Adapting National Nutrition Action Plans to the Subnational Context: The Case of Nepal

This brief is part of a series of "interim" technical briefs, which will culminate with a final two-year study report in 2016. This technical brief begins with a background on the study and goes on to discuss the case of Nepal’s multi-sector nutrition plan. It then describes the global guidance for adapting national plans to local contexts, followed by evidence that was gathered during the study and that relates to the adaptation of Nepal’s National Nutrition Action Plan (NNAP) at the subnational level. The brief concludes with observations on how to match the plan’s goals with the nutrition needs of these districts most effectively. The intended audience for this brief is national- and district-level policymakers and nutrition practitioners.

This brief is part of the Pathways to Better Nutrition (PBN) case study series.

Background

National Nutrition Action Plans have the potential to serve as major catalysts for renewed commitment to nutrition. For maximum impact, these plans must be tailored to each district’s context prior to implementation. SPRING’s sub-regional snapshot series for Nepal shows wide variation in nutrition status, need, and capacities at the sub-national level. Therefore, it is critical to understand how districts and sub-district administrative structures can adapt NNAPs to their own contexts to maximize this movement’s impact on child and maternal nutritional status.

The PBN Case Studies

With funding from the United States Agency for International Development (USAID), the SPRING project is collecting data in Nepal and Uganda to document the decision-making process for prioritizing and funding nutrition-relevant activities within the context of their NNAP.

These “Pathways to Better Nutrition” case studies provide insight into how stakeholders view their role in moving the NNAP forward, what factors affect the type and number of funded NNAP activities each year, and the likelihood that the structures being built to execute the nutrition plan can be sustained beyond the first five years.

Methods Summary

This brief is based on the district data for the Nepal case study, collected from February to April 2015. Three districts–Achham, Kapilvastu, and Parsa–were chosen from the six priority districts that the Nepali government selected for early rollout of the MSNP. Data were collected via key informant interviews in the district and in one village development committee (VDC)1 per district. per district.

SPRING is working closely with the Nepal National Planning Commission (NPC) and its secretariat for this study. Key informants from the districts were selected to represent nutrition donors, United Nations (UN) organizations, the six MSNP-related government sectors, civil society organizations (CSOs), including implementing partners of programs such as USAID's Suahaara and the World Bank's Sunaula Hazar Din, and private sector organizations to ensure a balanced account of information, funding, and activities. At the VDC level, key informants were members of the Village Nutrition and Food Security Steering Committees.

All key informant interviews were transcribed and translated from Nepali to English. The research team discussed the key themes and patterns both during data collection in each district and shortly thereafter. These discussions generated the codes that were entered into NVivo (a qualitative data analysis computer software package), and transcripts were then coded accordingly. Thus, NVivo coding allowed the research team to identify common patterns, themes, and trends across all transcripts. Quotations included in this brief illustrate these patterns.

Further information and more about the methods.

The Case of Nepal

Background on Nepal’s Multi-Sector Nutrition Plan

Recognizing that chronic malnutrition remains a critical developmental challenge, the Government of Nepal launched a five-year NNAP called the Multi-Sector Nutrition Plan 2013–2017. The primary goal of the MSNP is to reduce maternal, infant, and young child malnutrition (MIYCN) by one-third (Government of Nepal and NPC 2012). The plan focuses on the 1,000-day window between a woman’s pregnancy and her child’s second birthday. Six government sectors are involved in the MSNP: health, agriculture, education, urban development (sanitation), women and child development, and federal affairs and local development. The plan complements existing sector plans and strategies, and it has three key outcomes:

  • Outcome 1: Improved policies, plans, and multi-sector coordination at national and local levels
  • Outcome 2: Improved practices promoting optimal use of nutrition-specific and nutrition-sensitive services, ultimately leading to enhanced maternal and child nutritional status
  • Outcome 3: Strengthened capacity of central and local governments on nutrition to provide basic services in an inclusive and equitable manner

The Process of District Rollout

According to the Government of Nepal and NPC (2012), two committees primarily conduct rollout of the MSNP at the subnational level:

  • The District Nutrition and Food Security Steering Committees (DNFSSC): The DNFSSC are led by the District Development Committee (DDC) chair and the district health officer is executive secretary. Members include representatives of line agencies, the District Nongovernmental Organization (NGO) NGO Federation, the District Chamber of Commerce, and donors/international NGOs (INGOs).
  • The Village Nutrition and Food Security Steering Committees (VNFSSC): The VNFSSC include the VDC secretary and representatives from the School Management Committee, the Health Facility Operations and Management Committee (HFOMC), the Ward Citizen Forum, the Agriculture Service Center, and the Livestock Service Center.

According to the MSNP, rollout at the district level was to occur in phases. VDCs were selected in each of six “prototype” districts for rolling out the plan in 2013, which happened as scheduled (Government of Nepal and NPC 2012). An additional 12 districts were to be added in 2014; however, in practice seven of the additional 12 were approved for rollout just recently in 2015 (NPC and National Nutrition and Food Security Secretariat [NNFSS] 2015).

SPRING focused on three of the six districts where rollout began in 2013. By early 2015, when SPRING visited these districts, all had set up DNFSSC and VNFSCC structures and had selected two focal persons per government sector as required. Table 1 shows the timeline for the three districts that SPRING tracked, including some other key MSNP-related milestones that aimed to increase the skills and capacity of nutrition stakeholders, to include subnational actors in the workplanning and budgeting processes, and to improve the flow of information across all levels of government.

Table 1. Timeline of MSNP District Rollout

ActivityDistrict
AchhamKapilvastuParsa
MSNP launchApril 2013May 2013June 2013
Regional training of trainers (RTOT) workshopFebruary 2014February 2014February 2014
Launch of major nutrition-related donor funding

July 2014 (USAID Suaahara)2

February 2014 (USAID Knowledge-based Integrated Sustainable Agriculture & Nutrition [KISAN] project)

April 2015 (USAID Suaahara)

February 2014 (USAID KISAN)

March 2014 (World Bank Sunaula Hazar Din3)

MSNP line item included in the National BudgetFiscal Year 2014–2015
District support workshop, KathmanduSeptember 2014September 2014September 2014
District-level refresher training and orientation on the MSNP planning process for Multi-Sector Nutrition and Food Security Action PlanMarch 2015April 2015February 2015
VDC-level refresher training and orientation on the MSNP planning process for Multi-Sector Nutrition and Food Security Action PlanApril 2015April 2015February 2015

In the 2013–2014 fiscal year, sectors received funds from the United Nations Children’s Fund (UNICEF) for MSNP implementation in the last quarter (April–June 2014). UNICEF also has helped finance workshops and training meetings for district stakeholders. For fiscal year 2014–2015 the Government of Nepal allocated 60 million NRS for the MSNP through a separate MSNP line item in each of the related sectors except health, since a separate line of MSNP funding is available for the health sector through UNICEF and USAID.

In addition, in early 2014 the NPC organized a six-day workshop called the Regional Training of Trainers. National-level stakeholders traveled to the districts to run the workshops. Attended by district stakeholders, the goal of the RTOT was not only for district officials to learn about the MSNP, but for each district to prepare work plans and budgets best suited to the district’s needs.

Global Guidance on Adapting Plans to Local Context

NNAPs implemented by the central government rarely provide lessons on how to implement an NNAP successfully at the community level.. Indeed, the Government of Nepal, through the Ministry of Federal Affairs and Local Development, has called for a “top down, bottom up” planning approach that decentralizes much of the planning and implementation of the MSNP. This recommendation emphasizes the importance of a sandwich approach to local development: the top’s willingness to enable an issue to gain prominence validates the bottom’s demands and actions (Fox 2015; Mansuri and Rao 2012).

From the evidence on decentralized planning processes in health systems, we know that success relies upon balancing a minimum level of skills and capacities with authority and accountability, as well as facilitating a sufficient flow of information (Hutchinson and LaFond 2004).

Progress in Adapting the MSNP to the District and VDC Level

Skills and Capacity

SPRING’s interviews at the district level revealed that awareness of, and enthusiasm for, the MSNP is high among all stakeholder groups across the three districts. Stakeholders consider the MSNP’s integrated and multi-sectoral approach to be very relevant, and many recognize that malnutrition is a barrier to development in the district. Dissemination of the MSNP’s objectives and approach through workshops and trainings, such as the RTOT, has helped to increase district stakeholders’ capacity to make better decisions on nutrition. This effort has raised the profile of nutrition as a critical development issue. Furthermore, USAID’s Suaahara program in Achham and Kapilvastu, and the World Bank’s Sunaula Hazar Din program in Parsa are both closely aligned with the goals of the MSNP. These donor programs have strengthened awareness on nutrition issues at the district level. Respondents reported the following key takeaways from the RTOT meetings:

  • The importance of the first “golden 1,000 days” for fetal development;
  • Understanding the underlying causes of malnutrition can help clarify how each sector can contribute to the MSNP; and
  • The importance of micronutrients.

Heightened awareness of nutrition in the districts has resulted in increased personal commitment to improving nutrition. The MSNP trainings have increased capacity by creating nutrition champions among non-health government stakeholders, who now advocate for more programming on nutrition.

Despite having a Master’s degree, I came to know about the golden 1,000 days of the baby only from that training...If I knew about it before, I would have given more care to my own family. After RTOT...there is drastic change in my working pattern. I am advocating that we must invest in nutrition and 1,000 days. I have told the VDC council that they should organize training programs, and if they don’t have the budget I will run the program.
– Government stakeholder (non-health sector), Kapilvastu

However, at the VDC level across districts, several stakeholders could not explain what the MSNP was or how it was supposed to affect their yearly planning. VDC capacity would benefit from more orientation to the MSNP objectives, approach, and activities.

Inter-sectoral coordination is viewed positively across districts. This coordination has been strengthened by the creation of the district-level MSNP steering committee.

Coordination between sectors is not a problem here. We don’t wait for invitation letters to participate in other sectors’ programs. A phone call is enough.
– Government stakeholder, Parsa

Coordination in the district is good. There is no difficulty. Meetings of the nutrition steering committees are frequently conducted every three months.
– Government stakeholder, Achham

While district stakeholders’ capacity has increased in terms of greater awareness and information on nutrition issues, there is a need for increased capacity in human resources, especially since the selected VDCs may be located at a considerable distance from district headquarters.

Current human resources are not adequate to implement the MSNP... [Number of] staff is the same, although programs have been added...
– Government stakeholder, Achham

We lack manpower to conduct MSNP effectively.
– Government stakeholder, Kapilvastu

Given the existing resources, both in terms of manpower and time available to implement programs due to funding delays, MSNP funds have been used to conduct training sessions in the VDCs. Respondents believe that awareness-raising is a good place to start, since there is a gap in this area due to cultural practices, superstitious beliefs, food taboos, and lack of information especially in the disadvantaged MSNP VDCs.

We focus on behavior change, as in this district we don’t lack food, nor green vegetables, fruits or dairy products. To be honest, the bitter truth is that the programs do not reach intended beneficiaries. We have realized programs for literate and easy-to-reach communities, but not for Dalits, Janajati, Adivasi communities. In MSNP we directly interact with 1,000-day mothers, we don’t focus on political leaders or only limit our activities to FCHV [Female Health Care Volunteers]...
– Government stakeholder, Kapilvastu

Authority and Accountability

In preparation for the 2014–2015 fiscal year, district stakeholders developed context-specific work plans with budgets during the RTOT. These work plans included new activities as well as strategies to strengthen ongoing ones. Stakeholders sent plans and proposed budgets up to the central level for approval.

This workplanning was meant to be the “bottom-up” component of nutrition planning, complementing the “top-down” planning at the central level. The system of bottom-up planning is expected to ensure that plans meet community needs. However, according to key informants, the final district plans that were approved and sent back to districts did not reflect planning done at the RTOT and showed little variation across districts, either in approved activities or in corresponding budget allocations. Respondents stated that planning was primarily a top-down activity.

We don’t have bottom up-planning. We are sending the planning based on what we feel to the central level. And central level sends us planning made by them. So, most of them are based on a top-down approach.
– Government stakeholder, Kapilvastu

We did planning at district level. But the center doesn’t give resources as per those plans; they provide it as per their own decisions. They don’t look at our demands which we made through our council.
– Government stakeholder, Achham

The bottom-up planning from the ilaka and VDC levels to the district-level is also top-down, as there is a lack of diligence in understanding community needs.

If you visit the people and ask them to prepare a plan in 2 hours, what can we expect the plan to be? The people in the VDCs have to be informed ahead of time about the visit, we have to mention the purpose of the visit and ask them to prioritize.... Most of the people are illiterate and have limited vision and thinking. How can a person prepare a plan in 2 hours? That is the reason why they ask for one cow, one goat.
– Government stakeholder, Kapilvastu

Several respondents were not well-informed of the plans that central ministries finally approved.

Should we be frank? Planning was done, and we supported that. But we don’t know what has happened afterwards.
– UN Stakeholder

Program on nutrition has been implemented; the only question is whether it is in line with the planning done in RTOT and Kathmandu....I don’t know.
– Government stakeholder (who did not attend the RTOT)

Flow of Information

Regarding flow of information related to funding and planning, the majority of respondents across districts noted that the MSNP’s own budget code signaled nutrition prioritization. However, there was also frustration at the delays in funds disbursement, insufficient communication from the central level on final budget allocation, and the reduction in total funds allocated compared to the amounts requested during the workplanning conducted at the RTOT.

Budget code might have come, but unless funds come in the district, there is no use of budget code.
– Government stakeholder, Parsa

To improve the flow of information on nutrition status and monitoring data, the MSNP has outlined a monitoring and evaluation strategy that tasks the NPC with bringing together the nutrition information systems of various sectors into an overarching logical framework (Government of Nepal and NPC 2012). However, there is either little awareness of the logical framework among district stakeholders, or little awareness on where the plans stand for creating one.

Monitoring plans [for MSNP] haven’t been prepared yet.
– Government stakeholder, Achham

No training has been given to us on monitoring the MSNP.
– Government stakeholder, Parsa

Recognizing the importance of monitoring across districts, government stakeholders mentioned that their districts planned to conduct joint-monitoring visits that would include all sectors.

We will conduct a joint monitoring involving all these agencies and later have an information sharing meeting...and reports and presentations...
– Government stakeholder, Kapilvastu

Observations

Table 2 highlights our key stakeholders’ observations thus far on how to increase skills and capacity, authority and accountability, and the flow of information to support MSNP activities in these districts. While experiences varied by districts, the following actions are relevant in all settings. SPRING will collect one additional round of feedback on these themes in early 2016.

Table 2. Observations from Key Stakeholders

RecommendationQuote
Skills and Capacity
1. Allow local-level expertise to inform the selection of target groups and of types of programs chosen for intervention

“Understanding by women only is not going to work. In my opinion we have to put husband and mother-in-law also together in the training; then only possible changes can be seen.” – Government stakeholder, Achham

“Still the males are the decision makers. So, mothers and families both should be given equal skills as well as knowledge.”– UN Stakeholder

“We have to consider the local community as well. People here tend to keep goats rather than chickens. There are many people who don’t consume chicken. Talking about mushroom cultivation, it won’t be possible here. Madhesi community don’t consume mushrooms.” – Government stakeholder, Parsa

2. Provide additional guidance from the central level for coordination and continue central-level funding prioritization for nutrition

“If we [district] demand funds for nutrition then there is fear of not getting budget for other physical infrastructure needs. It will be more effective if a framework and budget for nutrition programming comes from the central level.” – Government stakeholder, Kapilvastu

“The help [that the central level gives] should be more than what there is. There is gap in coordination and harmonization between central-level and district-level MSNP committees.” – UN Stakeholder

Authority and Accountability
3.Ensure equity between national- and subnational-level workplanning by implementing bottom-up planning processes as intended

“The ministry just cuts and pastes. They give the same [budgets and programs] for Illam as for Bajura or Darchula.” – Government stakeholder, Achham

“We convince farmers also…. We tell them that there is a clear mandate that 15% budget will be invested in agriculture sector and they can demand it from village council. They say that ‘our demands aren’t addressed and other programs are only done, what to do?’” – Government stakeholder, Achham (different from respondent quoted above)

4. Sensitize “social leaders” in every sector on the importance of nutrition and increase their authority to prioritize nutrition

“Social leaders are yet to realize the need for change and the need to focus on disadvantaged groups. Therefore, social leaders have to be made positive in nutrition matters....the priorities are always roads and infrastructure...” – Government stakeholder, Kapilvastu

“Sector offices should be informed that MSNP is not only the responsibility of the DDC but it is a joint responsibility.” – Government stakeholder, Kapilvastu (different from the respondent quoted above)

Flow of Information
5. Support monitoring of MSNP funding and activities to increase the flow of information on the progress and impact of MSNP activities

“Though the money has arrived, it is not clear how to do monitoring of MSNP and sector compliance....strengthening of district-level MSNP steering committee part is still challenging....we need to focus on appropriate use of funds...” – UN Stakeholder

“…nutrition focal persons in the district do not have any source of transportation. [A] …vehicle would enable us to monitor the programs properly.” – Government stakeholder, Kapilvastu

Conclusion

These findings from three MSNP districts in Nepal suggest that skills and capacity to support the MSNP have increased in these three districts. Stakeholders seemed invigorated to move toward these goals—and in some ways, nutrition champions have started to emerge. There is still work to be done to increase capacity, authority, and accountability for annual work planning and budgeting for nutrition, which will increase the number and breadth of nutrition activities that can be supported in each district. More time may also be needed to institute two-way MSNP information-sharing mechanisms fully from the VDC up to the central level, and vice versa.