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Mother and Child Health Care Programme Joint review of the MCHC programme by MoHP, MoE and WFP
16 September to 5 November 2011
Submitted by
Prof. Ramesh Kant Adhikari
Ms. Irada Parajuli Gautam
Table of Contents
Contents Pages 1. Background 1 – 3 2. WFP supported food based MCHC programme 3 – 4 3. Implementation arrangements 4 – 5 4. Monitoring and evaluation 5 – 6 5. Objectives and scope of the review 6 – 7 6. Implementation strategy of the review 7 7. Composition of the review team 7 8. Activities of the team 8 9. Observations 8 Findings, Observations and Recommendations I. Performance of the MCHC programme: Results 9 II. Operational modalities: Efficiency and appropriateness 10 III. Targeting mechanism 11 IV. Opportunities for integration 11 – 13 a. With WFP Programme 11 b. With development partners 11 – 12 c. With government programmes 12 – 13 v. Government and community participation 13 – 14 vi. Sustainability 14 – 15 vii. Monitoring of the programme 15 10. General impressions 15 – 16 11. Recommendations 16 – 18 a. Continuation of MCHC programme 16 b. Integration with government programmes 17 c. Evidence of effectiveness 17 d. Strengthening of the programme 18 12. Future steps 18
Annexes: 18 – 41 Annex I: Documents reviewed 19 – 20 Annex II: List of persons met and interviewed 21 – 24 Annex III: Summary of surveys and reviews of the MCHC 25 Annex IV: Literature review 26 – 27 Annex V: Nutrient content of fortified food 28 Annex VI: Summary of reports of review of the MCHC 29 – 30 Annex VII: Report from the field visit 31 – 38 Annex VIII: Background to HHESS and its synopsis 38 ‐ 41
Abbreviations: ANC: Ante‐Natal Care ANM: Auxiliary Nursing Midwife AIDS: Acquired Immuno Deficiency Syndrome BMI: Body Mass Index CDO: Chief District Officer CHD: Child Health Division CBOs: Community Based Organizations CP: Country Programme CMAM: Community Based Management of Acute Malnutrition DACAW: Decentralized Action for Children and Women DC: Distribution Center DADO: District Agricultural Development Office DHO: District Health Office DPHO: District Public Health Office DoHS: Department of Health Services DDC: District Development Committee DEO: District Education Office DAO: District Administration Office DFID: Department for International Development EDP: Extended Delivery Point ECD: Early Childhood Development EB: Executive Board FDP: Final Delivery Point FFEP: Food for Education Project FCHV: Female Community Health Volunteer FSMAU: Food Security and Monitoring Analysis FAO: Food and Agriculture Organization Gm: Gramme GM: Growth Monitoring GIP: Girls Incentive Programme HP: Health Post HMIS: Health Management and Information System HFoMC: Health Facility Operation Management Committee HHESS: Himalayan Health and Environmental Services Solukhumbu HIV: Human Immunodeficiency Virus HKI: Hellen Keller International IYCF: Infant and Young Child Feeding Kg: Kilogramme LDO: Local Development Officer LMD: Logistic Management Division
MCHC: Mother and Child Health Care MoHP: Ministry of Health and Population MSNP: Multi‐Sectoral Nutrition Plan MoE: Ministry of Education MT: Metric ton MDG: Millennium Development Goal MD: Management Division MLD: Ministry of Local Development MoU: Memorandum of Understanding MoAC: Ministry of Agriculture and Cooperatives MCHW: Maternal Child Health Worker MAM: Moderate Acute Malnutrition NFSCC: Nutrition and Food Security Coordination Committee NuTEC: Nutrition Technical Committee NFHP: Nepal Family Health Programme NPC: National Planning Commission NeKSAP: Nepal Food Security Monitoring System NLSS: Nepal Living Standard Survey NGO: Non‐Governmental Organization NHSP IP II: Nepal Health Sector Implementation Plan II NNPS: National Nutrition Policy and Strategy ORC: Out‐Reach Clinic PLW/PLM: Pregnant and Lactating Women / Pregnant and Lactating Mothers PNC: Post‐Natal Care PHC: Primary Health Center PRRO: Protracted Relief and Rehabilitation Operations SHP: Sub‐Health Post Sq.m: Square meter SPHA: Senior Public Health Administrator SWC: Social Welfare Council SMP: School Meal Programme RUTF: Ready to Use Therapeutic Food RHD: Regional Health Directorate UNICEF: United Nations Children’s Fund UN: United Nations UC: User Committee VDC: Village Development Committee VAM: Vulnerability Assessment Mapping WDO: Women Development Officer WFP: World Food Programme WHO: World Health Organizations
Executive summary:
Background:
Nepal, being aware of the poor nutritional status of its population, particularly of children and women, has developed appropriate policies from time to time and designing and implementing programmes to improve the nutrition situation. The World Food Programme (WFP) has been operating in Nepal since 1963 and responding to changing food security needs and national priorities. One of the programmes implemented by WFP has been nutritious food assistance to children in the primary schools and Early Childhood Development Centers (ECDs), and additional food assistance to girl children as an incentive in the primary schools in order to help increase school attendance of the girl children in partnership with Ministry of Education (MoE). Thus, when National Nutrition Policy and Strategy (NNPS) developed by Ministry of Health and Population (MoHP) required assistance to provide the fortified food supplement to Pregnant and Lactating Women (PLW) and children less than 3 years of age, namely the three agencies, WFP, MoE and MoHP agreed to work in partnership with each other to implement the Mother and Child Health Care Programe (MCHC) in Nepal.
Main objectives of the MCHC programme were to improve the access of PLW and children less than 3 years of age with an increase of calorie intake, protein and micronutrients thereby reducing anemia, underweight and stunting rates among the target population; and also improve the utilization of maternal and child health care services and better knowledge among the PLW about desirable nutritional practices. The programme was started in 3 Village Development Committees (VDCs) in 2001 and gradually expanded to 98 VDCs in 11 districts and gradually the numbers of VDCs were decreased to 47 by 2008. Under this programme, a monthly take‐home ration of fortified supplementary food is provided along with related maternal health services and growth monitoring and counseling services for children through government health facilities.
WFP is responsible for procuring and delivering cargoes of food supplements up to the Extended Delivery Points (EDPs) established under the Food for Education Project (FFEP) units of District Education Offices (DEOs). The FFEP Units/DEOs are responsible for entire logistics after this point which consists of distribution, storage, record keeping and reporting up to the Distribution Centers (DCs) or Final Delivery Points (FDPs). WFP provides partial support for the transportation of the food supplement up to the FDPs or DCs. It also partially supports the coverage of services of VDC‐based storekeepers at the health facilities at VDC level answerable to the MCHC committees working under the Health Facility Operation Management Committees (HFoMCs). WFP had also started NGO support system through the Himalayan Health and Environmental Social Services (HHESS) since 2007‐2008, an NGO committed to strengthening health services at the health facilities at VDC level and social mobilization at community level. The health facilities together with HFoMCs and MCHC Committee also provide guidance and assistance to the ongoing MCHC programme. A district level management and monitoring committee comprising representatives from various government line agencies, such as the CDO, DPHO, DEO, DADO, DWO and LDO
oversees the implementation of the programme besides corrective measures as and when necessary.
The programme has been continuing as a part of WFP Country Programme (CP) over the last 10 years with an overall future strategy is yet to be developed. A number of evaluation mission reports in the past and a more recent World Bank Health Sector Review of Nutrition programme had recommended for a review of the programme in order to guide a policy decision about its possible role in national nutrition plans and programmes. In addition, WFP has also been working in 2011‐2012 for implementation of the next 2013 – 2017 CP period. Thus, the WFP requires a review of the ongoing programme in the formulation of the future strategy for the CP activities.
A team of experts and representatives from MoHP, MoE, WFP and UN agencies was constituted and entrusted with the task of reviewing the programme and recommending a future course of action.
The review team, after receiving an orientation regarding the scope of work, reviewed the available documents about the programme, visited the field sites and interacted with the stakeholders and held consultations with the relevant officials at the central level.
Observations:
The team has thus made the following recommendations as a result of key observations during the course of the study:
a. Performance of the programme: The programme has been successful in reaching more than 90% of the beneficiaries and has resulted in improving the uptake of Ante‐Natal Care (ANC), Post‐Natal Care (PNC) and growth monitoring services. The Standard Performance Reports from the field sites show a significantly low prevalence rate of underweight children in the programme VDCs. The programme VDCs show a much higher rate of utilization of ANC services: 91% of pregnant mothers received ANC services in programme VDCs compared to the national 58% and the percentage of children getting growth monitored was reported to be 97.5% compared to the national averages of 33%. Similarly, the percentage of underweight children in the programme VDCs was reported to be 9.9% compared to the national average of 28.8%.
b. The implementation modality which consists of WFP deciding on the composition of the blended fortified food, ensuring its quality and safety and delivering it to EDP in the district headquarters and subsequently FFEP/DEO delivering to FDP has been working efficiently. Except for occasional disruption in the supply chain due to unavoidable reasons, the beneficiaries are being reached most of the time. There is no evidence of any leakage or pilferage or wastage of the supply.
c. Health Facilities, such as the Sub‐Health Post (SHP), Health Post (HP) and Primary Health Care
Centre (PHCC), with support from an NGO have been able to provide the ANC, PNC, growth monitoring and counselling services to the majority of targeted beneficiaries. A very high ANC and PNC coverage rate in programme VDCs supports this observation. However, the situation
was rather unsatisfactory when the programme was operational through Out‐Reach Clinics (ORCs) which was the general practice till 2007 under the ongoing MCHC programme.
d. The health facilities with support of the HHESS staff records and collects regular data regarding
the expected and actual number of beneficiaries attending the clinics and taking the take‐home ration every month. Number of children growth monitored and their nutritional status is also collected each month and reported to the District Public Health Offices (D/PHOs). The D/PHO forwards this information to Nutrition Section, Child Health Division (CHD), Department of Health Services (DoHS), MoHP. However, this information is not used and reported through the government’s HMIS reporting system at district level. The outputs of this programme are yet to be appreciated within the government’s HMIS reporting system.
e. The district food security monitoring and analysis system uses a number of indicators to
identify vulnerable VDCs which are in need of external assistance. The same system identifies the VDCs for programme through a consultative process carried out in the district. The VDCs once selected under the MCHC at district level under the existing identification system thus continue as being a part of the CP.
f. A review of related programmes implemented by government and development partners offer
openings for integrating MCHC programme with them. Child Grants Programme, food supplement for children less than 2 years of age in the Karnali region, Community Management of Acute Malnutrition (CMAM) are some of the government programmes which can make use of the technical experience gained under the MCHC programme. Similarly, the SUAAHARA of the United States Agency for International Development (USAID), the Decentralized Action for Children and Woman (DACAW) of the United Nations Children’s Fund (UNICEF) and the Community Based New Born Care Programme (CB‐NCP) of the Nepal Family Health Programme (NFHP‐II) offer such opportunities in other districts.
g. The MCHC Committees and HFoMC at health facilities and DDC, DPHO have been engaged in the
management and monitoring of the MCHC programme. There have been examples of VDC and DDC funds being mobilized to hire health staff to provide the health services along with the food supplement. Furthermore, in discussion with health officials it transpired that the funds available with DPHO can also be utilized for this purpose. However, contributions being made at local level by the line agencies will have made a significant difference in the long run the way the MCHC programme will be implemented along with food supplementation.
h. An estimated cost of US$ 96 for one beneficiary per annum has raised some concerns about
financial viability for the current nutrition programmes of the government considering its integrations at national level. As the aim of the programme is geared towards the most food insecure districts, where lack of food has been the major determinant of under‐nutrition, efforts to raise resources for this programme can highly be justified on the ground of food insecurity.
i. The present arrangements for monitoring and evaluation are to guide the implementation of the programme and generate certain output level data on key indicators and not to create evidence for the efficacy of such an approach. Thus, without the rigors of a robust research methodology ensuring coverage and compliance above certain level, it would be difficult to prove the effectiveness of the programme to improve nutritional status of children and women.
Recommendations: A: Continuation of MCHC programme: • MCHC programme is still relevant in the VDCs with high levels of food insecurity; however,
continuation of the MCHC programme should be linked with Vulnerability Assessment Mapping (VAM) in light of newer findings from Nepal Living Standards Survey (NLSS).
• MCHC programme should be initiated after a baseline survey followed by a midterm and end‐line surveys at specific points and collect information on impact indicators of interest in any given number of new programme VDCs.
• Beneficiary target age group should be brought in line with the policy of “One Thousand Days”
of the Government of Nepal (GoN).
• Mechanisms to support the health facilities in providing health services need to be strengthened given the Field Supervisors (FSs) continue to provide technical as well social mobilization services in the future.
• Exploring the government funds in addition to social mobilization will offer some opportunities
for the key stakeholders to further work in more effective ways ensuring local ownership.
B: Integration with government programmes: • Bring the Family Health Division (FHD) on board demonstrating their role in improving
maternal nutrition.
• Explore the possibility of working with Logistic Management Division (LMD) of the MoHP to supply food supplements specifically in districts where MCHC program is going on.
• Open dialogue with District Development Committees (DDCs) and D/PHOs to hire health staff
with funds allocated to VDCs and DPHOs or even hire the Community Based Organizations (CBOs) in order to support ANC, PNC, growth monitoring, recording, reporting and counseling activities in addition to further support for storage facilities at ORCs.
• Explore the possibility of including food supplement in the treatment protocol for the management of Moderate Acute Malnutrition (MAM) (with Nutrition Section of CHD). The programme to follow the national guidelines for CMAM
C. Evidence of effectiveness:
• Explore the possibility of including data from program VDCs as additional information as annex
to HMIS to highlight the effectiveness
• Continuation of MCHC programme should be combined with a study to look into the effectiveness of food supplement in programme VDC against control in food deficit areas.
• Partner in the research to be funded by DFID to study the efficacy of food supplement vs. cash
transfer vs. nutrition education vs. control. Specifically ask for the study to look into the efficacy of food supplement approach among food deficit population groups.
D. Strengthening of the programme:
• NGO support is vital for the success of the programme. However, this should be more for nutritional counseling. It will need different types of human resources to be employed such as nutrition counselor rather than health worker. Equally critical is also the issue of lack of adequate human resources at the local health facilities for health and nutrition programme like the ongoing MCHC, which would also require a number of technical staff to support overall service delivery mechanisms of the government at VDC level.
• Local resources of VDCs, DDCs and DPHOs can also be mobilized to hire health staff at the local level. This is being partially done at VDC level in order to fill in a number of vacancies of the government health facilities in coordination with the VDC, DDC and DHO personnel.
• FFEP staff members require further support in overall programme strengthening. The pool of
human resources available within the FFEP structure can help improve different components of the programme, such as logistics management, monitoring, supervision, distribution and support to essential service deliveries.
• Issues of storage facilities and human resources should be resolved before considering
distribution of food at ORC locations.
• Mechanisms that can strengthen HFoMC and MCHC committees should be supported and there should be provision of charging a nominal fee from the beneficiaries during the monthly MCHC clinics in order to supplement the needs for snacks, allowances, purchase of essential equipments and tools and other services within the discretionary powers of the local user committees.
• There should be a minimal package in order to help improve the capacity of the government health facility staff members.
1. Background
National context: Nepal Nutrition Status Survey 1975 was the first systematic effort to understand nutritional problems prevalent in Nepal. Though small scale studies conducted from time to time, which included multiple indicator surveillance surveys, provided some insights into the nutritional trends, the nation‐wide Nepal Family Health Survey in 1996 and Nepal Micronutrient Status Survey 1998 provided more up to date data on the subject. Since then, regular demographic health surveys have been conducted every 5 years. They have collected more reliable data regarding the prevalent nutritional status of the population and their determinants. A number of initiatives have been taken to improve the nutritional status of the Nepalese people starting with the national nutrition strategies 1978 and 1986. These strategies recommended that programmes address increased availability of food, improved awareness about food and nutrition and better health services to prevent illnesses that adversely affect nutritional status. These strategies aimed to improve nutritional status through interventions in the area of agriculture, education, health and women’s development. An attempt to have a coordinated action between these different sectors led the government to implement a Joint Nutrition Support Programme from 1985 to 1990. The late 1990s saw a change with more stress on the nutrition programmes implemented through the health sector. The focus was to lower nutritional disorders arising from the deficiency of such micronutrients as Vitamin A, iodine and iron. These programmes have achieved remarkable success in improving the micronutrient nutritional status. Nepal is being lauded for the success it has achieved in almost eliminating Vitamin A deficiencies and lowering the prevalence of iodine and iron deficiency states. However the general nutritional status revealed by weight and height related indicators is still a matter of grave public health concern. Malnutrition as indicated by prevalence of stunting, underweight and wasting among children less than 5 years of age is a significant public health problem in Nepal. Though there has been a gradual and steady decline in the prevalence of stunting (by 1.6 percentage points per year from 2006 to 2011) and underweight among children, there is not much improvement in the prevalence of wasting. Further, malnutrition in childhood continues as a trend particularly among women. This is indicated by the fact that one in four mothers with a child less than 3 years of age suffer from chronic energy deficit (as indicated by a BMI less than 18.5 kg/sq.m). In addition to these general indicators of under‐nutrition, women and children suffer from deficiency of iron (leading to anemia) and till recently of iodine and Vitamin A. Over the last 15 years, there has been significant improvement in Vitamin A and iodine
nutritional status. Though there has been some reduction in the prevalence of anemia it is still unacceptably high and constitutes a public health problem. The current maternal mortality rate at 229/100,000 live births is very high which accounts for 11% of deaths among women of reproductive age. Similarly, less than a third of the deliveries occur at health facilities and only 36% are attended by skilled birth attendant, still half way from reaching the MDG target.
The National Nutrition Policies and Programmes (NNPP) of the MoHP since 2004 had identified and implemented different approaches to improve the maternal and child nutritional status. However, a more holistic and comprehensive approach was needed to address the status of general under‐nutrition prevalent among women and children. A technical working group constituted by National Planning Commission (NPC) in 2006 was assigned the task of examining the different determinants of nutritional status and identifying strategies to address them. This technical working group suggested strategies to address inadequacies in child care practices, health services, status of women and food insecurity. However, it was considered incomplete as it had not identified strategies that need to be implemented through other sectors such as agriculture, education and women’s welfare. This exercise, in the course of developing a national plan of action on nutrition recommended the detailed assessment and gap analysis which reviewed the issues related to agriculture, food security and cultural practices. The Nutrition Assessment and Gap Analysis (NAGA) recommended a comprehensive nutrition programme through a multi‐Sectoral structure from the center to the village level. The NPC is currently engaged in finalizing a Multi‐Sectoral Nutrition Plan (MSNP) involving the MoHP, MoE, MoAC and MLD. The key MSNP development processes would benefit from a review of a nutrition related programme being initiated in severely food deficit areas in order to mitigate the problem of food insecurity for improving maternal child health and nutrition. Background of the MCHC programme: Household food insecurity is a significant determinant of poor maternal and child nutrition in Nepal. The Nepal Food Security Monitoring System (NeKSAP) has recently projected that 36 districts in Nepal will remain food deficit in 2011, despite a forecast of a surplus production of cereal grains by 110,000 MT for the year. The number of food deficit districts in Nepal has usually been between 41 and 49. Food insecurity is further compounded by poverty, illiteracy, lack of access to markets and lack of robust government‐led development programmes. Majority of the districts in the Far/Mid Western development regions have remained food insecure over the last past many years according to NeKSAP. Preliminary findings of Nepal Living Standard Survey (NLSS) 2011 report that 38% of the people in Nepal are unable to consume the required calorie intake. The proportion of people who consume less than the required calories is highest in the Far/Mid western development regions. In addition, the people living with poverty are also higher in the Far/Mid West than those in the Eastern, Central and Western development regions. According to the NLSS 2011, 46% of the population in the Far Western development region is below the poverty line compared to the national average of 25%, and 32%, 22%, 22% and 21% for the Mid Western, Western, Central and Eastern regions respectively. Thus,
the food insecurity in the Far/Mid Western regions is further compounded by poverty, thus aggravating food security situation. Food insecurity is an important determinant of under‐nutrition, particularly in the food deficit districts of the Far/Mid Western development regions. In response, the National Nutrition Policy and Strategy (NNPS) 2004 and 2008 had included fortified food distribution in these areas as one of the strategic approaches to reduce under‐nutrition. Similarly, the Nepal Health Sector Programme ‐ Implementation Plan II (NHS ‐ IP 2) for 2010‐2015 has also identified household food insecurity as one of the main causes of under‐nutrition and recommended food and nutrition services including child growth monitoring and promotion, micronutrient supplementation and food supplementation and other interventions for improvement of child survival and nutrition.
2. WFP supported food‐based MCHC programme The UN WFP, Nepal has been providing food assistance to PLW and children aged 6 to 36 months through the MCHC termed as ACT – 3 under the WFP CP since 2001‐2002 in alignment with the Government’s long term and interim strategic plans stipulated under the nutrition and safer motherhood programmes of the MoHP. A monthly take‐home ration of the fortified supplementary food is provided under the ongoing MCHC programme along with health services, growth monitoring and counseling by the government health workers based at VDC level with backstopping support from the Female Community Health Volunteers (FCHVs) and Traditional Birth Attendants (TBAs) in Darchula, Bajhang, Baitadi, Dadeldhura, Doti, Achham, Bajura, Salyan and Solukhumbu districts.
In order to meet the WFP’s Strategic Objective ‐ 4 of Reducing chronic hunger and under‐nutrition, the provision of supplementary food is intended to improve the nutritional status of targeted women and children and raise the awareness and utilization of community‐based out‐reach services. The food supplement is expected to improve the access of PLW and children less than 3 years of age to increased calorie, protein and micronutrients thereby reducing anemia, underweight and stunting rates among the target population. In addition, it is also expected to improve utilization of maternal and child health services and better knowledge among the PLW about desirable nutritional practices.
The programme was started as a small scale pilot project in 3 VDCs in the Far West and gradually extended to 98 VDCs in 9 programme districts over the years.
Initially, the programme was implemented through both the health facilities and ORCs. However, lack of human resources, appropriate physical facilities at the ORC locations beyond the government health facilities put a significant constraint on both health workers and beneficiaries in maintaining their privacy during the course of ANC and PNC and lack of proper storage facilities at the so‐called ORC locations prompted a slight change of strategy during 2008. A perception that ORCs were being turned into food supplement distribution points without proper counseling and health services was another reason for a shift of strategy. Under the changed strategy, food supplements began to be distributed from the government health facilities, such as the SHPs, HPs and PHCs along with ANC, PNC, growth
monitoring and counseling. Services would be resumed at ORC locations on condition that the VDCs, DDCs and DPHOs would have to start working together to help improve physical infrastructure much needed at these imaginary government locations with financial contributions as well as manpower support specific to the programme VDCs as a gesture of increasing local ownership. Some of the VDCs have started allocating certain funds from VDCs’ annual budget programme in support of health facilities and ORCs that have ongoing MCHC activities. In addition to all these important developments, an NGO has also been hired to provide technical, managerial and social mobilization support for the programme.
In 2010, a total of 29,000 beneficiaries with 19,550 children and 9,450 mothers in 51 VDCs of 9 programme districts with 8 in the Far/Mid Western regions and o1 in the Eastern region were assisted through the MCHC programme followed by a total of 26,000 beneficiaries with 17,820 children and 8,180 mothers being assisted in 47 VDCs in the same programme districts in 2011. Resources are reallocated in mid‐July each year as per the government’s fiscal year planning period, based on which number of beneficiaries differs slightly from one year to another. The MCHC programme covers mainly the local health facilities such as the SHPs, HPs and PHCs, whereas given basic facilities fulfilled at the ORC locations with support from the local government line agencies, the ORC locations are also used as points of health and nutrition service delivery including food distribution.
In order to help provide quality health and nutrition services and capacity building measures, WFP has partnered with Himalayan Health and Environmental Services Solukhumbu (HHESS) to provide health facility‐based technical and social mobilization services to local health institutions in all 9 programme districts. The complementary support being provided through the NGO staff in addition to the government health staff members at the forefront of programme implementation modality serves to encourage women and children in regularly accessing and utilizing available government health and nutrition related services at the health institutions.
3. Implementation arrangements
The MCHC programme is implemented through a partnership between MoHP, MoE and WFP. The MoHP, MoE and WFP have jointly signed a tripartite agreement for the implementation of the programme. Nutrition Section/CHD/DoHS is responsible for the MoHP, FFEP Central Office for the MoE and CP Unit for the WFP at central level followed by DPHOs and respective health facilities, FFEP Units/DEOs and WFP SOs at regional/local/VDC/health facility level respectively for overall monitoring supervision and support for implementation of the programme. WFP delivers cargoes or consignments of specific quantities of Super Cereal as per Call Forward (CF) based on demands of its Cooperating Partners (CPs) to the Extended Delivery Points (EDPs) managed by the FFEP/DEO staff members. The EDPs are located in the district headquarters in majority of the cases with some exceptions on geographical ground. The FFEP Unit then ensures food delivery up to Distribution Centers (DCs) or Final Delivery Points (FDPs) is responsible for the entire logistics on receipt, storage, handling, transportation, and distribution, record keeping and reporting. The FFEP has been handling logistics in Nepal since 1972 and thus has considerable experience and expertise in logistics.
The FFEP has district offices in each programme district with 10 to 15 staff dependent upon geographical location and the programme size. Health Facility and Operation Management Committees (HFoMCs) and MCHC committees consisting of beneficiaries, local representatives, social workers and some of the key health staff are the entities responsible for food management, preparation, and distribution, record keeping and reporting at the VDC level beyond the DCs. There are orientation and refresher trainings jointly organized by the government and WFP to build the capacity of these committees in carrying out their daily responsibilities. The MCHC project committees function as User Committees (UCs) which are responsible and entrusted with the task of transporting food from the EDPs to DCs or the FDPs.
Under the ongoing health facility based system, storekeepers under the MCHC committees and DEOs directly hand over Super Cereal to the representatives of the MCHC Committee for transportation up to the health facilities. The beneficiary receives 7 kg of Super Cereal of monthly supplement at the health facility during the fixed monthly MCHC clinic schedule on account of receiving ANC, PNC, growth monitoring, individual or group counseling as stipulated in the implementation guidelines. This is further verified by the health workers and storekeepers respectively on the basis of beneficiary card that each woman or child has from the health facility at the time of his or her registration as MCHC beneficiary prior to being entitled for the services. Health workers and NGO support staff together agree on the scheduled monthly clinic dates, timing and division of responsibilities mobilizing the HFoMC and MCHC committee members and Female Community Health Volunteers (FCHVs) for ensuring smooth delivery of government supported services. This is the main thrust of the MCHC programme to lower the prevalence of underweight among children and to lower the prevalence of anemia among the PLW assisting the government’s service delivery system with an aim to also reducing stunting in the future.
The HFOMCs and MCHC committees are responsible for managing food distribution including providing support to the ongoing clinic services with additional support from the community‐based FCHVs. The districts were selected in collaboration with/between WFP and government partners. The targeted districts are categorized as food insecure by the Food Security Monitoring and Analysis Unit (FSMAU) / Vulnerability Assessment Mapping (VAM) of the WFP Nepal.
4. Monitoring and Evaluation
The staff at the health facilities record information about the beneficiaries and the services provided to them on a standard programme reporting format. They compile the data every month and forward it to the DPHOs, which send it to the Nutrition Section, CHD, DoHS. The data contributes to overall service utilization statistics for the district and is fed into the Health Management Information System (HMIS).
In addition, the MCHC programme collects data required for monitoring the effectiveness of the programme every six months. The beneficiaries are randomly selected for interviews during their clinic visits with the use of a standard questionnaire, and based on the collected data monitoring reports are prepared. Although such reports are helpful in tracking the effectiveness of the process, more rigorous methods are required to assess the impact of the programme.
In 2010, an evaluation of the WFP Nepal Country Portfolio recommended the strengthening of the monitoring and evaluation of programme activities through baseline and end‐line surveys in order to ensure measurable evidence of WFP activities and demonstrate impact of the MCHC activity across targeted districts1. It was further suggested that WFP monitor areas where multiple activities are carried out, to capture synergistic programme impacts.
5. Objectives and scope of the review
Over the last decade, the MCHC programme has undergone several joint missions, reviews and surveys in the programme districts. Reports of two key WFP evaluation missions, the Country Programme Evaluation cum Appraisal Mission ‐ 2006 and, the Country Portfolio Evaluation Mission ‐ 2010 as well as the World Bank health sector nutrition evidence review 2011 have recommended a comprehensive review of this programme. The results, outcomes and recommendations of this review will be very important as input to the CP formulation. The new WFP CP phase for the period from 2013 to 2017 is in the offing and already in the process of being proposed to the Executive Board (EB) for approval.
Concrete recommendations are also needed for better integration of the MCHC programme into the national nutrition strategy and Multi‐Sectoral Nutrition Programme (MSNP) framework. The NHSP IP II mentions that the government is reviewing the case for large‐scale food supplementation, and hence this review will also provide added information in this regard.
The main objective of this joint review is therefore to review and assess the ongoing food‐based MCHC programme activities. In addition, it will provide recommendations for future intervention modalities, readjustment in line with national health and nutrition strategies and plans, and the development of a viable handover strategy beyond 2012‐2013.
The joint review was based on desk reviews of relevant documents (listed in annex 1), field missions and consultative meetings with key government and non government stakeholders including staff from the CHD and FHD of MoHP, National Planning Commission (NPC), External Development Partners (EDPs) and NGOs.
6. Implementation strategy of the review
The review team collected and analyzed information with the following goals in mind:
• Review of the performance of the programme • Analysis of the appropriateness and efficiency of the operational modalities • Analysis of the appropriateness of the targeting mechanism • Exploration of opportunities for internal integration of WFP activities and linkages with
government programs and development partner activities • Exploration of the potential for increased ownership and government and community
partnership • Assessment of the alignment of the program objectives with national policies and priorities
1 Summary Evaluation Report Nepal Country Portfolio. WFP/EB.2/2010/6‐B, September 2010.
• Review of the Monitoring and Evaluation strategy and the recommendation of necessary changes
• Review of the possible mechanisms and its potential integration into government programmes in order to make it sustainable.
• Identification of possible strategies in transition in line with government polices and priorities as well as global WFP strategic objectives and draft global WFP nutrition policy.
7. Composition of the review team
Six of the review team members were involved in both central level consultation and field level missions under the team leader. The names below in italics played more prominent role consulted for high level meetings and sharing of relevant documents at central level during the course of the review.
• Dr. Ramesh Kant Adhikari, Team Leader, Professor in Child Health and former Dean, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
• Ms.Irada Parajuli Gautam, Consultant, Maternal and Child Health Expert, Kathmandu • Ms. Sharada Pandey, Senior Public Health Administrator (SPHA), MoHP, Ram Shah Path, Kathmandu • Mr.Leela Bikram Thapa, Senior Public Health Officer, CHD, DoHS, Teku, Kathmandu • Mr. Girish Kumar Jha, National Statistics Officer, CHD, DoHS, Teku, Kathmandu • Mr. Amrit Bahadur Gurung, Senior Programme Assistant, UN WFP, Chakupat, Patandhoka, Lalitpur
• Ms. Jolanda Hogenkamp, Head of Programme, UN WFP, Chakupat, Patandhoka, Lalitpur • Mr. Jibachh Mishra, Programme Director, FFEP Central Office, MoE, Naxal, Kathmandu • Mr. Ravi Upreti, Deputy Programme Director, FFEP Central Office, MoE, Naxal, Kathmandu • Ms. Saba Mebrahtu (PHD), Chief, Nutrition Section, UNICEF, Pulchowk, Lalitpur from UNICEF • Ms. Pramila Ghimire, CP Coordinator, UN WFP, Chakupat, Patandhoka, Lalitpur • Ms. Sophiya Upreti, National Nutrition Officer, UN WFP, Chakupat, Patandhoka, Lalitpur
Nutrition Technical Committee (NuTEC) under the chairpersonship of Dr.Shyam Raj Upreti, Director at the CHD, DoHS, Teku, Kathmandu, provided guidance to the review team in overall processes.
8. Activities of the team
There were three main activities carried out by the review team as below;
• The team started the review process on 16 September 2011 with a meeting with WFP officials and focal persons; Ms. Nicole Menage, WFP Country Representative, Ms. Jolanda Hogenkamp, Head of Programme, Ms. Pramila Ghimire, CP Coordinator, Ms. Sophiya Uprety, National Nutrition Officer and Mr. Amrit Bahadur Gurung, Senior Programme Assistant for MCHC and discussed over the scope and objectives of the joint review mission.
• Field visit schedules and development of tools for collecting information were discussed within the team members.
• Field visits were carried out from 18 to 23 September 2011 to Dadeldhura and Doti districts in the Far Western region, and 17 to 22 October 2011 to Nepalgunj, Banke and Salyan districts in the Mid Western region.
Other key activities may thus be summarized in order of priority.
• Mid‐term report and review of the findings on 15 October 2011
• Meeting with government officials as well as with the EDPs from 15 to 28 September and 18 to 31 October 2011
• Discussion within WFP about the observations and recommendations on 02 November 2011
• Submission of the draft report on 14 November 2011
• Review discussion within WFP and second draft further submitted on 12 December 2011
• MCHC review dissemination meeting among key stakeholders at the CHD on 10 February 2012
9: Observations
The observations have been grouped in the following categories:
• Performance of the programme • Appropriateness and efficiency of the operational modalities • Appropriateness of the targeting mechanism • Opportunities for internal integration within WFP activities and linkages with government
programmes and programme activities of other like‐minded development partners • Potential for increased ownership and government and community partnership • Alignment of the programme objectives with national policies and priorities • Monitoring and evaluation strategy and recommendations for necessary changes • Mechanism for integration of the MCHC into government programmes for its sustainability • Possible strategies in line with government policies and priorities as well as global WFP strategic
objectives and draft global WFP nutrition policy.
Findings, Observations and Recommendations
I: Performance of the MCHC programme: Results
The MCHC programme was initiated in 3 VDCs in 2001 in two districts and subsequently expanded to 98 VDCs in 11 districts by 2007. It is currently into operation in 47 VDCs in 9 districts of Nepal. The programme is reported to have been discontinued for some time period due to a lack of resources within the WFP at certain places in the past. Initially the food supplementation was given out to the PLW and children aged 6 to 36 months through both the health facilities and ORCs. Over the last 3 years, the programme partners agreed to distribute food at the health facility locations following a number of key observations made by visitors during monitoring and supervision in the past. The HHESS, an NGO committed to the field of health and nutrition has been providing support for key MCH related services, such as the ANC, PNC, growth monitoring and counseling. HHESS was also entrusted with the task of logistic management in Solukhumbu district between 2007 and mid‐2011 and also providing the key
technical services on health and nutrition. The logistic part has now been completely handed over to the Nepal Government.
Positive results through the regular programme monitoring can thus be summarized below:
• About 9,450 mothers and 19,550 children aged 6 to 36 months were provided the Super Cereal (fortified blended food) during 17 July 2010 – 15 June 2011 (2067 Shrawan – 2068 Ashad) period. Each beneficiary received 7 kg of Super Cereal with a calorie value of 380 kcal and protein content of 15 grams (Gms) per 100 gms in addition to multiple micronutrients. Though the beneficiaries are expected to consume 100gms/day/child and 125gms/day/PLW, an extra amount of supplement is being given to compensate for unavoidable intra‐household food sharing in alignment with the “WFP’s Supplementary Feeding for Mother and Children (Operational Guidelines) – 1998”, “the Maternal and Child Health and Nutrition (MCHN) Toolkit – Nutrition, MCH & HIV / AIDS Programme Design & Support Division, April 2011”, “WFP Food and Nutrition Handbook”, and “FAO Human Nutrition in the Developing World 1997”. This was a humane and practical but costly approach.
• Beneficiary mothers and other community members expressed their happiness in getting the food supplement at the health facilities. Except for brief periods of interruption of food supply, the beneficiaries were satisfied with overall health and nutrition related services at both of the government health facilities and ORCs. They were happy with the quality of the food supplied and had no complaints about its texture, taste or consistency.
• The programme VDCs showed a much higher service utilization rate of ANC and PNC. 91% of
mothers received ANC/PNC followed by 97.5% of the children having growth monitoring including counseling in the programme VDCs compared to the national averages of 25% and 33% respectively. Similarly, the percentage of underweight children in the age group of less than 3 years of age was reported to be 9.9% in the program VDCs compared to the national figure of 28.8%.
The programme has thus achieved the expected outcome of improving the utilization of health services by pregnant and lactating mothers. Similarly, the impact on reducing prevalence of underweight among children also has also been met as expected. Furthermore, this additional support through the MCHC is reported to have made a significant contribution to the government’s regular health services at the local level.
II: Operational modalities: Efficiency and appropriateness
FFEP/DEO is responsible for the distribution of food supplement. It is the responsibility of WFP to deliver Super Cereal up to EDPs. The FFEP has the experience and network for efficient delivery to deliver food through local transportation modes available up to FDPs or DCs, from where MCHC committee members take the responsibility of transporting food further to the health facilities at VDC level. Logistics unit of the FFEP Central Office has been utilizing the existent logistics mechanism of the School Meal Programme (SMP) for handling, transportation and distribution of the Super Cereal also for the MCHC programme.
• The utilization of the existent logistic network has been a key strength of the programme. Except for a short period of interrupted supply, the FFEP has met with its obligations of delivering the supplement on time. The review team did not come across any complaint of wastage or leakages in the course of handling the Super Cereal.
• The relationship between DEOs and FFEP Units at district level seemed strained at places. These uneasy relations were said to have emerged following the policy of reorganizing the then FFEP structure in 2003‐2004 and its amalgamation with the DEO for a quick district level implementation or operational arrangement without proper shift of policy at the level of Department of Education (DoE) at central level. The FFEP staff originally came from the Nutritious School Feeding Programme (NSFP) having been a part of the Social Welfare Council (SWC) at a certain point of time in the past. The FFEP staff members are still treated as project employees outside of the government system and of temporary nature. Similarly, they mentioned that the escalating costs of transport and the lack of funds for programme monitoring work were some of the issues that would have to be addressed.
• As the FFEP/DEO delivers the Super Cereal, health facility staff seemed to take it as a part of the
DEO’s programme. To what extent the existing reluctance of the government health staff at both the district and VDC level are reluctant as a result of the DEOs having handled chunk of the MCHC resources for overall MCHC implementation can thus be an interesting topic for further study. Food distribution was considered an additional and burdensome work by some of the health personnel consulted with during the review mission.
• Food supplementation without necessary human resources and storage capacity at the ORCs
had created problems in the past, and reportedly did not help in improving the ANC, PNC, growth monitoring and counseling. Better coordination between the FFEP/DEOs and DPHOs is needed to address this problem. The Nepal Government’s ORCs which are imaginary delimitations within the complex geography of the Nepali villages across the country have faced huge challenges over the recent years in reaching beneficiaries at the grassroots level as the health and nutrition programme has increased in size while manpower constraints and poor infrastructure continue to exist. The WFP‐supported MCHC programme cannot address underlying causes of the problems alone facing the ORCs without consistent lobbying with the local government line agencies and a major shift of policy to improve the ORCs’ infrastructure at the central level.
• Some health personnel mentioned the lack of involvement of DPHOs and health facility staff in
the logistics management of the food supplement as a constraint. This, apparently, prevents the health staff taking the ownership of the programme. This fact needs to be discussed at the Nutrition Technical Committee (NuTEC) meetings or at some of the regular PCC meetings of the MCHC programme provisioned under the implementation guidelines.
III: Targeting mechanism
The programme has been in operation in the Far/Mid Western regions regarded as the most vulnerable in terms of food insecurity and high prevalence of underweight and stunting. In addition, an extensive exercise to identify the vulnerable population had been carried out to identify the VDCs for programme implementation. One of the VAM exercises had used a number of indicators such as food security, rate
of malnutrition, girl enrolment in primary school, access to education and health, percentage of Dalits, accessibility, presence of development agencies, gender disparity and impact of conflict. The targeting exercises were carried out to identify the VDCs in order for the WFP to be able to provide support through the Food for Assets (FFA), SMP and MCHC. However, blanket coverage for all the beneficiaries, despite differences in economic and educational statuses of the family and productivity, tends to raise questions whether there is any potential for wastage and leakages.
The FSMAU conducts regular review of food insecurity together and District Food Security Network (DFSN) shares regular updates on food security situation at district level among the key government stakeholders. The MCHC programme continues to operate in one VDC for a period of five years. The review team found that there had not been any such robust plans for carrying out for baselines, follow‐up, mid‐term review, programme evaluation and end‐line studies during the five‐year period of the MCHC programme. It is recommended that definite end points be identified at which a VDC is weaned off the MCHC programme without waiting for a period of five years. It will allow other more needy VDCs to benefit from the programme.
IV: Opportunities for integration
a. With WFP programme:
The MCHC programme is a part of the five‐year WFP CP period. The focus of CP is on long‐term development, the aim of which is to reduce irreversible, economic and social damage caused by malnutrition. The programme objectives are to help improve maternal and child nutritional status and use food as an entry point to improve access to education and health care. The programme is well integrated with the SMP which provides “mid‐day meals” to ECDs and primary school children and vegetable oil to girl children under the Girls Incentive Programme (GIP). The “life cycle” and “continuum of care” approaches are integrated in these programmes and is expected to improve nutritional, health and educational outcome through interventions starting during the fetal period and continuing till adolescence. However, it is surprising to note that there has not been any such synergy between the Protracted Relief and Rehabilitation Operations (PRRO) and the MCHC including the FFEP or the SMP. Possibility of the PLW falling out of the purview of PRRO needs to be seriously considered. It is necessary that the guidelines for selecting the beneficiaries take note of households headed by the PLW and consider to include and assign them lighter work load to justify their inclusion.
b. With Development partners
• UNICEF implements a number of programmes in the community. The DACAW programme uses mothers groups’ facilitation and mobilization for various development outcomes. Integrating MCHC with these programmes is a possibility but no link has been established so far. A link between these two programmes of the WFP and UNICEF was attempted through the signing of a MoU at the central level sometime during the WFP CP during the period of 2002‐2006. However, the collaboration did not seem to have had any outcome evaluation‐based continuity.
• Nutrition Section/CHD/MoHP and UNICEF have partnered to implement Community Management of Acute Malnutrition (CMAM). The CMAM programme identifies Severe Acute Malnutrition (SAM) and treats it at the Stabilization Centres (SCs) if the child is found to be suffering from life threatening condition and through Out‐Patient Treatment (OPT) programme, if the child has no life threatening conditions. Ready to Use Therapeutic Food (RUTF) is the main intervention used to treat SAM cases. However, there is no food supplement for children suffering for Moderate Acute Malnutrition (MAM). The MCHC programme has a possibility of developing partnership with the CMAM programme by using food supplement as an intervention to prevent MAM cases among children less than five years of age. The prevention and treatment of the MAM is also in line with the global WFP draft nutrition policy.
• Save the Children (SC) and HKI and a number of partners are in the process of implementing an integrated nutrition programme titled “Suaahara” very soon. Food supplementation is not a part of the intervention under this programme. However, food will continue to remain an important issue in the causation of malnutrition. It would be appropriate to develop linkages with the groups working through “Suaahara” initiative in Nepal as regards the ongoing MCHC programme.
• Nepal Family Health Programme (NFHP) had been implementing Community Based Newborn Care Package (CBNCP) in some districts in the Mid Western region. The NFHP resources can be used to monitor the weight of the babies at birth in those VDCs where the MCHC programme is being implemented. This information can provide some tangible information on the impact of the programme on birth outcomes.
c. With government programs:
• An initiative of the NPC to launch a Multi‐Sectoral Nutrition Plan (MSNP) in a phase‐wise manner starting with a few districts is in the advanced stage of development. A number of interventions under the government ministries, namely the MoE, MoHP, MoAC, MLD and MoPP have been identified. Food supplementation combined with IYCF counselling is one of the interventions identified by the health sector. It is an opportune time to advocate the MCHC approach for inclusion in this plan. The dissemination of this report could help serve this purpose.
• Nutrition Section/CHD/MoHP has begun to distribute food supplement for children aged 6 to 23 months of age, not exceeding 2 children per family, in five districts of the Karnali region. WFP has provided some technical input into this programme. The experience of the MCHC programme can contribute to better implementation of this programme in the long run. The officials within the MoHP are interested to learn from the experience of the MCHC programme in order to implement it in the Karnali region more effectively. It has been suggested that a pilot programme with the use of measurable valid indicators and a mechanism to ensure high level of compliance and follow‐up as
regard the food supplement would create enough convincing evidence and can thus be used for further advocacy.
• The current MoHP food distribution programme consists of supplying 1.5 kg of fortified food to children 6 to 11 months of age and 2.5 kg per month for children 12‐23 months of age. The food supplement is distributed from the health facilities and is linked with counseling on IYCF practices provided by the health staff and FCHVs. MoHP can draw on the experience gained in the MCHC programme in selecting appropriate food supplement, quantity and its supply, and in monitoring its impact on the pattern of health service utilization and outcome in terms of nutritional status of children.
• NHSP‐2 has recommended studying the possibility of food supplement or cash transfer for improving maternal and child nutrition. . The present report of the review of MCHC programme will provide some information for the policy makers.
V: Government and community participation:
The MCHC committees and HFoMCs at community levels are engaged at different levels of participation under the programme. MCHC Committees had practiced raising some funds from the beneficiaries terming it as participation fees ranging from 5.00 per beneficiary per month during the monthly clinic schedule at the given health facility. Purpose was to utilize the fund on account of the FCHVs’ involvement during the monthly MCHC clinic days, purchase of essential equipments, medicine and NFIs. It was learnt during the review that the practice was discontinued as a result of the government’s free health policy, according to which charging additional fees has been forbidden. Further probing into this matter of importance showed that any study had not been done about to what extent the free health policy would apply for programmes falling under compensatory heading and those falling under non‐compensatory heading in term of various government health and nutrition programmes at community level. Both DDCs and VDCs have annual funds to support the health facilities in Nepal. Considering countless claims and proposals for capturing the available funds at local level from various social and political groups, it is suggested that consistent lobbying would have to be made along with HFoMCs to enable health facilities to make use of these funds.
Discussion with the MoHP officials revealed that D/PHOs also have a budget to hire staff to run the programme at the health facilities. But it is unlikely that that such fund will be available specifically for the MCHC programmes.
• The MSNP has plans to create a Nutrition and Food Security Coordination Committee (NFSCC) at DDC/VDC level, which will use the “analyze, assess and act” approach to help improve nutritional status. The MCHC programme will have to prepare itself to be accepted as a necessary intervention particularly in the food insecure districts and VDCs.
• Information, Education and Communication (IEC) as well as other technical materials on nutritional requirements for the PLW and children aged 6 to 23 months; their importance, values of different food supplements, best way of making them available etc are needed for advocacy.
• Active MCHC committees and HFoMCs offer opportunities for integration, but their existing competence poses serious challenges.
VI: Sustainability:
• At the current level of expenses, each beneficiary costs US $96 per year. At the current rate of Crude Birth Rate (CBR) and Total Fertility Rate (TFR), there is a reduction in the number of pregnancies and is likely to be further reduced. Similarly, the NLSS 2011 has shown reduction in the poverty levels. Therefore, a targeted approach with a stress on food insecure areas with higher poverty level will reduce the number of potential beneficiaries. Thus, further VAM/FSMAU‐led studies coupled with technical research studies are needed to help identify more vulnerable populations in different districts in order to select and target more appropriate areas or community.
• It seems that in each VDC, there are usually three types of families: the first one has a food surplus and is not necessarily in need of food supplement support, but would by and large benefit from nutrition education. The second group is in need of occasional food supplement support during the so‐called lean seasons in terms of agricultural production, and has the potential to benefit from counselling arrangements at the government’s health set‐ups. The third group is reported to be the most critical and vulnerable one in need of both food supplementation and nutrition education and counselling. It is thus recommended that the future nutrition programmes will have to be planned considering these three specific groups of people residing in the identified food insufficient intervention areas. A blanket approach to provide benefits to all families is easier to implement but may not be effective in achieving the objectives of the programme. Thus, a more efficient identification strategy of the needy beneficiaries should be put in place so as to supply them with the supplement as a key recommendation in the future. The MCHC programme can contribute to DDC or VDC level nutrition coordination committee in providing thematic information on the costs of different supplementation approaches. The HHESS has suggested a typical community‐driven model of helping family members through preparation of nutritious food based on local‐food‐mix before discontinuing the programme terming it as a sustainable alternative.
• A research on the efficacy of food supplement against cash transfer, nutrition education or control is being commissioned with DFID support. The WFP, with its experience in running a food supplementation programme is in the right position to get involved in such a study and learn whether food supplement leads to better nutritional outcome, particularly among the food insecure population. Furthermore, till such time that the MCHC programme gets integrated in the national nutrition progamme, WFP can engage into a research organization to study its impact on nutritional status, anemia prevalence and utilization of health services in programme and non‐programme VDCs.
• Studies mentioned above will pave the way for the Nepal government to take over food supplementation as a desirable intervention to improve nutritional and health status of the population.
VII: Monitoring of the programme:
The current monitoring and evaluation system is apparently functioning well with regular data gathering and reporting to HMIS combined with periodic monitoring based on interviews on a standard format with the beneficiaries. However, the data collected so far is not usable to assess the change in the prevalence of anemia and maternal under‐nutrition. Partners can assess these indicators through measurement of weight and height of women beneficiaries to identify the mothers with chronic energy deficiency (a BMI of less than 18.5 kg/meter square) and periodic estimation of hemoglobin. In addition, collecting information on weights of babies at birth in those communities where CBNCP is being implemented will provide a valuable indicator to assess the impact of the programme
10. General impressions
• Beneficiaries have contributed to gradual institutionalization of the ongoing MCHC programme through active participation during the given monthly clinic schedules for both receipt of food supplement and accessing of the primary health care services. This is in contrast to the mixed feelings of some government officials and ambivalence on the food‐based approach.
• It was observed that the programme could not follow a very rigorous method of follow up and data management. Nature of the programme does not necessarily lend itself to the creation of scientific database that would statistically prove or disprove the efficacy and effectiveness of the intervention. However, monitoring reports show a considerable increase in utilization of the ANC, PNC, growth monitoring, nutrition education, counselling and other related promotional activities in the programme VDCs. This increase and level of improvement in accessing and utilization of the services available at the community level are reported to have become two‐fold in recent years through the NGO support system in certain limited technical areas of the ongoing MCHC programme. Additional support through the NGO has been provided citing reasons of apparent lack of resources within the health system in order to utilize the food supplementation on their own. Continuity of additional support to the government health facilities is still relevant for providing effective services under the MCHC programme.
• Logistics management is a contentious issue and Logistic Management Division (LMD) of the MoHP has shown willingness to undertake this task. It is desirable that a decision in this regard should be taken only after Nutrition Section, CHD/DoHS,MoHP takes a policy level decision on this proposition. A study should be carried out whether the LMD has the capacity to deliver the services in this connection or not. However, current FFEP structure is already an asset for logistics in terms of professionalism.
• The MoE officials are willing to continue to work under the present arrangement despite the fact that the output of their efforts is reflected in the health sector. However, if the present arrangements are to continue in the future, some input to strengthen the FFEP structure is required through further enhancement of budgetary capacity, training and material support as and when needed in critical areas of high demands for such support.
• Nutrition programme of the MoHP and development partners expect more robust evidence to support this type of intervention. WFP has a good opportunity to partner with independent agencies looking into different aspects of the food supplementation linking with an ongoing study commissioned by DFID.
11. Recommendations
There will be more targeted approach in place for the next phase considering food insecurity and nutrition indicators considering also other social and political realities while building up the overall targeting strategy. Sustainability is being addressed by including more synergistic efforts in the 2013 – 2017 WFP CP with more life cycle approach for food insecure areas. This is to be understood in terms of being a part of fulfilling key requirements of health and nutrition related services by the government health workers involving local stakeholders by the local people under the MCHC. The different aspects that play a crucial role in sustainable livelihood through life‐cycle approach will be the key in highly food insecure areas. Observations have shown that VDCs with support from user groups and community members have made significant contributions to the MCHC programme in hiring health workers, establishing ORC set‐ups and improving infrastructure at the health facilities and ORCs within the programme VDCs. It is also suggested that how food supplement can be a part of national health delivery system should further be explored.
Costs become higher while providing support in the remote, food insecure areas in Nepal. The government’s ongoing supplementary feeding programme under the MoHP for under‐2 children in the Karnali region and beyond indicates a priority being given to the supplementary, and the government and WFP can further collaborate in joining hands in areas of logistics and technical expertise of lessons learnt. One of the operational issues directly observed during field observations, such as further need for discussion on alignment of the monthly ANC services under the MCHC with the government’s 4‐times ANC visits would also be a pertinent area for further strengthening of the programme. It is also suggested that further linkages with the FHD in addition to the CHD would steer the programme in the right direction and more relevant in the context of “the golden 1000 days”. This is also highly recommended that the food supplement to the mothers and children should be incorporated into the ongoing MSNP document.
A: Continuation of MCHC programme:
• MCHC programme is still relevant in the VDCs with high levels of food insecurity. However, continuation of MCHC programme should be linked with VAM in light of newer findings from NLSS so that targeting strategy becomes more convincing.
• The programme in a new VDC should be initiated after a baseline survey followed by midterm and end‐line surveys at specific points and information collection on impact indicators of interest.
• Reconsider the target age group to bring them in line with government policies as well as WFP’s new draft nutrition policy which focuses on one thousand days and ”The Right Food at the Right Time”.
• Mechanisms to support the health facilities in providing health services need to be strengthened if food supplementation is to continue. The current approach of utilizing the services of a non government organization needs to be continued for some more time period in the future.
B: Integration with government programmes:
• Bring FHD on‐board demonstrating their role in improving maternal nutritional status.
• Explore the possibility of working with LMD of the MoHP to supply food supplements specifically in districts where MCHC program is going on.
• Open dialogue with DDCs and DPHOs to hire health staff with funds allocated to VDCs and DPHOs to support ANC, PNC, GM, recording and reporting activities, storage facilities at ORCs etc.
• Explore the possibility of including food supplement in the treatment protocol for the management of MAM cases in coordination with the CHD. The programme should follow the national CMAM guidelines and would require development of national guidelines for addressing MAM as well as integration with the existing national CMAM guidelines. Support for MAM under the CMAM is further necessitated by the fact that MAM cases constitute the majority of acute malnutrition burden. Hence, a provision of appropriate supplementary food in addition to other routine activities for children with MAM caseload will complement the preventive and therapeutic programme components in highly food insecure areas.
• The food supplement currently being used has a high level of acceptability among beneficiaries and affordable for the partners. New products with better nutritional content and efficacy should be promoted as these products contain animal source protein and are specifically designed for under‐2 children for the management of the MAM in particular.
C. Evidence of effectiveness:
• Explore the possibility of including data from programme VDCs into HMIS to highlight its effectiveness in coordination with the CHD.
• Continue and combine the MCHC programme with a study to look into the effectiveness of food supplement in programme VDCs against control in food deficit areas.
• Partner in the research to be funded by DFID to study the efficacy of food supplement vs. cash transfer vs. nutrition education vs. control, and explore whether the study can look into the efficacy of the food supplement approach among food insecure population groups.
D. Strengthening of the programme:
• NGO support is vital for the success of the programme. This should be more for nutritional counselling. It will need different types of human resources to be employed in intervention areas. Nutrition counsellors would be more beneficial rather than health worker. However, the health workers being currently employed by the HHESS have played a crucial role in overall strengthening of the government system at the health facilities.
• Local resources such as the funds of VDCs, LDO and DPHO can be mobilized to hire health staff at the local level. Part of the funds has been utilized on hiring of temporary health workers and building of minimal infrastructure at local level with support of the NGO.
• The FFEP unit is need of further support in areas of capacity building as per discussion held with the concerned personnel during the review. Issues of storage facilities and human resources will have to be settled before considering distribution of food from ORCs with support from both the local government line agencies and the NGO partner.
• Explore the existing mechanisms to help strengthen HFoMC and MCHC committees, essentially by resuming MCHC fund collection referring to the free health policy of the government and previous MCHC implementation guidelines.
• Support government health workers at the health facilities through orientation and training to develop their sense of ownership of the programme.
12. Future steps
• Disseminate the report to the NuTEC members and the concerned stakeholders.
• Present the review report to or at the NuTEC members or meetings.
• Revise the report in response to the comments made by the NuTEC members.
• Develop consensual approach on the future integration of the MCHC programme within the national programmes and modalities.
• Develop a roll out/exit strategy on the basis of consensus thus reached in the process of finalizing the final report.
Annexes:
a. List of documents reviewed b. List of persons interviewed c. Summary of surveys and reviews of the MCHC programme carried out between 2001 and 2010, per
district d. Literature review on the impact of food supplementation on maternal and child nutrition e. Nutritional Value of fortified food with a stress on micronutrient content f. Summary of reports of review of MCHC activity g. Report from the Field visit to Dadeldhura and Doti for a review of MCHC program
Annex I: List of documents reviewed
1. National Nutrition Policy and Strategy, February 2008, Nutrition Section, CHD, DoHS, MoHP 2. Nepal Nutrition Assessment and Gap Analysis, Final Report, November 2009 by Mr. Raj Kumar
Pokharel, Robin Houston, Philip Harvey, RamuBishwakarma, JagannathAdhikari, KiranDev Pant, RituGartaula for Nepal Government
3. Multiple Micronutrient Vitamins and Mineral Mix Powders Supplementation and the Community‐Based Infant and Child Nutrition Promotion Programme Strategy 2066, Child Health Division, Nutrition Section, DoHS, Teku, Kathmandu
4. National Nutrition Policy and Strategy – 24 December 2004, Nutrition Section, CHD, DoHS, MoHP
5. Relevant WFP strategic/policy documents 6. Follow‐up Survey in Makawanpur District for the MCHC by Valley Research Group, November
2005 7. Follow‐up Survey in Doti District for the MCHC by Valley Research Group, November 2005 8. WFP Nepal: Next Steps in Integrating Protection, December 2010 by Roger Nash, Consultant,
Emergencies and Transitions Unit (PDPT), Policy, Strategy and Programme Support Division, Rome
9. Baseline Survey for WFP, MCH Supplementary Feeding Project in Dadeldhura and Doti Districts by New Era, RudramatiMarg, KaloPul, Kathmandu, April 2001
10. Nepal Health Sector Programme Implementation Plan II (NHSP‐IP 2), 2010 – 2015, MoHP, 07 April 2010
11. District and VDC Level Nutrition Refresher Orientation Training Programme – MCHC Training Report – January 2010 by HHESS on behalf of WFP, CHD and FFEP
12. Orientation Training Workshop Completion Report for WFP’s MCHC Project in Doti District from 01 to 03 November 2000 by NTAG, Maitighar, Kathmandu
13. Operational Contract Agreed Upon By HMGN and WFP Nepal concerning MCHC Activity – Country Programme Activity – 3 for 2002 to 2006 CP Period
14. Country Programme Evaluation cum Appraisal Mission Report (21 May to 16 June 2006), WFP Nepal
15. Operational Contract Agreed Upon By Nepal Government and WFP Nepal concerning MCHC Activity – Country Programme Activity – 3 for 2008 to 2010 CP Period
16. Targeting methods – training material, Targeting Study – Field Visit Report, 17/06/2010 17. Food For Education Implementation Guidelines 2067, Nepal Government and WFP
18. Report on Baseline Survey of 4 VDCs of Solukhumbu District submitted to WFP by NTAG, Feb – Mar 2010
19. Baseline Survey in Baitadi, Darchula and Salyan Districts for the MCHC Activity (Draft Report) by Valley Research Group, June 2004
20. Compilation of the MCHC Review Mission Reports from 2005 to 2009 21. MCHC Joint Monitoring Mission Report, 12 to 15 September 2010 by Mr. Shankar Prasad
Acharya (Nutrition Section/CHD), Mr.AmritGurung (WFP) and Ms. Dolma Sherpa (HHESS) 22. MCHC Regional Level Internal Joint Staff Meeing, 22 September 2010 prepared by
Mr.AmritGurung (WFP) and Ms. Dolma Sherpa (HHESS) 23. MCHC Activity – Baseline Nutrition Survey, Phaperbari and Dhiyal VDCs, Makawanpur District,
Nepal, A report prepared and submitted by Andrew Thorne‐Lyman, Public Health Nutrition Officer, WFP, Rome, June 2002
24. Regional Level Review Workshop, MCHC Activity, Review Workshop Report by Mr. Shankar Prasad Acharya (Nutrition Section/CHD), Mr.AmritGurung (WFP) and Ms. Dolma Sherpa (HHESS), 20 September 2010
25. A report on Refresher Nutrition Training and Review Workshop from 05 to 07 July 2010 submitted to WFP by HHESS in July 2010
26. A Baseline Survey for Decentralized Planning for the Child Programme in Dadeldhura district – Final Report submitted to DDC Dadeldhura, MoLD and UNICEF, UN House, Lalitpur by New Era, June 1999
27. Baseline Study of food intake pattern of mothers and children in Gangkhet VDC, Dadeldhura District, November 2000 by Helen Keller International Nepal and UNICEF
28. National Plan for Action on Nutrition (NPAN, 2007 submitted to UNICEF Nepal by New ERA, January 2007
29. Food Utilization Practices, Beliefs and Taboos in Nepal – An Overview, May 2010 by USAID 30. WFP, Nepal: A sub regional hunger index for Nepal; Nepal Food Security Monitoring System,
2009 31. WFP: Right Food at Right Time 32. LM Neufeld: Evidence review of Food Products appropriate to achieve improved birth weight in
Nepal: (consultant’s report) 33. UN/SCN: Maternal nutrition and intergenerational cycle of growth failure: In Sixth Report on the
World Nutrition Situation, Dec, 2010
Annex II: List of persons interviewed
Dadeldhura 1. Mr. Hikmat Kumar Shrestha, DADO 2. Mr. Ramhari Das Shrestha, DEO 3. Mr. Keshav Raj Joshi, Unit chief, FFEP Unit 4. Mr. BalbahadurMalla, DPHO 5. Mr. KabindraShrestha, Senior PHI 6. Mr. GaneshDutta Joshi, PHI 7. Mr. PremlalLamichhane, CDO 8. Ms. SitaThapa, WDO 9. Ms. Yangze Sherpa, Coordinator, HHESS 10. Mr. UmeshSawad, HHESS 11. Mr. Kiran Pal, Director, WFP Regional Office 12. Ms. MeenaThapa, Focal person, MCHC programme, WFP 13. Mr. Tapeshwar Mandal, Senior AHW, Chamda Health Post, Ajaymeru VDC 14. MCHC committee members, Chamda Health Post, Ajaymeru VDC 15. Beneficiary mothers and children, Chamda Health Post, Ajaymeru VDC 16. Storekeepers, Chamda Health Post, Ajaymeru VDC 17. ANMs and FCHVs, Chamda Health Post, Ajaymeru VDC Doti 1. Mr. MahendraShrestha, Director, Regional Health Directorate 2. Mr. KuberKhadka, AHW, Mr.Yogendra Shahi, Field Supervisor, MCHW, VHW, FCHVs,
Banjhkakeni VDC 3. Mr. Netra Prasad Pant, Chief, FFEP Unit 4. Mr. TekBahadur Thapa, DEO 5. Dr. Raj Kumar Bhatta, Acting DPHO 6. Mr. Keshar Saud, Focal Person, Nutrition Programme, DPHO 7. Mr. Kishor Shrestha Statistics Assistant, DPHO 8. Mr. Prem Bahadur Khapung, CDO 9. Mr. Yagya Raj Joshi, DADO 10. Mr. Hem Raj Joshi, Gender Equality Officer, WDO 11. Mr. Chuda Mani Joshi, Officiating LDO Kathmandu 1. Dr. Mingmar Gyalzen Sherpa, Director, Logistic Management Division 2. Dr. Shyam Raj Upreti, Director, Child Health Division 3. Mr. Raj Kumar Pokharel, Chief, Nutrition Section, CHD 4. Mr. Leela BikramThapa, Nutrition Section, CHD 5. Mr. Manoj Upreti, Logistic officer, WFP 6. Mr. Luc Laviollate, World Bank
Salyan 1. Dr Kamal Gautam, Acting DHO 2. Dr. Bishal Shrestha, DPHO 3. Mr. Dhir Jung Shahi, DPHO 4. Mr. Dasharath Kumar Shrestha, PHI, DHO, 5. Mr. Vijaya Kranti Shakya‐ MCHC focal person , DHO 6. Mr. Peshal Kumar Pokhrel – LDO 7. Mr. Suresh Adhikari, DDC 8. Mr. Tej Prasad Poudel – CDO 9. Mr. Biswomaya Sharma‐ WCDO 10. Mr. Balkrishna Gaire – DEO 11. Mr. Ram Hari Rijal ‐Program officer, DEO 12. Mr. Rabindra Singh Bhandari, FFEP Unit, DEO 13. Mr. Ram Milan Prasad Biswokarma – DADO 14. Mr. Hem Bahadur Chand, Sr.AHW, In charge, SHP, Kupindedaha 15. Ms. Remanta Basnet, ANM, Kupindedaha SHP 16. Ms. Thum Kumari Kunwar, Storekeeper, Kupindedaha SHP 17. Mr. Moti Lal Bhandari, VHW, Kupindedaha SHP 18. Mr. Om Bahadur Budhathoki: Support staff, Kupindedaha SHP 19. Mr. Mume Kunwar, Chairperson, MCHC Committee 20. Mr.Ram Bahadur Kunwar, Chairperson, Village Committee 21. Mr.Krishna Bahadur khadka, Acting Chairman, VDC 22. Mr. Dhruva Nepali, Social Worker, Kupindedaha 23. Ms. Nili Reule, Beneficiary, Kupindedaha SHP: Kupindedaha 24. Mr.Deepak Kumar Yeri, Political leader, UCPN (Maoist) Kupindedaha 25. Ms. Kewat Kunwar: FCHV: Kupindedaha SHP 26. Ms. Bhima BK: FCHV: Kupindedaha 27. Ms. Pokhari Kunwar: FCHV: Kupindedaha 28. Ms. Seti Giri: FCHV: Kupindedaha 29. Ms. Gaimati Bohara: FCHV: Kupindedaha 30. Ms. Bishnu Kunwar: FCHV: Kupindedaha 31. Ms. Gople BK: FCHV: Kupindedaha 32. Ms. Daili Budhathoki: FCHV: Kupindedaha 33. Mr. Ghanshyam Pokhrel – Director, Regional Health Directorate, Mid Western region 34. Mr. Gyan Bahadur Bhujel – Health and Nutrition section, UNICEF, Nepalgunj 35. Mr. Nar BdrBudha – Maternal and neonatal health section, UNICEF, Nepalgunj 36. Mr. Biswo Nath Poudel – Program Manager – Nepal Family Health Programme, Nepalgunj 37. Mr. Birendra Khagunna‐ Program Manager, Save the Children, Nepalgunj 38. Mr. Ravi Mohan Bhandari‐ Health and nutrition, focal person, Save the Children, Nepalgunj 39. Mr. Shailendra Shahii‐ Engineer, Save the children Nepalgunj
Annex: III Summary of surveys and reviews of the MCHC programme carried out between 2001 and 2010, per district
SN Region Districts 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
1 Far West Dadeldhura BS Rev Rev Rev Rev
2 Far West Baitadi BS Rev
3 Far West Doti BS FS Rev Rev
4 Far West Darchula BS Rev
5 Far West Bajura
6 Far West Achham
7 Far West Bajhang
8 Mid West Salyan BS Rev BS Rev Rev
9 Eastern Solukhumbu Rev Rev BS
10 Central Makawanpur BS FS
Note: The MCHC programme was completely phased out from Makawanpur district in February ‐ March 2007.
BS=Baseline Survey
FS=Follow‐up Survey
Rev=Programme Review/Evaluation
Summary of selected indicators for Doti district2
Indicator Doti Baseline April 2001
Doti Follow‐up Nov 2005
Makawanpur Baseline 2002
Makawanpur Follow‐up 2005
Children 6‐36 months
Underweight 54.8 42.6 47.2 29.4
Stunting 48 49.6 43.9 42.3
Wasting 11.7 15.5 10.3 7.4
Anaemia 58.3 48.8 73.4 47.5
Pregnant and lactating women
2 Technical Annex – Mother and Child Health Care Programme. E. Girerd-Barclay, June 2006.
Anaemia (pregnant) 55 30.4 66.9 43.1
Anaemia (lactating) 26.9 34.3 73.5 22
Night blindness (pregnant) 6.1 5.4 11.6 3.9
De‐worming‐tablets (pregnant)
2.5 50.7 ‐ 25.5
Iron‐supplements (pregnant) ‐ 37.5 ‐ 36.3
Seeking antenatal care (pregnant)
29.3 73.2 22 49
Annex IV: Literature Review specific to food supplementation and pregnancy outcome 1. Allen L, Gillespie S: What works? A review of efficacy and effectiveness of nutrition
interventions; UN/ACC/SCN Nutrition Policy Paper no. 19, Asian Development Bank 2001: This review has taken a life cycle approach in identifying the impact of malnutrition in the developing world. It has considered the different programmes for their efficacy or effectiveness. According to the authors “efficacy refers to the impact of an intervention under ideal conditions, when the components of the intervention (e.g., food supplements) are directly delivered to all the individuals in the target group (i.e., 100% coverage). This is possible under research conditions with a high level of supervision. Effectiveness refers to the impact of an intervention under real world conditions, when prorgrames are scaled up to reach large proportions.
A number of programmes were reviewed related to five major nutrition problems; low birth weight, early childhood growth failure, iodine deficiency disorders, anemia and Vitamin A deficiency. A comprehensive review of the existing knowledge of the efficacy of key nutrition interventions for preventing and alleviating low birth weight is summarized below:
Low Birth Weight: South Asia has the highest prevalence of low birth weight babies (about 30%) and this is strongly associated with under nutrition of mothers. LBW is probably the most important reason for underweight children in this region. Therefore, interventions to reduce the prevalence of LBW should receive highest priority. Randomized controlled intervention studies have shown the following:
‐ Supplementation with food containing a balanced protein and energy content (protein contributing less than 15% of the energy) during pregnancy significantly increases the birth weight.
‐ Though the expected benefits from maternal food supplementation in Asia are yet to be shown, a number of studies in Gambia have shown positive effect. Women with lowest weight from conception to early pregnancy and lowest energy intakes are most likely to benefit from supplementation.
‐ Young maternal age at conception is a risk factor for poor pregnancy outcome, therefore targeting mothers who are still growing will be beneficial. Continuing supplementation during lactation and subsequent pregnancy may cause even better outcome.
‐ Micronutrient supplementation during pregnancy is extremely important to reduce the prevalence of maternal anemia and its consequences including reduction in maternal mortality. Adequate iodine supplementation in pregnancy is critical for the prevention of neonatal deaths, LBW and abnormalities in physical growth and cognitive development.
2. Lancet Nutrition Series: Lancet 2008: Bhutta ZA, Ahamed T, Black RE, Cousens S Dewey K, Giugliani E, et al: What works? Interventions for maternal and child undernutrition and survival The authors reviewed 13 studies and one systematic review to summarize the understanding regarding the outcome of balanced protein energy supplementation on pregnancy outcomes. The systematic review included 6 studies with information on size at birth. The systematic review was heavily influenced by a large trial in Gambia that targeted pregnant women of low BMI, who were supplemented with 700 kcal per day. The pooled estimate showed that this strategy reduced the risk of Small for Gestational Age baby (which was taken as to indicate intrauterine growth restriction) by 32% (relative risk 068, 95% CI: 0.56 to 0.84). The key message from this study was stated by the authors as “interventions for maternal nutrition (supplementation with iron folate, multiple micronutrients, calcium, and balanced energy and protein) can improve outcomes of maternal health but few have been assessed at sufficient scale”.
3. Imdad A, Bhutta ZA: Effect of balanced protein energy supplementation during pregnancy on birth outcomes; BMC Public Health 2011; 11: S: 17 This article presented a more recent systematic review of the impact of balanced protein energy supplementation on birth outcome. The review reported that providing women with balanced protein and energy supplementation during pregnancy resulted in significant reduction in the risk of giving birth to Small for Gestational Age infants (relative risk: 0.69, 95% CI: 0.56 to 0.89). Pooled results showed that the balanced protein energy supplementation resulted in an overall significantly higher mean birth weight. (58.99 gm 95% CI: 33.09 to 86.68 gms). This effect was more pronounced in women with evidence of malnutrition (74.90 gm 95% CI: 42.42 to 107.6 gm) compared to adequately nourished women (27.8 gm, 95% CI: 19.57 to 75.31 gm). The effect of balanced protein energy supplementation on neonatal mortality was not statistically significant (relative risk 0.63, 95% CI: 0.37 to 1.06).
Annex V: Nutrient content of Fortified Food ‘Supercereal’ distributed under MCHC programme
Nutrients
Vitamin and Mineral Requirements in Human Nutrition,
FAO‐WHO 2004
Nutrient content (Native plus Premix)in WFP Supercereal*
RNI/day for Pregnant women
RNI/day for Lactating women
Per 100g
Kcal 380
Protein, % of energy 16.4
Fat 6.0
Carbohydrates
Iron, mg 23‐27 30 8.2
Folic acid, µg 600 500 Fola (128.3)
Fola_DFE (170.3)
Retinol, µg 800 850 499.2 µg**
Vitamin D, IU 200 200 6mcg/240 IU***
Vitamin E, mg 9.5
Vitamin C, mg 50 70 101.2
Vitamin K, µg 55 55 39.5
Thiamine, mg 1.4 1.5 0.4
Niacin, mg 18 17 9.1
Vitamin B2, mg 1.4 1.6 0.6
Vitamin B5, mg 6 7 2
Vitamin B6, mg 1.9 2 1.1
Vitamin B7, µg 30 35
Vitamin B12, µg 2.6 2.8 2
Zinc, mg 11‐20 14‐19 6.6
Copper, mg 0.4
Selenium, µg 28‐30 35‐42 26.3
Iodine, µg 200 200 40
Sodium, mg 1.7
Calcium, mg 1200 407.8
Potassium, mg 498.3
Phosphorous, mg 350.1
Magnesium, mg 220 270 70.4
Manganese, mg 1
Biotin, ug 1.5
* Wheat Soya Blend with Sugar Annex VI: Summary of reports of review of MCHC activity Date Title Reviewers Objectives Findings Recommendations
April 2005 (Nov 2004 to Feb 2005)
MCHC review mission’s report
Dr.Genequand
Dr.Gartaulla
Ms. Ghimire
Ms. Kudsk‐Iversen
To assess the overall imp’tion process and to suggest actions for improvement
1.No specific funding in DHS, freq transfer of trained staff to non‐progr districts
2.Insufficient staffing at NS of CHD
3.Lack of coord’tion btw MoHP and FFEP ofMoE
4.Inactive DCC, no provision for NFPerson in the prog district,
5. Inadequate equip,instruments in ORCs, S/HPs, no staff for recording and reporting
6. MCHC members help in running ORCs but are not supported in any way(no money
Ensure appropriate MoH funding (WFPN &ODB mission) Policy decision not to transfer staff (DHS)
Strengthen the HR in NS, CHD to seek fund
(WFPCO to help)
MoHP/DHS to have control over the log man of MCHC act (transport and
for snacks or tea), the reports sent by MCHCC to S/HP and onward to DHO are incomplete & irregular
6. No ORC building for running ORC
7.No refresher training for the staff of S/HPs,
8. UNICEF/DACAW run areas showed marked reduction in UW prevalence
9.GTZ had provided equipment to 1 ORC in Doti
10.Follow up survey reports showed lowering in UW rates in M”pur, less so in Doti, red in anemia prev more in M’pur and less so in Doti, increase in ANC and PNC practices and GM rates
food )
Hold DCC meets regularly, NFP to be nominated from DHO WFP SO and DHO to train supervisors and NFP,
DHS to develop minimum std for equip and services at S/HP & ORCs, allow money raised during food dist to be used by MCHCC or DHS funding for this purpose
DCC to explore possible NGO support for equipments to ORC
MCHCC to be provided funds for tea & snacks, members to have exposure visits to well run prog areas
Regularize recording and reporting
WFP to seek support for construction of ORC buildings or procure curtains to create privacy for ANC and PNC
Refresher training for S/HP staff and
FCHVLearn from DACAW exp; explore possible help form GTZ for equipment
WFP to organize a meeting of INGOs to discuss the possible collaboration
Explore the possibility of making the nutrimx available at an affordable price in local market. Advocate for the use of locally available food to meet the daily req of PLM and children
May 2009 MCHC activity: A joint review of WFP and UNFPA collaboration at community level, Jogbudha and Shirsha VDC, DDL
Ms.Meena Thapa
Mr.Ganesh Shahi
To learn the lessons from the joint implementation process an recommend actions for future effective collaboration in common VDCs
Utilization of nutrimix at HH level: Health staff believed that the ben shared NM with other members; NM was consumed within 15‐20 days though it was supposed to last for the month
There was no problem with the distribution of NM in both VDC
Ben knew the content of NM A reduction in the prevalence of UW was reported from both VDCs according to DHO report
ANC and PNC use has increased but home deliveries are still prevalent
UNFPA should continue to support S/HP with ANM, training and enhance awareness about MCHC
Expand collaboration to other VDCs
July 2008 MCHC Madhav To assess and Comprehensive recording and Better ownership
Activity: Review report on the NGO support
Sapkota
Ms.Elaine Reinke
BBAmatya
Raju Neupane
LB Thapa
Prakash Shakya
NT Sherpa
Niraj Shrestha
review the NGO modality options in areas of food distribution, utilization and maximization of existing health services and facilities
reporting system for monitoring system was designed and implemented which was very effective
Effective utilization of MCHC funds available at S/HP for ANC and PNC services, better services at S/HP compared to ORCs.
Staff members of awareness about possible losses found to be high, better storage arrangements
by the health facility staff
Better coordination between MCHC and HFOMC needed
Minimum stock level at FDP to last for at least 2 months, need for lead time between commodity received and distribution
Wooden pellets recommended for some storage sites
Concerned about an exit strategy
Annex VII: Report from the Field visit to Dadeldhura and Doti for a review of MCHC programme
1. Notes from different meetings: 19 September 2011, Monday, 02 Ashwin 2068 Mr. Hikmat Kumar Shrestha, Senior DADO The first person we went to meet was Mr.Hikmat Kumar Shrestha, District Agriculture Development Officer (DADO). He is a member of the District Food Coordination and Monitoring Committee (DFCMC) responsible for monitoring the MCHC programme. He was very supportive of the programme and felt that awareness regarding consumption of nutritious food which is locally available should also be promoted. He explained that Soyabean, maize and corn are produced locally and these could be used to prepare the nutritious meals for pregnant and lactating mother. He also talked about food security monitoring system using a number of indicators to monitor the food situation in the district. According to him, Dadeldhura is not badly off in terms of food security. In his opinion, there are three categories of people in the district; landless, small landholders and big landholders. He suggested that MCHC programme along with nutrition education should continue for the first two categories and the nutrition education alone would suffice for the big landholders as they produce enough.
Mr. Ramhari Das Shrestha, DEO
The second person we went to see was Mr. Ramhari Das Shrestha, DEO. His office has the FFEP Unit responsible for overall implementation of the SMP and GIP and also for the logistics management of the ongoing the MCHC programme. Mr. Keshav Raj Joshi who we met at the office is the officer in‐charge of the FFEP. DEO is one of the key DFCMC members under the Chief District Officer (CDO). Mr. Shrestha mentioned about his involvement in the monitoring process time and again. He was supportive of the programme but mentioned the difficulties his office has had to face to continue the work, for instance, running the transport vehicle, unavailability of funds for monitoring or inadequate funds for storage and transport. When asked about what he thought about a programme having a host of output indicators related to health, he was not very specific in his answer. He said he supported the programme but needed more support. Mr. Joshi of the FFEP said that his office exists only for logistic support to provide food to schools and this facility has been utilized to deliver meals to health facilities. Thus, it is a part of their job. However, he asked for more support for transport and monitoring. He pointed to the fact that the cost for transport is about NPR 25,000 to 30,000 per month and the budget last year was only Rs. 350, 000, and this year it has been reduced to Rs.150, 000 and there was no budget for monitoring at all. Mr. Amrit Gurung from the Country Office who was one of the review team members explained that WFP funds 50% of the cost under Internal Transport and Storage Handling (ITSH) budget and it does not include costs for monitoring. CHD of the MoHP used to support with annual budget of Rs. 100, 000 for monitoring in the past. It has now been discontinued for some time. Later in private conversation Mr. Joshi mentioned the difficulties he faces from the DEO in logistic management. He mentioned that it would be better if the DEO is not involved on logistic management on daily basis.
Mr. BalBahadur Malla, DPHO
Mr. Bal Bahadur Malla, DPHO, Mr. Kabindra Bista, Senior PHI and Mr. Ganesh Dutta Joshi, PHO offered us their insights into the different aspects of the MCHC activity. Mr. Malla was not very articulate and was more cautious in his responses. He let Mr. Bista talk most of the time. Mr. Malla opened the meeting by saying that the MCHC is a good programme ongoing in 7 VDCs. It had allegedly interfered with the functioning of the ORCs as the PLW did not come to the ORCs as Super Cereal was available only through the SHPs and HPs. Thus they would rather prefer to go to the health facilities rather than going to the ORCs. However, when the ORCs also started providing the Super Cereal with the help of the HHESS, the ORC attendance began to improve. He felt that storage facilities at a place nearby ORCs would facilitate the distribution of Super Cereal. When questioned about workload associated with the distribution of Super Cereal, he said that it had indeed increased the workload of the staff at health facilities, but beginning the NGO’s involvement, things have improved over the year functioning with the system of providing services an average number of 80 beneficiaries per clinic day. He appreciated this practical approach adopted by the NGO at local level in consultation with the DPHO in the past. The DPHO is preparing groundwork for alternative options given the exit strategy being much talked about the WFP as well as the CHD in the past with silent issues such as what next if the NGO support has stopped or what plans the health facilities have in the case of the MCHC being phased for a strong fallback position for the rural poor women and children. DPHO as suggested by the DFCMC has corresponded with to the government in order to be able to utilize a part of VDCs’ annual development
funds under the headings of health and nutrition so that the health facilities can use the funds for their own capacity building and infrastructure improvement. He was quite happy with the logistic support provided by the FFEP. He was wondering whether the FFEP could be asked to transport the supply to the ORCs. Mr. Kabindra Bista felt the program strengthening is needed and NGO support necessary in future as well. In his opinion, there should be a certain amount of budget for monitoring. A focal person in nutrition would help strengthen the programme. He also felt that the scarce human resources at the SHPs and HPs are hampering smooth delivery of services at the health facilities. He informed that the Super Cereal is a good attraction for the PLW as shown by the decrease in the number of service users coming to health facilities when the supplies were interrupted for 5 months from Falgun 067 to Shrawan 068. Mr. Ganesh D Joshi also offered his suggestions to improve the health services. He suggested micro planning at the VDC level, adjusting the health services to the recent population.
Mr.PremlalLamichhane, Chief District Officer:
Mr.Lamichahne welcomed us though it seemed he was not informed of the appointment. He was familiar with the MCHC programme as chairperson of the DFCMC. He thought that it was a good programme and the people deserved it as the district was prone to food deficiency and natural disaster. However, he advised us to consider the sustainability aspect as well. He also suggested that efforts to help improve water supply and hygiene also should be enhanced.
Ms. Sita Thapa, WCDO
We had reached her office without any prior appointment yet she was quite welcoming. She had joined the office only a few months back. She recounted her experience during her posting in Solukhumbu district, where there was a tradition of watermills to grind cereals and legumes into flour. She opined that local people should be encouraged to consume flour made of corn, soya and wheat, which is available in plenty and food distribution should be discontinued, given the resources necessary to an extent possible available with the donor organization. She said that such activities are not sustainable and only increase the dependence. When Ms. Sharada Pandey asked whether she was aware that the locally prepared or eaten food items lacked multiple micronutrients or not, she conceded that in such cases, distribution of the enriched food could be justified. She was familiar with the program as she was also a member of the DFCMC.
Observation of the storage facilities at DEO
On the way out from WCDO office, we drove to DEO office again to see the storage of food supplements. A rubber tent known as “Raubhall” within WFP was seen to have been used in the DEO premises for storage of sacks, packets, jerkins and containers of WSB or Super Cereal, vegetable oil and belonging to the SMP, GIP and MCHC. The storehouse looked clean and well‐organized.
Visit to HHESS Office, RFO
We visited the HHESS entrusted with the main tasks of providing support to DPHOs and health facilities in the region on behalf of the WFP Nepal under the MCHC programme. Ms. Yangze Sherpa, PHO and
Mr.Umesh Sawad, Field Supervisor and their colleagues briefed us about the ongoing status of the MCHC programme in the region. The HHESS has been providing technical and social mobilization support under the MCHC for about three years in the region. The FFEP/DEO and DPHO have worked together as per the operational guidelines; the FFEP solely responsible for overall logistics at EDP and beyond, and the DPHOs for delivery of health services and programme implementation. Mr. Girish Kumar Jha, National Statistics Officer from the CHD raised some valid concerns about the viability of the MCHC data in the perspective of the government’s HMIS. The issue raised was whether data presented to the team members was for the whole fiscal year or based on quarterly report comprising an aggregate of the last four months. Mr. Sawad explained that the number of beneficiaries was only for a period of 4 months. The HHESS staff presented how they were entrusted with the tasks of providing support to the health facilities and ORCs and ensures delivery of key health and nutrition services, such as the ANC, PNC, growth monitoring, nutrition education and counseling.
Visit to WFP Regional Office
We drove to the WFP SO around 4 pm. We had a very stimulating discussion about the MCHC and the need to continue the programme. Mr. Kiran Pal, HSO mentioned about the demand for the MCHC from other VDCs and districts indicating that it is a very popular programme with the people. However, due to certain limitations in the health facilities, for example absence of key government staff and their quick turn‐over, the MCHC is unlikely to demonstrate the impact it had aimed at. Ms. Meena Thapa, Focal Person for the MCHC briefed us further on the ongoing statuses in individual programme districts. She explained that the programme was designed to operate along with ORCs but due to ineffective functioning of the ORCs, for instance almost 300 beneficiaries to be provided with health services per day as well as the distribution of Super Cereal led to questioning of the quality of the services, it was decided to shift distribution of food supplement through health posts. It was first piloted in Solokhumbu by the HHESS and the experience gained through the pilot programme was used to implement similar approach in the FW/MW regions. Now, the distribution is mainly through health facilities but attempts to improve the ORCs are also under way. The HHESS is helping health facilities to increase PLW attendance as well as the quality of health services in addition to more smooth distribution of the food supplement. Most of the health facilities distribute food only 5 days a month with an exception for over 10 clinic days in some of the VDCs, and not more than 80 beneficiaries get the services. This has considerably helped improve the services to a great extent. However, there was a pipeline break break for about 6 months starting Magh 2067 and continuing up to Shrawan 2068. This had caused a drop in the attendance of beneficiaries at the health facilities. The support provided by HHESS was appreciated by the DPHO and Nutrition Focal Officers. When asked whether the VDCs could be asked to look after the strengthening of the ORCs, Ms. Thapa gave a mixed reaction. Belapur VDC had used local resources to upgrade birthing centre whereas Jogbudha VDC had used the user fees to improve their facilities. However, user fees can not be used any more as government had abolished it by making all services free of cost. There is a possibility that VDC grants could be used for health purposes but the absence of an elected body is a big constraint in this effort. She also opined that the absence of health staff at the health facilities is a major constraint to fully achieve the objectives of the MCHC programme. As a consequence, food supplements become the main attraction for visiting the health facilities and not the
health services. Ms. Thapa, upon being asked about the future of MCHC responded saying that it should be linked with the MAM cases and better targeting would be required to demonstrate the impact of this programme. However, other members of WFP staff present in the meeting were doubtful about the feasibility of targeting the services in those VDCs where blanket coverage has been the practice.
We had a general discussion about other activities of the WFP such as SMP, PRRO and GIP, particularly how the WFP along with the government would better target the beneficiaries through the FFW, CFW and take home ration provisions. We also briefly talked about the need to better inform the opinion builders in the society in order to generate support.
20 September 2011/Tuesday/3 Ashwin 2068
Chamda Health Post, Ajayameru VDC
Staff at the HP
We had a meeting with Mr.Tapeshwar Mandal, SeniorAHW and in charge of the health centre. He has had CMA background in Surkhet district way back in 1988. It was his first experience of working in a health post. He confessed his ignorance of various recording and reporting systems for which he had to rely on his junior colleagues. He was clinically more competent and said that he had conducted 36 deliveries in one year since he joined the health centre. The regular ANM was deputed elsewhere leaving only one AHW working on volunteering basis under the National Volunteer Services (NVS). There was no administrative staff practically making his life difficult. According to what transpired in the discussion, the MCHC programme was mainly handing out food supplement to the PLW and children less than 3 years of age. According to him, much needed to be done in areas of nutrition education and counseling indicating areas for improvement in terms of the NGO staff members supposed to be doing those extra things at the health facility.
HFoMC and MCHC Committee members
We also talked with HFoMC and MCHC members. The HFoMC members expressed their limitation to help the health facility as the VDC does not have enough funds and are not in fact in a position to convince the village council to allocate funds for hiring additional health staff on temporary basis at the health facility level. MCHC committee members were unhappy that the money they could raise some funds as easily as being done in the past with the consent of the beneficiaries for tea and snacks for the volunteers, but the provision of raising the funds was suddenly discontinued through a central level correspondence based on free health service policy without considering the local realities. They expected some funds to support the MCHC programme on urgent action basis.
Beneficiaries
I (“I” herein would mean the team leader) also went out to interact with the mothers and children having arrived at the health facility as per MCHC clinic monthly schedule and also waiting for us to talk to them. There were about 10 infants and young children ranging from 2 to 21 months of age. All of them looked well‐nourished or well‐fed. All the mothers said that they had benefited from the Super
Cereal handed out at their health centre. Talking with the mothers gave us lot of optimism. I had a lurking doubt that probably these mothers were from better off families and probably did not need the food supplement. There was no food supply for the last six months according to the storekeeper further verified by the mothers themselves. One of the mothers I was interacting with had a child aged about two months, and probably weighed 2 kg in my observation. The questioned still lurked in my mind the child did not look that malnourished despite the pipeline break on the part of the WFP in the past few months.
I noticed another problem of growth monitoring having a Salter scale without Infanto‐meter. There was a measuring tape hanging on the wall which could be used for measuring the height but not the length. Majority of the child beneficiaries were of less than 3 years of age and it would be inaccurate to record their height. However, I was told later that there was an Infantometer in the birthing centre.
21 September 2011, Wednesday (04 Ashwin 2068)
Travel to Dipayal, Banjkakeni SHP and Silgadhi, Doti
The distance from Dadeldhura to Dipayal is about 50 km and we covered that distance within 1 hr and 45 minutes.
Mr.Mahendra Shrestha, Director, Regional Health Directorate, Dipayal, Doti
Mr.Shrestha was an MPH student at the IoM and I knew him well. After a round of introductions, we started to talk about the MCHC programme. Mr. Shrestha felt that it was a good programme but had some reservations on the way the beneficiaries are being targeted with a blanket approach. Limited coverage was also one of the limitations that the MCHC had had compared to other health and nutrition related development programmes in the region. He thought linking it up with the MAM cases and the women with low BMI would make it more effective. When asked whether it would be possible to make it a large programme with a targeted approach, he agreed that the people used to the ongoing blanket coverage would definitely protest and make health workers’ life more difficult. However, it would be acceptable in the new areas. When asked about whether the MCHC committees could charge the beneficiaries a nominal amount of participation fees, he expressed that it should be possible on the basis of the MCHC still falling under the non‐compensatory heading in financial terms.
Visit to SHP, Banjhkakeni VDC
We left for Banjhkakeni SHP around 12.20 pm. After travelling for about two hours, we reached the spot, where we had to leave the vehicle and walk to the SHP. The starting point of the trail presented rudimentary steps on a rocky face. We took around 20 minutes to reach the SHP from the road‐head.
Mr.Kuber Khadka, SHP in‐charge, MCHW and VHW were present at the SHP. Some mothers and a few FCHVs were also present for the meeting. The storekeeper hired by the HHESS to support the MCHC programme was also present. Mr.Yogendra Shahi, an employee of the HHESS had arrived to facilitate our visit. There were very few men at the meeting. On being asked why there were very few men present for the meeting, the women replied that majority of the men were out of the village working in
India on seasonal migration. They come back home only once in a period of two to three years. Women manage the households in the absence of their husbands. The women looked thin though some of them looked quite cheerful and were very articulate. They praised the food supplementation programme and said that it considerably improved health and nutrition status of the women and children in the village. They demanded that it should be continued for a few more years. It should include children up to the age of five years. Upon being asked whether other VDCs also should receive it, they said that others also should get it but not at the cost of having to lose the ongoing MCHC programme in the name of providing the Super Cereal to the beneficiaries residing in the adjoining VDCs. The MCHW was categorical that none of the villagers out of a population of 5,100 was in a food surplus situation. Almost each household in the village was dependent upon purchase of food from the nearly local market for over five months of the year.
22 September 2011, Thursday (05 Ashwin 2068)
Mr. Netra Prasad Pant, FFEP Unit, DEO
We drove to the FFEP office for a meeting. We were briefed about the programme by Mr. Netra Prasad Pant, FFEP Unit in‐charge. He had written down whatever he had to tell us and used the notes for the briefing quite attractively. He explained his work and the difficulties as regards his position and resources cum authority. He thought the programme was good and it should continue. He was still a project staff meaning a temporary employee for the last 16 years or so. He also wanted some support for monitoring activities, improved coordination with health staff and more support for transport expenses.
Mr. TekBahadur Thapa, DEO
Mr.Tek Bahadur Thapa, DEO of the district, seemed to be quite new to Doti. He was transferred from Salyan district only three months back and still needed a lot to learn about the district. He did not know much about the programme but thought that it was a worthwhile programme for continuity. He suggested that community ownership would be helpful to make it sustainable.
Dr. Raj Kumar Bhatta, DPHO
Our next stop was at the DPHO to have a meeting with Dr.Raj Kumar Bhatta. He was present at the meeting with us during the absence of Mr. Shri Krishna Bhatta, DPHO. We also started to chat with Mr. Keshar Saud, focal person for nutrition programme. He had been working in this office for last one year and did not have much experience of the ongoing MCHC programme. Mr.Kishor Shrestha, Assistant Statistician was more knowledgeable about the programme instead. He informed us that the programme was originally implemented in 16 VDCs but later limited to only 8 VDCs. Originally, the food distribution was done through the ORCs but shifted to HPs and SHPs later with the general findings thast the ORCs would rather promote more of food distribution than delivery of government health services as per guidelines. The problems were all related to the lack of proper physical facilities at the ORCs as originally envisioned in the guidelines and project documents at the beginning of the programme.
Dr.Bhatta instead did not know much about the programme and kept quiet during most of the conversation.
Mr.Prem Bahadur Khapung, CDO
We drove to CDO office from the DPHO for another round of meeting. Mr. Prem Bahadur Khapung, CDO was originally from Terhathum district but currently a resident of Kathmandu. He was a very careful person who noted our names and later even our telephone numbers. He did not know about the programme and thanked us for informing him about it. He was not involved in any monitoring exercise as well. He said that the efforts to increase the local production should be accelerated and fruit plantation can improve livelihood of local people. When asked about food security situation in the district, he advised us to visit the DADO for more information.
Mr. Yagya Raj Joshi, DADO
We walked to the DADO from the CDO’s office just across the street. Mr. Yagya Raj Joshi was the senior Agriculture Development Officer (ADO). He was from Dadeldhura district and was here for over a year. His family was in Kathmandu but liked it here and wanted to change the agriculture practices of this area. He did not agree with the concept of handing over food brought from outside as it was not sustainable and fostered dependence. He talked about his experiments to grow improved variety of pears by transplanting them on the wild varieties widely found in the forests of Doti. He was not sure how it would develop.
WCDO
WCDO and her deputy were both out of town and Mr. Amrit, one of our colleagues advised that we would better consult with Mr. Hem Raj Joshi, Gender Equality Officer at the WCDO for more past information on the MCHC. He was a former employee of the WFP, as a junior engineer on a short term SA contract hired for about half of the year way back in 2003‐2004 for construction of 12 storehouses at the 12 ORC locations of the ongoing MCHC programme in 3 programme VDCs of Doti district at that point of time.
The project had received some financial backing from a Japanese NGO, and later ran out of funds, and the project did not get its original drive for expansion of the storehouse construction project for improvement of the ORCs in the programme VDCs, not only in Doti, but across the programme VDCs in other districts as well. He advised the programme needed to continue in other areas as well in more food insecure areas. He shared an interesting story from the past memory of his that the people of his village still ask about the MCHC programme and the way it was withdrawn citing reason of having to move to other areas as well. This is something that villagers find hard to understand despite providing timely information sharing of the nature and extent of any development project.
DDC
Our final meeting was with Mr. Chuda Mani Joshi, an OIC ‐ LDO. He thought the MCHC programme was a good programme and wanted it to be expanded to other VDCs as well. He said if the DDC is going to be
asked for financial assistance to the going MCHC jointly by the key programme partners and other local stakeholders, a proposal can be tabled during the VDC council meetings and forwarded for approval for allocation of certain amount of funds intended for the MCHC programme VDCs. He suggested that local contribution from VDCs is one area still unexplored and under‐reported, and could be utilized for the MCHC. He gave a real example of DDC’s funds being used to hire the ANMs atn the SHPs and HPs in the entire VDCs in order to contribute to the government’s drive for improving maternal and child health care activities for years now.
2. Some observations:
• There was a general good feeling about the progamme and it seemed that the beneficiaries appreciated the WFP, staff at health facilities, DPHO, DEO and other officials in the district. However, limited interventions, blanket coverage and its inability to make much impact were some of the concerns implied in some of the government officials’ conversation. The question of sustainability and the programme’s tendency to promote dependence were also voiced by different officials.
• Lack of adequate number of health staff at the health facilities was repeatedly brought up as one of the major limiting factors that would hinder the MCHC program to achieve its objective of improved utilization of health services. This has highly justified the support being provided by the WFP for the MCHC through an NGO committed to the field of health and nutrition in Nepal and its continuity is sought for as per conversations.
• Inability to ensure consumption of the food supplement by the intended beneficiaries alone and not by other family members was another constraint that would not allow the programme to achieve expected reduction in the prevalence of underweight and anaemia in the targeted population. This needs further clarification at policy level, such as an average kcal requirement per day for a child or an adult as being used by WFP globally and within Nepal by Nepali authorities, and further interpretation of intra‐household sharing information dissemination, and how this information should be disseminated at household level on proper food utilization at household level. Further reference should be made to the WFP’s policy document on ration size such as “the Right Food at the Right Time” for both treatment of MAM and prevention of stunting.
• Though it was repeatedly mentioned that the VAM was used to identify the benefiting VDCs, the reasons for selecting these VDCs for food supplement were not obvious. Their fields were full of ripening crops and looked fertile. However, some of the beneficiaries did mention that none of the households within the VDC that they lived in could manage to live on the produce of their land for the whole year. The lurking question was what would be the situation in those VDCs which did not have the programme.
• The FFEP managed logistics whereas the health services were the responsibility of the health facilities. DPHOs and Health facilities did not have a major role in the processes of resource
mangement. It looks logical that the FFEP has been involved in this task as they seemed more experienced and have an existing network for the purpose. But the FFEP does not have anything to show in short term as the impact of their work. The DPHO has to manage the increased work‐load created by the increased attendance of PLW for ANC and PNC and of children under 36 months of age for growth monitoring. There is no support for them in terms of human resources and incentives to carry out this extra work. Local HFoMC has limited resources and these are not sufficient to strengthen the human resource situation. The current government rule that no participation fees can be charged by the health facilities has further limited the local community’s ability to raise funds to support the programme.
• Using an NGO to support the programme looks like a short term measure. There is a need for institutionalizing whatever the NGO has additionally been doing at VDC level in support of the MCHC on behalf of the donor agency so as to be able to show an impact in the long run. It just strengthens the argument that to provide effective services of good quality health services, the health facilities need human resources and VDCs have had the tendency of allocating their annual funds to other development areas than the health related areas.
• As these districts did not have a programme for management of acute malnutrition, we could not observe the relationship between the MCHC and CMAM. Field reports from Accham and Bajura could be reviewed to see how it works. This issue could be brought up during discussion with Ms.Saba Mabrehtu and Mr. Anirudra Sharma of the UNICEF at central level.
• Apparently, UNICEF and WFP had worked in collaboration when the DACAW programme was operational in Dadeldhura district. It would be a worthwhile exercise to explore how that collaboration helped each other’s programme.
• Discussion with the Directors of the CHD and FHD should seek in an effort for opinion building and policy building about how they perceive the role of the food supplement to improve maternal and child health and nutrition. A review of the international experiences in food supplement usually produces a mixed picture. It is a very difficult exercise to demonstrate a positive impact as the programme does not work under the rigours of a research. At this stage, extensive discussions with the MoHP officials from CHD, FHD and LMD of the DoHS and Policy Division at the MoHP are very important before proceeding further. The MoE have reportedly had no problem as regards the overall structure except the district level FFEP staff members having expected more support in operational areas from both the WFP and government.
Annex VIII: Background to the HHESS and synopsis of its achievements at local level HHESS began to work in Solukhumbu district for the MCHC programme in partnership with the WFP since 2007. The partnership happened following the visit of WFP Country Representative to Solukhumbu and overall observation of innovative ideas being used by HHESS in the promotion of health and
nutrition as per reports. Main purpose of this partnership was to pilot NGO support into the ongoing MCHC and further scale up the system in the Far/Mid Western regions based on recommendations of the following joint review visits and do away with some of the observations made by concerned stakeholders prior to 2007 on issues of quality of service delivery. Further piloting was done in Dadeldhura and Salyan districts in 2008, and from 2009 onwards the NGO support system was scaled up in all programme districts.
It was considerably discussed at the outset whether the NGO support was to fill into specific human resource gap at the government health facilities provisioning limited number of junior level health staff with some technical background or function as a short‐term entity only for health and nutrition education/counseling. Joint reviews time and again recommended that the existing gaps of human resource including social mobilization support would be the key in overall sustainability of the support system. As a result of this field level exercise, the support strategy was packaged in such a way that the NGO would have to help improve not only technical aspects of ANC, PNC, growth monitoring, counseling and logistical components, but also social mobilization targeting utilization of locally available resources; be it in the form of increasing funding from local government line agencies, collaboration, human resource or user contribution.
Ongoing support to the government health facilities has considerably helped improve quality of maternal and child health service delivery, logistic management and advocacy of food utilization. Monthly monitoring reports from July 2011 to January 2012 during the last six months have shown a significant progress on key output indicators; 94.85% progress on the number of children aged 6 to 36 months growth monitored, 95.40% progress achieved on ANC, 95.15% progress achieved on PNC, and underweight prevalence rate standing at only 4.12%, a huge step forward compared to the last year’s underweight prevalence rate at 9.9%. Even if queries may be raised on meeting minimal anthropometric measurement parameters, overall progress has been seen beyond expectations.
Support in financial terms is very minimal. One supervisor covers an area ranging from one VDC to two to three VDCs in the given district. With a focus more on sustainability of the MCHC at health facility level, the HHESS has been able to show some tangible results in line with mobilizing locally available resources in collaboration with the government line agencies in the Far West as per the table shown below; Districts VDCs Contributions
made from VDCs (NRS)
Purpose of contribution Remarks
Dadeldhura Gangkhet 200,000.00 ORC set-up in Hartola for wards 8 & 9
Birthing center established and an ANM hired.
Shirsha 140,000.00 Hiring of an ANM Birthing center established.
Belapur VDC 400,000.00 (through GIZ)
Drinking water, hiring of 3 ANMs, ORC set-up
Through lobbying by HHESS and MCHC committee
Chipur Budget not specified yet
An additional ANM hired for MCHC
VDC secretary has committed to propose a
separate budget. Jogbudha Budget not
specified yet 2 ANMs being hired for SHP and ORC both.
VDC and PAF to support for two-room house for health initiated by HHESS.
Achham Kuntibandali Budget not specified yet
An ANM hired for MCHC Counseling session linked with FCHVs on monthly basis.
Khaptad 183,000.00 An ANM hired for MCHC Birthing center established at the initiative of HHESS.
Sokot 1,000,000.00 Strong lobby for health post building
Ongoing two-year long lobbying with the VDC and DHO on the need for improving poor infrastructure by HHESS
Bajhang Kafalseri 36,000.00 Management of snacks during monthly clinics
Birthing center established at the initiative of committee, HFoMC and HHESS together
Daulichaur 130,000.00 For construction of an ORC set-up
At the initiative of HHESS with VDC secretary
Dahabagar 250,000.00 For construction of sub-health post building
Through joint efforts of HFoMC and HHESS
Sunikot 150.000.00 Hiring of an ANM and management of snacks during monthly clinics
Birthing center established at the initiative of HHESS
Syandi 241,000.00 For construction of sub-health post building
HHESS has started sale of empty Super Cereal bags to raise budget for snacks during monthly clinics.
Deulekh 60,000.00 Hiring of an ANM Doti Simchaur Budget not
specified yet An ANM hired and solar panel set up in addition to improved birthing center
HHESS played a key role for this arrangement over the past 2 years.
Chamarachautara
Budget not specified yet
An ANM hired and solar panel set up in addition to improved birthing center
HHESS played a key role for this arrangement over the past 2 years.
Daud Budget not specified yet
For management of snacks during monthly clinics in addition to an ANM for MCHC
Birthing center established through lobbying with VDC secretary by HFoMC and HHESS.
Bajura Chhatara Budget not specified yet
2 ANMs hired for MCHC in addition to birthing center and sub-health post building construction
Lobbying with VDC secretary and local youth clubs still continuing through HHESS for MCHC
Budget not specified yet
1 ANM hired for MCHC in addition to birthing center and sub-health post building construction
Lobbying with VDC secretary and local youth clubs still continuing through HHESS for MCHC
Baitadi Bhumiraj Budget being For ORC set-up in ward-7 Lobbying / advocacy
proposed going on for MCHC in order for locals to take ownership
Sakar Budget not specified yet
Hiring of an AHW and 1 MCHW for MCHC
Lobbying / advocacy going on for MCHC in order for locals to take ownership