Protein Energy Malnutrition (PEM) in Under Five Years Old Children and Service Delivery Mechanism in Nepal
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 : firstname.lastname@example.org
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