination of evidence-based nutrition-specific and nutrition-
sensitive interventions.S T U N T I N G I N N EPA L 3
4 EXECUTIVE SUMMARY
6 ANALYSIS
13 CONTEXT
15 PIVOTAL PROGR AMMING I
HEALTH CARE
22 PIVOTAL PROGR AMMING II
EDUCATION
25 PIVOTAL PROGR AMMING III
SANITATION
27 PIVOTAL PROGR AMMING IV
POVERTY REDUCTION
29 CONCLUSIONSS T U N T I N G I N N EPA L 4
EXECUTIVE SUMMARY
I N 19 9 5 , N E PA L R E C O R D E D A S T U N T I N G R AT E O F 6 8 PE R C E N T, T H E H I G H E S T I N T H E WO R L D.
This amounted to more than 2 million stunted children. By 2016, the rate had been cut
almost in half, to 36 percent.1 Because the size of the under-five population had shrunk,
the absolute number of stunted children had dropped by more than half, to fewer than 1
million. Moreover, Nepal had made this progress in the midst of a violent Maoist insurgency
(1996–2006) and political instability (2006–2015).
Stunting prevalence declined faster in Nepal than in its neighbors
80%
Nepal
68%
PE R C E N T O F C H I L D R E N U N D E R FI V E S T U N T E D
60%
4 5% PA K I S TA N
41% A FG H A N I S TA N
40% 38% INDIA
36% N E PA L
20%
1996–2006: Civil War
0%
1990 1995 2000 2005 2010 2015
YEAR
Data source: UNICEF-WHO-World Bank Joint Child Malnutrition Estimates, 2018
Child growth is determined by multiple factors, and in 1995, several of these
interacted in Nepal, leading to extraordinarily high rates of stunting. Extreme poverty
was rampant, with 62 percent of Nepalese living on less than $1.90 per day. 2 Government
systems, especially the health, education, and sanitation systems, were weak.
Improvements related to even one of these factors would have had a big impact on the
stunting rate.
In the two decades that followed, however, Nepal made improvements across the board.
The Government of Nepal, with a new pro-poor outlook and ample support from donors and
international NGOs, invested heavily in health, education, and sanitation. Furthermore, by
decentralizing authority, they enabled these systems to function properly in a country with
such cultural diversity and challenging terrain. At the same time, Nepalese started to migrate
in large numbers to the Gulf Region and India for work (by 2010/2011, a third of households
had at least one member working abroad), sending remittances home and relieving the
burden of poverty. Between 1995 and 2010, thanks in large part to these remittances, the
extreme poverty rate dropped by three quarters, to 15 percent. 3
With a stunting rate of 36 percent, Nepalese children are still among the most likely
in the world to be stunted. However, the necessary infrastructure to address health and
nutrition is now in place, setting the country up to build on the progress of the
past generation.S T U N T I N G I N N EPA L 5 S T U NTI NG I S M U LTI FAC TOR I A L , A N D N E PA L R E DUC E D S T U NTI NG BY A DDR E S S I NG M A N Y FAC TOR S BOTH I N S I DE A N D OU T S I DE TH E H E A LTH S EC TOR . W E H AV E FOC U S E D ON FOU R OF TH E MOS T I M PAC TFU L : H E A LT H Following the 1991 National Health Policy, which set forth the vision of a health system that reached the rural poor with basic primary care, 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. 4 E D U CAT I O N Beginning with the Basic Primary Education Program in 1992, donors and the government built new schools, enrolled more than a million more children in primary school, achieved gender parity in primary enrollment and got closer to parity in secondary school completion, and boosted literacy among all groups. S A N I TAT I O N 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 to just one quarter of its people defecating outside. P OV E R T Y R E D U C T I O N An influx of remittances from millions of labor migrants complemented the government’s increasingly pro-poor policies and investments, cutting the poverty rate dramatically, which in turn improved life in many ways, including increased food security, diet quality, and health- seeking behavior, thereby contributing to the stunting decline. PROGRESS IN ALL THESE AREAS WAS FACILITATED BY A FEW CROSS-CUTTING THEMES: A PR O - P O O R P O L I CY E N V I R O N M E N T 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 (e.g., health, education, sanitation) 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. D O N O R I N VO LV E M E N T 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 8 percent in Bangladesh, 7 percent in Pakistan, and just 1 percent in India. 5 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. D E C E N T R A L I Z AT I O N 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 Local Self Government Act created a legal structure to match the policy-making principle that key decisions should belong to communities. 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.
S T U N T I N G I N N EPA L 6
ANALYSIS
O U R R E S E A R C H C O N S I S T E D O F A VA R I E T Y O F Q UA N T I TAT I V E A N A LYS E S , qualitative analyses
based on consultations with national experts, regional stakeholders, and mothers in
communities and an evaluation of key policies and programs. We synthesized our findings
to interpret Nepal’s stunting decline.
DECOM POS ITION A N A LYS I S
Let us begin with the decomposition analysis, which identifies how much of the change
in height-for-age z-score (HAZ) among Nepalese children between 2001 and 2016 can be
explained by each of 33 potentially relevant variables. (Some or our data goes back beyond
2001, to 1996; we note some of these key data points below.)
DECOM POS ITION A N A LYS I S M E THODOLOGY
Oaxaca-Blinder decomposition analysis was used to identify the relative The analysis is based largely on individual and household-level
contribution of each predictive factor to height-for-age z-score (HAZ) data, focusing on index mother-child pairs (i.e., the youngest child and
change. A linear least square regression model was used to assess youngest mother in any given household). This standard approach
associations between HAZ, time, control variables (e.g., child age and sex), simplifies modeling and interpretation with minimal loss in data.
and any trend effects. Here, we show analysis of the under-five age group across the
2001–2016 time period.
Supporting evidence: quantitative evaluation of drivers
Oaxaca-Blinder decomposition, HAZ increase in Nepal children under-five, 2001–2016
25% E D U C AT I O N 11% O T H E R
Mothers’ years of education, Fathers’ years Number of health facilities, breastfeeding,
of education child age, sex, region
Nepal started from a low baseline and Individual indicators in this category
achieved dramatic gains in schooling and accounted for a small proportion of the
literacy for both men and women change in HAZ
19% M AT E R N A L
N U T R I T I O N A L S TAT U S
Children Under 5 3% F E R T I L I T Y
9% unexplained
Interpregnancy interval
Maternal height, Body mass index (BMI)
Increases in maternal height and BMI Between 2001 and 2016, the average number of
were reflected in significant increase in HAZ months between births increased from 32 to
at birth 37. These longer interpregnancy intervals
improved mothers’ health and ability to recover
12% M AT E R N A L A N D N E W B O R N between pregnancies, enabling children to be
H E A LT H C A R E born healthier and larger
Women with 4 or more antenatal care visits
(ANC4+), skilled attendant at birth (SBA) 12% WA S H 9% E C O N O M I C E M P O W E R M E N T
Improvements in health service utilization, Open defecation Asset index
driven partly by improved supply 70 percent of households lacked a toilet Increased household wealth, associated with
(health workers and facilities) and access facility in 2001; dramatic reduction, driven a substantial portion of HAZ increase, was
(especially primary care for women) were by community-based promotion, largely driven by remittances
linked to HAZ gains continued to contribute to improved growth
among childrenS T U N T I N G I N N EPA L 7
In the decomposition, six factors explain at least 10 percent each of the change in HAZ,
suggesting that the stunting decline was driven by improvements in many overlapping
aspects of Nepalese life rather than just one or two.
Ǻ Maternal nutritional status (19 percent): This refers specifically to improvements
in BMI and height, which could be used as markers of healthier intrauterine growth.
The change in maternal nutritional status likely resulted from gradual improvements
to diet and health care and a cleaner environment in which mothers were likely to
encounter fewer pathogens.
Ǻ Paternal education (13 percent): Better-educated fathers tend to earn more and
therefore have more resources to devote to their children. In addition, they are more
likely know about health and nutrition and accept women in decision-making roles. In
Nepal, men with more education may also have been more able to migrate for work,
even though the work itself was mostly low skill. The money migrants sent home
helped reduce household poverty, and there is strong evidence that mothers tended
to spend the extra income on their children’s well-being. (See Pivotal Programs
section for more on remittances.)
Ǻ Maternal education (12 percent): There are many plausible pathways from maternal
education to decreases in stunting, including:
Ǻ First, girls who stay in school longer tend to have fewer children, later in life. The data
from Nepal bears this out. Between 1995 and 2016, expected years of schooling
for girls increased from 6.4 to 12.6 years. 6 Between 1996 and 2016, the number
of births per woman dropped by half, from 4.6 to 2.3; meanwhile, the median age
at first marriage, strongly correlated with age at first birth, rose from 16.2 to 17.9;
in addition, the adolescent fertility rate (the percentage of girls who get pregnant
before turning 20) fell from 127 per 1,000 women to 88 per 1,000 women.7
Total fertility rate in Nepal
by level of maternal education
5 .1
5
4.6
4
3.8
B I R T H S PE R WO M A N
3 . 3 N O E D U CAT I O N
3
2 .7 PR I M A RY
2.5
2.3 2 . 3 TOTA L
2 2 .1 S EC O N DA RY
1. 8 H I G H E R
1
0
1995 2000 2005 2010 2015
YEAR
These
Data source: United Nations Population changes
Division, Worldmake a diffProspects,
Population erence in twoDHS,
Nepal ways. Biologically, older mothers who
MICS
are pregnant less often are healthier, stronger, and more prepared for the rigors
of childbirth, which means their children tend to be healthier, stronger, and taller.
Financially, older mothers are more likely to have the means to support children
properly, and mothers with fewer children have more to spend on each one.S T U N T I N G I N N EPA L 8
Ǻ The second pathway from increases in maternal education to decreases in stunting
is empowerment—specifically, greater knowledge and decision-making authority
for mothers. Mothers who attend school for longer know more about how to feed
and care for themselves and their children. Moreover, educated mothers have
more power to negotiate in decisions about how the family will spend money and
rear children.
“ THIS CYCLE OF CHANGE THAT IS INCREASE IN AGE OF MARRIAGE,
DECREASE IN NUMBER OF TIMES OF PREGNANCY, INCREASE IN WOMEN
LITER ACY HAS CONTRIBUTED [ TO THE EMPOWERMENT OF WOMEN AND
REDUCTION IN MALNUTRITION].”
� R E PR E S E N TAT I V E FRO M T H E PATA N ACA D E M Y O F H E A LT H S C I E N C E S
Ǻ Maternal and newborn health care (12 percent): More educated, empowered
mothers are better able to seek care for themselves and their children. Moreover,
in Nepal, accessing health care was progressively easier over the study period
because the health and road systems expanded considerably, improving access
among rural citizens. The percentage of mothers who made the recommended
number of prenatal visits increased from 14 percent in 2001 to 69 percent in 2016.
The percentage of births attended by a skilled health worker increased from 11
percent in 2001 to 58 percent in 2016. 8 Overall, improvements in health service
utilization and access (especially primary care for women) were linked to gains in
childhood growth.
Relative to other South Asian Countries, Nepal dramatically
increased coverage of antenatal Care
Percentage of women who had a live birth in the five years preceding the survey who had 4+ antenatal care visits
70% 6 9 % N E PA L
PE R C E N TAG E O F WO M E N W I T H
60%
4+ A N T E N ATA L CA R E V I S I T S
50% 51% I N D I A
40%
37% PA K I S TA N
37%
30%
24% B A N G L A D E S H
20%
18 % A FG H A N I S TA N
14% 14%
10%
7%
0%
1990 1995 2000 2005 2010 2015
YEAR
Data source: Nepal DHS, MICS
D I FFE R E N C E � I N � D I FFE R E N C E Ǻ Reduced open defecation (12 percent): Improvements in sanitation address the burden
A N A LYS I S M E T H O D O LO GY
of diseases like diarrhea and pneumonia that stunt children’s growth. The percentage
The difference-in-difference (DID)
of households in Nepal without toilet access declined rapidly, from 77 percent in 1996
framework was used to estimate impact
of change in predictors on child HAZ to 15 percent in 2016. (Our difference-in-difference analysis methodology, which
improvement in Nepal. Four cross- demonstrates which determining factors most increased change over time, also
sectional DHS rounds from 2001-2016
were assembled into panel datasets identifies the increase in the proportion of people using piped water, from 32 to 53
for analysis. Hierarchical multivariable percent over the same period, as significant. 9) Partly as a result of these improvements
linear regression models were fi t using
main effects (covariable, time), and
to sanitation, the incidence of diarrhea dropped from 20 percent in 2001 to 8 percent
time*covariable interaction terms to in 2016, and the incidence of acute respiratory infection dropped from 23 percent to 2
estimate the DID effect. Analysis was
percent over the same period.10
based on individual child/household
level data and models were adjusted for
child age, sex and region. The complex
sampling design of DHS surveys was
taken into account in analyses.S T U N T I N G I N N EPA L 9
Ǻ Wealth index (9 percent): The average wealth index score (measured on a scale
of 0–10) in Nepal increased significantly—in large part because of the inflow of
remittances. As Nepalese households got wealthier, they were more able buy
nutritious food, seek health care, and adopt other behaviors that reduce stunting. In
our decomposition analysis for 6–23 month olds, dietary diversity accounted for 8
percent of the change in HAZ, suggesting that some parents with the means to do so
made the choice to buy or grow higher quality food for their children.
Predicted HAZ score by child's age ("Victora curves"), Nepal
1996 2001 2006 2011 2016 95% CONFIDENCE INTERVAL
-0.5 2
1 1. Change in y-intercept from 1996 to 2016 1
demonstrates that child birth disadvantage
reduces gradually over time. This suggests that 3
mothers improved their nutrition and healthcare -1
and improved intrauterine fetal growth.
PR E D I C T E D H A Z S C O R E
-1.5
2 2. Postnatal growth faltering (0–6 months) has 4
historically not been a major concern in Nepal,
suggesting persistent protective behavior
(e.g., breastfeeding) and optimal environment -2
for young children.
3 3. Flattening of HAZ slope occurs for 6–23 -2.5
month children, suggesting improvements in
disease management, dietary intake and
household environment from 1996–2016. -3
4 4 Children at 24 months start off significantly -3.5
taller and healthier in 2016 (HAZ -1.8) than
those in 1996 (HAZ -3.0); growth faltering 0 10 20 30 40 50 60
plateaus thereafter.
C H I L D ’ S AG E � I N M O N T H S �
Nepal’s linear growth curves, or Victora curves, confirm many of the insights from the
decomposition analysis. Victora curves track a child’s predicted HAZ from birth to five
years at a given point in time, thereby capturing two important pieces of information: First,
how big infants are at birth, which depends on the mothers’ nutritional status and prenatal
care. Second, when, and how severely, children’s growth falters; this helps researchers
know where to look for the key causes of stunting.*
In 1996, Nepalese babies were born an average of 1.5 standard deviations smaller than
the international reference population. The mean HAZ score at birth improved steadily
over time, and by 2016, babies were smaller than average by only 0.5 standard deviations.11
This significant improvement in intrauterine growth aligns with the findings from the
decomposition related to prenatal factors—specifically, maternal nutritional status and
maternal health care.
Similarly, in 1996, infants’ growth faltered sharply after about six months, the period
when children tend to stop breastfeeding exclusively and start interacting more with their
environment. Though growth faltering remained extreme in 2001 and 2006, by 2011, it had
started to decrease, a trend that continued in 2016. This aligns with the findings from the
decomposition related to child care and feeding—specifically, reduced open defecation
and paternal and maternal education.
*Restricted cubic splines were also calculated to estimate infl ection points in the Victora curves.S T U N T I N G I N N EPA L 10
EQUALITY
Nepal regional map
Prevalence of stunting (%)
0% 60%+
1996 2001 2006
Far-western Province-7 Province-7
67.7% 58.9% Province-6 52.1% Province-6
Mid-western 70.6% 62.7%
63.3%
Western Province-4 Province-4
66.7% 55.8% 47.3%
Central Province-3 Province-3
63.9% Eastern 59.7% 46.5%
Province-1 Province-1
54.4)% Province-5 49.7% 37.9%
Province-5
55.7% 53.3%
Province-2
56.8% Province-2
2011 2016 52.4%
Province-7
46.0% Province-6 Province-7 Province-6
55.2% 35.4% 54.9%
Province-4 Province-4
36.4% 26.7%
Province-3 Province-3
33.2% Province-1 30.6% Province-1
Province-5 37.0% 32.7%
42.1% Province-5
38.0%
Province-2 Province-2
39.6% 36.6%
Though the stunting burden in Nepal has decreased, mountainous and underdeveloped, has always
inequalities have not. We can demonstrate the rise been an outlier. In 2001, it had the highest stunting
in inequality with several quantitative analyses. rates in the country, and since then it has had the
First, a regional analysis. Nepal is divided into lowest annual rate of change in stunting, which
seven provinces (it was five until 2015, but we have means that the inequality that already existed has
been able to retrofit data to the new subdivisions only gotten worse. In the other six provinces, the
going back to 2001). Six of the provinces had current stunting rate ranges from 27 to 38 percent.
relatively similar stunting rates to each other In Province 6, it is 55 percent.12
over the study period, but Province 6, the most
Stunting decline in Nepal has been significant but not equitable
across population sub-segments
by wealth quintile by residence by maternal education
LOW EST Q2 Q3 RURAL U R BA N NONE P R I M A RY S ECO N DA RY
Q4 HIGHEST NATION A L N ATI O N A L HI GHE R N ATI O N A L
PE RCE N T O F U ND E R� F I V E C HI L D R E N ST U NT E D
60% 60% 60%
40% 40% 40%
20% 20% 20%
0% 0% 0%
2000 2005 2010 2015 2000 2005 2010 2015 2000 2005 2010 2015
Note: Increase in stunting prevalence among urban residents likely partially driven by reclassifi cation of formerly "rural" areas
to "urban" after 2011.
Data Source: Analysis based on Nepal DHS, 2018S T U N T I N G I N N EPA L 11
Second, we conducted a number of equity the curve moves to the right and gets taller and
analyses to quantify the relationship between narrower. The move to the right means that the
stunting and wealth, maternal education, caste, and average HAZ score increased. The pinching of the
rural or urban residence. curve means that more children clustered around
In 1996, children from the richest 20 percent the new, healthier mean. In Nepal’s kernel density
of Nepalese families were significantly less likely plots for 0-6 month olds and 6-23 month olds, the
to be stunted than other children, but the rates for curve moves to the right but does not get taller
all other children were similar, whether they were and narrower. In fact, the curve for 2016 is shorter
in the second or fifth wealth quintile. Over time, and wider than the curve for 2001. This suggests
although stunting has declined in all quintiles, the that while the overall situation is improving—that
gap between the richest and everyone else has is, the mean HAZ is higher—inequality is a growing
stayed wide, and a new gap has developed between concern as more children are distributed further
the poorest and the middle three quintiles. The gaps away from the new, healthier mean.
are similarly wide in the cases of maternal education Understanding the meaning of increasing
and caste, although the caste system in Nepal is so inequality in Nepal may require a unique
complex that it is difficult to capture precise data.13 interpretation, given the epidemiology of stunting in
There is also a gap between rural and urban the country. In the mid-1990s, the stunting burden
dwellers, though this gap closed in 2016. While a in Nepal was almost universal—the majority of
smaller gap seems like a good thing, a closer look children were stunted, making them, in some sense,
shows that the reason for the convergence is an equal. But what may have looked like equality was
increase in the stunting rate in urban areas from 27 actually the pervasiveness of malnutrition.
to 32 percent, reflecting both the growth of slums Now, as the rate comes down, it is clear that it
and a change in the way Nepal classified rural and is coming down faster for some groups than others.
urban areas, which led to more areas with relatively Many countries with stunting rates around 30
high rates of stunting being counted as urban. percent (similar to Nepal’s rate now), including Peru
Children from the poorest families in urban areas and Kyrgyz Republic, have driven stunting down into
currently have the highest stunting rates in Nepal, at the teens by focusing specifically on marginalized
above 50 percent. groups. As Nepal makes investments and policies
A third set of analyses that help us think about to build on its progress so far, it should follow these
equity are HAZ kernel density plots. These graphs examples and concentrate on reaching the most
represent the full distribution of HAZ scores in disadvantaged children and families.
a population in any given year. Ideally, over time,
HAZ Kernel Density Curves
.4
D HS – 1996 adjusted
D HS – 2001
.3 D HS – 2016
DENSITY
Curve shifted right from
1996 to 2016 as average
.2 HAZ score increased. The
2016 curve is shorter and
wider than those of 2001
.1 and 1996, suggesting
1996-2016 growing inequality.
Curve shifted right as
HAZ score increased
0
-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6
H E I G H T FO R AG E Z� S C O R E �C H I L D R E N 0 � 59 M O N T H S �
Data source: Analysis based on Nepal DHSS T U N T I N G I N N EPA L 12
EVIDENCE-BASED NUTRITION INTERVENTIONS
In 2008, the Lancet published its first series on of the problem—and how difficult it is to isolate
maternal and child undernutrition. The series was discrete pathways to addressing stunting.
updated in 2013, when the authors outlined ten What follows is a list of the evidence-based
evidence-based nutrition interventions that, at 90 nutrition interventions listed in the Lancet, alongside
percent coverage, could avert 20 percent of stunting. a summary of how Nepal prioritized or did not
The fact that a large proportion of stunting prioritize each one. By and large, Nepal’s success
cannot be averted by these direct nutrition with stunting cannot be attributed to expanding
interventions underscores the multicausal nature coverage of these nutrition-specific interventions.
E V I D E N C E - B A S E D I N T E RV E N T I O N S N E PA L’ S PR I O R I T I Z AT I O N
FO L I C AC I D S U PPL E M E N TAT I O N Prioritized recently (since 2011) as a part of a Mandatory Flour Fortification initiative; however,
intervention reach (it largely failed to reach rural populations) and timing suggest that it made little
contribution to Nepal’s progress on stunting
M U LT I PL E M I C R O N U T R I E N T Not prioritized
S U PPL E M E N TAT I O N
CA LC I U M S U PPL E M E N TAT I O N Not prioritized
B A L A N C E D E N E R GY PR OT E I N Not prioritized
S U PPL E M E N TAT I O N
E XC LU S I V E B R E A S T FE E D I N G ( E B F ) Prioritized as a part of health promotion by health workers; however, prevalence of exclusive
breastfeeding through six months of age has actually decreased over the last two decades;
increased rates of early breastfeeding have helped to offset some of these effects
C O M PL E M E N TA RY FE E D I N G Prioritized by community health workers working with mothers and young children; more recently
incorporated formally into the Strategy for Infant, Young Child Feeding
V I TA M I N A S U PPL E M E N TAT I O N Prioritized early on, starting in 1993, Nepal’s vitamin A supplementation program for children
consistently reaches over 80% of the population and is consistently identified as a success
PR E V E N T I V E Z I N C S U PPL E M E N TAT I O N Not prioritized as a supplement, but zinc is given as treatment for diarrhea as a part of Integrated
Management of Childhood Illness (IMCI)
M A N AG E M E N T O F S E V E R E AC U T E Not prioritized
MALNUTRITION (SAM)
M A N AG E M E N T O F M O D E R AT E AC U T E Not prioritized
MALNUTRITION (MAM)S T U N T I N G I N N EPA L 13
CONTEXT
N E PA L’ S R E C E N T H I S TO RY I S F U L L O F C H A L L E N G E S , from decades of autocracy through
N E PA L AT A G L A NC E
a Maoist insurgency and a period of extreme political instability to the devastating
2000 2 016 2015 earthquake. Despite this string of difficulties, Nepal has demonstrated resilience,
U5MR (per 1,000
14 79 33 accelerating both economic growth and progress on most key development indicators in
live births)
recent years.
NMR15 (per 1,000 39 19
live births)
Demographics and Topography
MMR156 (per 100,000 548 258
live births) (2015)
TOTAL FERTILITY 4.1 2.3 Bordered on all sides by the two most populous nations in the world, Nepal is a land
RATE17 (per woman)
apart—a distinctive and diverse country of 30 million people representing a wide range of
ANC4+ 18 14 69 ethnic, cultural, religious, linguistic, economic, social, and political identities.
(percent) (2001)
A 2011 census found that Nepal’s population includes members of 125 different
WASTING 19 11 10
(2001)
castes and ethnic groups speaking 123 separate languages. 63 marginalized indigenous
(percent)
peoples make up more than a third of the population; the rest is organized into 59 castes,
DTP3 COVERAGE 20 74 87
(percent) 15 of them Dalit or “untouchable.”25 While the caste system was officially abolished in 1963,
OPEN DEFECATION 21 65 30 it is informally still in effect, particularly in the marginalization of some groups such as the
(percent) (2015) Chamars, Musahars, and Tatma. 26
GDP PER CAPITA 22 1,540 2,302 The people of Nepal overwhelmingly live in rural areas, but in recent years, the country
(PPP, constant
2011 int’l $)
has become one of the most rapidly urbanizing in South Asia, with an average urban
population growth of 6 percent since 1970. Many recent migrants to cities have clustered in
LITERACY RATE 23 49 60
(percent of adults) (2001) (2011) informal settlements, and slumdwellers are among the populations most at risk of stunting. 27
POVERTY HEADCOUNT 46 15
RATIO AT $1.90/DAY24 (2003) (2010) While Nepal’s urban population is increasing, it remains low
(percent) N E PA L INDIA PA K I S TA N BANGLADESH A FG H A N I S TA N
PE R C E N T O F P O P U L AT I O N L I V I N G I N U R B A N A R E A S
50
40
3 6 % PA K I S TA N
36% BANGLADESH
3 4% I N D I A
30
25% A FG H A N I S TA N
20
19 % N E PA L
10
0
1990 2000 2010 2020
YEAR
Note: UNDP estimates
Data source: do notPopulation
United Nations fully align with NepalWorld
Division. national estimates,Prospects:
Urbanization especially2018
following the post-2011 reclassification of
Revision.
urban and rural areas. According to the 2016 Nepal DHS, 59% of the total population lives in urban areas.
Data source: United Nations Population Division. World Urbanization Prospects: 2018 Revision.
Nepal’s diversity is also reflected in the terrain itself. The country is divided into three
Mountains
geographic zones. The remote mountainous region, which includes not only Mount Everest
but also seven other peaks above 8,000 meters, constitutes about a third of the nation’s
Hills
land area but has less than 7 percent of its population. A hill zone comprises approximately
40 percent of Nepal’s land and population, including the approximately 5 million living in the
Kathmandu Valley. The terai, or low-lying flatlands, make up less than a quarter of Nepal’s
Terai
landmass but are home to half of its people. 28S T U N T I N G I N N EPA L 14
Conflict
Ruled for almost 200 years first by a king and then by a hereditary prime minister, the
Kingdom of Nepal tended to spend little money outside Kathmandu except on the military
and the police. Eventually, a pro-democracy movement developed in response to the
impoverished, undemocratic condition of the country. Under pressure, the king agreed to a
new constitution whereby the government became a multi-party constitutional monarchy
in 1990. Although a long period of instability was just beginning, from this moment on, the
Government of Nepal pursued a variety of pro-poor investments and policies.
Among the most important of these was the Local Self-Government Act, which in 1999
transferred power from the central government to the local governments closer to the
people. This principle of decentralization was not only a move toward greater democratic
participation; it was also an effective implementation strategy for a range of health and
social policies in a country of diverse and remote communities where centralized authority
was a challenge. In the period under study, decentralization was an enabling factor for
success in many key policy areas.
A ten-year-long Maoist insurgency began in 1996, killing over 12,000 people, internally
displacing another 200,000, and sending approximately 2 million people across the border
into India. 29
Surprisingly, the health system continued to improve during the insurgency. Certainly,
the violence and destruction it caused were impediments, but since the monarchy’s lack of
concern for the rural poor was a major factor in the insurgency, there was pressure on both
sides of the conflict to invest in the health system. The Maoist insurgents fought for a more
egalitarian health agenda, and the government responded by trying to show that they were
already pursuing one. During the conflict, health infrastructure and health workers were
rarely targeted.
The insurgency came to an end in 2006 with the signing of a peace deal and the
declaration of Nepal as a federal democratic republic; however, the new government was
unable to agree on a permanent constitution until 2015. Between 2000 and 2015, there
were ten different prime ministers. 30
Development and Economy
During these years of political instability, especially those following 1990, foreign donors
and NGOs came to play a big role in policymaking and program design and implementation,
especially in the areas of education, health, and transportation. For example, the World
Bank has funded 12 roads projects in Nepal since the early 1970s, when the country’s road
network totaled 2,700 kilometers. Now, it spans over 42,000 kilometers, half the population
enjoys access to paved roads, and travel time has dropped nearly 80 percent on average. 31
Just under 40,000 NGOs were registered in Nepal between 1977 and 2014, the vast
majority after 1990. 32 Total donor spending increased from $420 million in 2000 to $1.07
billion in 2015. 33
Alongside assistance from external partners, the economy has continued to
grow at a steady if unspectacular pace, despite the political instability. GDP per capita
(purchasing power parity, in constant 2011 dollars) grew at about 3 percent per year from
2000 to 2015. As of 2016, it stood at approximately $2,302, still well below the South Asia
average of $5,625. 34S T U N T I N G I N N EPA L 15
GDP per capita
$7,000
G D P PE R CA PI TA � PPP C O N S TA N T I N T ' L $ �
$ 6 , 427 I N D I A
$6,000
$5,000 $ 5 , 0 3 5 PA K I S TA N
$4,000
$ 3 , 524 B A N G L A D E S H
$3,000
$ 2 , 4 4 3 N E PA L
$2,000
$1, 8 0 4 A FG H A N I S TA N
$1,198
$1,000
$0
1990 1995 2000 2005 2010 2015
YEAR
Data source: World Bank national accounts data
PIVOTAL PROGR AMMING I
HEALTH CARE
S T U N T I N G WA S N OT T H E O N LY H E A LT H - R E L AT E D C R I S I S N E PA L FAC E D I N T H E 19 9 0 s. Key
indicators like child and maternal mortality were in line with very high regional averages,
and other data suggested that most Nepalis’ connection to the health system was severely
limited. For example, as late as 2001, only 28 percent of mothers received any prenatal
care from a skilled provider, and only 11 percent had a skilled attendant at birth. 35
However, two important foundations laid in 1988 and 1991 set the health system up for
significant progress after the turn of the millennium.
Female Community Health Volunteers
In 1988, as part of the push for decentralization in response to the lack of health care
FE M A LE COM M U N IT Y
in remote communities, the Government of Nepal launched the Female Community Health
H E A LTH VOLU NTE E R S
Volunteer (FCHV) program to extend the reach of the health system into every community.
DESCRIPTION To be a candidate to be selected as an FCHV, women must be between the ages of 25
National cadre of local volunteers
who provide basic health education and 45, they must be married and have children, and they must be from the community
and services they serve. Literacy is strongly preferred. Chosen by local mothers’ groups and trained
TIMELINE
and supervised by health workers at nearby facilities, they provide health and nutrition
1988–present information and basic services. By 1992, the FCHV program had been rolled out nationally,
with approximately 20,000 volunteers. In 2017, more than 50,000 FCHVs covered the
C OV E R AG E
Universal coverage with entire country. 36
~50,000 FCHVs.
At first, the FCHVs concentrated mainly on promoting family planning, an area in which
they have helped drive considerable progress. In 1996, 27 percent of women were using
contraception. By 2016, that figure had increased by half, to 41 percent. This development
has contributed to the steep drop in fertility, from 4.6 births per woman in 1996 to 2.3 births
per woman in 2016. 37S T U N T I N G I N N EPA L 16
Over time, FCHVs offered more kinds of advice about maternal and child health care,
such as optimal breastfeeding practices. Although exclusive breastfeeding and duration
of breastfeeding has stayed basically flat, early initiation of breastfeeding (within the first
hour) has increased dramatically, from 18 percent to 55 percent between 1996 and 2016.
Similarly, prelacteal feeding decreased from 41 percent in 2001 to 29 percent in 2016. 38
These trends are especially important because they signal a shift away from a cultural
norm against feeding the baby colostrum, a vital source of infant nutrition.
Early initiation of breastfeeding (within 1 hour of birth), Nepal
by wealth quintile by residence by maternal education
LOW EST Q3 RURAL U R BA N NONE P R I M A RY S ECO N DA RY
HIGHEST NATION A L N ATI O N A L HI GHE R N ATI O N A L
60% 60% 60%
P E RC E N T O F U N D E R- FI V E CHIL D RE N
P E RC E N T O F U N D E R- FI V E CHIL D RE N
P E RC E N T O F U N D E R- FI V E CHIL D RE N
40% 40% 40%
20% 20% 20%
0% 0% 0%
‘00 ‘05 ‘10 ‘15 ‘00 ‘05 ‘10 ‘15 ‘00 ‘05 ‘10 ‘15
Data source: Analysis based on Nepal DHS
In addition to providing information, FCHVs have been trained to deliver basic health
products and services and refer patients to facilities for more advanced care. For instance,
the FCHVs have been the linchpin on Nepal’s successful campaign to provide all children
with high doses of vitamin A semiannually. The campaign was relatively slow to get off
the ground. Vitamin A’s effectiveness was researched locally, and then the program was
piloted in 1993 in eight districts before being scaled up to all 75 by 2002. One study showed
that this effort reduced the odds of death among 12 to 60 month-olds by slightly more than
half. 39 The FCHVs have also been instrumental in Nepal’s Community-Based Integrated
Management of Childhood Illness (CB-IMCI) initiative (discussed below).
The FCHVs remain a pillar of the health system, providing both a source of local health
knowledge and a critical link between far-flung communities and the public health system.
The program has worked in part because FCHVs receive certain benefits such as free
health care, a small retirement stipend, respect and stature within the community, and
a sense of accomplishment. However, as many older FCHVs reach retirement age and
women gain more options in society, the government needs to plan to attract and train
qualified replacements.S T U N T I N G I N N EPA L 17
Basic Primary Health Services
In 1991, as the FCHV program was scaling up across the country, the government released
N ATION A L a National Health Policy designed to “upgrade the health standards of the majority of
H E A LTH POLICY
the rural population by extending Basic Primary Health Services up to the village level.”
DESCRIPTION The policy envisioned the creation of sub-health posts staffed by “one village health
Framework for Nepali health system
worker, one maternal and child health worker, and one auxiliary health worker” to reach
based on accessibility
all citizens. In conjunction with the growing cadre of frontline health workers, this policy
TIMELINE
promised to create a new health system based on the principle of access and equity. Up
1991–present
until the current day, the National Health Policy has been augmented by a series of detailed
implementation plans and strategies, including the Second National Long Term Health
Plan (1997–2017) and successive sector strategies and implementation plans of varying
lengths, all of which support the principles first laid out in 1991. 40
In 2006, Nepal issued its free health care policy, which provides essential health care
services free of charge. Some services, including delivery services—normal, complicated,
and caesarean sections—were free of charge to all women at government facilities
nationwide. Other services were available free of charge to selected disadvantaged
groups, including the poor, marginalized castes and ethnic groups, the disabled, the
elderly, and FCHVs. 41
Nepal has dramatically expanded its health workforce
3.0
2.9 INDIA
2 . 6 N E PA L
2.5
PY H S I C I A N S , N U R S E S A N D M I DW I V E S
2.0
PE R 1, 0 0 0 P O P U L AT I O N
1.5 1. 5 PA K I S TA N
1.0
0 .7 B A N G L A D E S H
0.7 0 .7 A FG H A N I S TA N
0.5
0.0
1995 2000 2005 2010 2015
YEAR
Data source: World Health Organization's Global Health Workforce Statistics, OECD, supplemented by country data
With support from a wide range of donors, the government spent the 1990s and
2000s investing in the growth in health facilities and human resources for health. Although
data from the 1990s is sparse, we know that the number of doctors and nurses per 1,000
people increased from 0.7 in 2004 to 2.6 in 2014, bypassing the WHO’s guideline of 2.3
per 1,000 along the way. 42 Only 19 percent of health training courses in Nepal are offered
by the government. The remainder are offered by for-profit institutions that are clustered
around Kathmandu and attract relatively well-off students who intend to stay in the city. As
a result, there is still a serious shortage of staff in rural health facilities. 43S T U N T I N G I N N EPA L 18
Still, investments in the health system, along with key policy changes, have led to a
revolution in access. One clear indication of the greater reach of the health system is the
steadily increasing vaccination rates. Although the national immunization program was
introduced in 1979, as late as 1996 only 65 percent of children received at least one dose
of measles vaccine. By 2017, that number had improved to 90 percent. 44
“IN COMPARISON TO THE PAST 20 YEARS, EVERY THING HAS IMPROVED AND
DEVELOPED. THERE HAS BEEN AN IMMENSE IMPROVEMENT IN HEALTH SERVICE
DELIVERY. THE HEALTH FACILITIES ARE BUILT WITHIN 30 MINUTES WALKING
DISTANCE. ROAD ACCESSIBILIT Y HAS ALSO IMPROVED AND MADE IT EASIER TO
REACH THE HEALTH INSTITUTIONS OF EVEN URBAN PL ACES.”
� H E A LT H WO R K E R I N D U K U C H H A P
Nepal’s high measles vaccine coverage is representative of a strong
immunization system
MCV1 coverage
100%
90%
PE R C E N T O F C OV E R AG E , M E A S L E S
80%
VAC C I N E FI R S T D O S E
60%
40%
Pneumococcal conjugate
34%
vaccine and rotavirus
vaccine introduced
20%
0%
1985 1990 1995 2000 2005 2010 2015
YEAR
Data source: WHO-UNICEF estimates
Maternal, Newborn, and Child Health
Strengthening the health system was not donors’ only interest; they also funded programs
SA FE MOTH E R HOOD to address specific priority health challenges. Two of the most important, the Safe
PROJ EC T
Motherhood Project and Community-Based Integrated Management of Childhood Illness,
DESCRIPTION were launched in 1997.
Pilot program focused on prenatal care
and skilled birth attendance
Spearheaded by the UK’s Department for International Development, the Safe
Motherhood Project focused on increasing access to high-quality obstetric care. 45
TIMELINE
Although coverage was limited to nine poor districts in the western part of the country
1997–2002
(out of a total of 75 districts), or approximately 15 percent of the population, stakeholders
C OV E R AG E suggest that the Project led to a nationwide emphasis on safe motherhood.
Nine poor districts in the western
region of the country, though pieces In 2006, Nepal became one of the few countries in the region to have a specific skilled
were eventually scaled up nationally birth attendance policy. Between 2007 and 2011, the number of birthing centers in the
country almost tripled. 46S T U N T I N G I N N EPA L 19
In 2005, in response to research suggesting that women were not delivering in
facilities because of the travel expense, Nepal launched the Maternity Incentive Scheme,
later renamed the Safe Delivery Incentive Program. This initiative, which provided a cash
incentive to mothers to deliver at a facility, went through some growing pains at first. Most
mothers and many providers simply were not aware of it. Moreover, although the money
was supposed to be provided at the time of delivery to defray transportation costs, there
were long delays in disbursement. 47
By the time the program was renamed again in 2009—this time it was called Aama
A AM A (“ MOTH E R ” )
(which means “mother” in Nepali)—it was running more smoothly. Aama currently provides
DESCRIPTION free delivery services at accredited facilities and a range of cash incentives to improve
Incentive scheme to promote prenatal
both the supply of and the demand for prenatal care and facility-based deliveries—
care and skilled birth attendance
specifically, it pays both pregnant women for seeking such services and caregivers for
TIMELINE providing them. The facility delivery incentive varies according to the difficulty of reaching
2009–present (originated in 2005
under a different name) a health facility: it is $15 in the mountains, $10 in the hills, and $5 in the terai. 48
Women receiving 4 or more antenatal care visits,
assistance during delivery from a skilled provider, Nepal
ASSISTANCE DURING DELIVERY FROM A SKILLED 4+ ANTENATAL VISITS FOR PREGNANCY (ANC4+)
BIRTH AT TENDANT �SBA�
Percentage of live births in the five (or three) years
preceding the survey assisted by a skilled provider
80%
69%
60% 58%
PE R C E N T C OV E R AG E
40%
20%
14%
11%
0%
2000 2005 2010 2015
YEAR
Data source: Nepal DHS
Initiatives like Safe Motherhood and Aama, along with a strategic focus on maternal
and newborn care and a more robust health system, contributed to significantly better
health outcomes for mothers and their babies. In 2001, just 28 percent of pregnant
women received any prenatal care from a skilled provider. By 2016, that figure was 84
percent. Meanwhile, the percentage of women who made the recommended four visits
quadrupled, from 14 percent to 69 percent. Progress in skilled birth attendance was
just as impressive. In 2001, just 11 percent of pregnant women had a skilled attendant at
birth, compared to 58 percent in 2016. 49 This figure is especially impressive because of
the distance women have to travel to get to birthing centers. A 2006 survey found that,
in spite of the investment in the road system, women took on average 2.8 hours to reach
a birthing facility in the terai, 5.6 hours in the hills, and 8.3 hours in mountain areas. 50 Our
quantitative analysis suggests that these transformations in prenatal care and skilled
birth attendance contributed to the large improvement in intrauterine fetal growth and
early newborn nutrition.S T U N T I N G I N N EPA L 20
Community-Based Integrated Management of Childhood Illness (CB-IMCI) was
COM M U N IT Y-
designed to improve the detection and treatment of diarrhea, pneumonia, and other
BAS E D I NTEG R ATE D
M A N AG E M E NT OF common child diseases. (It is now called CB-IMNCI because community-based newborn
C H I LDHOOD I LLN E S S care was folded into the protocol in 2014.) In 1995, the World Health Organization and
(C B - I MC I) UNICEF launched Integrated Management of Childhood Illness (IMCI) as a global initiative
DESCRIPTION to bolster facility-based care. In Nepal, IMCI was implemented in a few facilities beginning in
Nepali adaptation of WHO/UNICEF 1997, but in 1999 it was adapted so that FCHVs could also provide care in the village; hence
protocol for diarrhea and pneumonia
management the addition of “Community-Based” to the name. 51 The program began in just three districts
in 1999 but was gradually scaled up to all 75. 52 FCHVs are now trained to diagnose and
TIMELINE
1999–present
treat routine cases of diarrhea and pneumonia and refer more serious cases to the nearest
health facility. Between 2001 and 2016, care-seeking for diarrhea and pneumonia in Nepal
increased substantially. For example, the proportion of children with acute respiratory
infections who were taken to a health facility increased from 26 percent to 85 percent. 53
Treatment of acute respiratory infection (ARI) and diarrhea in children, Nepal
Percent of children with ARI symptoms taken to a health facility and children with diarrhea symptoms treated with ORS
85% with ARI
80% taken to a
health facility
70%
PE R C E N T O F C H I L D R E N U N D E R FI V E
60%
50%
40%
37% with diarrhea
treated with ORS
30% 3 2 %
26%
20%
10%
0%
2001 2006 2011 2016
YEAR
Data source: Nepal DHS
Health Financing
By 2016, after two decades of investments in the health system and evidence-based
health programs, the health situation in Nepal had improved significantly. With a more
reasonable number of health facilities and health workers and a cadre of volunteers on the
front lines, care was indeed more accessible. Stunting, of course, was down by 47 percent
since 1995, child mortality rate was down by 67 percent (from 104 per 1,000 live births to
31 per 1,000), 54 and maternal mortality ratio was down by 61 percent (from 660 per 100,000
live births to 258 per 100,000). 55
Of course, this progress cost money, and the Government of Nepal had indeed
increased its spending on health significantly. Between 2000 and 2016, health spending as
a percentage of GDP increased by more than half—and GDP almost quadrupled. 56 Donor
contributions also increased.S T U N T I N G I N N EPA L 21
Overall, health expenditure per capita more than doubled, from $64 (2017 PPP-
adjusted US dollars) 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. 57 Almost 15 percent is spent by
donors. 58 Most of the rest is spent out of pocket, mostly on private providers, although
some public providers still illegally demand payment, too. 59 In 2017, Nepal passed the
National Health Insurance Act to address the problem of out-of-pocket payments; it is too
soon to tell whether it is working. 60
Health expenditure per capita by source in Nepal (PPP)
TOTAL HEALTH SPEND AS % OF GDP PREPAID PRIVATE GOVERNMENT OUT�OF�POCKET DEVELOPMENT ASSISTANCE
(e.g. insurance) FOR HEALTH (DAH)
$152 $160
$160 6.4%
$140 6.4%
$140 5.6%
$123
$120 $114 4.8%
P E R CA P I TA � P P P D O L L A R S �
$110
4.2%
H E A LT H E X P E N D I T U R E
$100 $94 4.0%
$92
$79 $78
$80 $74 $75 $75 $72 $73 $75 3.2%
$66 $69 $68
$61 $64
$60 2.4%
$40 1.6%
$20 0.8%
$0 0%
1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015
Data source: IHME health finance
Although Nepal’s investments in health have been based on the principles of access
and equity, the growth of the private sector suggests two things: First, the public system
has yet to solve its access problem, with 45 percent of people in the poorest wealth
quintile using private providers. Second, the quality of the public facilities is not high
enough, which encourages 60 percent of those in the richest wealth quintile to seek care
in the private sector, even though the quality of private-sector care is also uneven. The
burgeoning private sector means more people are receiving care, but it may be a barrier to
equity if it further impoverishes the poorest and provides the richest with better care. 61S T U N T I N G I N N EPA L 22
PIVOTAL PROGR AMMING II
EDUCATION
AC C O R D I N G TO O U R D E C O M P O S I T I O N A N A LYS I S , paternal and maternal education together
BAS IC PR I M A RY
account for 27 percent of the increase in HAZ among children. Possible pathways
E DUCATION
PROG R A M (B PE P) from parental education to improved child nutrition include greater earnings, greater
knowledge of healthy practices, greater decision-making authority among mothers, and
DESCRIPTION
Education program that began
greater desire for smaller families.
decentralization Nepali schools In 1990, primary school enrollment in Nepal was less than 70 percent, 62 and the youth
literacy rate was under 50 percent; for girls, it was just 33 percent. 63 That year, the World
TIMELINE
1992–1999 (BPEP I); 1999–2004 Conference on Education for All, convened by UNESCO, UNICEF, the World Bank, the UN
(BPEP II)
Development Program, and the UN Population Fund, met in Thailand. The conference
moved education, especially basic and primary education, to the top of the development
agenda, and donor funding increased considerably.
School enrollment, especially for girls, has risen significantly in Nepal
PE R C E N T PR I M A RY S C H O O L E N R O L L M E N T � A L L C H I L D R E N � GENDER PARIT Y INDEX (GPI)
1.08
1.06
100% 99% 1
PE R C E N T PR I M A RY S C H O O L E N R O L L M E N T
95%
G E N D E R PA R I T Y I N D E X �G PI �
90% 0.75
80% 0.5
0.45
70% 0.25
67%
66%
60% 0
1985 1990 1995 2000 2005 2010 2015
YEAR
Note: Gender
Data Parity
source: IndexInstitute
UNESCO (GPI) is the
forratio of girls to boys in education (of various levels). Its purpose is to measure relative access to education by gender.
Statistics
Data source:
Gender UNESCO
Parity Institute
Index (GPI) is thefor Statistics
ratio of girls to boys in education (of various levels). Its purpose is to measure relative access to education by gender.
In the early 1990s, the Government of Nepal responded to donor interest with a
E DUCATION FOR A LL string of policies to decentralize and improve education. The first, the Basic Primary
(E FA )
Education Program (BPEP), fundamentally reorganized the Nepalese school system.
DESCRIPTION Based on two successful donor-funded pilots from the early 1980s, BPEP created school
Education program that continued
decentralization of Nepali Schools
resource centers that would offer support to clusters of ten to 15 nearby schools. This
model allowed for meaningful decentralization and local engagement while addressing
TIMELINE
the lack of capacity at individual schools. Along with the structural reform, BPEP also
2004–2015
focused on the basics of education: new and renovated facilities, teacher training, and
classroom materials.
BPEP was succeeded by BPEP II in 1999, although the Maoist insurgency interfered
with its implementation; during the war, 2,000 schools were closed and 150 teachers
were killed. 64 Nevertheless, by the time BPEP II concluded in 2004, the education
landscape in Nepal looked considerably different than it had in 1990. The number of
primary schools had increased by 39 percent, and the number of students enrolled had
increased by 38 percent. 65S T U N T I N G I N N EPA L 23
In 2000, ten years after the original Education for All conference, the World Education
G OA L S OF E DUCATION
Forum met again in Senegal. The participants adopted a list of six goals to be achieved
FOR A LL
by 2015, and UNESCO led the global movement and coordinated international efforts to
1. achieve Education for All.
Expanding and improving
comprehensive early childhood care
In 2004, Nepal launched its Education for All (EFA) program, designed to increase
and education, especially for the most educational access, equity, and quality. EFA continued the trend of decentralization,
vulnerable and disadvantaged children;
transferring the management of more than 9,000 primary schools to local communities
2.
and making more resources available to schools through block grants. Education for All
Ensuring that by 2015 all children,
particularly girls, children in difficult got close to its equity and access targets; in 2011, 98 percent of Nepalese children, girls
circumstances and those belonging and boys, were enrolled in primary school. 66 However, quality was tougher to achieve:
to ethnic minorities, have access to a
complete free and compulsory primary attendance, promotion, completion, and learning outcomes were still low.
education of good quality; 2009’s School Sector Reform Program, a collection of loosely related initiatives to
3. continue to improve access, especially for children from marginalized groups, and quality,
Ensuring that the learning needs of all
which remained elusive. 67 Over the course of the plan, completion rates in primary school
young people and adults are met through
equitable access to appropriate learning increased from 58 percent to 81 percent.
and life skills programmes;
As of 2016, primary enrollment was at 97 percent and secondary enrollment at 55
4. percent. 68 (The secondary enrollment was down from a high of 60 percent the previous
Achieving a 50 percent improvement in
levels of adult literacy by 2015, especially year, presumably because of the 2015 earthquake.) The gender parity index for primary
for women, and equitable access to basic and secondary schools (the ratio of girls to boys) had jumped from 0.17 in 1973 to 1.08,
and continuing education for all adults;
which is in line with the trends across South Asia. 69 Compulsory basic education now
5.
lasted eight years instead of five, and instruction was provided not only in Nepali and
Eliminating gender disparities in primary
and secondary education by 2005, and English but also, where appropriate, in minority languages. The constitution guaranteed
achieving gender equality in education
every citizen the right to “free education up to the secondary level,” although school fees
by 2015, with a focus on ensuring girls’
full and equal access to and achievement and expenses for books, uniforms, etc., meant in practice education was not entirely
in basic education of good quality; free.70 Since many of these improvements, especially in the later years of the study period,
6. affected children who have yet to become parents, it is likely that we will continue to see
Improving all aspects of the quality of
education, and ensuring excellence of
the impact of these investments on stunting over the next decade or more.
all so that recognized and measurable However, there are still real problems. Overall, achievement is low. Large achievement
learning outcomes are achieved by all,
gaps separate students in public and private schools, in rural and urban areas, and in
especially in literacy, numeracy, and
essential life skills. homes where minority languages are spoken and homes where Nepali and English are
spoken.71 Moreover, graduation rates remain relatively low, with only 25 percent of upper
secondary school students completing their education in 2016. Most of those who
dropped out were impoverished or lived far away from school.72
WOMEN’S EMPOWERMENT
In line with other developing countries, Nepal’s Every analysis we conducted showed that
gender equity indicators improved substantially stunting reduction went hand in hand with women’s
between 2000 and 2016. The gender inequality empowerment. Most of the key drivers, including
index decreased from 0.670 to 0.497, and the gender maternal nutritional status, maternal education, and
development index increased from 0.769 to 0.925. maternal and newborn healthcare, are directly linked
Despite this improvement, Nepal’s ranking on the to women’s ability to make decisions for their own
gender inequality index is still relatively low—116 benefit, or for the benefit of their children. Even the
out of 160 countries—suggesting that there is more hypothesis that paternal education enabled men to
progress to be unlocked as women continue to gain leave the country for work depends on the fact that
power and status in society.73 women were left at home, running the householdYou can also read
