A Groundbreaking Nutrition Program in Nepal Became a Model for the Rest of the World
March 30th, 2016 | Story
March 30th, 2016 | Story
In 1991 the under-five mortality rate in Nepal was 121 per 1,000 live births nationwide and a staggering 147 deaths per 1,000 live births in rural areas, where 90 percent of the population lived. Diarrhea and pneumonia were the leading causes of death, but chronic undernutrition, including high rates of vitamin A deficiency, and the vicious cycle of repeated infections and poor feeding kept the vulnerable populations at risk.
Two field trials conducted in Nepal, one by the Nepal Nutrition Intervention Project, Sarlahi (NNIPS) with Johns Hopkins University (Sarlahi, 1989) and another by John Snow, Inc. (Jumla, 1991), demonstrated that high-dose supplementation with vitamin A of pre-school children every four-to-six months can reduce mortality by about 30 percent.
Based on this evidence, the Government of Nepal and Ministry of Health (MOH) initiated a program in 1993, primarily with USAID funding, to provide high-dose vitamin A capsules to children 6 months to 5 years of age, twice yearly. JSI and local NGO, Nepal Technical Assistance Group (NTAG), were the main implementing partners from 1993 to 2003, strengthening the female community health volunteer (FCHV) program and the entire health system to train and support the FCHVs, procure and deliver vitamin A capsules, monitor coverage, and institutionalize the program into the MOH infrastructure to ensure that it was fully sustainable when funding ceased.
In the 1990s, very few Nepali families used health posts for routine health services. Since high-dose vitamin A supplementation requires twice yearly dosing, it was clear that a community-based model that did not rely solely on health post visits, was needed to achieve results.
The program used a campaign approach, selecting the same dates in the spring and fall each year and putting significant staff time into FCHV training and support, with promotional activities before each distribution round. These efforts engaged the wider multi sectoral community (health, education, agriculture, political and religious leaders) to encourage all caretakers to bring their children to the FCHVs to receive the capsules during the campaign, not once but twice each year.
There were steep obstacles. Government policy had to be established to allow the FCHVs to distribute the high-dose capsules. A training program was required to teach FCHVs about dosing, how to keep records, and the importance of vitamin A in the diet so they could teach this to their fellow villagers. These unpaid workers needed to be motivated to promote the campaign and follow up with children who didn’t get the capsules. And critically, there needed to be trust in communities so caretakers of children understood the importance of vitamin A, knew where to go to get the capsules during the campaign, and trusted that the service would be available. Funding shortages also necessitated better donor coordination to help this MOH program reach nationwide coverage. JSI remained an anchor through these times, with continuous on-the-ground technical assistance.
Within a few years, the distribution rounds became routine, with JSI and NTAG providing only emergency assistance and support for monitoring efforts. The district health staff ensured that capsules were available and helped with local promotional activities, with FCHVs doing local advocacy and promotion and caretakers becoming accustomed to taking children for a capsule every April and October.
By 2003, the program reached more than 90 percent coverage of children between 6 months and 5 years of age. In reality, this meant that a cadre of 50,000 FCHVs dosed approximately 3.6 million children every 6 months. In a country with infrastructure weaknesses where most delivery systems face serious constraints, and where routine immunization coverage in children was low, such high coverage was an unprecedented achievement.
In Nepal, vitamin A deficiency no longer constitutes a public health problem. Nepal is one of only a few countries to meet it’s MDG 4 goal for reduction in under-5 mortality. This intervention is one of the main reasons for the success.
Nepal was the first country in the world to start semi-annual vitamin A dosing campaigns and became an international model for vitamin A supplementation for children. Many other countries benefited from Nepal’s experience as they visited to observe how the FCHVs were trained and supported to distribute vitamin A semi-annually to children. By 2013, 69 percent of children between the ages of 6 and 59 months worldwide were fully protected with two high-dose vitamin A supplements.
Nepal’s campaign approach also has been successful in other health interventions, including, most recently, the National Immunization Days to improve polio immunization coverage.
In 2005, the initiative was highlighted as one of 10 Millions Saved case studies by the Center for Global Development.