Mother and Child Health Care Programme A Joint Review of the MCHC programme by MoHP, MoE and WFP

Mother and Child Health Care Programme A Joint Review of the MCHC programme by MoHP, MoE and WFP Mother and Child Health Care Review Report: November 2012 Social Protection, Women and Children Unit WFP CO, Kathmandu,

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Executive Summary

Background: Education Project (FFEP) units of District Education Government of Nepal, being aware of the poor nutri- Offices (DEOs). The FFEP Units/DEOs are respon- tional status of its population, particularly of children sible for logistics after this point which consists of and women, is continually developing appropriate pol- distribution, storage, record keeping and reporting icies from time to time and designing and implement- to the Distribution Centers (DCs) or Final Delivery ing programmes to improve the nutrition situation. Points (FDPs). WFP provides partial support for the The World Food Programme (WFP) has been operat- transportation of the food supplement to the FDPs ing in Nepal since 1963 and responding to changing or DCs. It also partially supports the coverage of food security needs and national priorities. One of services of VDC-based storekeepers at the health the programmes implemented by WFP in partnership facilities at VDC level answerable to the MCHC com- with the Government of Nepal has been nutritious mittees working under the Health Facility Operation food assistance to children in the primary schools and Management Committees (HFoMCs). WFP has also Early Childhood Development Centers (ECDs), and ad- started NGO support system through the Himalayan ditional food assistance to girl children as an incen- Health and Environmental Social Services (HHESS) tive in the primary schools in order to help increase since 2007-2008, an NGO committed to strengthen- school attendance of the girl children in partnership ing health services at the health facilities at VDC lev- with Ministry of Education (MoE). Thus, the National el and social mobilization at community level. The Nutrition Policy and Strategy (NNPS) developed by the health facilities together with HFoMCs and MCHC Ministry of Health and Population (MoHP), it required Committee also provide guidance and assistance assistance to provide the fortified food supplement to the ongoing MCHC programme. A district level to Pregnant and Lactating Women (PLW) and children management and monitoring committee compris- less than 3 years of age. Three agencies, WFP, MoE and ing representatives from various government line MoHP agreed to work in partnership with each other agencies, such as the CDO, DAO, DPHO, DEO, DADO, to implement the Mother and Child Health Care Pro- DWO, WDO, LDO and DDC oversees the implemen- grame (MCHC) in Nepal. tation of the programme besides corrective meas- ures as and when necessary. The main objectives of the MCHC programme were to improve the access of PLW and children less than The programme has been continuing as a part of WFP three years of age with an access to increased calorie Country Programme (CP) over the last 10 years; how- intake protein and micronutrients thereby reducing ever, an overall future strategy is yet to be developed. anemia, underweight and stunting rates among the A number of evaluation mission reports in the past and target population; and also to improve the utilization a more recent World Bank Health Sector Review of Nu- of maternal and child health care services and improve trition programme had recommended a review of the knowledge among the PLW about desirable nutritional programme in order to guide a policy decision about practices. The programme was started in three Village its possible role in national nutrition plans and pro- Development Committees (VDCs) in 2001 and gradu- grammes. In addition, WFP has also been working dur- ally expanded to 98 VDCs in 11 districts and eventually ing 2011 – 2012 for developing plans and programmes the number of VDCs were phased out to 47 by 2008. for implementation of the next 2013 – 2017 CP. Thus, Under this programme, a monthly take-home ration the WFP requires a review of the ongoing programme of fortified supplementary food is provided along with for the formulation of the future strategy for the related maternal health services and growth monitor- CP activities. ing and counseling services are conducted for children through government health facilities. A team of experts and representatives from MoHP, MoE, WFP and UN agencies was constituted and en- WFP is responsible for procuring and delivering car- trusted with the task of reviewing the programme and goes of food supplements up to the Extended De- recommending a future course of action from Septem- livery Points (EDPs) established under the Food for ber to December 2011.

Mother and Child Health Care Programme i The review team namely led by Prof. Ramesh Kant b. The implementation modality which consists of Adhikari and Ms. Irada Parajuli Gautam after receiving WFP deciding on the composition of the blended an orientation regarding the scope of work, reviewed fortified food, ensuring its quality and safety and the available documents about the programme, vis- delivering it to EDP in the district headquarters and ited the field sites, interacted with the stakeholders subsequently FFEP/DEO delivering to FDP has been and held consultations with the relevant officials at working efficiently. There are, however, occasional the central level. disruptions in the supply chain due to unavoidable reasons and the beneficiaries are being reached Observations most of the time. There is no evidence of any leakage, The observations of the study are as follows; pilferage or wastage of the supply. a. The programme has been successful in reaching c. Health Facilities, such as the Sub-Health Post more than 90% of the beneficiaries and has re- (SHP), Health Post (HP) and Primary Health Care sulted in improving the uptake of Ante-Natal Care Centre (PHCC), with support from an NGO have (ANC), Post-Natal Care (PNC) and growth monitor- been able to provide the ANC, PNC, growth moni- ing services. The Standard Performance Reports toring and counselling services to the majority of from the field sites show a significantly low prev- targeted beneficiaries. A very high ANC and PNC alence rate of underweight children in the pro- coverage rate in programme VDCs supports this gramme VDCs. The programme VDCs show a much observation. However, the situation was rather higher rate of utilization of ANC services: 91% of unsatisfactory when the programme was opera- pregnant mothers received ANC services in pro- tional through Out-Reach Clinics (ORCs) which gramme VDCs, compared to the national 58%, and was the general practice until 2007 under the the percentage of children getting growth moni- ongoing MCHC programme. tored was reported to be 97.5%, compared to the d. The health facilities, with support of the HHESS national averages of 33%. Similarly, the percentage staff, records and collects regular data regarding of underweight children in the programme VDCs the expected and actual number of beneficiaries was reported to be 9.9% compared to the national attending the clinics and taking the take-home ra- average of 28.8%. tion every month. The number of children growth

Senior MCHW examining a pregnant women in Deulek VDC, Bajhang during monthly MCHC clinic

ii Mother and Child Health Care Programme monitored and their nutritional status is also col- lected each month and reported to the District Public Health Offices (D/PHOs). The D/PHO- for wards this information to Nutrition Section, Child Health Division (CHD), Department of Health Ser- vices (DoHS) and MoHP. However, this information is not used and reported through the government’s Health Management Information System (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 analy- Part of regular check-up during pregnancy under the MCHC sis system uses a number of indicators to identi- fy vulnerable VDCs which are in need of external h. An estimated cost of US$ 96 for one beneficiary assistance. The same system identifies the VDCs per annum has raised some concerns about finan- for programme through a consultative process cial viability for the current nutrition programmes carried out in the district. The VDCs once select- of the government considering its integrations ed under the MCHC at district level, under the at national level. As the aim of the programme is existing identification system, continue as being geared towards the most food insecure districts, a part of the CP. where lack of food has been the major determi- f. A review of related programmes implemented by nant of under-nutrition, efforts to raise resources the government and development partners offer for this programme can highly be justified on the openings for integrating MCHC programme with ground of food insecurity. them. The Child Grants Programme, which enables i. The present arrangements for monitoring and food supplement for children less than 2 years of evaluation are to guide the implementation of the age in the Karnali region and Community Manage- programme and generate certain output level data ment of Acute Malnutrition (CMAM) are some on key indicators and not to create evidence for of the government programmes which can make the efficacy of such an approach. Thus, without use of the technical experience gained under the the rigors of a robust research methodology ensur- MCHC programme. Similarly, SUAAHARA project ing coverage and compliance above certain level, of the United States Agency for International De- it would be difficult to prove the effectiveness of velopment (USAID), the Decentralized Action for the programme to improve nutritional status of Children and Woman (DACAW) of the United Na- children and women. tions Children’s Fund (UNICEF) and the Community Based New Born Care Programme (CB-NCP) of the Recommendations Nepal Family Health Programme (NFHP-II) offer A: Continuation of MCHC programme such opportunities in other districts. • MCHC programme is still relevant in the VDCs with g. The MCHC Committees, HFoMCs, DDCs and DPHOs high levels of food insecurity; however, continu- have been engaged in the management and moni- ation of the MCHC programme should be linked toring of the MCHC programme. There have been with Vulnerability Assessment Mapping (VAM) in examples of VDC and DDC funds being mobilized light of newer findings from Nepal Living Standards to hire health staff to provide the health services Survey (NLSS). along with the food supplement. Furthermore, in • MCHC programme should be initiated after a base- discussion with health officials it transpired that line survey followed by a midterm and end-line the funds available with DPHO can also be utilized surveys at specific points of time period and collect for this purpose. However, contributions being information on impact indicators of interest in any made at local level by the line agencies will have given number of new programme VDCs. made a significant difference in the long run the • Beneficiary target age group should be brought in way the MCHC programme will be implemented line with the policy of “One Thousand Days” of the along with food supplementation. Government of Nepal (GoN).

Mother and Child Health Care Programme iii • Mechanisms to support the health facilities in pro- funds allocated to VDCs and DPHOs or even hire viding health services need to be strengthened giv- the Community Based Organizations (CBOs) in order en the Field Supervisors (FSs) continue to provide to support ANC, PNC, growth monitoring, recording, technical as well social mobilization services in the reporting and counseling activities in addition to- fur future. ther support for storage facilities at ORCs. • Exploring the government funds in addition to so- • Explore the possibility of including food sup- cial mobilization will offer some opportunities for plement in the treatment protocol for the the key stakeholders to further work in more effec- management of Moderate Acute Malnutrition tive ways ensuring local ownership. (MAM) (with Nutrition Section of CHD). The programme to follow the national guidelines B: Integration with government programmes for CMAM. • Bring the Family Health Division (FHD) on board demonstrating their role in improving maternal C. Evidence of effectiveness nutrition. • Explore the possibility of including data from pro- • Explore the possibility of working with Logistic gram VDCs as additional information as annexed to Management Division (LMD) of the MoHP to sup- HMIS to highlight the effectiveness ply food supplements specifically in districts where • Continuation of MCHC programme should be com- MCHC program is going on. bined with a study to look into the effectiveness of • Open dialogue with District Development Commit- food supplement in programme VDCs against con- tees (DDCs) and D/PHOs to hire health staff with trol in food deficit areas.

Joint MCHC monitoring mission to , including Mr. Raj Kumar Pokharel, Chief, Nutrition Section, Child Health Division

iv Mother and Child Health Care Programme • Partner in the research to be funded by DFID to study • FFEP staff members require further support in the efficacy of food supplement vs. cash transfer vs. overall programme strengthening. The pool of hu- nutrition education vs. control. Specifically reques man resources available within the FFEP structure study to look into the efficacy of food supplement ap- can help improve different components of the pro- proach among food deficit population groups. gramme, such as logistics management, monitor- ing, supervision, distribution and support to essen- D. Strengthening of the programme tial service deliveries. • NGO support is vital for the success of the pro- • Issues of storage facilities and human resources gramme. However, this should be more for nutri- should be resolved before considering distribution tional counseling. It will need different types of of food at ORC locations. human resources to be employed such as nutri- • Mechanisms that can strengthen HFoMC and tion counselor rather than health worker. Equally MCHC committees should be supported and critical is also the issue of lack of adequate human there should be provision of charging a nominal resources at the local health facilities for health fee from the beneficiaries during the monthly and nutrition programme like the ongoing MCHC, MCHC clinics in order to supplement the needs which would also require a number of technical for snacks, allowances, purchase of essential staff to support overall service delivery mecha- equipments and tools and other services with- nisms of the government at VDC level. in the discretionary powers of the local user • Local resources of VDCs, DDCs and DPHOs can also committees. be mobilized to hire health staff at the local level. • There should be a minimal package in order to help This is being partially done at VDC level in order improve the capacity of the government health fa- to fill in a number of vacancies of the government cility staff members. health facilities in coordination with VDC, DDC and DHO personnel.

Central level government officials interacting with health workers at Deulek PHC, Bajhang

Mother and Child Health Care Programme v Table of Contents

1. Background 1 National Context 1 Background of MCHC programme 2 2. WFP supported food based MCHC programme 3 National Context 3 3. Implementation arrangements 5 4. Monitoring and evaluation 7 5. Objectives and scope of the review 8 6. Implementation strategy of the review 9 7. Composition of the review team 10 8. Activities of the team 11 9. Observations 12 Findings, Observations and Recommendations i. Performance of the MCHC programme: Results 12 ii. Operational modalities: Efficiency and appropriateness 13 iii. Targeting mechanism 14 iv. Opportunities for integration 15 v. Government and community participation 17 vi. Sustainability 17 vii. Monitoring of the programme 18 10. General impressions 19 11. Recommendations 20 a. Continuation of MCHC programme 20 b. Integration with government programmes 20 c. Evidence of effectiveness 21 d. Strengthening of the programme 21 12. Annexes: 23 Annex I: List of persons interviewed 24 Annex II: Summary of surveys and reviews of the MCHC programme carried out between 2001 and 2010, per district 26 Annex III: Literature review specific to food supplementation and pregnancy outcomes 27 Annex IV: Nutrient content of fortified food ‘Super Cereal’ distributed under MCHC programme 29 Annex V: Summary of reports of review of the MCHC programme 30 Annex VI: Summary of observations from the field mission 32 Annex VII: Background to HHESS and its synopsis of its achievements at local level 34 Annex VIII: Contributions made at local level 35 Annex IX: MCHC Review Dissemination Meeting 37 Annex X: References 40 Abbreviations:

ANC: Ante-Natal Care ANM: Auxiliary Nurse 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 Unit 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 01 Background

National context: related indicators is still a matter of grave public Nepal Nutrition Status Survey 1975 was the first sys- health concern. tematic effort to understand nutritional problems prevalent in Nepal. Though small scale studies con- Malnutrition as indicated by prevalence of stunting, ducted from time to time, which included multiple underweight and wasting among children less than 5 indicator surveillance surveys, provided some insights years of age is a significant public health problem in into the nutritional trends, the nation-wide Nepal Nepal. Though there has been a gradual and steady de- Family Health Survey in 1996 and Nepal Micronutrient cline in the prevalence of stunting (by 1.6 percentage Status Survey 1998 provided more up to date data on points per year from 2006 to 2011) and underweight the subject. Since then, regular demographic health among children, there is not much improvement in the surveys have been conducted every five years. They prevalence of wasting. Further, malnutrition in child- have collected more reliable data regarding the hood continues as a trend particularly among women. prevalent nutritional status of the population and This is indicated by the fact that one in four mothers their determinants. with a child less than 3 years of age suffer from chronic energy deficit (as indicated by a BMI less than 18.5 kg/ A number of initiatives have been taken to improve the sq.m). In addition to these general indicators of under- nutritional status of the Nepalese people starting with nutrition, women and children suffer from deficiency the national nutrition strategies 1978 and 1986. These of iron (leading to anemia) and until recently of iodine strategies recommended that programmes address in- and Vitamin A. Over the last 15 years, there has been creased availability of food, improved awareness about significant improvement in Vitamin A and iodine nutri- food and nutrition and better health services to pre- tional status. Though there has been some reduction vent illnesses that adversely affect nutritional status. in the prevalence of anemia it is still unacceptably high These strategies aimed to improve nutritional status and constitutes a public health problem. The current through interventions in the areas of agriculture, edu- maternal mortality rate at 229/100,000 live births is cation, health and women’s development. An attempt very high which accounts for 11% of deaths among to have a coordinated action between these different women of reproductive age. Similarly, less than a third sectors led the government to implement a Joint Nutri- of the deliveries occur at health facilities and only 36% tion Support Programme from 1985 to 1990. are attended by skilled birth attendant, still half way from reaching the MDG target. The late 1990s saw a change with more stress on the nutrition programmes implemented through the The National Nutrition Policies and Programmes health sector. The focus was to lower nutritional disor- (NNPP) of the MoHP since 2004 had identified and ders arising from the deficiency of such micronutrients implemented different approaches to improve the ma- as Vitamin A, iodine and iron. These programmes have ternal and child nutritional status. However, a more achieved remarkable success in improving the micro- holistic and comprehensive approach was needed to nutrient nutritional status. Nepal is being lauded for address the status of general under-nutrition preva- the success it has achieved in almost eliminating Vi- lent among women and children. A technical working tamin A deficiencies and lowering the prevalence of group constituted by National Planning Commission iodine and iron deficiency states. However the gen- (NPC) in 2006 was assigned the task of examining eral nutritional status revealed by weight and height the different determinants of nutritional status and

Mother and Child Health Care Programme 1 identifying strategies to address them. This technical development programmes. Majority of the districts in working group suggested strategies to address inad- the Far/Mid Western development regions have re- equacies in child care practices, health services, status mained food insecure over the last past many years of women and food insecurity. However, it was con- according to NeKSAP. Preliminary findings of Nepal sidered incomplete as it had not identified strategies Living Standard Survey (NLSS) 2011 report that 38% that need to be implemented through other sectors of the people in Nepal are unable to consume the re- such as agriculture, education and women’s welfare. quired calorie intake. The proportion of people who This exercise, in the course of developing a national consume less than the required calories is highest in plan of action on nutrition recommended the detailed the Far/Mid western development regions. assessment and gap analysis which reviewed the is- sues related to agriculture, food security and cultural In addition, the people living with poverty are also practices. The Nutrition Assessment and Gap Analysis higher in the Far/Mid West than those in the Eastern, (NAGA) recommended a comprehensive nutrition pro- Central and Western development regions. According gramme through a multi-Sectoral structure from the to the NLSS 2011, 46% of the population in the Far center to the village level. Western development region live below the poverty line compared to the national average of 25%, and The NPC is currently engaged in finalizing a Multi-Sec- 32%, 22%, 22% and 21% for the Mid Western, West- toral Nutrition Plan (MSNP) involving the MoHP, MoE, ern, Central and Eastern regions respectively. Thus, MoAC and MLD. The key MSNP development process- the food insecurity in the Far/Mid Western regions is es would benefit from a review of a nutrition related further compounded by poverty. programme being initiated in severely food deficit -ar eas in order to mitigate the problem of food insecurity Food insecurity is an important determinant of under- for improving maternal child health and nutrition. nutrition, particularly in the food deficit districts of the Far/Mid Western development regions. In response, the Background of the MCHC programme: National Nutrition Policy and Strategy (NNPS) 2004 and Household food insecurity is a significant determi- 2008 had included fortified food distribution in these- ar nant of poor maternal and child nutrition in Nepal. eas as one of the strategic approaches to reduce under- The Nepal Food Security Monitoring System (NeKSAP) nutrition. Similarly, the Nepal Health Sector Programme has recently projected that 36 districts in Nepal will - Implementation Plan II (NHS - IP 2) for 2010-2015 has remain food deficit in 2011, despite a forecast ofa also identified household food insecurity as one of the surplus production of cereal grains by 110,000 MT for main causes of under-nutrition and recommended food the year. The number of food deficit districts in Nepal and nutrition services including child growth monitor- has usually been between 41 and 49. Food insecurity ing and promotion, micronutrient supplementation and is further compounded by poverty, illiteracy, lack of food supplementation and other interventions for im- access to markets and lack of robust government-led provement of child survival and nutrition.

2 Mother and Child Health Care Programme 02 WFP supported food-based MCHC programme

National context: chula, Bajhang, Baitadi, , , Achham, The UN WFP, Nepal has been providing food assistance Bajura, Salyan and Solukhumbu districts. to PLW and children aged 6 to 36 months through the MCHC termed as ACT – 3 under the WFP CP since In order to meet the WFP’s Strategic Objective - four of 2001-2002 in alignment with the Government’s long reducing chronic hunger and under-nutrition, the provi- term and interim strategic plans stipulated under the sion of supplementary food is intended to improve the nutrition and safer motherhood programmes of the nutritional status of targeted women and children and MoHP. A monthly take-home ration of the fortified raise the awareness and utilization of community-based supplementary food is provided under the ongoing out-reach services. The food supplement is expected to MCHC programme along with health services, growth improve the access of PLW and children less than three monitoring and counseling by the government health years of age to increased calorie, protein and micronutri- workers based at VDC level with backstopping sup- ents thereby reducing anemia, underweight and stunting port from the Female Community Health Volunteers rates among the target population. In addition, it is also (FCHVs) and Traditional Birth Attendants (TBAs) in Dar- expected to improve utilization of maternal and child

A child being weighed at the health facility during monthly MCHC clinic

Mother and Child Health Care Programme 3 health services and better knowledge among the PLW ies differs slightly from one year to another. The MCHC about desirable nutritional practices. programme covers mainly the local health facilities such as the SHPs, HPs and PHCs, whereas given basic facilities The programme was started as a small scale pilot project fulfilled at the ORC locations with support from the lo- in three VDCs in the Far West and gradually extended to cal government line agencies, the ORC locations are also 98 VDCs in nine programme districts over the years. used as points of health and nutrition service delivery in- cluding food distribution. Initially, the programme was implemented through both the health facilities and ORCs. However, lack of In order to help provide quality health and nutrition human resources, appropriate physical facilities at the services and capacity building measures, WFP has ORC locations beyond the government health facili- partnered with Himalayan Health and Environmental ties put a significant constraint on both health workers Services Solukhumbu (HHESS) to provide health facility- and beneficiaries in maintaining their privacy during based technical and social mobilization services to local the course of ANC and PNC and lack of proper stor- health institutions in all nine programme districts. age 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 strat- egy. 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 work- ing together to help improve physical infrastructure much needed at these imaginary government loca- tions 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 nine pro- A mother breastfeeding her child gramme districts with eight in the Far/Mid Western regions and one in the Eastern region were assisted The complementary support being provided through through the MCHC programme followed by a total of the NGO staff in addition to the government health staff 26,000 beneficiaries with 17,820 children and 8,180 members at the forefront of programme implementa- mothers being assisted in 47 VDCs in the same pro- tion modality serves to encourage women and children gramme districts in 2011. Resources are reallocated in in regularly accessing and utilizing available govern- mid-July each year as per the government’s fiscal year ment health and nutrition related services at the health planning period, based on which number of beneficiar- institutions.

4 Mother and Child Health Care Programme 03 Implementation arrangements

The MCHC programme is implemented through a in Nepal since 1972 and thus has considerable experi- partnership between MoHP, MoE and WFP. The MoHP, ence and expertise in logistics. The FFEP has district MoE and WFP have jointly signed a tripartite agree- offices in each programme district with 10 to 15 staff ment for the implementation of the programme. Nu- dependent upon geographical location and the pro- trition Section/CHD/DoHS is responsible for the MoHP, gramme size. FFEP Central Office for the MoE and CP Unit for the WFP at central level followed by DPHOs and respec- Health Facility and Operation Management Commit- tive health facilities, FFEP Units/DEOs and WFP SOs tees (HFoMCs) and MCHC committees consisting of at regional/local/VDC/health facility level respectively beneficiaries, local representatives, social workers and for overall monitoring supervision and support for im- some of the key health staff are the entities responsi- plementation of the programme. ble for food management, preparation, and distribu- tion, 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 car- rying out their daily responsibilities. The MCHC project committees function as User Committees (UCs) which are responsible and entrusted with the task of trans- porting food from the EDPs to DCs or the FDPs.

Under the ongoing health facility based system, store- keepers under the MCHC committees and DEOs direct-

Joint review mission members holding talks with DPHO in

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 locate d 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 respon- sible for the entire logistics on receipt, storage, han- dling, transportation, and distribution, record keeping Women returning home with monthly take-home ration of and reporting. The FFEP has been handling logistics 7 kg Super Cereal Mother and Child Health Care Programme 5 ly hand over Super Cereal to the representatives of the ensure smooth delivery of government supported MCHC Committee for transportation up to the health services. This is the main thrust of the MCHC pro- facilities. The beneficiary receives 7 kg of Super Cereal gramme to lower the prevalence of underweight of monthly supplement at the health facility during among children and to lower the prevalence of ane- the fixed monthly MCHC clinic schedule on the basis mia among the PLW assisting the government’s ser- of receiving ANC, PNC, growth monitoring, individual vice delivery system with an aim to also reducing or group counseling as stipulated in the implementa- stunting in the future. tion guidelines. This is further verified by the health workers and storekeepers respectively on the basis of The HFOMCs and MCHC committees are responsible beneficiary card that each woman or child has from for managing food distribution including providing the health facility at the time of his or her registration support to the ongoing clinic services with additional as MCHC beneficiary prior to being entitled for the support from the community-based FCHVs. The dis- services. Health workers and NGO support staff to- tricts were selected in collaboration with/between gether agree on the scheduled monthly clinic dates, WFP and government partners. The targeted districts timing and division of responsibilities mobilizing the are categorized as food insecure by the Food Security HFoMC and MCHC committee members and Female Monitoring and Analysis Unit (FSMAU) / Vulnerability Community Health Volunteers (FCHVs) in order to Assessment Mapping (VAM) of the WFP Nepal.

Prof. Ramesh Kant Adhikari and Ms. Irada Parajuli Gautam, principle resource persons for the joint review interacting with health workers in Dadeldhura

6 Mother and Child Health Care Programme 04 Monitoring and Evaluation

The staff at the health facilities record information on the collected data monitoring reports are prepared. about the beneficiaries and the services provided to Although such reports are helpful in tracking the ef- them on a standard programme reporting format. fectiveness of the process, more rigorous methods are They compile the data every month and forward it required to assess the impact of the programme. to the DPHOs, which send it to the Nutrition Section, CHD, DoHS. The data contributes to overall service In 2010, an evaluation of the WFP Nepal Country Port- utilization statistics for the district and is fed into the folio recommended the strengthening of the monitor- Health Management Information System (HMIS). ing and evaluation of programme activities through baseline and end-line surveys in order to ensure meas- In addition, the MCHC programme collects data re- urable evidence of WFP activities and demonstrate im- quired for monitoring the effectiveness of the pro- pact of the MCHC activity across targeted districts . It gramme every six months. The beneficiaries are ran- was further suggested that WFP monitor areas where domly selected for interviews during their clinic visits multiple activities are carried out, to capture synergis- with the use of a standard questionnaire, and based tic programme impacts.

MCHC committee members attend briefing of the joint review mission in VDC, Dadeldhura Mother and Child Health Care Programme 7 05 Objectives and scope of the review

Over the last decade, the MCHC programme has un- mentions that the government is reviewing the case dergone several joint missions, reviews and surveys in for large-scale food supplementation, and hence the programme districts. Reports of two key WFP eval- this review will also provide added information in uation missions, the Country Programme Evaluation this regard. cum Appraisal Mission - 2006 and, the Country Port- folio Evaluation Mission - 2010 as well as the World The main objective of this joint review is therefore Bank health sector nutrition evidence review 2011 to review and assess the ongoing food-based MCHC have recommended a comprehensive review of this programme activities. In addition, it will provide -rec programme. The results, outcomes and recommenda- ommendations for future intervention modalities, re- tions of this review will be very important as input to adjustment in line with national health and nutrition the CP formulation. The new WFP CP phase for the pe- strategies and plans, and the development of a viable riod from 2013 to 2017 is in the offing and already in handover strategy beyond 2012-2013. the process of being proposed to the Executive Board (EB) for approval. The joint review was based on desk reviews of relevant documents (listed in annex 1), field missions and con- Concrete recommendations are also needed for sultative meetings with key government and non gov- better integration of the MCHC programme into the ernment stakeholders including staff from the CHD and national nutrition strategy and Multi-Sectoral Nutri- FHD of MoHP, National Planning Commission (NPC), Ex- tion Programme (MSNP) framework. The NHSP IP II ternal Development Partners (EDPs) and NGOs.

1Summary Evaluation Report Nepal Country Portfolio. WFP/EB.2/2010/6-B, September 2010.

8 Mother and Child Health Care Programme 06 Implementation strategy of the review

The review team collected and analyzed information • Assessment of the alignment of the program objec- with the following goals in mind: tives with national policies and priorities • Review of the Monitoring and Evaluation strategy • Review of the performance of the programme and the recommendation of necessary changes • Analysis of the appropriateness and efficiency of • Review of the possible mechanisms and its poten- the operational modalities tial integration into government programmes in -or • Analysis of the appropriateness of the targeting der to make it sustainable. mechanism • Identification of possible strategies in transition in • Exploration of opportunities for internal integra- line with government polices and priorities as well tion of WFP activities and linkages with govern- as global WFP strategic objectives and draft global ment programs and development partner activities WFP nutrition policy. • Exploration of the potential for increased -owner ship and government and community partnership

Mother and Child Health Care Programme 9 07 Composition of the review team Six of the review team members were involved in both • Mr. Amrit Bahadur Gurung, Senior Programme central level consultation and field level missions un- Assistant, UN WFP, Chakupat, Patandhoka, der the team leader. The names below in italics played Lalitpur more prominent roles were consulted for high level • Ms. Jolanda Hogenkamp, Head of Programme, UN meetings and sharing of relevant documents at central WFP, Chakupat, Patandhoka, Lalitpur level during the course of the review. • Mr. Jibachh Mishra, Programme Director, FFEP Central Office, MoE, Naxal, Kathmandu • Dr. Ramesh Kant Adhikari, Team Leader, Professor • Mr. Ravi Upreti, Deputy Programme Director, FFEP in Child Health and former Dean, Institute of Medi- Central Office, MoE, Naxal, Kathmandu cine, Maharajgunj, Kathmandu, Nepal • Ms. Saba Mebrahtu (PHD), Chief, Nutrition Section, • Ms.Irada Parajuli Gautam, Consultant, Maternal UNICEF, Pulchowk, Lalitpur from UNICEF and Child Health Expert, Kathmandu • Ms. Pramila Ghimire, CP Coordinator, UN WFP, • Ms. Sharada Pandey, Senior Public Health Ad- Chakupat, Patandhoka, Lalitpur ministrator (SPHA), MoHP, Ram Shah Path, • Ms. Sophiya Uprety, Programme Officer (Nutri- Kathmandu tion), UN WFP, Chakupat, Patandhoka, Lalitpur • Mr.Leela Bikram Thapa, Senior Public Health Of- Nutrition Technical Committee (NuTEC) under the ficer, CHD, DoHS, Teku, Kathmandu chairpersonship of Dr.Shyam Raj Upreti, Director at • Mr. Girish Kumar Jha, National Statistics Officer, the CHD, DoHS, Teku, Kathmandu, provided guidance CHD, DoHS, Teku, Kathmandu to the review team in overall processes.

Joint review mission members on the way to Salyan district

10 Mother and Child Health Care Programme 08 Composition of the Activities of the team There were three main activities carried out by the -re Nepalgunj, Banke and Salyan districts in the Mid review team view team as below; Western region. • The team started the review process on 16 Sep- Other key activities may thus be summarized in order tember 2011 with a meeting with WFP officials and of priority. focal persons; Ms. Nicole Menage, WFP Country Representative, Ms. Jolanda Hogenkamp, Head of • Mid-term report and review of the findings on 15 Programme, Ms. Pramila Ghimire, CP Coordinator, October 2011 Ms. Sophiya Uprety, Programme Officer (Nutrition) • Meeting with government officials as well as with and Mr. Amrit Bahadur Gurung, Senior Programme the EDPs from 15 to 28 September and 18 to 31 Assistant for MCHC and discussed over the scope October 2011 and objectives of the joint review mission. • Discussion within WFP about the observations and • Field visit schedules and development of tools for recommendations on 02 November 2011 collecting information were discussed within the • Submission of the draft report on 14 November 2011 team members. • Review discussion within WFP and second draft • Field visits were carried out from 18 to 23 Septem- further submitted on 12 December 2011 ber 2011 to Dadeldhura and Doti districts in the • MCHC review dissemination meeting among key Far Western region, and 17 to 22 October 2011 to stakeholders at the CHD on 10 February 2012

Ms. Irada Gautam Parajuli getting to know perceptions of political representatives on the MCHC programme in Kupindedaha VDC, Salyan Mother and Child Health Care Programme 11 09 Observations The observations have been grouped in the following • Mechanism for integration of the MCHC into gov- categories: ernment programmes for its sustainability • Possible strategies in line with government policies • Performance of the programme and priorities as well as global WFP strategic objec- • Appropriateness and efficiency of the operational tives and draft global WFP nutrition policy. modalities • Appropriateness of the targeting mechanism Findings, Observations and • Opportunities for internal integration within WFP Recommendations activities and linkages with government pro- I: Performance of the MCHC programme: grammes and programme activities of other like- Results minded development partners The MCHC programme was initiated in three VDCs in • Potential for increased ownership and government 2001 in two districts and subsequently expanded to 98 and community partnership VDCs in 11 districts by 2007. It is currently operating • Alignment of the programme objectives with na- in 47 VDCs in nine districts of Nepal. The programme tional policies and priorities is reported to have been discontinued for some time • Monitoring and evaluation strategy and recom- period due to a lack of resources within the WFP at mendations for necessary changes certain places in the past. Initially the food supple-

A social map of Kupindedaha VDC, Salyan prepared by FCHVs and health workers for the joint review mission

12 Mother and Child Health Care Programme mentation was given out to the PLW and children aged the children having growth monitoring including 6 to 36 months through both the health facilities and counseling in the programme VDCs compared to ORCs. Over the last 3 years, the programme partners the national averages of 25% and 33% respectively. agreed to distribute food at the health facility loca- Similarly, the percentage of underweight children tions following a number of key observations made by in the age group of less than three years of age was visitors during monitoring and supervision in the past. reported to be 9.9% in the program VDCs com- The HHESS, an NGO committed to the field of health pared to the national figure of 28.8%. and nutrition has been providing support for key MCH related services, such as the ANC, PNC, growth moni- The programme has thus achieved the expected out- toring and counseling. HHESS was also entrusted come of improving the utilization of health services with the task of logistic management in Solukhum- by pregnant and lactating mothers. Similarly, the im- bu district between 2007 and mid-2011 and also pact on reducing prevalence of underweight among providing the key technical services on health and children also has also been met as expected. Further- nutrition. The logistic part has now been completely more, this additional support through the MCHC is re- handed over to the Nepal Government. ported to have made a significant contribution to the government’s regular health services at the local level. Positive results through the regular programme moni- toring can, thus, be summarized below: II: Operational modalities: Efficiency and appropriateness • About 9,450 mothers and 19,550 children aged FFEP/DEO is responsible for the distribution of food 6 to 36 months were provided the Super Cereal supplement. It is the responsibility of WFP to deliver (fortified blended food) during 17 July 2010 – 15 Super Cereal up to EDPs. The FFEP has the experi- June 2011 (2067 Shrawan – 2068 Ashad) period. ence and network for efficient delivery to deliver food Each beneficiary received 7 kg of Super Cereal through local transportation modes available up to with a calorie value of 380 kcal and protein con- FDPs or DCs, from where MCHC committee members tent of 15 grams (Gms) per 100 gms in addition to take the responsibility of transporting food further multiple micronutrients. Though the beneficiaries to the health facilities at VDC level. Logistics unit of are expected to consume 100gms/day/child and the FFEP Central Office has been utilizing the existent 125gms/day/PLW, an extra amount of supplement logistics mechanism of the School Meal Programme is being given to compensate for unavoidable in- (SMP) for handling, transportation and distribution of tra-household food sharing in alignment with the the Super Cereal also for the MCHC programme. “WFP’s Supplementary Feeding for Mother and Children (Operational Guidelines) – 1998”, “the • The utilization of the existent logistic network has Maternal and Child Health and Nutrition (MCHN) been a key strength of the programme. Except Toolkit – Nutrition, MCH & HIV / AIDS Programme for a short period of interrupted supply, the FFEP Design & Support Division, April 2011”, “WFP Food has met with its obligations of delivering the sup- and Nutrition Handbook”, and “FAO Human Nutri- plement on time. The review team did not come tion in the Developing World 1997”. This was a hu- across any complaint of wastage or leakages in the mane and practical but costly approach. course of handling the Super Cereal. • Beneficiary mothers and other community mem- • The relationship between DEOs and FFEP Units at bers expressed their happiness in getting the food district level seemed strained at places. These un- supplement at the health facilities. Except for brief easy relations were said to have emerged following periods of interruption of food supply, the benefi- the policy of reorganizing the then FFEP structure ciaries were satisfied with overall health and nu- in 2003-2004 and its amalgamation with the DEO trition related services at both of the government for a quick district level implementation or opera- health facilities and ORCs. They were happy with tional arrangement without proper shift of policy the quality of the food supplied and had no com- at the level of Department of Education (DoE) at plaints about its texture, taste or consistency. central level. The FFEP staff originally came from • The programme VDCs showed a much higher the Nutritious School Feeding Programme (NSFP) service utilization rate of ANC and PNC. 91% of having been a part of the Social Welfare Council mothers received ANC/PNC followed by 97.5% of (SWC) at a certain point of time in the past. The

Mother and Child Health Care Programme 13 having handled chunk of the MCHC resources for overall MCHC implementation can thus be an in- teresting 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 hu- man 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 grass- roots 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 lo- Samana Joshi, Banjhkakeni VDC, Doti briefly talking to the cal government line agencies and a major shift of mission members while returning home from the MCHC policy to improve the ORCs’ infrastructure at the clinic central level. FFEP staff members are still treated as project em- • Some health personnel mentioned the lack of in- ployees outside of the government system and of volvement of DPHOs and health facility staff in the temporary nature. Similarly, they mentioned that 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 Tech- nical 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 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 The FFEP Deputy Director, Mr. Ravi Upreti inspecting a VDC identify the vulnerable population had been carried storeroom during the mission out to identify the VDCs for programme implementa- the escalating costs of transport and the lack of tion. One of the VAM exercises had used a number of funds for programme monitoring work were some indicators such as food security, rate of malnutrition, of the issues that would have to be addressed. girl enrolment in primary school, access to education • As the FFEP/DEO delivers the Super Cereal, health and health, percentage of Dalits, accessibility, pres- facility staff seemed to take it as a part of the DEO’s ence of development agencies, gender disparity and programme. To what extent the existing reluctance impact of conflict. The targeting exercises were carried of the government health staff at both the district out to identify the VDCs in order for the WFP to be able and VDC level are reluctant as a result of the DEOs to provide support through the Food for Assets (FFA),

14 Mother and Child Health Care Programme School Meal Programme (SMP) and MCHC. However, ment, the aim of which is to reduce irreversible, eco- blanket coverage for all the beneficiaries, despite differ- nomic and social damage caused by malnutrition. The ences in economic and educational statuses of the family programme objectives are to help improve maternal and productivity, tends to raise questions whether there and child nutritional status and use food as an entry is any potential for wastage and leakages. point to improve access to education and health care. The programme is well integrated with the SMP which The FSMAU conducts regular review of food insecu- provides “mid-day meals” to ECDs and primary school rity together with the District Food Security Network children and vegetable oil to girl children under the (DFSN) and regularly shares updates on food secu- Girls Incentive Programme (GIP). The “life cycle” and rity situation at district level among the key govern- “continuum of care” approaches are integrated in ment stakeholders. The MCHC programme continues these programmes and is expected to improve nutri- to operate in one VDC for a period of five years. The tional, health and educational outcome through- inter review team found that there had not been any such ventions starting during the fetal period and continuing robust plans for carrying out for baselines, follow-up, till adolescence. However, it is surprising to note that mid-term review, programme evaluation and end-line there has not been any such synergy between the Pro- studies during the five-year period of the MCHC pro- tracted Relief and Rehabilitation Operations (PRRO) and gramme. It is recommended that definite end points the MCHC including the FFEP or the SMP. Possibility of be identified at which a VDC is weaned off the MCHC the PLW falling out of the purview of PRRO needs to be programme without waiting for a period of five years. seriously considered. It is necessary that the guidelines It will allow other more needy VDCs to benefit from for selecting the beneficiaries take note of households the programme. headed by the PLW and consider to include and assign them lighter work load to justify their inclusion. IV: Opportunities for integration a. With WFP programme: b. With Development partners The MCHC programme is a part of the five-year WFP • UNICEF implements a number of programmes CP period. The focus of CP is on long-term develop- in the community. The DACAW programme uses

Ms. Nicole Menage, Country Representative for the UN WFP in Nepal during her MCHC field mission to Deusa VDCin on April 05, 2011

Mother and Child Health Care Programme 15 mothers groups’ facilitation and mobilization for starting with a few districts is in the advanced various development outcomes. Integrating MCHC stage of development. A number of interventions with these programmes is a possibility but no link under the government ministries, namely the has been established so far. A link between these MoE, MoHP, MoAC, MLD and MoPP have been two programmes of the WFP and UNICEF was at- identified. Food supplementation combined with tempted through the signing of a MoU at the cen- IYCF counselling is one of the interventions identi- tral level sometime during the WFP CP during the fied by the health sector. It is an opportune time to period of 2002-2006. However, the collaboration advocate the MCHC approach for inclusion in this did not seem to have had any outcome evaluation- plan. The dissemination of this report could help based continuity. serve this purpose. • Nutrition Section/CHD/MoHP and UNICEF have • Nutrition Section/CHD/MoHP has begun to dis- partnered to implement Community Manage- tribute food supplement for children aged 6 to ment of Acute Malnutrition (CMAM). The CMAM 23 months of age, not exceeding 2 children per programme identifies Severe Acute Malnutrition family, in five districts of the Karnali region. WFP (SAM) and treats it at the Stabilization Centres has provided some technical input into this pro- (SCs) if the child is found to be suffering from life gramme. The experience of the MCHC programme threatening condition and through Out-Patient can contribute to better implementation of this Treatment (OPT) programme, if the child has no life programme in the long run. The officials within the threatening conditions. Ready to Use Therapeutic MoHP are interested to learn from the experience Food (RUTF) is the main intervention used to treat of the MCHC programme in order to implement it SAM cases. However, there is no food supplement in the Karnali region more effectively. It has been for children suffering for Moderate Acute Malnu- suggested that a pilot programme with the use of trition (MAM). The MCHC programme has a pos- measurable valid indicators and a mechanism to sibility of developing partnership with the CMAM ensure high level of compliance and follow-up as programme by using food supplement as an inter- regard the food supplement would create enough vention to prevent MAM cases among children less convincing evidence and can thus be used for fur- than five years of age. The prevention and treat- ther advocacy. ment 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 appro- priate 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 A girl child with her younger sibling at the health center in the weight of the babies at birth in those VDCs where Deusa VDC quoted as saying both her parents do portering the MCHC programme is being implemented. This in- for a living, and are absent during most lean seasons. formation can provide some tangible information on the impact of the programme on birth outcomes. • The current MoHP food distribution programme consists of supplying 1.5 kg of fortified food to c. With government programs: children 6 to 11 months of age and 2.5 kg per • An initiative of the NPC to launch a Multi-Sectoral month for children 12-23 months of age. The Nutrition Plan (MSNP) in a phase-wise manner food supplement is distributed from the health

16 Mother and Child Health Care Programme facilities and is linked with counseling on IYCF have annual funds to support the health facilities in practices provided by the health staff and FCH- Nepal. Considering countless claims and proposals Vs. MoHP can draw on the experience gained in for capturing the available funds at local level from the MCHC programme in selecting appropriate various social and political groups, it is suggested that food supplement, quantity and its supply, and in consistent lobbying would have to be made along monitoring its impact on the pattern of health with HFoMCs to enable health facilities to make use service utilization and outcome in terms of nu- of these funds. tritional status of children. • NHSP-2 has recommended studying the possibility Discussion with the MoHP officials revealed that D/ of food supplement or cash transfer for improving PHOs also have a budget to hire staff to run the pro- maternal and child nutrition. . The present report gramme at the health facilities. But it is unlikely that of the review of MCHC programme will provide that such fund will be available specifically for the some information for the policy makers. MCHC programmes.

V: Government and community participation: • The MSNP has plans to create a Nutrition and The MCHC committees and HFoMCs at community Food Security Coordination Committee (NFSCC) levels are engaged at different levels of participation at DDC/VDC level, which will use the “analyze, under the programme. MCHC Committees had prac- assess and act” approach to help improve nutri- ticed raising some funds from the beneficiaries term- tional status. The MCHC programme will have to ing it as participation fees ranging from five rupees prepare itself to be accepted as a necessary in- per beneficiary per month during the monthly clinic tervention particularly in the food insecure dis- schedule at the given health facility. Purpose was to tricts and VDCs. utilize the fund on account of the FCHVs’ involvement • Information, Education and Communication (IEC) during the monthly MCHC clinic days, purchase of es- as well as other technical materials on nutritional sential equipments, medicine and NFIs. It was learnt requirements for the PLW and children aged 6 to during the review that the practice was discontinued 23 months; their importance, values of different as a result of the government’s free health policy, ac- food supplements, best way of making them avail- cording to which charging additional fees has been able etc are needed for advocacy. forbidden. Further probing into this matter of impor- • Active MCHC committees and HFoMCs offer- op tance showed that any study had not been done about portunities for integration, but their existing com- to what extent the free health policy would apply for petence poses serious challenges. programmes falling under compensatory heading and those falling under non-compensatory heading VI: Sustainability: in term of various government health and nutrition • At the current level of expenses, each beneficiary programmes at community level. Both DDCs and VDCs 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 - lev els. 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 appropri- ate 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 Mothers group members actively responding to WFP Coun- support, but would by and large benefit from nu- try Representative’s queries in Deusa VDC, Solukhumbu

Mother and Child Health Care Programme 17 trition education. The second group is in need of plementation programme is in the right position occasional food supplement support during the so- to get involved in such a study and learn whether called lean seasons in terms of agricultural produc- food supplement leads to better nutritional - out tion, and has the potential to benefit from coun- come, particularly among the food insecure popu- selling arrangements at the government’s health lation. Furthermore, till such time that the MCHC set-ups. The third group is reported to be the programme gets integrated in the national nutri- most critical and vulnerable one in need of both tion progamme, WFP can engage into a research food supplementation and nutrition education and organization to study its impact on nutritional sta- counselling. It is thus recommended that the fu- tus, anemia prevalence and utilization of health ture nutrition programmes will have to be planned services in programme and non-programme VDCs. considering these three specific groups of people • Studies mentioned above will pave the way for the residing in the identified food insufficient interven- Nepal government to take over food supplementa- tion areas. A blanket approach to provide benefits tion as a desirable intervention to improve nutri- to all families is easier to implement but may not tional and health status of the population. be effective in achieving the objectives of the pro- gramme. A key recommendation for the future is VII: Monitoring of the programme: that, a more efficient identification strategy of the The current monitoring and evaluation system is ap- needy beneficiaries should be put in place soas parently functioning well with regular data gather- to supply them with the supplement. The MCHC ing and reporting to HMIS combined with periodic programme can contribute to DDC or VDC level monitoring based on interviews on a standard for- nutrition coordination committee in providing mat with the beneficiaries. However, the data col- thematic information on the costs of different lected so far is not usable to assess the change in supplementation approaches. The HHESS has the prevalence of anemia and maternal under-nu- suggested a typical community-driven model of trition. Partners can assess these indicators through helping family members through preparation of measurement of weight and height of women bene- nutritious food based on local-food-mix before ficiaries to identify the mothers with chronic energy discontinuing the programme terming it as a deficiency (a BMI of less than 18.5 kg/meter square) sustainable alternative. and periodic estimation of hemoglobin. In addition, • A research on the efficacy of food supplement collecting information on weights of babies at birth against cash transfer, nutrition education or con- in those communities where CBNCP is being imple- trol is being commissioned with DFID support. The mented will provide a valuable indicator to assess WFP, with its experience in running a food sup- the impact of the programme

18 Mother and Child Health Care Programme 10 General impressions

• Beneficiaries have contributed to gradual institu- the LMD has the capacity to deliver the services tionalization of the ongoing MCHC programme in this connection or not. However, current FFEP through active participation during the given structure is already an asset for logistics in terms monthly clinic schedules for both receipt of food of professionalism. supplement and accessing of the primary health • The MoE officials are willing to continue to work care services. This is in contrast to the mixed feel- under the present arrangement despite the fact ings of some government officials and ambivalence that the output of their efforts is reflected in the on the food-based approach. health sector. However, if the present arrange- • It was observed that the programme could not fol- ments are to continue in the future, some in- low a very rigorous method of follow up and data put to strengthen the FFEP structure is required management. Nature of the programme does not through further enhancement of budgetary necessarily lend itself to the creation of scientific capacity, training and material support as and database that would statistically prove or disprove when needed in critical areas of high demands the efficacy and effectiveness of the intervention. for such support. However, monitoring reports show a considerable • Nutrition programme of the MoHP and develop- increase in utilization of the ANC, PNC, growth ment partners expect more robust evidence to monitoring, nutrition education, counselling and support this type of intervention. WFP has a good other related promotional activities in the pro- opportunity to partner with independent agencies gramme VDCs. This increase and level of improve- looking into different aspects of the food supple- ment in accessing and utilization of the services mentation linking with an ongoing study commis- available at the community level are reported to sioned by DFID. have become two-fold in recent years through the NGO support system in certain limited technical ar- eas 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 supple- mentation 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/ Mr. Shree Dhoj Rai briefing over the status of the ongoing DoHS,MoHP takes a policy level decision on this MCHC in Deusa VDC, Solukhumbu to WFP Country Repre- proposition. A study should be carried out whether sentative

Mother and Child Health Care Programme 19 11 Recommendations

There will be more targeted approach in place for and more relevant in the context of “the golden the next phase considering food insecurity and nu- 1000 days”. This is also highly recommended that trition indicators considering also other social and the food supplement to the mothers and children political realities while building up the overall tar- should be incorporated into the ongoing MSNP doc- geting strategy. Sustainability is being addressed ument. by including more synergistic efforts in the 2013 – 2017 WFP CP with more life cycle approach for food A: Continuation of MCHC programme: insecure areas. This is to be understood in terms of • MCHC programme is still relevant in the VDCs being a part of fulfilling key requirements of health with high levels of food insecurity. However, and nutrition related services by the government continuation of MCHC programme should be health workers involving local stakeholders by the linked with VAM in light of newer findings from local people under the MCHC. The different aspects NLSS so that targeting strategy becomes more that play a crucial role in sustainable livelihood convincing. through life-cycle approach will be the key in highly • The programme in a new VDC should be initiated food insecure areas. Observations have shown that after a baseline survey followed by midterm and VDCs with support from user groups and commu- end-line surveys at specific points and information nity members have made significant contributions collection on impact indicators of interest. to the MCHC programme in hiring health workers, • Reconsider the target age group to bring them in establishing ORC set-ups and improving infrastruc- line with government policies as well as WFP’s new ture at the health facilities and ORCs within the pro- draft nutrition policy which focuses on one thou- gramme VDCs. It is also suggested that how food sand days and ”The Right Food at the Right Time”. supplement can be a part of national health deliv- • Mechanisms to support the health facilities in pro- ery system should further be explored. viding health services need to be strengthened if food supplementation is to continue. The current Costs become higher while providing support in the approach of utilizing the services of a non govern- remote, food insecure areas in Nepal. The govern- ment organization needs to be continued for some ment’s ongoing supplementary feeding programme more time period in the future. under the MoHP for under-2 children in the Karnali region and beyond indicates a priority being given to B: Integration with government programmes: the supplementary, and the government and WFP can • Bring FHD on-board demonstrating their role in im- further collaborate in joining hands in areas of logis- proving maternal nutritional status. tics and technical expertise of lessons learnt. One of • Explore the possibility of working with LMD of the the operational issues directly observed during field MoHP to supply food supplements specifically in observations, such as further need for discussion on districts where MCHC program is going on. alignment of the monthly ANC services under the • Open dialogue with DDCs and DPHOs to hire health MCHC with the government’s 4-times ANC visits staff with funds allocated to VDCs and DPHOs to would also be a pertinent area for further strength- support ANC, PNC, GM, recording and reporting ening of the programme. It is also suggested that activities, storage facilities at ORCs etc. further linkages with the FHD in addition to the CHD • Explore the possibility of including food supple- would steer the programme in the right direction ment in the treatment protocol for the manage-

20 Mother and Child Health Care Programme ment of MAM cases in coordination with the CHD. counselling. It will need different types of hu- The programme should follow the national CMAM man resources to be employed in intervention guidelines and would require development of na- areas. Nutrition counsellors would be more tional guidelines for addressing MAM as well as in- beneficial rather than health worker. However, tegration with the existing national CMAM guide- the health workers being currently employed by lines. Support for MAM under the CMAM is further the HHESS have played a crucial role in overall necessitated by the fact that MAM cases constitute strengthening of the government system at the the majority of acute malnutrition burden. Hence, health facilities. a provision of appropriate supplementary food • Local resources such as the funds of VDCs, LDO and in addition to other routine activities for children DPHO can be mobilized to hire health staff at the with MAM caseload will complement the preven- local level. Part of the funds has been utilized on tive and therapeutic programme components in hiring of temporary health workers and building of highly food insecure areas. minimal infrastructure at local level with support • The food supplement currently being used has a high of the NGO. level of acceptability among beneficiaries and afford- • The FFEP unit is need of further support in able for the partners. New products with better nu- areas of capacity building as per discussion tritional content and efficacy should be promoted as held with the concerned personnel during the these products contain animal source protein and are review. Issues of storage facilities and human specifically designed for under-two years of children resources will have to be settled before con- for the management of the MAM in particular. sidering distribution of food from ORCs with support from both the local government line C. Evidence of effectiveness: agencies and the NGO partner. • Explore the possibility of including data from pro- • Explore the existing mechanisms to help strength- gramme VDCs into HMIS to highlight its effective- en HFoMC and MCHC committees, essentially by ness in coordination with the CHD. resuming MCHC fund collection referring to the • Continue and combine the MCHC programme with free health policy of the government and previous a study to look into the effectiveness of food sup- MCHC implementation guidelines. plement in programme VDCs against control in • Support government health workers at the food deficit areas. health facilities through orientation and training • Partner in the research to be funded by DFID to to develop their sense of ownership of the pro- study the efficacy of food supplement vs. cash gramme. transfer vs. nutrition education vs. control, and -ex • Develop consensual approach on the future in- plore whether the study can look into the efficacy tegration of the MCHC programme within the of the food supplement approach among food in- national programmes and modalities. secure population groups. • Develop a roll out/exit strategy on the basis of consensus thus reached in the process of final- D. Strengthening of the programme: izing the final report. • NGO support is vital for the success of the pro- gramme. This should be more for nutritional

Mother and Child Health Care Programme 21

Annexes:

Annex i. List of persons interviewed Annex ii. Summary of surveys and reviews of the MCHC programme carried out between 2001 and 2010, per district Annex iii. Literature review on the impact of food supplementation on maternal and child nutrition Annex iv. Nutritional Value of fortified food with a stress on micronutrient content Annex v. Summary of reports of review of MCHC activity Annex vi. Report from the Field visit to Dadeldhura and Doti for a review of MCHC program Annex vii. MCHC Review Dissemination Meeting – 10 February 2012 Annex viii: Contributions made at local level Annex x. References

Mother and Child Health Care Programme 23 Annex i: List of persons interviewed Dadeldhura Kathmandu 1. Mr. Hikmat Kumar Shrestha, DADO 1. Dr. Mingmar Gyalzen Sherpa, Director, Logistic 2. Mr. Ramhari Das Shrestha, DEO Management Division 3. Mr. Keshav Raj Joshi, Unit chief, FFEP Unit 2. Dr. Shyam Raj Upreti, Director, Child Health 4. Mr. BalbahadurMalla, DPHO Division 5. Mr. KabindraShrestha, Senior PHI 3. Mr. Raj Kumar Pokharel, Chief, Nutrition Section, 6. Mr. GaneshDutta Joshi, PHI CHD 7. Mr. PremlalLamichhane, CDO 4. Mr. Leela BikramThapa, Nutrition Section, CHD 8. Ms. SitaThapa, WDO 5. Mr. Manoj Upreti, Logistic officer, WFP 9. Ms. Yangze Sherpa, Coordinator, HHESS 6. Mr. Luc Laviollate, World Bank 10. Mr. UmeshSawad, HHESS 11. Mr. Kiran Pal, Director, WFP Regional Office Salyan 12. Ms. MeenaThapa, Focal person, MCHC 1. Dr Kamal Gautam, Acting DHO programme, WFP 2. Dr. Bishal Shrestha, DPHO 13. Mr. Tapeshwar Mandal, Senior AHW, Chamda 3. Mr. Dhir Jung Shahi, DPHO Health Post, Ajaymeru VDC 4. Mr. Dasharath Kumar Shrestha, PHI, DHO, 14. MCHC committee members, Chamda Health 5. Mr. Vijaya Kranti Shakya- MCHC focal person , DHO Post, Ajaymeru VDC 6. Mr. Peshal Kumar Pokhrel – LDO 15. Beneficiary mothers and children, Chamda 7. Mr. Suresh Adhikari, DDC Health Post, Ajaymeru VDC 8. Mr. Tej Prasad Poudel – CDO 16. Storekeepers, Chamda Health Post, Ajaymeru 9. Mr. Biswomaya Sharma- WCDO VDC 10. Mr. Balkrishna Gaire – DEO 17. ANMs and FCHVs, Chamda Health Post, 11. Mr. Ram Hari Rijal -Program officer, DEO Ajaymeru VDC 12. Mr. Rabindra Singh Bhandari, FFEP Unit, DEO 13. Mr. Ram Milan Prasad Biswokarma – DADO Doti 14. Mr. Hem Bahadur Chand, Sr.AHW, In charge, 1. Mr. MahendraShrestha, Director, Regional SHP, Kupindedaha Health Directorate 15. Ms. Remanta Basnet, ANM, Kupindedaha SHP 2. Mr. KuberKhadka, AHW, Mr.Yogendra Shahi, Field 16. Ms. Thum Kumari Kunwar, Storekeeper, Supervisor, MCHW, VHW, FCHVs, Banjhkakeni Kupindedaha SHP VDC 17. Mr. Moti Lal Bhandari, VHW, Kupindedaha SHP 3. Mr. Netra Prasad Pant, Chief, FFEP Unit 18. Mr. Om Bahadur Budhathoki: Support staff, 4. Mr. TekBahadur Thapa, DEO Kupindedaha SHP 5. Dr. Raj Kumar Bhatta, Acting DPHO 19. Mr. Mume Kunwar, Chairperson, MCHC 6. Mr. Keshar Saud, Focal Person, Nutrition Committee Programme, DPHO 20. Mr.Ram Bahadur Kunwar, Chairperson, Village 7. Mr. Kishor Shrestha Statistics Assistant, DPHO Committee 8. Mr. Prem Bahadur Khapung, CDO 21. Mr.Krishna Bahadur khadka, Acting Chairman, VDC 9. Mr. Yagya Raj Joshi, DADO 22. Mr. Dhruva Nepali, Social Worker, Kupindedaha 10. Mr. Hem Raj Joshi, Gender Equality Officer, WDO 23. Ms. Nili Reule, Beneficiary, Kupindedaha SHP: 11. Mr. Chuda Mani Joshi, Officiating LDO Kupindedaha

24 Mother and Child Health Care Programme 24. Mr.Deepak Kumar Yeri, Political leader, UCPN 34. Mr. Gyan Bahadur Bhujel – Health and Nutrition (Maoist) Kupindedaha section, UNICEF, Nepalgunj 25. Ms. Kewat Kunwar: FCHV: Kupindedaha SHP 35. Mr. Nar BdrBudha – Maternal and neonatal 26. Ms. Bhima BK: FCHV: Kupindedaha health section, UNICEF, Nepalgunj 27. Ms. Pokhari Kunwar: FCHV: Kupindedaha 36. Mr. Biswo Nath Poudel – Program Manager – 28. Ms. Seti Giri: FCHV: Kupindedaha Nepal Family Health Programme, Nepalgunj 29. Ms. Gaimati Bohara: FCHV: Kupindedaha 37. Mr. Birendra Khagunna- Program Manager, Save 30. Ms. Bishnu Kunwar: FCHV: Kupindedaha the Children, Nepalgunj 31. Ms. Gople BK: FCHV: Kupindedaha 38. Mr. Ravi Mohan Bhandari- Health and nutrition, 32. Ms. Daili Budhathoki: FCHV: Kupindedaha focal person, Save the Children, Nepalgunj 33. Mr. Ghanshyam Pokhrel – Director, Regional 39. Mr. Shailendra Shahii- Engineer, Save the Health Directorate, Mid Western region children Nepalgunj

A woman in on her way to collect fodder with wicker basket on her back, and holding her child in spite of her pregnancy clearly depicting increasing workload of women in the arF West

Mother and Child Health Care Programme 25 Annex: ii: 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 Doti Follow-up Nov Makawanpur Base- Makawanpur 2001 2005 line 2002 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 Anaemia (pregnant) 55 30.4 66.9 43.1 Anaemia (lactating) 26.9 34.3 73.5 22 Night blindness 6.1 5.4 11.6 3.9 (pregnant) De-worming-tablets 2.5 50.7 - 25.5 (pregnant) Iron-supplements - 37.5 - 36.3 (pregnant) Seeking antenatal 29.3 73.2 22 49 care (pregnant)

26 Mother and Child Health Care Programme Annex iii: Literature Review specific to food supplementation and pregnancy outcome 1. Allen L, Gillespie S: What works? A review of ef- - Young maternal age at conception is a risk factor for ficacy and effectiveness of nutrition interventions; poor pregnancy outcome, therefore targeting moth- UN/ACC/SCN Nutrition Policy Paper no. 19, Asian ers who are still growing will be beneficial. Continu- Development Bank 2001: ing supplementation during lactation and subsequent pregnancy may cause even better outcome. This review has taken a life cycle approach in identi- fying the impact of malnutrition in the developing - Micronutrient supplementation during pregnancy is world. It has considered the different programmes extremely important to reduce the prevalence of ma- for their efficacy or effectiveness. According tothe ternal anemia and its consequences including reduc- authors “efficacy refers to the impact of an interven- tion in maternal mortality. Adequate iodine supple- tion under ideal conditions, when the components of mentation in pregnancy is critical for the prevention the intervention (e.g., food supplements) are directly of neonatal deaths, LBW and abnormalities in physical delivered to all the individuals in the target group (i.e., growth and cognitive development. 100% coverage). This is possible under research condi- tions with a high level of supervision. Effectiveness refers 2. Lancet Nutrition Series: Lancet 2008: Bhutta ZA, to the impact of an intervention under real world con- Ahamed T, Black RE, Cousens S Dewey K, Giugliani E, ditions, when prorgrames are scaled up to reach large et al: What works? Interventions for maternal and proportions. child undernutrition and survival The authors reviewed 13 studies and one systematic A number of programmes were reviewed related to review to summarize the understanding regarding the five major nutrition problems; low birth weight, early outcome of balanced protein energy supplementa- childhood growth failure, iodine deficiency disorders, tion on pregnancy outcomes. The systematic review anemia and Vitamin A deficiency. A comprehensive re- included 6 studies with information on size at birth. view of the existing knowledge of the efficacy of key The systematic review was heavily influenced by a nutrition interventions for preventing and alleviating large trial in Gambia that targeted pregnant women low birth weight is summarized below: of low BMI, who were supplemented with 700 kcal per day. The pooled estimate showed that this strat- Low Birth Weight: South Asia has the highest preva- egy reduced the risk of Small for Gestational Age baby lence of low birth weight babies (about 30%) and this (which was taken as to indicate intrauterine growth is strongly associated with under nutrition of mothers. restriction) by 32% (relative risk 068, 95% CI: 0.56 to LBW is probably the most important reason for under- 0.84). The key message from this study was stated by weight children in this region. Therefore, interventions the authors as “interventions for maternal nutrition to reduce the prevalence of LBW should receive high- (supplementation with iron folate, multiple micronu- est priority. Randomized controlled intervention stud- trients, calcium, and balanced energy and protein) can ies have shown the following: improve outcomes of maternal health but few have been assessed at sufficient scale”. - Supplementation with food containing a balanced protein and energy content (protein contributing less 3. Imdad A, Bhutta ZA: Effect of balanced protein than 15% of the energy) during pregnancy significantly energy supplementation during pregnancy on birth increases the birth weight. outcomes; BMC Public Health 2011; 11: S: 17

- Though the expected benefits from maternal food This article presented a more recent systematic review supplementation in Asia are yet to be shown, a num- of the impact of balanced protein energy supplemen- ber of studies in Gambia have shown positive effect. tation on birth outcome. The review reported that Women with lowest weight from conception to early providing women with balanced protein and energy pregnancy and lowest energy intakes are most likely to supplementation during pregnancy resulted in sig- benefit from supplementation. nificant reduction in the risk of giving birth to Small

2Technical Annex – Mother and Child Health Care Programme. E. Girerd-Barclay, June 2006.

Mother and Child Health Care Programme 27 Primary Health Center in VDC at Bajhang District providing MCHC service

for Gestational Age infants (relative risk: 0.69, 95% (74.90 gm 95% CI: 42.42 to 107.6 gm) compared to ad- CI: 0.56 to 0.89). Pooled results showed that the bal- equately nourished women (27.8 gm, 95% CI: 19.57 anced protein energy supplementation resulted in an to 75.31 gm). The effect of balanced protein energy overall significantly higher mean birth weight. (58.99 supplementation on neonatal mortality was not sta- gm 95% CI: 33.09 to 86.68 gms). This effect was more tistically significant (relative risk 0.63, 95% CI: 0.37 pronounced in women with evidence of malnutrition to 1.06).

28 Mother and Child Health Care Programme Annex iv: Nutrient content of Fortified Food ‘Supercereal’ distributed under MCHC programme

Nutrients Vitamin and Mineral Requirements in Human Nutrient content (Native plus Nutrition, FAO-WHO 2004 Premix)in WFP Supercereal* RNI/day for Pregnant RNI/day for Lactat- Per 100g women ing women 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

Mother and Child Health Care Programme 29 Annex v: Summary on reports of review of MCHC Programme

Date Title Reviewers Objectives Findings Recommendations

April 2005 MCHC Dr.Genequand To assess l No specific funding in Ensure appropriate (Nov 2004 review the overall DHS, frequent transfer MoH funding (WFPN to Feb mission’s Dr.Gartaulla imp’tion of trained staff to non- &ODB mission) 2005) report process programme districts Policy decision not to Ms. Ghimire and to sug- l Insufficient staff at NS transfer staff (DHS) gest actions of CHD Strengthen the HR in Ms. Kudsk- for improve- l Lack of coordination NS, CHD to seek fund Iversen ment between MoHP and (WFPCO to help) FFEP of MoE l Inactive DCC, no pro- MoHP/DHS to have vision for NFPerson in control over the log the programme district man of MCHC act l Inadequate equip- (transport and food ) ment, instruments in Hold DCC meets ORCs and S/HPs, no regularly, NFP to be staff for recording and nominated from DHO reporting WFP SO and DHO to l MCHC members train supervisors and help in running ORCs NFP, but are not supported DHS to develop in any way with no minimum std for equip budget for snacks or and services at S/HP tea, the reports sent by & ORCs, allow money MCHC committees to raised during food dist S/HPs and onward to to be used by MCHCC DHOs are incomplete & or DHS funding for this irregular purpose l No proper ORC build- DCC to explore pos- ings sible NGO support for l No refresher training equipments to ORC for the staff of S/HPs MCHCC to be provided l UNICEF/DACAW-run funds for tea & snacks, areas showed marked members to have reduction in UW preva- exposure visits to well lence run prog areas l GIZ had provided Regularize recording equipment to one ORC and reporting in Doti WFP to seek sup- l Follow up survey re- port for construction ports showed lower UW of ORC buildings or rates in Makawanpur, procure curtains to less in Doti, red in ane- create privacy for ANC mia prevalence more in and PNC Makawanpur and less Refresher training for in Doti, ANC and PNC S/HP staff and FCHV practices and GM rates Learn from DACAW increased exp; explore possi-

30 Mother and Child Health Care Programme ble help form GTZ for equipment WFP to organize a meeting of INGOs to discuss the possible col- laboration

May 2009 MCHC activ- Ms.Meena To learn Utilization of nutrimix UNFPA should continue ity: A joint Thapa the lessons at HH level: to support S/HP with review of Mr.Ganesh from the Health staff believed ANM, training and en- WFP and Shahi joint imple- that the ben shared NM hance awareness about UNFPA col- mentation with other members; MCHC laboration process an NM was consumed Expand collaboration to at commu- recommend within 15-20 days other VDCs nity level, actions though it was supposed Jogbudha for future to last for the month and Shirsha effective col- There was no problem VDC, DDL laboration with the distribution of in common NM in both VDC VDCs 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

July 2008 MCHC Madhav Sap- To assess Comprehensive re- Better ownership by Activity: Re- kota and review cording and reporting the health facility staff view report Ms.Elaine the NGO system for monitoring Better coordination on the NGO Reinke modality op- system was designed between MCHC and support BBAmatya tions in ar- and implemented which HFOMC needed Raju Neupane eas of food was very effective Minimum stock level at distribution, Effective utilization of FDP to last for at least 2 LB Thapa utilization MCHC funds available at months, need for lead Prakash and maximi- S/HP for ANC and PNC time between com- Shakya zation of ex- services, better services modity received and NT Sherpa isting health at S/HP compared to distribution Niraj Shrestha services and ORCs. Wooden pellets recom- facilities Staff members of mended for some stor- awareness about pos- age sites sible losses found to Concerned about an be high, better storage exit strategy arrangements

Mother and Child Health Care Programme 31 Annex vi: Summary of observations from the field mission

• There was a general good feeling about the pro- • The FFEP managed logistics whereas the health gamme and it seemed that the beneficiaries ap- services were the responsibility of the health facili- preciated the WFP, staff at health facilities, DPHO, ties. DPHOs and Health facilities did not have a ma- DEO and other officials in the district. However, jor role in the processes of resource mangement. It limited interventions, blanket coverage and its in- looks logical that the FFEP has been involved in this ability to make much impact were some of the con- task as they seemed more experienced and have cerns implied in some of the government officials’ an existing network for the purpose. But the FFEP conversation. The question of sustainability and does not have anything to show in short term as the programme’s tendency to promote depend- the impact of their work. The DPHO has to manage ence were also voiced by different officials. the increased work-load created by the increased • Lack of adequate number of health staff at the attendance of PLW for ANC and PNC and of chil- health facilities was repeatedly brought up as one dren under 36 months of age for growth moni- of the major limiting factors that would hinder the toring. There is no support for them in terms of MCHC program to achieve its objective of improved human resources and incentives to carry out this utilization of health services. This has highly justi- extra work. Local HFoMC has limited resources and fied the support being provided by the WFP for the these are not sufficient to strengthen the human MCHC through an NGO committed to the field of resource situation. The current government rule health and nutrition in Nepal and its continuity is that no participation fees can be charged by the sought for as per conversations. health facilities has further limited the local com- • Inability to ensure consumption of the food sup- munity’s ability to raise funds to support the pro- plement by the intended beneficiaries alone and gramme. not by other family members was another con- • Using an NGO to support the programme looks straint that would not allow the programme to like a short term measure. There is a need for in- achieve expected reduction in the prevalence of stitutionalizing whatever the NGO has additionally underweight and anaemia in the targeted popu- been doing at VDC level in support of the MCHC on lation. This needs further clarification at policy behalf of the donor agency so as to be able to show level, such as an average kcal requirement per day an impact in the long run. It just strengthens the for a child or an adult as being used by WFP glob- argument that to provide effective services of good ally and within Nepal by Nepali authorities, and quality health services, the health facilities need further interpretation of intra-household sharing human resources and VDCs have had the tendency information dissemination, and how this informa- of allocating their annual funds to other develop- tion should be disseminated at household level on ment areas than the health related areas. proper food utilization at household level. Further • As these districts did not have a programme for reference should be made to the WFP’s policy management of acute malnutrition, we could document on ration size such as “the Right Food not observe the relationship between the MCHC at the Right Time” for both treatment of MAM and and CMAM. Field reports from Accham and Ba- prevention of stunting. jura could be reviewed to see how it works. This • Though it was repeatedly mentioned that the issue could be brought up during discussion with VAM was used to identify the benefiting VDCs, the Ms.Saba Mabrehtu and Mr. Anirudra Sharma of reasons for selecting these VDCs for food supple- the UNICEF at central level. ment were not obvious. Their fields were full of • Apparently, UNICEF and WFP had worked in collab- ripening crops and looked fertile. However, some oration when the DACAW programme was opera- of the beneficiaries did mention that none of the tional in Dadeldhura district. It would be a worth- households within the VDC that they lived in could while exercise to explore how that collaboration manage to live on the produce of their land for the helped each other’s programme. whole year. The lurking question was what would • Discussion with the Directors of the CHD and FHD be the situation in those VDCs which did not have should seek in an effort for opinion building and the programme. policy building about how they perceive the role

32 Mother and Child Health Care Programme of the food supplement to improve maternal and the MoHP officials from CHD, FHD and LMD of the child health and nutrition. A review of the -inter DoHS and Policy Division at the MoHP are very im- national experiences in food supplement usu- portant before proceeding further. The MoE have ally produces a mixed picture. It is a very difficult reportedly had no problem as regards the overall exercise to demonstrate a positive impact as the structure except the district level FFEP staff mem- programme does not work under the rigours of a bers having expected more support in operational research. At this stage, extensive discussions with areas from both the WFP and government.

Mother and Child Health Care Programme 33 Annex vii: Background to the HHESS and synopsis of its achievements at local level

HHESS began to work in Solukhumbu district for the monitoring, counseling and logistical components, MCHC programme in partnership with the WFP since but also social mobilization targeting utilization of lo- 2007. The partnership happened following the visit cally available resources; be it in the form of increasing of WFP Country Representative to Solukhumbu and funding from local government line agencies, collabo- overall observation of innovative ideas being used by ration, human resource or user contribution. HHESS in the promotion of health and nutrition as per reports. Main purpose of this partnership was to pilot Ongoing support to the government health facilities NGO support into the ongoing MCHC and further scale has considerably helped improve quality of maternal up the system in the Far/Mid Western regions based and child health service delivery, logistic management on recommendations of the following joint review vis- and advocacy of food utilization. Monthly monitoring its and do away with some of the observations made reports from July 2011 to January 2012 during the last by concerned stakeholders prior to 2007 on issues of six months have shown a significant progress on key quality of service delivery. Further piloting was done output indicators; 94.85% progress on the number in Dadeldhura and Salyan districts in 2008, and from of children aged 6 to 36 months growth monitored, 2009 onwards the NGO support system was scaled up 95.40% progress achieved on ANC, 95.15% progress in all programme districts. achieved on PNC, and underweight prevalence rate standing at only 4.12%, a huge step forward compared It was considerably discussed at the outset whether to the last year’s underweight prevalence rate at 9.9%. the NGO support was to fill into specific human re- Even if queries may be raised on meeting minimal an- source gap at the government health facilities provi- thropometric measurement parameters, overall pro- sioning limited number of junior level health staff with gress has been seen beyond expectations. some technical background or function as a short- term entity only for health and nutrition education/ Support in financial terms is very minimal. One super- counseling. Joint reviews time and again recommend- visor covers an area ranging from one VDC to two to ed that the existing gaps of human resource including three VDCs in the given district. With a focus more on social mobilization support would be the key in overall sustainability of the MCHC at health facility level, the sustainability of the support system. As a result of this HHESS has been able to show some tangible results in field level exercise, the support strategy was packaged line with mobilizing locally available resources in col- in such a way that the NGO would have to help im- laboration with the government line agencies in the prove not only technical aspects of ANC, PNC, growth Far West as per the table shown below;

34 Mother and Child Health Care Programme Annex viii: Contributions made at local level

Districts VDCs Contributions made Purpose of contribution Remarks from VDCs (NRS) Dadeldhura Gangkhet 200,000.00 ORC set-up in Hartola Birthing center established for wards 8 & 9 and an ANM hired. Shirsha 140,000.00 Hiring of an ANM Birthing center established. Belapur VDC 400,000.00 (through Drinking water, hiring of Through lobbying by HHESS GIZ) 3 ANMs, ORC set-up and MCHC committee Budget not specified An additional ANM VDC secretary has commit- yet hired for MCHC ted to propose a separate budget. Jogbudha Budget not specified 2 ANMs being hired for VDC and PAF to support for yet SHP and ORC both. two-room house for health initiated by HHESS. Achham Kuntibandali Budget not specified An ANM hired for MCHC Counseling session linked yet 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 Ongoing two-year long lob- post building bying with the VDC and DHO on the need for improv- ing poor infrastructure by HHESS Bajhang Kafalseri 36,000.00 Management of snacks Birthing center established during monthly clinics at the initiative of com- mittee, HFoMC and HHESS together 130,000.00 For construction of an At the initiative of HHESS ORC set-up with VDC secretary 250,000.00 For construction of sub- Through joint efforts of health post building HFoMC and HHESS 150.000.00 Hiring of an ANM and Birthing center established management of snacks at the initiative of HHESS during monthly clinics 241,000.00 For construction of sub- HHESS has started sale of health post building empty Super Cereal bags to raise budget for snacks dur- ing monthly clinics. Deulekh 60,000.00 Hiring of an ANM Doti Simchaur Budget not specified An ANM hired and solar HHESS played a key role for yet panel set up in addition this arrangement over the to improved birthing past 2 years. center

Mother and Child Health Care Programme 35 Chamarachau- Budget not specified An ANM hired and solar HHESS played a key role for tara yet panel set up in addition this arrangement over the to improved birthing past 2 years. center Daud Budget not specified For management of Birthing center established yet snacks during monthly through lobbying with VDC clinics in addition to an secretary by HFoMC and ANM for MCHC HHESS. Bajura Chhatara Budget not specified 2 ANMs hired for MCHC Lobbying with VDC secretary yet in addition to birthing and local youth clubs still center and sub-health continuing through HHESS post building construc- for MCHC tion Budget not specified 1 ANM hired for MCHC Lobbying with VDC secretary yet in addition to birthing and local youth clubs still center and sub-health continuing through HHESS post building construc- for MCHC tion Baitadi Budget being pro- For ORC set-up in ward- Lobbying / advocacy going posed 7 on for MCHC in order for locals to take ownership Sakar Budget not specified Hiring of an AHW and 1 Lobbying / advocacy going yet MCHW for MCHC on for MCHC in order for locals to take ownership

36 Mother and Child Health Care Programme Annex ix: MCHC Review Dissemination Meeting MCHC Review Dissemination Meeting ments, constraints and suggested measures for future NHICC Conference Hall, DoHS, Teku, Kathmandu directions. 10 February 2012 A total of 28 participants representing the key NuTEC Note for Record members attended the meeting on 10 February 2012 Dissemination meeting on the MCHC programme at the NHICC hall from 09:00 to 11:15 am at the invi- review report was jointly organized by the WFP and tation of the CHD earlier through formal correspond- CHD at the NHICC conference room, Teku, Kathmandu ence. Following is the list of participants for further on 10 February 2012. Main objective of the dis- reference; semination was to share key findings, major achieve-

SN Names Designation Organization Email/contact 1 Dr. Shyam Raj Upreti Director CHD/DoHS [email protected] 2 Mr. Robin Houston Deputy Director NFHP [email protected] 3 Dr. Madhu Dixit Devkota Professor IOM [email protected] 4 Natasha Mesko Maternal Health & DFID [email protected] Nutrition Advisor 5 Dr. Shilu Aryal Senior Obstetrician/ FHD [email protected] Gynecologist 6 Mr. Jibachh Mishra Director FFEP/MoE [email protected] 7 Dr. Lhamo Sherpa ED HHESS [email protected] 8 Mr. Ngima T. Sherpa Chairperson HHESS [email protected] 9 Dr. Jaganath Sharma Coordinator NFHP II [email protected] 10 Ms. Bhim Kumari Pun Programme Manager SC [email protected] 11 Ms. Neera Sharma Sr. PC Nutrition SC Neera.sharma@savethechildren. org 12 Mr. Devendra Adhikari M & E Manger HKI [email protected] 13 Mr. Anirudra Sharma Nutrition Specialist UNICEF [email protected] 14 Mr. Madhukar Bdr Senior Programme HKI [email protected] Shrestha Manager 15 Ms. Nicole Menage Country Representa- WFP [email protected] tive 16 Mr. Nicolas Oberlin Deputy Country Direc- WFP [email protected] tor 17 Ms. Pramila Ghimire CP Coordinator WFP [email protected] 18 Ms. Sophiya Upreti Programme Officer WFP [email protected] 19 Ms. Shreejana Rana Vice Chair SCWEC [email protected] 20 Ms. Pramila Acharya Rijal Chairperson SCWEC [email protected] 21 Ms. Swastika Sirohiya SCWEC [email protected] 22 Mr. Raj K. Pokharel Chief CHD/DoHS [email protected] 23 Mr. Shankar P. Acharya Public Health Officer CHD/DoHS [email protected] 24 Prof. Ramesh Kant Adhikari MCHC Review Team [email protected] Leader

Mother and Child Health Care Programme 37 25 Mr. Sumit Karn Programme Coordina- CHD/DoHS [email protected] tor 26 Mr. Lila Bikram Thapa Senior PHO CHD/DoHS [email protected] 27 Dr. Kedar Prasad Baral Professor PAHS 28 Mr. Amrit Bdr Gurung SPA WFP [email protected]

Proceedings - There will be more targeted approach in place for - Dr. Shayam Raj Upreti, Director, CHD chaired the the next phase considering food insecurity and nu- meeting. trition indicators. Other social and political realities - Mr. Raj Kumar Pokharel, Chief, Nutrition Section will also be considered while building up the over- facilitated overall sessions. all targeting strategy. - Prof. Ramesh Kant Adhikari presented the report - Sustainability is being addressed by including on MCHC review. more synergistic efforts in the 2013 – 2017 CP with - Ms. Nicole Menage, Country Representative, WFP more life cycle approach for food insecure areas. shed closing overall remarks followed by Dr. Upreti Sustainability is to be understood in terms of be- closing overall meeting at the end. ing a part of fulfilling key requirements of health and nutrition related services by the government Queries from the participants during plenary health workers involving local stakeholders by the discussion local people themselves under the MCHC. How- - Baselines, mid-term follow-up and end line evalua- ever, Nicole Menage, WFP Country Representative tion. expressed her hope that the different aspects that - Targeting strategy based on multiple indicators, play a crucial role sustainable livelihood through particularly food security and nutrition. life-cycle approach will be the key in such highly - Sustainability to be high on the agenda, a top prior- food insecure areas. ity. - Work burden or extra human resource issue is be- - Alignment of food distribution with 4 ANC visits. ing dealt with by the locals, health workers and - Strengthening linkages with the Family Health Divi- user committees themselves without much- ex sion (FHD). ternal assistance, an example of which is ongoing - Need for extra human resources and filling in the contributions from VDCs and local user groups in existing gaps. hiring health workers, establishing ORC set-ups - Food supplement to be a part of the health deliv- and improving infrastructure at the health facilities ery system. / ORCs within the programme VDCs. - Programme implementation modality for supple- - Need to explore the mechanism and evidence on mentary feeding programme in Karnali and be- how food supplement can be a part of national yond, and ongoing MCHC activities. health delivery system. - Workload for health workers, FCHVs and HFMCs/ - Costs become higher while providing support in MCHC committees. the remote, food insecure areas in Nepal. MoHP’s - Cost implications for the government and overall ongoing supplementary feeding programme for capacity of the government. children under-2 in Karnali and beyond indicates a priority being given to the supplementary feeding, Response to queries from Prof. Adhikari and MCHC & and the government and WFP can further collabo- Nutrition Team from the WFP, and concluding remarks rate in joining hands in areas of logistics and tech- from Nicole Menage, Country Representative, WFP nical expertise and sharing of lessons learnt. Nepal and Dr. Shyam R. Upreti, Director, CHD, Teku - Further discussion will be made at the next Pro- gramme Coordination Committee (PCC) meeting - There had been baselines and follow-up evalua- considering alignment with the 4 ANC visits. tions of the MCHC until 2006-2007. Results were - Prof. Adhikari stressed the need for further link- then positive. This has been a top priority in the ages with the FHD considering maternal health upcoming WFP CP period from 2013 to 2017. and nutrition. In response to a specific question

38 Mother and Child Health Care Programme about the role of food supplementation during - In closing, Dr. Upreti recognized the role of food pregnancy and lactation, Prof. Adhikari empha- supplement in improving the utilization of ANC, sized the role of food particularly for pregnant and PNC and GM services by the PLM living in the pro- lactating mothers in food deficit households. He gramme VDCs, however, expected to see more also stressed that every VDCs have three types of valid data to demonstrate effectiveness of pro- families: first: families with food sufficiency don’t gramme on other outcome indicators (prevalence need food supplement but still need nutrition of anemia, LBW, underweight etc). He suggested education, second: those families which may need that the recommendations from the review that food supplement during lean seasons occasionally future implementation of the programme be car- but will need nutrition education all the time and ried out in such a way that the outcome indicators third: families which are chronically food deficient are collected in a rigorous way to demonstrate the and would benefit from food supplementation impact. He also announced that MCHC activities along with nutrition education. The programmatic will be included in the national multi sectoral nu- challenges lie in identifying the different categories trition plan in such a way that its implementation of families and provide the services as needed. would help generate more valid evidence.

Mother and Child Health Care Programme 39 Annex x: References

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 Ne- pal 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 – Janu- ary 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 Pro- gramme 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 Re- search 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)

40 Mother and Child Health Care Programme 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, No- vember 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

Mother and Child Health Care Programme 41

Contact Information

WFP Country Office WFP Sub-Office WFP Sub-Office Chakupat, Patan Dhoka, Lalitpur Adarsha Nagar, Nepalgunj Kirtipur, Dadeldhura P.O. Box 107, Kathmandu, Nepal P.O. Box 3, Banke, Nepal , Nepal Tel: 977-1-5260607 Tel: 977-81-525132 Tel: 977-96-420469 Fax: 977-1-5260201 Fax: 977-81-525133 Fax: 977-96-420398