Unit-7 : National nutritional

problem/ Programme
Unit- 8: National Strategic and
Programme
Prepared By: Ms. Shubheksha
Sharma
BASED ON NUTRITION POLICY AND STRATEGY
2004
 Nutritional problems
• The main types of malnutrition seen in Nepal are:
– Protein Energy Malnutrition (PEM)
– Iodine deficiency disorder (IDD)
– Iron deficiency anemia (IDA)
– Vitamin A deficiency (VAD)
• Seen mostly in children and women.
 • Not only affect people’s health but also quality
of life and development of socio economic
situation in the county.
• 68% (more than two thirds) of disease burden in
Nepal due to infectious diseases, maternal and
prenatal disorders and nutrition deficiency.
• Nutrition intervention has been recommended
as priority element of essential health care
services.
• Nepal Health Sector strategy 2004 and Nepal
Health Sector Implementation Plan-
recognized the problem and recommended
adopting a specific implementation strategy
with regards to nutrition.
CAUSES AND CONSEQUENCIES
 Causes and consequences (PEM- children)
Problems Causes Consequences
Protein energy •Inappropriate •Failing to grow
Malnutrition breastfeeding (underweight, stunted and
(PEM)- •Inadequate wasted)
children complementary •Reduced learning ability
feeding practices •Reduced resistance and
•Insufficient health immunity against infection
services (Growth •Reduced productivity in the
monitoring and future
counseling)
•Low birth weight
•Infectious diseases
•Inadequate energy
intake
 Causes and consequences (PEM- women)
Problems Causes Consequences
Protein energy •Inadequate energy •Low birth weight
Malnutrition intake •Increased risk of maternal
(PEM)- •Inadequate mortality and morbidity
WOMEN knowledge and •Reduced productivity
practice of maternal
feeding
•Heavy physical
workload
•Lack of extra food
intake during
pregnancy and
lactation
 Causes and consequences (IDA)
Problems Causes Consequences
Iron Deficiency •Inadequate intake of •Impaired human function
Anemia (IDA) iron from daily diets at all stages of life.
•Inadequate •Impaired work
absorption of dietary performances, endurance
iron and productivity
•Infestations such as •Increased risk of maternal
hookworms and morbidity and mortality
malaria •Increased risk of sickness
•High requirements of and death for the baby
iron particularly during
growth and pregnancy
•Blood loss
(menstruation and
injury)
•Vitamin A deficiency
 Causes and consequences (IDD)
Problems Causes Consequences
Iodine •Lack of iodine in food •Cretinism
Deficiency •Goiter
Disorders (IDD) •Impaired cognitive function
•Increased prenatal
morbidity and mortality
•Reduced productivity
 Causes and consequences (VAD)
Problems Causes Consequences
Vitamin A • low intake of Vitamin • Xerophthalmia (Night
deficiency A from daily diets blindness, Bitot’s spot,
(VAD) •Restricted Vitamin A corneal ulcer, Keratomalacia
(VA) absorption , Xerosis)
•Worm infestation •Increased risk of morbidity
•Increased Vitamin A and mortality
requirement resulting •Increased risk of anemia
from infectious
diseases.
CURRENT NURTITIONAL SITUATION
 Current nutritional situation in
Problems Current nutritional situation
Protein •51% of children below 5 years of age are affected by
energy stunting (short for their age), which can be a sign of early
Malnutrition chronic under-nutrition.
(PEM) • 48% of the children are underweight (low weight for age).
• 10 % of the children are wasted (thin for their age), which
can be an indicator of acute under-nutrition.
• Stunting is more common in the Mountain areas than in
the Terai, but underweight and wasting are more common in
the Terai areas.
•27% of women fall below the cut-off point of BMI (<18.5)
• Prevalence of stunting, underweight and wasting tended to
increase after 6 months of age indicating that the practice of
complementary feeding was not appropriate for their
growth.
 Current nutritional situation in
Problems Current nutritional situation
Iron •Higher in preschool children (78%) than in women (67%).
Deficiency •High rate found in infants (6-11 months old) i.e 90%
Anemia •Among women- distinct variation between ecological
(IDA) zones- highest levels in Terai followed by Mountains.
•Only Pre-school children (32%) and pregnant women
(29%) – consumed and adequate amount of iron to fulfill
their daily requirements.
•Prevalence of anemia- also high in high school
adolescents (64%) who attended Govt. girl’s high school in
KTM valley.
 Current nutritional situation in
Problems Current nutritional situation
Iodine •Only 63% households in Nepal- using
Deficiency adequately iodized salt
Disorder (IDD) •Only 35% of the respondents had heard
educational messages about iodized salt and
very few of the respondents (19%) knew about
the importance of iodized salt for health
•39.1% (adult women and school- aged
children)- low UIE (Urinary Iodine Excretion)
values
•The prevalence of low UIE is highest among
women in the Terai zone.
 Current nutritional situation in
Problems Current nutritional situation
Vitamin A •Over all prevalence- night blindness in
deficiency reproductive aged women (4.7%) and pregnant
(VAD) women (6.0%), while 16.7%- women reported
having night blindness during their last prenancy.
•12-59 mnths children- night blindness 0.27%
•6-59 mnths children- Bitot’s spot- 0.33%
•School aged children- night blindness- 1.2% and
Bitot’s spot-1.9%
•Serum retinol levels revealed 16.6% of women
and 32.2% of preschool children had subclinical
VAD.
•Only 42% of pre-school children and 37% of
women consumed an adequate amount of vit. A.
GOVERNMENT ACTION IN NUTRITION
 Government action in Nutrition
Problems Action

PEM (Protein energy • growth monitoring and nutrition

malnutrition) counseling at PHCC, HPs, SHPs and
Outreach Clinics (ORCs)
•Promotion of exclusive breastfeeding
through mass media.
•Implementation of Breast Milk
Substitute Act 2049 and Regulation
2051
•Promotion of complementary feeding
after 6 months.
•7 hospitals certified as Baby Friendly
Hospital Initiatives (BFHI) in various
parts of country.
 Government action in Nutrition
Problems Action

IDA (Iron deficiency • Distribution of iron/ folate tablets to

anemia) pregnant women and lactating mothers
through- hospitals, PHCC, HPs, SHPs
and ORCs. (Outreach clinic).
•Intensification program of maternal
iron supplementation through Female
Community Health Volunteers (FCHVs)
in 12 districts.
 Government action in Nutrition
Problems Action

IDD (Iodine • Universal salt iodization- sole strategy.

Deficiency •Distribution of iodized salt in remote districts at
Disease) subsidized rates.
•Implementation of Iodized Salt Social marketing
Campaign.
•Monitoring of iodized salt at the entry points, regional
and national levels.
•Evaluation of IDD status through National Survey and
integrated mini- surveys for Vit. A, Iodized salts and
deworming.
•Iodized slat warehouse constructions in various parts of
country.
•Development of Iodized Salt Act in 1998.
 Government action in Nutrition
Problems Action

VAD • Mass supplementation- high dose Vit. A capsules to

(Vitamin A children aged 6 and 59 months of age in 75 districts.
deficiency) •Nutrition education activities through Behaviour Change
communication (BCC) and mass media, community level
health workers and agricultural extension worker.
•Initiation of VA capsules supplementations for
Postpartum mothers through FCHVs. And health facilities.
•Treatment of night blind pregnant women with low dose
VA capsules in the selected districts.
•Case treatment for measles, severe malnutrition, chronic
diarrhea and eye problems related to VAD
 Overall goal each strategic
Achieving nutritional well being of all people in
Nepal so that they can maintain a healthy life
and contribute to the socio-economic
development of the country, through
improved nutrition program implementation
in collaboration with relevant sectors.
 In order to achieve the overall goal, the
following conditions are indispensable:
• The measures mentioned have to be
implemented and sustained to reduce the
burden of nutritional problems such as
protein-energy malnutrition, iron deficiency
anemia, iodine deficiency disorder, vitamin A
deficiency, low birth weight, diet-related
diseases (life-style related diseases) and other
nutritional disorders.
 Continue…
• The measures for improved dietary habits,
household food security and ‘school health
and nutrition’ should be implemented as long-
term strategies to modify nutritional status of
the people and to reduce the prevalence of
the nutritional disorders.
 Continue…
• The control of infectious diseases including
intestinal worm infestation has to be
strengthened to help reduce the risk of
malnutrition as well.
 Continue…
• It is urgently necessary to address or promote
the measures regarding nutrition in exceptionally
difficult circumstances such as breastfeeding of
HIV positive mothers and food shortages in crisis
situation.
• In order to promote the above mention
measures efficiently and effectively, the
monitoring, assessment and supervision of
program implementation must be conducted
regularly.
 OBJECTIVES AND TARGET
CATEGORIES OBJECTIVES AND TARGETS
PEM Objective 1 To reduce protein energy
malnutrition in children under
5 yrs of age and reproductive
aged women
Target 1 To reduce the prevalence of
PEM among children to half of
the 2000 level by the year 2017
Target 2 To reduce the prevalence of low
BMI in women to half of the
2000 level by the year 2017
 OBJECTIVES AND TARGET
CATEGORIES OBJECTIVES AND TARGETS

IDA Objective 2 To reduce the prevalence of

anemia among women and
children

Target 1 To reduce the prevalence of

iron deficiency anemia to less
than 40% by the year 2017
 OBJECTIVES AND TARGET
CATEGORIES OBJECTIVES AND TARGETS

IDD Objective 3 To virtually eliminate iodine

deficiency disorders and
sustain the elimination

Target 1 To virtually eliminate IDD by the

year 2017
 OBJECTIVES AND TARGET
CATEGORIES OBJECTIVES AND TARGETS

VAD Objective 4 To virtually eliminate Vitamin

A deficiency and sustain the
elimination

Target 1 To virtually eliminate vitamin A

deficiency disorder by the year
2017
Basis for Nutrition Policy
 BASIS OF NUTRITION POLICY
In order to reduce/control nutritional problems, the
Govt. of Nepal needs to take various measures based
on the following important principles:

• HUMAN RIGHTS: accesses

to nutritionally adequate
and safe food and services
for nutrition education are
the rights of each
individual.

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• PRE-CONDITION FOR DEVELOPMENT: Nutritional
well being should be a key objective for progress in
human development.

• HEALTHY LIFE: Nutritional improvement has to be

enhanced to ensure the healthy life of all people.

• UNIVERSAL PRIMARY EDUCATION : Under nutrition

in infancy and early childhood affects school
enrolment and on cognitive and behavioral
development.

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• PRIORITIZED GROUPS : Infants, young children,
pregnant and nursing women, disabled people and
the elderly within poor households are the most
nutritionally vulnerable groups.

• PEOPLE’S PARTICIPATION: People-focused policies for

nutritional improvement must acknowledge the fact
that people’s own knowledge, practices and creativity
are important driving forces for social change.

• GENDER: Special attention should be given to the

nutrition of women during pregnancy and lactation.
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GENERAL STRATEGIES
 GENERAL STRATEGIES to improve the
national situation of Nepal
Community participation:
• Promote, facilitate and utilize community
participation and involvement for all nutrition
activities;
Coordination among Sectors :
Maintain and strengthen co-ordination
among other agencies involved in nutrition
activities, i.e., the Ministry of Agriculture and
Cooperatives (MoAC), Ministry of Education
(MoE), Ministry of Women, Children and
Social Welfare (MoWCSW), Ministry of Local
Development (MoLD) and the National
Planning Commission (NPC), as well as with
other programs, International Development
agencies, NGOs, INGOs and private sectors.
Coordination among Intra Sectors:
Develop understanding and effective co-
ordination between the various sections
and divisions in the Department of
Health Services, i.e., Family Health
Division (FHD), Logistics Management
Division (LMD), National Health Training
Centre (NHTC) and the National Health
Education, Information and
Communication Centre (NHEICC).
Decentralization
Decentralize authority to the region, district,
Health Post, Sub Health Post and
community for assessment, planning,
implementation, and monitoring of nutrition
activities.
Advocacy
Conduct National Advocacy and Social
Mobilization Campaigns.
Communication
Develop behavior change communication
strategies to implement nutrition programs
with adequate messages and media use.
Strengthen effective use of interpersonal
communication and mass media for
synergistic effect
Integration
Integrate/incorporate nutrition plans in
activities such as the Expanded Programmes
on Immunization (EPI), Integrated
Management of Childhood Illness (IMCI),
Maternal and Child Health, Family Planning
programs, etc.
Monitoring and evaluation
Monitor and evaluate the situations of
nutritional status and program implementation
to strengthen nutrition policy and strategy
and to modify programs as necessary
Research
Carry out research and feasibility study to
analyze the current nutritional situation to
identify the major factors of nutritional
problems and to clarify the possibility of new
approaches.
Capacity Building
Develop the capacity of all health workers so
they can effectively transfer appropriate
knowledge and implement nutrition
programs with good skills. Develop the
system to educate dieticians. Nutrition
institution building is essential to strengthen
all the nutrition programs.
 Analyzing, Monitoring and Evaluating
Nutrition
Objective: To strengthen the system for
analyzing, monitoring and evaluating nutrition
situations.
Specific Strategy Activity Responsibil Indicator
objectives ity

To Increase •Seminar NS/CHD Situationa

strengthen knowledge •Workshop university l analysis
existing and skills of •Nutritional
institutional key actors at education at
capacities all levels academic
and institutions
capabilities
at various
level
Specific Strategy Activity Responsibility Indicator
objectives

To improve •Strengthen •Establish NS/CHD university Data

coordination of collaboration committee collection
data collection, amongst •Establish
analysis and relevant nutrition
reporting institutions association

•Develop •network
networks for
data collection,
processing and
databank
Specific Strategy Activity Responsibi Indicator
objectives lity

To Acquire •Create NS/CHD Nepal RDAs and

standardize necessary nutritional RDAs university Anthropometric
tools for tools and for Nepali standards
monitoring facilities people
and required •Identify
evaluation for data standard values
of nutrition collection, of
situation processing anthropometric
and measurements
reporting. for Nepali
people
Specific Strategy Activity Responsibility Indicator
objectives

To Strengthen •Training NS/CHD National

implement capacity •Implementation survey
national building for of national
survey too national nutrition survey
assess nutritional
nutritional survey.
status in
Nepal
 Health Training
• The National Health Training Centre (NHTC), under
the Ministry of Health (MoH) is part of a network of
government health training facilities. The NHTC
operationalize its training activities in line with the
2004 National Health Training Strategy.  
• Aim: to train health service providers to deliver
quality health care services.
• To achieve this objective the centre delivers the
different training programs related to public health,
clinical and managerial.
• In‐service training is delivered through a
network of National Health Training
Programmes which provide technical as well
as managerial training at national, regional,
district and community levels.
• NHTC which conduct training like
– family planning,     
–    skilled birth attendance,
– safe abortion services,
– rural USG,
– anaesthesia assistance,
– paediatric nursing,
– medico‐legal etc.
• A training working group (TWG) comprising
various supporting partners was formed under
leadership of NHTC with the purpose of
ensuring
– the efficient running of national health training
programs,
– maintaining the quality of the training and
– improving the coordination of all training provided
under NHTC.
• There are :
– 5 regional training centers
– 1 sub regional training center
– 30 district level training facilities and
– 14 training health posts in 13 districts.
• National Health Training Centre (NHTC) is one
of the 5 centres with a degree of autonomy in
personnel and financial management.
• The NHTC coordinates all training programs of
the respective Divisions and implements
training by sharing common inputs and
reducing the travelling time of care providers.
•  NHTC provides training on SBA, ASBA
(Advanced Skill Birth Attendant), OT
management, Family Planning training
including Implants and IUCD, and antenatal
USG. More than 7100 SBAs and 140 ASBAs
have already been trained since SBA training
began.
 Goal
• The overall goal of NHTC is to
produce/prepare efficient health service
providers by means of training to contribute
to deliver quality health care services towards
attainment of the highest level of health
status.
 Objectives
• To assess training requirements of Health
Workers and prepare training plans based on
the program’s requirement.
• To plan, implement and train health workers
as demanded by program division.
• To design, develop and refine teaching,
learning materials to support implementation
of training programs.
• To develop/improve capacity of trainers to
deliver quality training at central, regional and
district level.
• To support RHDs and DHOs in organizing,
implementing and evaluating the training
programs.
• To orient newly recruited health workers on
different health programs.
• To coordinate with all National and
International, Governmental and Non‐
Governmental Organizations to avoid
duplication of training and improve quality of
training
• To supervise, monitor, follow‐up and evaluate
training programs.
• To conduct operational studies to improve
training efficiency and effectiveness.
• To organize International Training as per need.
• To establish TIMS for the quality recording and
reporting systems of all training programs at
central, regional, district, and community
levels.