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Protein Energy Malnutrition (PEM) in Under Five Years Old Children and Service Delivery Mechanism in Nepal

Submitted by on August 6, 2012 – 1:02 AM 105 Comments

Nepal Demographic and Health Survey (NDHS) 2011, demonstrates that 41 percent of children under five in Nepal are stunted, 11 percent are wasted, and 29 percent were underweight. It also shows that the distribution of the problem is not uniform. Rural population is most affected with stunting, wasting, and underweight and that while stunting is a major problem in the mountainous areas, wasting is more significant in the Terai.

The study also shows that the Western areas are most affected with stunting. These data on stunting, wasting, and underweight as compared to NDHS 2006 – stunting (49%), wasting (13%), and underweight (39%), which follow a declining trend shows that nutritional status of under five children in Nepal has improved over the past five year. This also indicates that Nepal is close to achieving the Millennium Development Goals (MDGs) target of reducing the percent of under-weight children to 29 % by 2015.


To control PEM, the Nepal Ministry of Health and Population (MOHP) has introduced various nutritional policies, strategies, programs, services, intervention, and Protein Energy Malnutrition (PEM) specific objectives.


National Nutritional Policies and Strategies :

MOHP has introduced various nutritional strategies. It developed national nutritional strategies in 1978, introduced a comprehensive nutrition program in 1979, national nutrition strategy for Nepal in 1986, and Nepal National Plan of Action in 1998. A National Nutrition Policy and Strategy (NNPS) was formed in 2004 under the Child Health Division of Department of Health Services of MOHP. The National Strategy for Infant and Young Child Feeding (IYCF), was also developed in the year 2004 based on the global strategy of WHO and UNICEF.


A National School Health and Nutrition Strategy jointly approved by MOHP and Ministry of Education (MOE) to develop physical, mental, emotional, and educational status of the government-run school children was also formulated. A National School Health and Nutrition program had been piloted in two districts namely Sindhupalchowk and Syangja from June 2008 to May 2012.


National Nutritional Programs :

MOHP has designed and implemented nutrition programs to control PEM such as growth monitoring and nutrition counseling at Primary Health Care Center (PHCC), Health Posts (HPs), Sub-Health Posts (SHPs) and Outreach Clinics (ORCs). Also, the practice of exclusive breastfeeding is promoted through mass media together with the concept of complementary feeding after the child reaches six months.

To address the problem of PEM, MOHP has also developed interventional programs such as Community Based-Integrated Management of Childhood Illness (CB-IMCI) as proposed by Second Long Term Health Plan (SLTHP).


Nutritional services :

The Government of Nepal provides various nutritional services at different levels of health service. At the central level, the Ministry of Local Development (MOLD) coordinates child development programs with other relevant ministries and International Non Governmental Organizations (INGOs). At the intermediate level, Directorates of health services and District Public Health Office/ District Health Office (DPHO/DHO) provide counseling and mobilize women group, train health professionals, community level service providers and volunteers, implement and strengthen nutritional programs, integrate community-based programs with other health programs, and implement growth monitoring.


At the local level, the Municipalities and Village Development Committees (VDCs) implement and monitor Early Childhood Development (ECD) programs– in particular; they monitor the nutritional status of children below three years. For example, Ministry of Health has child nutrition and health program run in its health posts all over the country.


Besides the government programs and activities on PEM, NDHS 2011 shows that United Nations Mission in Nepal (UNMIN), World Food Program (WFP), Save the Children Alliance, United States Agency for International Development (USAID), and UNICEF-Nepal have performed a vital roles in introducing nutritional programs in Nepal.


PEM Specific Objectives :

MOHP has also formulated PEM specific objectives for reducing its prevalence in children under five years to half of the 2000 level by the year 2017 through a multi-sectoral approach. For example various activities were carried out in the fiscal year 2008/09 by MOHP to prevent PEM such as regular growth monitoring at health centers, capacity building and orientation on growth monitoring to health workers, Infant and Young Child Feeding (IYCF) promotion and establishment of nutrition rehabilitation centers in all Regional & Zonal Hospitals among others.


Other actions :

Additionally, the Nutrition Section of the MOHP has launched a nutrition promotion week in different districts to enhance knowledge on timely initiation of proper feeding practices. It has also recommended nutritional intervention (nutritional supplementation, enrichment, nutrition education and rehabilitation) as a priority element of essential health care services. Moreover, it has placed nutrition among the main health program areas for inter-sectoral cooperation. MOHP through Maternal and Child Health (MCH) program is also monitoring the nutritional status of children below three years in some of its project district.


With all these nutritional programs and services MOHP hopes to reduce the prevalence of underweight to 27 %, stunting to 28%, and wasting to 5% in under five years children by the end of 2015(MDGs). In addition, MOHP has aimed to reduce PEM in under five years of children to half of the 2000 level by the year 2017.


Issues and Challenges :

The Maternal and Child Health (MCH) program of MOHP has launched the nutrition package in collaboration with the nutrition section of ECD services. However, a review of the ECD services shows that the direction of most of its programs is skewed towards psycho-social development and education and cognitive development with no or very little inputs on health and nutrition.

The Government has written program plans to address PEM listed in its report, and they have the capacity to be strong and effective because they are based on the WHO global strategy. However they are either poorly implemented or not properly executed. In addition, MOHP should be very clear that nutritional programs do not only address PEM. In this condition, PEM may not be fully addressed. Also, the MOHP may not be able to attract an adequate number of concentrations of interested people and organizations. Before 1980, developing countries were focused on PEM but then the focus shifted due to the perceived glamour of micronutrients. If this situation should occur in Nepal, this would exacerbate the current situation even further.


Thus, there is a need for the government of Nepal to give first priority to the nutrition interventions to improve the situation of protein energy malnutrition among under five children.


About the Author: Amrit Banstola is the  founder cum editor-in-chief of Public Health Perspective (PHP) Online Newsletter—the first public health online newsletter of Nepal. He is also the country representative for Health Information For All by the year 2015 (HIFA2015) and working as a youth leader speak column writer for Climate Himalaya (India) and  is an international honorary member of American Public Health Association (APHA)- International Health (IH) Section, a new project that deals with the climate change. He can be reached at :  [email protected]

About this article: This article is competing for the JPMS International Medical Writing Contest 2012 for the theme: Global Health/Public Health. To learn more about the contest and to participate in it, follow this link:


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  • Nida Rasul

    Its tooooooo long…:(

    • Amrit Banstola

      not actually…it seems so because there is huge space between paragraphs…thank you

  • Mars09

    what are cause of under weight in five year child in Nepal?

    • Amrit Banstola

      Causes of underweight in five yeaer child in Nepal:
      the lowest socio-economic status,
      the highest percentage of women with no education,
      birth weight less than 2.5 kg,
      the highest percentage of women with BMI < 18.5 km/m2, all of which contribute to the increase in the number of underweight cases among under five years children.

  • John Smith

    If the govt, WHO, charities, etc WANTED to solve any type of problem in Nepal (or any country) they would have done it long ago, instead of exploiting  and destroying all life upon Holy Mother Earth

    • Amrit Banstola

      John…however, Nepal has it own problem…such as political instability, limited health manpower, poverty, illiteracy, lack of public awareness on health among others..having said that…it takes time to improve the situation…and the problem like malnutrition are not like fever, headache, that improve over night…

  • kopila

    Is that picture of Nepal??? I wonder.

    • Amrit Banstola

      no not of Nepal…JPMS blogger have kept it from somewhere Arfica…i suppose…just to have a glimpse of the malnutrition situation,…thank you for the note…

  • ramaknata

    bastola bhai you have done good job..i would like to comment on your heading..your title includes an abbreviation PEM and i think it  represents protein energy malnutrition. is it right? what i want to suggest u that if you use such abbreviation then you should specify the full form in the paragraph when it comes in the paragraph for the first time. And after that it is not necessary to repeat the full form. you have mentioned protein energy malnutrition but it is somewhere at the last of the article and there is no abbreviation PEM on its side. otherwise nice try. keep it up. 

    • Amrit Banstola

       thank you ramaknata bro for the comment and suggestion…i will inform the admin to change it to the full form in the title..thank you again…

    • Amrit Banstola

       ramaknata bro…thank u for the comments…i have made appropriate changes..please have a look at the changes…

  • Rajendra Giri

    Great! You have written excellent article on community health of Nepal.


    • Amrit Banstola

      Thank you Rajendra ji. Thrilled to hear that you like it.

  • madan

    what government are planing to reduce protein energy malnutrition? 

    • Amrit Banstola

      they have come up with different nutrition policies, strategies, programs, actions…however…they are only well written…not properly implemented….or poorly executed…

  • madan

    nice article. enjoyed reading it

    • Amrit Banstola

      glad u like it….

  • ceci nepolia

    Has MOHP  formulated PEM specific objectives for reducing its
    prevalence in children under five years? can it be share.please?

    • Amrit Banstola

       To reduce protein-energy malnutrition (PEM) in children less than five years of age to half of the 2000 level by the year 2017 through a multi-sectoral approach.

  • Amrit Banstola

    Hello readers,
    If you have any comments and suggestions or queries….please feel free to post. Thank you

  • Johan B. N

    Excellent writing!

    • Amrit Banstola

      thank you johan…glad u like it////:)

  • John B.N

    good job! 

  • William jackson

    Great work and compilation. Scenario of underdeveloped country. keep writing on similar topic. good luck

    • Amrit Banstola

       thank you William. Will write on similar topic on coming days…

  • Saval Khanal

    Good Job brother!!

    • Amrit Banstola

       thank you bro…

  • Subash Timilsina

    Good job Amrit. You addressed all the issues about PEM in Nepal,

    • Amrit Banstola

      thank u dude…

  • Rajani

    Well written!!!
    Certainly there are issues of insufficient and improper execution of nutirion related program.
    I think there is also lack of comprehensive programs. Mother themselves are undernourished leading to vicious cycle of malnutrition in children and there is not much program to address this. Also, distributing nutritional pitho in some areas can’t address the problems arised by food insecurity. How many projects have worked for sustainability of programs? How many programs teach people to maximise the benefit of locally available food? Is celebrating a week of nutrition promotion sufficient? Are health workers and community workers well trained to advise on nutrition? Many questions need to be addressed

    • Amrit Banstola

       thank u Rajani ji for the comments and providing some food for thought…

  • Prof Dr Madhav Gautam

    Growth monitoring is  basically important effective implementation of programm ,and the data must be analyzed continusly ,and action need to be taken in the particular areas ot community .All it dependent on the type of the problem like PEM or micronutrient etc  The monitoring must be regrious and continued for certain period. It shoudl be like project for 5 years Iike in Costa Rica , and Indonesia .

    • Amrit Banstola

       Thank you Prof Dr Madahav Gautam for your feedback…growth monitoring as you have mentioned is really an effective program for screening and prevention of PEM and should be carried out at various health facilities such as hospital, PHC, HP, SHP, and outreach clinics.

  • Anjuman

    Good effort!

    • Amrit Banstola

       Thank you anjuman

  • Manish shah

    good job aamrit. keep on writing!

    • Amrit Banstola

       Thank you manish…

  • Avik Pradhan

    nice article in context of nepal..

    • Amrit Banstola

       thank you Avik…

  • Nakarmirachana

    Good job sir.. All the best :)

    • Amrit Banstola

       Thank you rachana…..:)

  • Kathrin942000

    wish you all the best……..

    • Amrit Banstola

      tq kathrin :)

  • kamal

    Great piece of article on Malnutrition from Nepal.

    • Amrit Banstola

      Thank you Kamal ji

  • Amit Shrestha

    All the best of luck.. your article is really nice

    • Amrit Banstola

      Thank you :)

  • Sangita Shrestha

    A valuable source of information in PEM of Nepal. Good luck for the contest!

    • Amrit Banstola

      Thanks a lot!

  • Dharma Raj Banstola

    I fell for this it is organized and completed with a lot of information in this single piece of writing is a strength of this article

    • Amrit Banstola

      Thrilled to hear from you Dharma ji…

  • Devashish Chhetri

    Very informative article. Well done.

    After I saw that you had entered it for a contest. I wish you luck.

    I was hoping to see the issues of ‘…either poorly implemented or not
    properly executed’ and ‘…may not be able to attract an adequate number
    of concentrations of interested people and organizations’ being somehow
    addressed with possible solutions, even if only in theory

    • Amrit Banstola

      Tq dev ji…will try to address these things in my next article

  • Madhav Gautam

    it is a nice article ,and it would good if more focus
    should have been placed on monitoring in order to be effective action
    for improving PEM

    • Amrit Banstola

      Thank you sir… i will take this things into consideration in my next article

  • Bishnu Dawadi

    Hi Amrit,

    We are very proud to know that your article is competing in the JPMS
    inte’l medical writing contest. Many Many congratulation for the great

    • Amrit Banstola

      thank you di

  • Rachana Nakarmi

    All the best :)

    • Amrit Banstola

      tq :)

  • Anil

    Well written article

    • Amrit Banstola

      thank a lot anil ji

  • Tashi

    keep up the good work

    • Amrit Banstola

      tq Tashi. hope everything is going well with you.

  • Roshan Senchuri

    We are all so very proud of you, not just for
    competing or for winning, but for showing each of us what it means to be
    the best you can be.

    • Amrit Banstola

      thanks a lot dude for your wishes

  • Ashish Kunwar

    All the best to you taking part in the competition.

    • Amrit Banstola

      thank you

  • Amir Lamagade

    Every sunset gives us one day

    Every sunset gives us one day less to live! But every
    sunrise give us, one day more to hope! So, hope for the best.
    Good Day & Good Luck!

    • Amrit Banstola

      thank you!

  • Suman Nepali

    Reading doesn’t get much better than this!Great Artilce

    • Amrit Banstola

      : ) for ur kind words

  • Manit Cinapol

    Amrit! Nicee to read your article. All the best of luck for you.

    • Amrit Banstola

      thank u manit

  • Rujira Tragoolpua

    Amrit provides detailed information on exactly what PEM situation is in Nepal,
    and what the service delivery mechanism are.
    If you ever heard about malnutrition and were wondering what its situation is in Nepal, this is a must read article.

    • Amrit Banstola

      Rujira…m thrilled that you like my article…

  • Nirmala

    This excellent article by Amrit deals with a topic that doesn’t get enough mention in the mainstream media.

    • Amrit Banstola

      thank u so much Nirmala ji

  • Laura Wiggins

    This is an article that needs thumps up. Great work Amrit.

    • Amrit Banstola

      m happy…u like it…

  • Kriti Pun

    We all know about the malnutrition but not yet about the service delivery mechanism. Amrit keep up the good work.

    • Amrit Banstola

      thank you kriti

  • Anu Thapa

    I guess the title of this article pretty much sums it up.

    • Amrit Banstola

      thank you anu..glad u like it

  • Margaret

    This is an article that anyone who is interested in malnutrition should read.

    • Amrit Banstola

      thank you margaret

  • Guru Bhai

    Sir, I liked your article very much

    • Amrit Banstola

      thank u guru bhai

  • Mahesh Kumar

    A Must Read Articles That inform you about malnutrition in Nepal

    • Amrit Banstola

      thank u mahesh kumar ji for your nice words

  • Dhanny Raj

    what a perspective on malnutrition?

    • Amrit Banstola

      dhanny raj…glad u like it

  • Mohan Joshi

    I’ve been searching this one for my assignment..thanks a lot for the idea

    • Amrit Banstola

      glad to hear it.

  • Jaco Lotriet

    A good effort to try and present the current situation in Nepal.

    • Amrit Banstola

      thank u jaco

  • John Klawitter

    i enjoyed reading it

    • Amrit Banstola

      great…u enjoyed it

  • Jagat MAn Shrestha

    Marvolous work. However it could be more visible and distinct if presented supplemented with graphic presentation

    • Amrit Banstola

      thank u jagat sir for your suggestion…i will take this into consideration…next time

  • Naveen Poudel

    I like your writing Amrit ji

    • Amrit Banstola

      thank you naveen ji


    what is being done about it. if the problem has been identified, it does not end there.

    • Amrit Banstola

      yes…it does not end there…more has to be done…

  • Rahual

    A good effort to try and present the current situation in Nepal.

  • Amrit Banstola

    Thank you all for your wonderful comments.