Mother and Child Health Care Programme -...

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 2012Social Protection, Women and Children UnitWFP CO, Kathmandu, Nepal

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Executive Summary Background: Government of Nepal, being aware of the poor nutri-tional status of its population, particularly of children and women, is continually developing appropriate pol-icies from time to time and designing and implement-ing programmes to improve the nutrition situation. The World Food Programme (WFP) has been operat-ing in Nepal since 1963 and responding to changing food security needs and national priorities. One of the programmes implemented by WFP in partnership with the Government of Nepal has been nutritious food assistance to children in the primary schools and Early Childhood Development Centers (ECDs), and ad-ditional food assistance to girl children as an incen-tive in the primary schools in order to help increase school attendance of the girl children in partnership with Ministry of Education (MoE). Thus, the National Nutrition Policy and Strategy (NNPS) developed by the Ministry of Health and Population (MoHP), it required assistance to provide the fortified food supplement to Pregnant and Lactating Women (PLW) and children less than 3 years of age. Three agencies, WFP, MoE and MoHP agreed to work in partnership with each other to implement the Mother and Child Health Care Pro-grame (MCHC) in Nepal.

The main objectives of the MCHC programme were to improve the access of PLW and children less than three years of age with an access to increased calorie intake protein and micronutrients thereby reducing anemia, underweight and stunting rates among the target population; and also to improve the utilization of maternal and child health care services and improve knowledge among the PLW about desirable nutritional practices. The programme was started in three Village Development Committees (VDCs) in 2001 and gradu-ally expanded to 98 VDCs in 11 districts and eventually the number of VDCs were phased out to 47 by 2008. Under this programme, a monthly take-home ration of fortified supplementary food is provided along with related maternal health services and growth monitor-ing and counseling services are conducted for children through government health facilities.

WFP is responsible for procuring and delivering car-goes of food supplements up to the Extended De-livery Points (EDPs) established under the Food for

Education Project (FFEP) units of District Education Offices (DEOs). The FFEP Units/DEOs are respon-sible for logistics after this point which consists of distribution, storage, record keeping and reporting to the Distribution Centers (DCs) or Final Delivery Points (FDPs). WFP provides partial support for the transportation of the food supplement to the FDPs or DCs. It also partially supports the coverage of services of VDC-based storekeepers at the health facilities at VDC level answerable to the MCHC com-mittees working under the Health Facility Operation Management Committees (HFoMCs). WFP has also started NGO support system through the Himalayan Health and Environmental Social Services (HHESS) since 2007-2008, an NGO committed to strengthen-ing health services at the health facilities at VDC lev-el and social mobilization at community level. The health facilities together with HFoMCs and MCHC Committee also provide guidance and assistance to the ongoing MCHC programme. A district level management and monitoring committee compris-ing representatives from various government line agencies, such as the CDO, DAO, DPHO, DEO, DADO, DWO, WDO, LDO and DDC oversees the implemen-tation of the programme besides corrective meas-ures as and when necessary.

The programme has been continuing as a part of WFP Country Programme (CP) over the last 10 years; how-ever, an overall future strategy is yet to be developed. A number of evaluation mission reports in the past and a more recent World Bank Health Sector Review of Nu-trition programme had recommended a review of the programme in order to guide a policy decision about its possible role in national nutrition plans and pro-grammes. In addition, WFP has also been working dur-ing 2011 – 2012 for developing plans and programmes for implementation of the next 2013 – 2017 CP. Thus, the WFP requires a review of the ongoing programme for the formulation of the future strategy for the CP activities.

A team of experts and representatives from MoHP, MoE, WFP and UN agencies was constituted and en-trusted with the task of reviewing the programme and recommending a future course of action from Septem-ber to December 2011.

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The review team namely led by Prof. Ramesh Kant Adhikari and Ms. Irada Parajuli Gautam after receiving an orientation regarding the scope of work, reviewed the available documents about the programme, vis-ited the field sites, interacted with the stakeholders and held consultations with the relevant officials at the central level.

ObservationsThe observations of the study are as follows;a. The programme has been successful in reaching

more than 90% of the beneficiaries and has re-sulted in improving the uptake of Ante-Natal Care (ANC), Post-Natal Care (PNC) and growth monitor-ing services. The Standard Performance Reports from the field sites show a significantly low prev-alence rate of underweight children in the pro-gramme VDCs. The programme VDCs show a much higher rate of utilization of ANC services: 91% of pregnant mothers received ANC services in pro-gramme VDCs, compared to the national 58%, and the percentage of children getting growth moni-tored was reported to be 97.5%, compared to the national averages of 33%. Similarly, the percentage of underweight children in the programme VDCs was reported to be 9.9% compared to the national average of 28.8%.

b. The implementation modality which consists of WFP deciding on the composition of the blended fortified food, ensuring its quality and safety and delivering it to EDP in the district headquarters and subsequently FFEP/DEO delivering to FDP has been working efficiently. There are, however, occasional disruptions in the supply chain due to unavoidable reasons and the beneficiaries are being reached most of the time. There is no evidence of any leakage, pilferage or wastage of the supply.

c. Health Facilities, such as the Sub-Health Post (SHP), Health Post (HP) and Primary Health Care Centre (PHCC), with support from an NGO have been able to provide the ANC, PNC, growth moni-toring and counselling services to the majority of targeted beneficiaries. A very high ANC and PNC coverage rate in programme VDCs supports this observation. However, the situation was rather unsatisfactory when the programme was opera-tional through Out-Reach Clinics (ORCs) which was the general practice until 2007 under the ongoing MCHC programme.

d. The health facilities, with support of the HHESS staff, records and collects regular data regarding the expected and actual number of beneficiaries attending the clinics and taking the take-home ra-tion every month. The number of children growth

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

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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-sis system uses a number of indicators to identi-fy vulnerable VDCs which are in need of external assistance. The same system identifies the VDCs for programme through a consultative process carried out in the district. The VDCs once select-ed under the MCHC at district level, under the existing identification system, continue as being a part of the CP.

f. A review of related programmes implemented by the government and development partners offer openings for integrating MCHC programme with them. The Child Grants Programme, which enables food supplement for children less than 2 years of age in the Karnali region and Community Manage-ment of Acute Malnutrition (CMAM) are some of the government programmes which can make use of the technical experience gained under the MCHC programme. Similarly, SUAAHARA project of the United States Agency for International De-velopment (USAID), the Decentralized Action for Children and Woman (DACAW) of the United Na-tions Children’s Fund (UNICEF) and the Community Based New Born Care Programme (CB-NCP) of the Nepal Family Health Programme (NFHP-II) offer such opportunities in other districts.

g. The MCHC Committees, HFoMCs, DDCs and DPHOs have been engaged in the management and moni-toring of the MCHC programme. There have been examples of VDC and DDC funds being mobilized to hire health staff to provide the health services along with the food supplement. Furthermore, in discussion with health officials it transpired that the funds available with DPHO can also be utilized for this purpose. However, contributions being made at local level by the line agencies will have made a significant difference in the long run the way the MCHC programme will be implemented along with food supplementation.

h. An estimated cost of US$ 96 for one beneficiary per annum has raised some concerns about finan-cial viability for the current nutrition programmes of the government considering its integrations at national level. As the aim of the programme is geared towards the most food insecure districts, where lack of food has been the major determi-nant of under-nutrition, efforts to raise resources for this programme can highly be justified on the ground of food insecurity.

i. The present arrangements for monitoring and evaluation are to guide the implementation of the programme and generate certain output level data on key indicators and not to create evidence for the efficacy of such an approach. Thus, without the rigors of a robust research methodology ensur-ing coverage and compliance above certain level, it would be difficult to prove the effectiveness of the programme to improve nutritional status of children and women.

RecommendationsA: Continuation of MCHC programme• MCHC programme is still relevant in the VDCs with

high levels of food insecurity; however, continu-ation of the MCHC programme should be linked with Vulnerability Assessment Mapping (VAM) in light of newer findings from Nepal Living Standards Survey (NLSS).

• MCHC programme should be initiated after a base-line survey followed by a midterm and end-line surveys at specific points of time period and collect information on impact indicators of interest in any given number of new programme VDCs.

• Beneficiary target age group should be brought in line with the policy of “One Thousand Days” of the Government of Nepal (GoN).

Part of regular check-up during pregnancy under the MCHC

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• Mechanisms to support the health facilities in pro-viding health services need to be strengthened giv-en the Field Supervisors (FSs) continue to provide technical as well social mobilization services in the future.

• Exploring the government funds in addition to so-cial mobilization will offer some opportunities for the key stakeholders to further work in more effec-tive ways ensuring local ownership.

B: Integration with government programmes• Bring the Family Health Division (FHD) on board

demonstrating their role in improving maternal nutrition.

• Explore the possibility of working with Logistic Management Division (LMD) of the MoHP to sup-ply food supplements specifically in districts where MCHC program is going on.

• Open dialogue with District Development Commit-tees (DDCs) and D/PHOs to hire health staff with

funds allocated to VDCs and DPHOs or even hire the Community Based Organizations (CBOs) in order to support ANC, PNC, growth monitoring, recording, reporting and counseling activities in addition to fur-ther support for storage facilities at ORCs.

• Explore the possibility of including food sup-plement in the treatment protocol for the management of Moderate Acute Malnutrition (MAM) (with Nutrition Section of CHD). The programme to follow the national guidelines for CMAM.

C. Evidence of effectiveness• Explore the possibility of including data from pro-

gram VDCs as additional information as annexed to HMIS to highlight the effectiveness

• Continuation of MCHC programme should be com-bined with a study to look into the effectiveness of food supplement in programme VDCs against con-trol in food deficit areas.

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

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

• Partner in the research to be funded by DFID to study the efficacy of food supplement vs. cash transfer vs. nutrition education vs. control. Specifically reques study to look into the efficacy of food supplement ap-proach among food deficit population groups.

D. Strengthening of the programme• NGO support is vital for the success of the pro-

gramme. However, this should be more for nutri-tional counseling. It will need different types of human resources to be employed such as nutri-tion counselor rather than health worker. Equally critical is also the issue of lack of adequate human resources at the local health facilities for health and nutrition programme like the ongoing MCHC, which would also require a number of technical staff to support overall service delivery mecha-nisms of the government at VDC level.

• Local resources of VDCs, DDCs and DPHOs can also be mobilized to hire health staff at the local level. This is being partially done at VDC level in order to fill in a number of vacancies of the government health facilities in coordination with VDC, DDC and DHO personnel.

• FFEP staff members require further support in overall programme strengthening. The pool of hu-man resources available within the FFEP structure can help improve different components of the pro-gramme, such as logistics management, monitor-ing, supervision, distribution and support to essen-tial service deliveries.

• Issues of storage facilities and human resources should be resolved before considering distribution of food at ORC locations.

• Mechanisms that can strengthen HFoMC and MCHC committees should be supported and there should be provision of charging a nominal fee from the beneficiaries during the monthly MCHC clinics in order to supplement the needs for snacks, allowances, purchase of essential equipments and tools and other services with-in the discretionary powers of the local user committees.

• There should be a minimal package in order to help improve the capacity of the government health fa-cility staff members.

Table of Contents1. Background 1 National Context 1 Background of MCHC programme 22. WFP supported food based MCHC programme 3 National Context 33. Implementation arrangements 54. Monitoring and evaluation 75. Objectives and scope of the review 86. Implementation strategy of the review 97. Composition of the review team 108. Activities of the team 119. 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 1810. General impressions 1911. Recommendations 20 a. Continuation of MCHC programme 20 b. Integration with government programmes 20 c. Evidence of effectiveness 21 d. Strengthening of the programme 2112. 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

ANC: Ante-Natal CareANM: Auxiliary Nurse MidwifeAIDS: Acquired Immuno Deficiency SyndromeBMI: Body Mass IndexCDO: Chief District OfficerCHD: Child Health DivisionCBOs: Community Based OrganizationsCP: Country ProgrammeCMAM: Community Based Management of Acute MalnutritionDACAW: Decentralized Action for Children and WomenDC: Distribution CenterDADO: District Agricultural Development OfficeDHO: District Health OfficeDPHO: District Public Health OfficeDoHS: Department of Health ServicesDDC: District Development CommitteeDEO: District Education OfficeDAO: District Administration OfficeDFID: Department for International DevelopmentEDP: Extended Delivery PointECD: Early Childhood DevelopmentEB: Executive BoardFDP: Final Delivery PointFFEP: Food for Education ProjectFCHV: Female Community Health VolunteerFSMAU: Food Security and Monitoring UnitFAO: Food and Agriculture OrganizationGm: GrammeGM: Growth MonitoringGIP: Girls Incentive ProgrammeHP: Health PostHMIS: Health Management and Information SystemHFoMC: Health Facility Operation Management CommitteeHHESS: Himalayan Health and Environmental Services SolukhumbuHIV: Human Immunodeficiency VirusHKI: Hellen Keller InternationalIYCF: Infant and Young Child FeedingKg: Kilogramme

Abbreviations:

LDO: Local Development OfficerLMD: Logistic Management DivisionMCHC: Mother and Child Health CareMoHP: Ministry of Health and PopulationMSNP: Multi-Sectoral Nutrition PlanMoE: Ministry of EducationMT: Metric tonMDG: Millennium Development GoalMD: Management DivisionMLD: Ministry of Local DevelopmentMoU: Memorandum of UnderstandingMoAC: Ministry of Agriculture and CooperativesMCHW: Maternal Child Health WorkerMAM: Moderate Acute MalnutritionNFSCC: Nutrition and Food Security Coordination CommitteeNuTEC: Nutrition Technical CommitteeNFHP: Nepal Family Health ProgrammeNPC: National Planning CommissionNeKSAP: Nepal Food Security Monitoring SystemNLSS: Nepal Living Standard SurveyNGO: Non-Governmental OrganizationNHSP IP II: Nepal Health Sector Implementation Plan IINNPS: National Nutrition Policy and StrategyORC: Out-Reach ClinicPLW/PLM: Pregnant and Lactating Women / Pregnant and Lactating MothersPNC: Post-Natal CarePHC: Primary Health CenterPRRO: Protracted Relief and Rehabilitation OperationsSHP: Sub-Health PostSq.m: Square meterSPHA: Senior Public Health AdministratorSWC: Social Welfare CouncilSMP: School Meal ProgrammeRUTF: Ready to Use Therapeutic FoodRHD: Regional Health DirectorateUNICEF: United Nations Children’s FundUN: United NationsUC: User CommitteeVDC: Village Development CommitteeVAM: Vulnerability Assessment MappingWDO: Women Development OfficerWFP: World Food ProgrammeWHO: World Health Organizations

National context: Nepal Nutrition Status Survey 1975 was the first sys-tematic effort to understand nutritional problems prevalent in Nepal. Though small scale studies con-ducted from time to time, which included multiple indicator surveillance surveys, provided some insights into the nutritional trends, the nation-wide Nepal Family Health Survey in 1996 and Nepal Micronutrient Status Survey 1998 provided more up to date data on the subject. Since then, regular demographic health surveys have been conducted every five years. They have collected more reliable data regarding the prevalent nutritional status of the population and their determinants.

A number of initiatives have been taken to improve the nutritional status of the Nepalese people starting with the national nutrition strategies 1978 and 1986. These strategies recommended that programmes address in-creased availability of food, improved awareness about food and nutrition and better health services to pre-vent illnesses that adversely affect nutritional status. These strategies aimed to improve nutritional status through interventions in the areas of agriculture, edu-cation, health and women’s development. An attempt to have a coordinated action between these different sectors led the government to implement a Joint Nutri-tion Support Programme from 1985 to 1990.

The late 1990s saw a change with more stress on the nutrition programmes implemented through the health sector. The focus was to lower nutritional disor-ders arising from the deficiency of such micronutrients as Vitamin A, iodine and iron. These programmes have achieved remarkable success in improving the micro-nutrient nutritional status. Nepal is being lauded for the success it has achieved in almost eliminating Vi-tamin A deficiencies and lowering the prevalence of iodine and iron deficiency states. However the gen-eral nutritional status revealed by weight and height

related indicators is still a matter of grave public health concern.

Malnutrition as indicated by prevalence of stunting, underweight and wasting among children less than 5 years of age is a significant public health problem in Nepal. Though there has been a gradual and steady de-cline in the prevalence of stunting (by 1.6 percentage points per year from 2006 to 2011) and underweight among children, there is not much improvement in the prevalence of wasting. Further, malnutrition in child-hood continues as a trend particularly among women. This is indicated by the fact that one in four mothers with a child less than 3 years of age suffer from chronic energy deficit (as indicated by a BMI less than 18.5 kg/sq.m). In addition to these general indicators of under-nutrition, women and children suffer from deficiency of iron (leading to anemia) and until recently of iodine and Vitamin A. Over the last 15 years, there has been significant improvement in Vitamin A and iodine nutri-tional status. Though there has been some reduction in the prevalence of anemia it is still unacceptably high and constitutes a public health problem. The current maternal mortality rate at 229/100,000 live births is very high which accounts for 11% of deaths among women of reproductive age. Similarly, less than a third of the deliveries occur at health facilities and only 36% are attended by skilled birth attendant, still half way from reaching the MDG target.

The National Nutrition Policies and Programmes (NNPP) of the MoHP since 2004 had identified and implemented different approaches to improve the ma-ternal and child nutritional status. However, a more holistic and comprehensive approach was needed to address the status of general under-nutrition preva-lent among women and children. A technical working group constituted by National Planning Commission (NPC) in 2006 was assigned the task of examining the different determinants of nutritional status and

01 Background

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identifying strategies to address them. This technical working group suggested strategies to address inad-equacies in child care practices, health services, status of women and food insecurity. However, it was con-sidered incomplete as it had not identified strategies that need to be implemented through other sectors such as agriculture, education and women’s welfare. This exercise, in the course of developing a national plan of action on nutrition recommended the detailed assessment and gap analysis which reviewed the is-sues related to agriculture, food security and cultural practices. The Nutrition Assessment and Gap Analysis (NAGA) recommended a comprehensive nutrition pro-gramme through a multi-Sectoral structure from the center to the village level.

The NPC is currently engaged in finalizing a Multi-Sec-toral Nutrition Plan (MSNP) involving the MoHP, MoE, MoAC and MLD. The key MSNP development process-es would benefit from a review of a nutrition related programme being initiated in severely food deficit ar-eas in order to mitigate the problem of food insecurity for improving maternal child health and nutrition.

Background of the MCHC programme: Household food insecurity is a significant determi-nant of poor maternal and child nutrition in Nepal. The Nepal Food Security Monitoring System (NeKSAP) has recently projected that 36 districts in Nepal will remain food deficit in 2011, despite a forecast of a surplus production of cereal grains by 110,000 MT for the year. The number of food deficit districts in Nepal has usually been between 41 and 49. Food insecurity is further compounded by poverty, illiteracy, lack of access to markets and lack of robust government-led

development programmes. Majority of the districts in the Far/Mid Western development regions have re-mained food insecure over the last past many years according to NeKSAP. Preliminary findings of Nepal Living Standard Survey (NLSS) 2011 report that 38% of the people in Nepal are unable to consume the re-quired calorie intake. The proportion of people who consume less than the required calories is highest in the Far/Mid western development regions.

In addition, the people living with poverty are also higher in the Far/Mid West than those in the Eastern, Central and Western development regions. According to the NLSS 2011, 46% of the population in the Far Western development region live below the poverty line compared to the national average of 25%, and 32%, 22%, 22% and 21% for the Mid Western, West-ern, Central and Eastern regions respectively. Thus, the food insecurity in the Far/Mid Western regions is further compounded by poverty.

Food insecurity is an important determinant of under-nutrition, particularly in the food deficit districts of the Far/Mid Western development regions. In response, the National Nutrition Policy and Strategy (NNPS) 2004 and 2008 had included fortified food distribution in these ar-eas as one of the strategic approaches to reduce under-nutrition. Similarly, the Nepal Health Sector Programme - Implementation Plan II (NHS - IP 2) for 2010-2015 has also identified household food insecurity as one of the main causes of under-nutrition and recommended food and nutrition services including child growth monitor-ing and promotion, micronutrient supplementation and food supplementation and other interventions for im-provement of child survival and nutrition.


National context: The UN WFP, Nepal has been providing food assistance to PLW and children aged 6 to 36 months through the MCHC termed as ACT – 3 under the WFP CP since 2001-2002 in alignment with the Government’s long term and interim strategic plans stipulated under the nutrition and safer motherhood programmes of the MoHP. A monthly take-home ration of the fortified supplementary food is provided under the ongoing MCHC programme along with health services, growth monitoring and counseling by the government health workers based at VDC level with backstopping sup-port from the Female Community Health Volunteers (FCHVs) and Traditional Birth Attendants (TBAs) in Dar-

chula, Bajhang, Baitadi, Dadeldhura, Doti, Achham, Bajura, Salyan and Solukhumbu districts.

In order to meet the WFP’s Strategic Objective - four of reducing chronic hunger and under-nutrition, the provi-sion of supplementary food is intended to improve the nutritional status of targeted women and children and raise the awareness and utilization of community-based out-reach services. The food supplement is expected to improve the access of PLW and children less than three years of age to increased calorie, protein and micronutri-ents thereby reducing anemia, underweight and stunting rates among the target population. In addition, it is also expected to improve utilization of maternal and child

WFP supported food-based MCHC programme

02

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


ies differs slightly from one year to another. The MCHC programme covers mainly the local health facilities such as the SHPs, HPs and PHCs, whereas given basic facilities fulfilled at the ORC locations with support from the lo-cal government line agencies, the ORC locations are also used as points of health and nutrition service delivery in-cluding food distribution.

In order to help provide quality health and nutrition services and capacity building measures, WFP has partnered with Himalayan Health and Environmental Services Solukhumbu (HHESS) to provide health facility-based technical and social mobilization services to local health institutions in all nine programme districts.

health services and better knowledge among the PLW about desirable nutritional practices.

The programme was started as a small scale pilot project in three VDCs in the Far West and gradually extended to 98 VDCs in nine programme districts over the years.

Initially, the programme was implemented through both the health facilities and ORCs. However, lack of human resources, appropriate physical facilities at the ORC locations beyond the government health facili-ties put a significant constraint on both health workers and beneficiaries in maintaining their privacy during the course of ANC and PNC and lack of proper stor-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-gramme districts with eight in the Far/Mid Western regions and one in the Eastern region were assisted through the MCHC programme followed by a total of 26,000 beneficiaries with 17,820 children and 8,180 mothers being assisted in 47 VDCs in the same pro-gramme districts in 2011. Resources are reallocated in mid-July each year as per the government’s fiscal year planning period, based on which number of beneficiar-

The complementary support being provided through the NGO staff in addition to the government health staff members at the forefront of programme implementa-tion modality serves to encourage women and children in regularly accessing and utilizing available govern-ment health and nutrition related services at the health institutions.

A mother breastfeeding her child


The MCHC programme is implemented through a partnership between MoHP, MoE and WFP. The MoHP, MoE and WFP have jointly signed a tripartite agree-ment for the implementation of the programme. Nu-trition Section/CHD/DoHS is responsible for the MoHP, FFEP Central Office for the MoE and CP Unit for the WFP at central level followed by DPHOs and respec-tive health facilities, FFEP Units/DEOs and WFP SOs at regional/local/VDC/health facility level respectively for overall monitoring supervision and support for im-plementation of the programme.

in Nepal since 1972 and thus has considerable experi-ence and expertise in logistics. The FFEP has district offices in each programme district with 10 to 15 staff dependent upon geographical location and the pro-gramme size.

Health Facility and Operation Management Commit-tees (HFoMCs) and MCHC committees consisting of beneficiaries, local representatives, social workers and some of the key health staff are the entities responsi-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-

03Implementation arrangements

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 and reporting. The FFEP has been handling logistics

Joint review mission members holding talks with DPHO in Dadeldhura district

Women returning home with monthly take-home ration of 7 kg Super Cereal


ensure smooth delivery of government supported services. This is the main thrust of the MCHC pro-gramme to lower the prevalence of underweight among children and to lower the prevalence of ane-mia among the PLW assisting the government’s ser-vice delivery system with an aim to also reducing stunting in the future.

The HFOMCs and MCHC committees are responsible for managing food distribution including providing support to the ongoing clinic services with additional support from the community-based FCHVs. The dis-tricts were selected in collaboration with/between WFP and government partners. The targeted districts are categorized as food insecure by the Food Security Monitoring and Analysis Unit (FSMAU) / Vulnerability Assessment Mapping (VAM) of the WFP Nepal.

ly hand over Super Cereal to the representatives of the MCHC Committee for transportation up to the health facilities. The beneficiary receives 7 kg of Super Cereal of monthly supplement at the health facility during the fixed monthly MCHC clinic schedule on the basis of receiving ANC, PNC, growth monitoring, individual or group counseling as stipulated in the implementa-tion guidelines. This is further verified by the health workers and storekeepers respectively on the basis of beneficiary card that each woman or child has from the health facility at the time of his or her registration as MCHC beneficiary prior to being entitled for the services. Health workers and NGO support staff to-gether agree on the scheduled monthly clinic dates, timing and division of responsibilities mobilizing the HFoMC and MCHC committee members and Female Community Health Volunteers (FCHVs) in order to

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


The staff at the health facilities record information about the beneficiaries and the services provided to them on a standard programme reporting format. They compile the data every month and forward it to the DPHOs, which send it to the Nutrition Section, CHD, DoHS. The data contributes to overall service utilization statistics for the district and is fed into the Health Management Information System (HMIS).

In addition, the MCHC programme collects data re-quired for monitoring the effectiveness of the pro-gramme every six months. The beneficiaries are ran-domly selected for interviews during their clinic visits with the use of a standard questionnaire, and based

04Monitoring and Evaluation

on the collected data monitoring reports are prepared. Although such reports are helpful in tracking the ef-fectiveness of the process, more rigorous methods are required to assess the impact of the programme.

In 2010, an evaluation of the WFP Nepal Country Port-folio recommended the strengthening of the monitor-ing and evaluation of programme activities through baseline and end-line surveys in order to ensure meas-urable evidence of WFP activities and demonstrate im-pact of the MCHC activity across targeted districts . It was further suggested that WFP monitor areas where multiple activities are carried out, to capture synergis-tic programme impacts.

MCHC committee members attend briefing of the joint review mission in Ajayameru VDC, Dadeldhura


05Objectives and scope of the reviewOver the last decade, the MCHC programme has un-dergone several joint missions, reviews and surveys in the programme districts. Reports of two key WFP eval-uation missions, the Country Programme Evaluation cum Appraisal Mission - 2006 and, the Country Port-folio Evaluation Mission - 2010 as well as the World Bank health sector nutrition evidence review 2011 have recommended a comprehensive review of this programme. The results, outcomes and recommenda-tions of this review will be very important as input to the CP formulation. The new WFP CP phase for the pe-riod from 2013 to 2017 is in the offing and already in the process of being proposed to the Executive Board (EB) for approval.

Concrete recommendations are also needed for better integration of the MCHC programme into the national nutrition strategy and Multi-Sectoral Nutri-tion Programme (MSNP) framework. The NHSP IP II

mentions that the government is reviewing the case for large-scale food supplementation, and hence this review will also provide added information in this regard.

The main objective of this joint review is therefore to review and assess the ongoing food-based MCHC programme activities. In addition, it will provide rec-ommendations for future intervention modalities, re-adjustment in line with national health and nutrition strategies and plans, and the development of a viable handover strategy beyond 2012-2013.

The joint review was based on desk reviews of relevant documents (listed in annex 1), field missions and con-sultative meetings with key government and non gov-ernment stakeholders including staff from the CHD and FHD of MoHP, National Planning Commission (NPC), Ex-ternal Development Partners (EDPs) and NGOs.

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

06Implementation strategy of the reviewThe review team collected and analyzed information with the following goals in mind:

• Review of the performance of the programme• Analysis of the appropriateness and efficiency of

the operational modalities• Analysis of the appropriateness of the targeting

mechanism• Exploration of opportunities for internal integra-

tion of WFP activities and linkages with govern-ment programs and development partner activities

• Exploration of the potential for increased owner-ship and government and community partnership

• Assessment of the alignment of the program objec-tives with national policies and priorities

• Review of the Monitoring and Evaluation strategy and the recommendation of necessary changes

• Review of the possible mechanisms and its poten-tial integration into government programmes in or-der to make it sustainable.

• Identification of possible strategies in transition in line with government polices and priorities as well as global WFP strategic objectives and draft global WFP nutrition policy.



07Composition of the review teamSix of the review team members were involved in both central level consultation and field level missions un-der the team leader. The names below in italics played more prominent roles were consulted for high level meetings and sharing of relevant documents at central level during the course of the review.

• Dr. Ramesh Kant Adhikari, Team Leader, Professor in Child Health and former Dean, Institute of Medi-cine, Maharajgunj, Kathmandu, Nepal

• Ms.Irada Parajuli Gautam, Consultant, Maternal and Child Health Expert, Kathmandu

• Ms. Sharada Pandey, Senior Public Health Ad-ministrator (SPHA), MoHP, Ram Shah Path, Kathmandu

• Mr.Leela Bikram Thapa, Senior Public Health Of-ficer, CHD, DoHS, Teku, Kathmandu

• Mr. Girish Kumar Jha, National Statistics Officer, CHD, DoHS, Teku, Kathmandu

• Mr. Amrit Bahadur Gurung, Senior Programme Assistant, UN WFP, Chakupat, Patandhoka, Lalitpur

• Ms. Jolanda Hogenkamp, Head of Programme, UN WFP, Chakupat, Patandhoka, Lalitpur

• Mr. Jibachh Mishra, Programme Director, FFEP Central Office, MoE, Naxal, Kathmandu

• Mr. Ravi Upreti, Deputy Programme Director, FFEP Central Office, MoE, Naxal, Kathmandu

• Ms. Saba Mebrahtu (PHD), Chief, Nutrition Section, UNICEF, Pulchowk, Lalitpur from UNICEF

• Ms. Pramila Ghimire, CP Coordinator, UN WFP, Chakupat, Patandhoka, Lalitpur

• Ms. Sophiya Uprety, Programme Officer (Nutri-tion), UN WFP, Chakupat, Patandhoka, Lalitpur

Nutrition Technical Committee (NuTEC) under the chairpersonship of Dr.Shyam Raj Upreti, Director at the CHD, DoHS, Teku, Kathmandu, provided guidance to the review team in overall processes.

Joint review mission members on the way to Salyan district


Composition of the review team

08Activities of the team There were three main activities carried out by the re-view team as below;

• The team started the review process on 16 Sep-tember 2011 with a meeting with WFP officials and focal persons; Ms. Nicole Menage, WFP Country Representative, Ms. Jolanda Hogenkamp, Head of Programme, Ms. Pramila Ghimire, CP Coordinator, Ms. Sophiya Uprety, Programme Officer (Nutrition) and Mr. Amrit Bahadur Gurung, Senior Programme Assistant for MCHC and discussed over the scope and objectives of the joint review mission.

• Field visit schedules and development of tools for collecting information were discussed within the team members.

• Field visits were carried out from 18 to 23 Septem-ber 2011 to Dadeldhura and Doti districts in the Far Western region, and 17 to 22 October 2011 to

Nepalgunj, Banke and Salyan districts in the Mid Western region.

Other key activities may thus be summarized in order of priority.

• Mid-term report and review of the findings on 15 October 2011

• Meeting with government officials as well as with the EDPs from 15 to 28 September and 18 to 31 October 2011

• Discussion within WFP about the observations and recommendations on 02 November 2011

• Submission of the draft report on 14 November 2011 • Review discussion within WFP and second draft

further submitted on 12 December 2011• MCHC review dissemination meeting among key

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


09ObservationsThe observations have been grouped in the following categories:

• Performance of the programme• Appropriateness and efficiency of the operational

modalities• Appropriateness of the targeting mechanism• Opportunities for internal integration within WFP

activities and linkages with government pro-grammes and programme activities of other like-minded development partners

• Potential for increased ownership and government and community partnership

• Alignment of the programme objectives with na-tional policies and priorities

• Monitoring and evaluation strategy and recom-mendations for necessary changes

• Mechanism for integration of the MCHC into gov-ernment programmes for its sustainability

• Possible strategies in line with government policies and priorities as well as global WFP strategic objec-tives and draft global WFP nutrition policy.

Findings, Observations and RecommendationsI: Performance of the MCHC programme: ResultsThe MCHC programme was initiated in three VDCs in 2001 in two districts and subsequently expanded to 98 VDCs in 11 districts by 2007. It is currently operating in 47 VDCs in nine districts of Nepal. The programme is reported to have been discontinued for some time period due to a lack of resources within the WFP at 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


mentation was given out to the PLW and children aged 6 to 36 months through both the health facilities and ORCs. Over the last 3 years, the programme partners agreed to distribute food at the health facility loca-tions following a number of key observations made by visitors during monitoring and supervision in the past. The HHESS, an NGO committed to the field of health and nutrition has been providing support for key MCH related services, such as the ANC, PNC, growth moni-toring and counseling. HHESS was also entrusted with the task of logistic management in Solukhum-bu district between 2007 and mid-2011 and also providing the key technical services on health and nutrition. The logistic part has now been completely handed over to the Nepal Government.

Positive results through the regular programme moni-toring can, thus, be summarized below:

• About 9,450 mothers and 19,550 children aged 6 to 36 months were provided the Super Cereal (fortified blended food) during 17 July 2010 – 15 June 2011 (2067 Shrawan – 2068 Ashad) period. Each beneficiary received 7 kg of Super Cereal with a calorie value of 380 kcal and protein con-tent of 15 grams (Gms) per 100 gms in addition to multiple micronutrients. Though the beneficiaries are expected to consume 100gms/day/child and 125gms/day/PLW, an extra amount of supplement is being given to compensate for unavoidable in-tra-household food sharing in alignment with the “WFP’s Supplementary Feeding for Mother and Children (Operational Guidelines) – 1998”, “the Maternal and Child Health and Nutrition (MCHN) Toolkit – Nutrition, MCH & HIV / AIDS Programme Design & Support Division, April 2011”, “WFP Food and Nutrition Handbook”, and “FAO Human Nutri-tion in the Developing World 1997”. This was a hu-mane and practical but costly approach.

• Beneficiary mothers and other community mem-bers expressed their happiness in getting the food supplement at the health facilities. Except for brief periods of interruption of food supply, the benefi-ciaries were satisfied with overall health and nu-trition related services at both of the government health facilities and ORCs. They were happy with the quality of the food supplied and had no com-plaints about its texture, taste or consistency.

• The programme VDCs showed a much higher service utilization rate of ANC and PNC. 91% of mothers received ANC/PNC followed by 97.5% of

the children having growth monitoring including counseling in the programme VDCs compared to the national averages of 25% and 33% respectively. Similarly, the percentage of underweight children in the age group of less than three years of age was reported to be 9.9% in the program VDCs com-pared to the national figure of 28.8%.

The programme has thus achieved the expected out-come of improving the utilization of health services by pregnant and lactating mothers. Similarly, the im-pact on reducing prevalence of underweight among children also has also been met as expected. Further-more, this additional support through the MCHC is re-ported to have made a significant contribution to the government’s regular health services at the local level.

II: Operational modalities: Efficiency and appropriatenessFFEP/DEO is responsible for the distribution of food supplement. It is the responsibility of WFP to deliver Super Cereal up to EDPs. The FFEP has the experi-ence and network for efficient delivery to deliver food through local transportation modes available up to FDPs or DCs, from where MCHC committee members take the responsibility of transporting food further to the health facilities at VDC level. Logistics unit of the FFEP Central Office has been utilizing the existent logistics mechanism of the School Meal Programme (SMP) for handling, transportation and distribution of the Super Cereal also for the MCHC programme.

• The utilization of the existent logistic network has been a key strength of the programme. Except for a short period of interrupted supply, the FFEP has met with its obligations of delivering the sup-plement on time. The review team did not come across any complaint of wastage or leakages in the course of handling the Super Cereal.

• The relationship between DEOs and FFEP Units at district level seemed strained at places. These un-easy relations were said to have emerged following the policy of reorganizing the then FFEP structure in 2003-2004 and its amalgamation with the DEO for a quick district level implementation or opera-tional arrangement without proper shift of policy at the level of Department of Education (DoE) at central level. The FFEP staff originally came from the Nutritious School Feeding Programme (NSFP) having been a part of the Social Welfare Council (SWC) at a certain point of time in the past. The


FFEP staff members are still treated as project em-ployees outside of the government system and of temporary nature. Similarly, they mentioned that

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-cal government line agencies and a major shift of policy to improve the ORCs’ infrastructure at the central level.

• Some health personnel mentioned the lack of in-volvement of DPHOs and health facility staff in the 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 mechanismThe 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 identify the vulnerable population had been carried out to identify the VDCs for programme implementa-tion. One of the VAM exercises had used a number of indicators such as food security, rate of malnutrition, girl enrolment in primary school, access to education and health, percentage of Dalits, accessibility, pres-ence of development agencies, gender disparity and impact of conflict. The targeting exercises were carried out to identify the VDCs in order for the WFP to be able to provide support through the Food for Assets (FFA),

the escalating costs of transport and the lack of funds for programme monitoring work were some of the issues that would have to be addressed.

• As the FFEP/DEO delivers the Super Cereal, health facility staff seemed to take it as a part of the DEO’s programme. To what extent the existing reluctance of the government health staff at both the district and VDC level are reluctant as a result of the DEOs

The FFEP Deputy Director, Mr. Ravi Upreti inspecting a VDC storeroom during the mission

Samana Joshi, Banjhkakeni VDC, Doti briefly talking to the mission members while returning home from the MCHC clinic


School Meal Programme (SMP) and MCHC. However, blanket coverage for all the beneficiaries, despite differ-ences in economic and educational statuses of the family and productivity, tends to raise questions whether there is any potential for wastage and leakages.

The FSMAU conducts regular review of food insecu-rity together with the District Food Security Network (DFSN) and regularly shares updates on food secu-rity situation at district level among the key govern-ment stakeholders. The MCHC programme continues to operate in one VDC for a period of five years. The review team found that there had not been any such robust plans for carrying out for baselines, follow-up, mid-term review, programme evaluation and end-line studies during the five-year period of the MCHC pro-gramme. It is recommended that definite end points be identified at which a VDC is weaned off the MCHC programme without waiting for a period of five years. It will allow other more needy VDCs to benefit from the programme.

IV: Opportunities for integrationa. With WFP programme:The MCHC programme is a part of the five-year WFP CP period. The focus of CP is on long-term develop-

ment, the aim of which is to reduce irreversible, eco-nomic and social damage caused by malnutrition. The programme objectives are to help improve maternal and child nutritional status and use food as an entry point to improve access to education and health care. The programme is well integrated with the SMP which provides “mid-day meals” to ECDs and primary school children and vegetable oil to girl children under the Girls Incentive Programme (GIP). The “life cycle” and “continuum of care” approaches are integrated in these programmes and is expected to improve nutri-tional, health and educational outcome through inter-ventions starting during the fetal period and continuing till adolescence. However, it is surprising to note that there has not been any such synergy between the Pro-tracted Relief and Rehabilitation Operations (PRRO) and the MCHC including the FFEP or the SMP. Possibility of the PLW falling out of the purview of PRRO needs to be seriously considered. It is necessary that the guidelines for selecting the beneficiaries take note of households headed by the PLW and consider to include and assign them lighter work load to justify their inclusion.

b. With Development partners • UNICEF implements a number of programmes

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 VDC in Solukhumbu district on April 05, 2011


mothers groups’ facilitation and mobilization for various development outcomes. Integrating MCHC with these programmes is a possibility but no link has been established so far. A link between these two programmes of the WFP and UNICEF was at-tempted through the signing of a MoU at the cen-tral level sometime during the WFP CP during the period of 2002-2006. However, the collaboration did not seem to have had any outcome evaluation-based continuity.

• Nutrition Section/CHD/MoHP and UNICEF have partnered to implement Community Manage-ment of Acute Malnutrition (CMAM). The CMAM programme identifies Severe Acute Malnutrition (SAM) and treats it at the Stabilization Centres (SCs) if the child is found to be suffering from life threatening condition and through Out-Patient Treatment (OPT) programme, if the child has no life threatening conditions. Ready to Use Therapeutic Food (RUTF) is the main intervention used to treat SAM cases. However, there is no food supplement for children suffering for Moderate Acute Malnu-trition (MAM). The MCHC programme has a pos-sibility of developing partnership with the CMAM programme by using food supplement as an inter-vention to prevent MAM cases among children less than five years of age. The prevention and treat-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 the weight of the babies at birth in those VDCs where the MCHC programme is being implemented. This in-formation can provide some tangible information on the impact of the programme on birth outcomes.

c. With government programs:• An initiative of the NPC to launch a Multi-Sectoral

Nutrition Plan (MSNP) in a phase-wise manner

starting with a few districts is in the advanced stage of development. A number of interventions under the government ministries, namely the MoE, MoHP, MoAC, MLD and MoPP have been identified. Food supplementation combined with IYCF counselling is one of the interventions identi-fied by the health sector. It is an opportune time to advocate the MCHC approach for inclusion in this plan. The dissemination of this report could help serve this purpose.

• Nutrition Section/CHD/MoHP has begun to dis-tribute food supplement for children aged 6 to 23 months of age, not exceeding 2 children per family, in five districts of the Karnali region. WFP has provided some technical input into this pro-gramme. The experience of the MCHC programme can contribute to better implementation of this programme in the long run. The officials within the MoHP are interested to learn from the experience of the MCHC programme in order to implement it in the Karnali region more effectively. It has been suggested that a pilot programme with the use of measurable valid indicators and a mechanism to ensure high level of compliance and follow-up as regard the food supplement would create enough convincing evidence and can thus be used for fur-ther advocacy.

A girl child with her younger sibling at the health center in Deusa VDC quoted as saying both her parents do portering for a living, and are absent during most lean seasons.

• The current MoHP food distribution programme consists of supplying 1.5 kg of fortified food to children 6 to 11 months of age and 2.5 kg per month for children 12-23 months of age. The food supplement is distributed from the health


facilities and is linked with counseling on IYCF practices provided by the health staff and FCH-Vs. MoHP can draw on the experience gained in the MCHC programme in selecting appropriate food supplement, quantity and its supply, and in monitoring its impact on the pattern of health service utilization and outcome in terms of nu-tritional status of children.

• NHSP-2 has recommended studying the possibility of food supplement or cash transfer for improving maternal and child nutrition. . The present report of the review of MCHC programme will provide some information for the policy makers.

V: Government and community participation:The MCHC committees and HFoMCs at community levels are engaged at different levels of participation under the programme. MCHC Committees had prac-ticed raising some funds from the beneficiaries term-ing it as participation fees ranging from five rupees per beneficiary per month during the monthly clinic schedule at the given health facility. Purpose was to utilize the fund on account of the FCHVs’ involvement during the monthly MCHC clinic days, purchase of es-sential equipments, medicine and NFIs. It was learnt during the review that the practice was discontinued as a result of the government’s free health policy, ac-cording to which charging additional fees has been forbidden. Further probing into this matter of impor-tance showed that any study had not been done about to what extent the free health policy would apply for programmes falling under compensatory heading and those falling under non-compensatory heading in term of various government health and nutrition programmes at community level. Both DDCs and VDCs

have annual funds to support the health facilities in Nepal. Considering countless claims and proposals for capturing the available funds at local level from various social and political groups, it is suggested that consistent lobbying would have to be made along with HFoMCs to enable health facilities to make use of these funds.

Discussion with the MoHP officials revealed that D/PHOs also have a budget to hire staff to run the pro-gramme at the health facilities. But it is unlikely that that such fund will be available specifically for the MCHC programmes.

• The MSNP has plans to create a Nutrition and Food Security Coordination Committee (NFSCC) at DDC/VDC level, which will use the “analyze, assess and act” approach to help improve nutri-tional status. The MCHC programme will have to prepare itself to be accepted as a necessary in-tervention particularly in the food insecure dis-tricts and VDCs.

• Information, Education and Communication (IEC) as well as other technical materials on nutritional requirements for the PLW and children aged 6 to 23 months; their importance, values of different food supplements, best way of making them avail-able etc are needed for advocacy.

• Active MCHC committees and HFoMCs offer op-portunities for integration, but their existing com-petence poses serious challenges.

VI: Sustainability:• At the current level of expenses, each beneficiary

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 support, but would by and large benefit from nu-Mothers group members actively responding to WFP Coun-

try Representative’s queries in Deusa VDC, Solukhumbu


trition education. The second group is in need of occasional food supplement support during the so-called lean seasons in terms of agricultural produc-tion, and has the potential to benefit from coun-selling arrangements at the government’s health set-ups. The third group is reported to be the most critical and vulnerable one in need of both food supplementation and nutrition education and counselling. It is thus recommended that the fu-ture nutrition programmes will have to be planned considering these three specific groups of people residing in the identified food insufficient interven-tion areas. A blanket approach to provide benefits to all families is easier to implement but may not be effective in achieving the objectives of the pro-gramme. A key recommendation for the future is that, a more efficient identification strategy of the needy beneficiaries should be put in place so as to supply them with the supplement. The MCHC programme can contribute to DDC or VDC level nutrition coordination committee in providing thematic information on the costs of different supplementation approaches. The HHESS has suggested a typical community-driven model of helping family members through preparation of nutritious food based on local-food-mix before discontinuing the programme terming it as a sustainable alternative.

• A research on the efficacy of food supplement against cash transfer, nutrition education or con-trol is being commissioned with DFID support. The WFP, with its experience in running a food sup-

plementation programme is in the right position to get involved in such a study and learn whether food supplement leads to better nutritional out-come, particularly among the food insecure popu-lation. Furthermore, till such time that the MCHC programme gets integrated in the national nutri-tion progamme, WFP can engage into a research organization to study its impact on nutritional sta-tus, anemia prevalence and utilization of health services in programme and non-programme VDCs.

• Studies mentioned above will pave the way for the Nepal government to take over food supplementa-tion as a desirable intervention to improve nutri-tional and health status of the population.

VII: Monitoring of the programme: The current monitoring and evaluation system is ap-parently functioning well with regular data gather-ing and reporting to HMIS combined with periodic monitoring based on interviews on a standard for-mat with the beneficiaries. However, the data col-lected so far is not usable to assess the change in the prevalence of anemia and maternal under-nu-trition. Partners can assess these indicators through measurement of weight and height of women bene-ficiaries to identify the mothers with chronic energy deficiency (a BMI of less than 18.5 kg/meter square) and periodic estimation of hemoglobin. In addition, collecting information on weights of babies at birth in those communities where CBNCP is being imple-mented will provide a valuable indicator to assess the impact of the programme


10General impressions • Beneficiaries have contributed to gradual institu-

tionalization of the ongoing MCHC programme through active participation during the given monthly clinic schedules for both receipt of food supplement and accessing of the primary health care services. This is in contrast to the mixed feel-ings of some government officials and ambivalence on the food-based approach.

• It was observed that the programme could not fol-low a very rigorous method of follow up and data management. Nature of the programme does not necessarily lend itself to the creation of scientific database that would statistically prove or disprove the efficacy and effectiveness of the intervention. However, monitoring reports show a considerable increase in utilization of the ANC, PNC, growth monitoring, nutrition education, counselling and other related promotional activities in the pro-gramme VDCs. This increase and level of improve-ment in accessing and utilization of the services available at the community level are reported to 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/DoHS,MoHP takes a policy level decision on this proposition. A study should be carried out whether

the LMD has the capacity to deliver the services in this connection or not. However, current FFEP structure is already an asset for logistics in terms of professionalism.

• The MoE officials are willing to continue to work under the present arrangement despite the fact that the output of their efforts is reflected in the health sector. However, if the present arrange-ments are to continue in the future, some in-put to strengthen the FFEP structure is required through further enhancement of budgetary capacity, training and material support as and when needed in critical areas of high demands for such support.

• Nutrition programme of the MoHP and develop-ment partners expect more robust evidence to support this type of intervention. WFP has a good opportunity to partner with independent agencies looking into different aspects of the food supple-mentation linking with an ongoing study commis-sioned by DFID.

Mr. Shree Dhoj Rai briefing over the status of the ongoing MCHC in Deusa VDC, Solukhumbu to WFP Country Repre-sentative


11Recommendations There will be more targeted approach in place for the next phase considering food insecurity and nu-trition indicators considering also other social and political realities while building up the overall tar-geting strategy. Sustainability is being addressed by including more synergistic efforts in the 2013 – 2017 WFP CP with more life cycle approach for food insecure areas. This is to be understood in terms of being a part of fulfilling key requirements of health and nutrition related services by the government health workers involving local stakeholders by the local people under the MCHC. The different aspects that play a crucial role in sustainable livelihood through life-cycle approach will be the key in highly food insecure areas. Observations have shown that VDCs with support from user groups and commu-nity members have made significant contributions to the MCHC programme in hiring health workers, establishing ORC set-ups and improving infrastruc-ture at the health facilities and ORCs within the pro-gramme VDCs. It is also suggested that how food supplement can be a part of national health deliv-ery system should further be explored.

Costs become higher while providing support in the remote, food insecure areas in Nepal. The govern-ment’s ongoing supplementary feeding programme under the MoHP for under-2 children in the Karnali region and beyond indicates a priority being given to the supplementary, and the government and WFP can further collaborate in joining hands in areas of logis-tics and technical expertise of lessons learnt. One of the operational issues directly observed during field observations, such as further need for discussion on alignment of the monthly ANC services under the MCHC with the government’s 4-times ANC visits would also be a pertinent area for further strength-ening of the programme. It is also suggested that further linkages with the FHD in addition to the CHD would steer the programme in the right direction

and more relevant in the context of “the golden 1000 days”. This is also highly recommended that the food supplement to the mothers and children should be incorporated into the ongoing MSNP doc-ument.

A: Continuation of MCHC programme:• MCHC programme is still relevant in the VDCs

with high levels of food insecurity. However, continuation of MCHC programme should be linked with VAM in light of newer findings from NLSS so that targeting strategy becomes more convincing.

• The programme in a new VDC should be initiated after a baseline survey followed by midterm and end-line surveys at specific points and information collection on impact indicators of interest.

• Reconsider the target age group to bring them in line with government policies as well as WFP’s new draft nutrition policy which focuses on one thou-sand days and ”The Right Food at the Right Time”.

• Mechanisms to support the health facilities in pro-viding health services need to be strengthened if food supplementation is to continue. The current approach of utilizing the services of a non govern-ment organization needs to be continued for some more time period in the future.

B: Integration with government programmes: • Bring FHD on-board demonstrating their role in im-

proving maternal nutritional status. • Explore the possibility of working with LMD of the

MoHP to supply food supplements specifically in districts where MCHC program is going on.

• Open dialogue with DDCs and DPHOs to hire health staff with funds allocated to VDCs and DPHOs to support ANC, PNC, GM, recording and reporting activities, storage facilities at ORCs etc.

• Explore the possibility of including food supple-ment in the treatment protocol for the manage-


ment of MAM cases in coordination with the CHD. The programme should follow the national CMAM guidelines and would require development of na-tional guidelines for addressing MAM as well as in-tegration with the existing national CMAM guide-lines. Support for MAM under the CMAM is further necessitated by the fact that MAM cases constitute the majority of acute malnutrition burden. Hence, a provision of appropriate supplementary food in addition to other routine activities for children with MAM caseload will complement the preven-tive and therapeutic programme components in highly food insecure areas.

• The food supplement currently being used has a high level of acceptability among beneficiaries and afford-able for the partners. New products with better nu-tritional content and efficacy should be promoted as these products contain animal source protein and are specifically designed for under-two years of children for the management of the MAM in particular.

C. Evidence of effectiveness: • Explore the possibility of including data from pro-

gramme VDCs into HMIS to highlight its effective-ness in coordination with the CHD.

• Continue and combine the MCHC programme with a study to look into the effectiveness of food sup-plement in programme VDCs against control in food deficit areas.

• Partner in the research to be funded by DFID to study the efficacy of food supplement vs. cash transfer vs. nutrition education vs. control, and ex-plore whether the study can look into the efficacy of the food supplement approach among food in-secure population groups.

D. Strengthening of the programme:• NGO support is vital for the success of the pro-

gramme. This should be more for nutritional

counselling. It will need different types of hu-man resources to be employed in intervention areas. Nutrition counsellors would be more beneficial rather than health worker. However, the health workers being currently employed by the HHESS have played a crucial role in overall strengthening of the government system at the health facilities.

• Local resources such as the funds of VDCs, LDO and DPHO can be mobilized to hire health staff at the local level. Part of the funds has been utilized on hiring of temporary health workers and building of minimal infrastructure at local level with support of the NGO.

• The FFEP unit is need of further support in areas of capacity building as per discussion held with the concerned personnel during the review. Issues of storage facilities and human resources will have to be settled before con-sidering distribution of food from ORCs with support from both the local government line agencies and the NGO partner.

• Explore the existing mechanisms to help strength-en HFoMC and MCHC committees, essentially by resuming MCHC fund collection referring to the free health policy of the government and previous MCHC implementation guidelines.

• Support government health workers at the health facilities through orientation and training to develop their sense of ownership of the pro-gramme.

• Develop consensual approach on the future in-tegration of the MCHC programme within the national programmes and modalities.

• Develop a roll out/exit strategy on the basis of consensus thus reached in the process of final-izing the final report.


Annexes:Annex i. List of persons interviewedAnnex 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


Dadeldhura1. Mr. Hikmat Kumar Shrestha, DADO2. Mr. Ramhari Das Shrestha, DEO3. Mr. Keshav Raj Joshi, Unit chief, FFEP Unit4. Mr. BalbahadurMalla, DPHO5. Mr. KabindraShrestha, Senior PHI6. Mr. GaneshDutta Joshi, PHI7. Mr. PremlalLamichhane, CDO8. Ms. SitaThapa, WDO9. Ms. Yangze Sherpa, Coordinator, HHESS10. Mr. UmeshSawad, HHESS11. Mr. Kiran Pal, Director, WFP Regional Office12. Ms. MeenaThapa, Focal person, MCHC

programme, WFP13. Mr. Tapeshwar Mandal, Senior AHW, Chamda

Health Post, Ajaymeru VDC14. MCHC committee members, Chamda Health

Post, Ajaymeru VDC15. Beneficiary mothers and children, Chamda

Health Post, Ajaymeru VDC16. Storekeepers, Chamda Health Post, Ajaymeru

VDC17. ANMs and FCHVs, Chamda Health Post,

Ajaymeru VDC

Doti1. Mr. MahendraShrestha, Director, Regional

Health Directorate2. Mr. KuberKhadka, AHW, Mr.Yogendra Shahi, Field

Supervisor, MCHW, VHW, FCHVs, Banjhkakeni VDC

3. Mr. Netra Prasad Pant, Chief, FFEP Unit4. Mr. TekBahadur Thapa, DEO5. Dr. Raj Kumar Bhatta, Acting DPHO6. Mr. Keshar Saud, Focal Person, Nutrition

Programme, DPHO7. Mr. Kishor Shrestha Statistics Assistant, DPHO8. Mr. Prem Bahadur Khapung, CDO9. Mr. Yagya Raj Joshi, DADO10. Mr. Hem Raj Joshi, Gender Equality Officer, WDO11. Mr. Chuda Mani Joshi, Officiating LDO

Kathmandu1. Dr. Mingmar Gyalzen Sherpa, Director, Logistic

Management Division2. Dr. Shyam Raj Upreti, Director, Child Health

Division 3. Mr. Raj Kumar Pokharel, Chief, Nutrition Section,

CHD4. Mr. Leela BikramThapa, Nutrition Section, CHD5. Mr. Manoj Upreti, Logistic officer, WFP6. Mr. Luc Laviollate, World Bank

Salyan1. Dr Kamal Gautam, Acting DHO2. Dr. Bishal Shrestha, DPHO3. Mr. Dhir Jung Shahi, DPHO 4. Mr. Dasharath Kumar Shrestha, PHI, DHO, 5. Mr. Vijaya Kranti Shakya- MCHC focal person , DHO6. Mr. Peshal Kumar Pokhrel – LDO7. Mr. Suresh Adhikari, DDC8. Mr. Tej Prasad Poudel – CDO9. Mr. Biswomaya Sharma- WCDO 10. Mr. Balkrishna Gaire – DEO11. Mr. Ram Hari Rijal -Program officer, DEO12. Mr. Rabindra Singh Bhandari, FFEP Unit, DEO13. Mr. Ram Milan Prasad Biswokarma – DADO 14. Mr. Hem Bahadur Chand, Sr.AHW, In charge,

SHP, Kupindedaha15. Ms. Remanta Basnet, ANM, Kupindedaha SHP16. Ms. Thum Kumari Kunwar, Storekeeper,

Kupindedaha SHP17. Mr. Moti Lal Bhandari, VHW, Kupindedaha SHP18. Mr. Om Bahadur Budhathoki: Support staff,

Kupindedaha SHP19. Mr. Mume Kunwar, Chairperson, MCHC

Committee20. Mr.Ram Bahadur Kunwar, Chairperson, Village

Committee21. Mr.Krishna Bahadur khadka, Acting Chairman, VDC22. Mr. Dhruva Nepali, Social Worker, Kupindedaha23. Ms. Nili Reule, Beneficiary, Kupindedaha SHP:

Kupindedaha

Annex i: List of persons interviewed


24. Mr.Deepak Kumar Yeri, Political leader, UCPN (Maoist) Kupindedaha

25. Ms. Kewat Kunwar: FCHV: Kupindedaha SHP26. Ms. Bhima BK: FCHV: Kupindedaha27. Ms. Pokhari Kunwar: FCHV: Kupindedaha28. Ms. Seti Giri: FCHV: Kupindedaha29. Ms. Gaimati Bohara: FCHV: Kupindedaha30. Ms. Bishnu Kunwar: FCHV: Kupindedaha31. Ms. Gople BK: FCHV: Kupindedaha32. Ms. Daili Budhathoki: FCHV: Kupindedaha33. Mr. Ghanshyam Pokhrel – Director, Regional

Health Directorate, Mid Western region

34. Mr. Gyan Bahadur Bhujel – Health and Nutrition section, UNICEF, Nepalgunj

35. Mr. Nar BdrBudha – Maternal and neonatal health section, UNICEF, Nepalgunj

36. Mr. Biswo Nath Poudel – Program Manager – Nepal Family Health Programme, Nepalgunj

37. Mr. Birendra Khagunna- Program Manager, Save the Children, Nepalgunj

38. Mr. Ravi Mohan Bhandari- Health and nutrition, focal person, Save the Children, Nepalgunj

39. Mr. Shailendra Shahii- Engineer, Save the children Nepalgunj

A woman in Doti district 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 Far West


Summary of selected indicators for Doti district2

Indicator Doti Baseline April 2001

Doti Follow-up Nov 2005

Makawanpur Base-line 2002

Makawanpur Follow-up 2005

Children 6-36 monthsUnderweight 54.8 42.6 47.2 29.4Stunting 48 49.6 43.9 42.3Wasting 11.7 15.5 10.3 7.4Anaemia 58.3 48.8 73.4 47.5Pregnant and lactating womenAnaemia (pregnant) 55 30.4 66.9 43.1Anaemia (lactating) 26.9 34.3 73.5 22Night blindness (pregnant)

6.1 5.4 11.6 3.9

De-worming-tablets (pregnant)

2.5 50.7 - 25.5

Iron-supplements (pregnant)

- 37.5 - 36.3

Seeking antenatal care (pregnant)

29.3 73.2 22 49

Annex: ii: Summary of surveys and reviews of the MCHC programme carried out between 2001 and 2010, per districtSN Region Districts 2001 2002 2003 2004 2005 2006 2007 2008 2009 20101 Far West Dadeldhura BS Rev Rev Rev Rev2 Far West Baitadi BS Rev3 Far West Doti BS FS Rev Rev4 Far West Darchula BS Rev5 Far West Bajura6 Far West Achham7 Far West Bajhang8 Mid West Salyan BS Rev BS Rev Rev9 Eastern Solukhumbu Rev Rev BS10 Central Makawanpur BS FS

Note: The MCHC programme was completely phased out from Makawanpur district in February - March 2007.

BS=Baseline SurveyFS=Follow-up SurveyRev=Programme Review/Evaluation


Annex iii: Literature Review specific to food supplementation and pregnancy outcome

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

1. Allen L, Gillespie S: What works? A review of ef-ficacy and effectiveness of nutrition interventions; UN/ACC/SCN Nutrition Policy Paper no. 19, Asian Development Bank 2001:

This review has taken a life cycle approach in identi-fying the impact of malnutrition in the developing world. It has considered the different programmes for their efficacy or effectiveness. According to the authors “efficacy refers to the impact of an interven-tion under ideal conditions, when the components of the intervention (e.g., food supplements) are directly delivered to all the individuals in the target group (i.e., 100% coverage). This is possible under research condi-tions with a high level of supervision. Effectiveness refers to the impact of an intervention under real world con-ditions, when prorgrames are scaled up to reach large proportions.

A number of programmes were reviewed related to five major nutrition problems; low birth weight, early childhood growth failure, iodine deficiency disorders, anemia and Vitamin A deficiency. A comprehensive re-view of the existing knowledge of the efficacy of key nutrition interventions for preventing and alleviating low birth weight is summarized below:

Low Birth Weight: South Asia has the highest preva-lence of low birth weight babies (about 30%) and this is strongly associated with under nutrition of mothers. LBW is probably the most important reason for under-weight children in this region. Therefore, interventions to reduce the prevalence of LBW should receive high-est priority. Randomized controlled intervention stud-ies have shown the following:

- Supplementation with food containing a balanced protein and energy content (protein contributing less than 15% of the energy) during pregnancy significantly increases the birth weight.

- Though the expected benefits from maternal food supplementation in Asia are yet to be shown, a num-ber of studies in Gambia have shown positive effect. Women with lowest weight from conception to early pregnancy and lowest energy intakes are most likely to benefit from supplementation.

- Young maternal age at conception is a risk factor for poor pregnancy outcome, therefore targeting moth-ers who are still growing will be beneficial. Continu-ing supplementation during lactation and subsequent pregnancy may cause even better outcome.

- Micronutrient supplementation during pregnancy is extremely important to reduce the prevalence of ma-ternal anemia and its consequences including reduc-tion in maternal mortality. Adequate iodine supple-mentation in pregnancy is critical for the prevention of neonatal deaths, LBW and abnormalities in physical growth and cognitive development.

2. Lancet Nutrition Series: Lancet 2008: Bhutta ZA, Ahamed T, Black RE, Cousens S Dewey K, Giugliani E, et al: What works? Interventions for maternal and child undernutrition and survivalThe authors reviewed 13 studies and one systematic review to summarize the understanding regarding the outcome of balanced protein energy supplementa-tion on pregnancy outcomes. The systematic review included 6 studies with information on size at birth. The systematic review was heavily influenced by a large trial in Gambia that targeted pregnant women of low BMI, who were supplemented with 700 kcal per day. The pooled estimate showed that this strat-egy reduced the risk of Small for Gestational Age baby (which was taken as to indicate intrauterine growth restriction) by 32% (relative risk 068, 95% CI: 0.56 to 0.84). The key message from this study was stated by the authors as “interventions for maternal nutrition (supplementation with iron folate, multiple micronu-trients, calcium, and balanced energy and protein) can improve outcomes of maternal health but few have been assessed at sufficient scale”.

3. Imdad A, Bhutta ZA: Effect of balanced protein energy supplementation during pregnancy on birth outcomes; BMC Public Health 2011; 11: S: 17

This article presented a more recent systematic review of the impact of balanced protein energy supplemen-tation on birth outcome. The review reported that providing women with balanced protein and energy supplementation during pregnancy resulted in sig-nificant reduction in the risk of giving birth to Small


for Gestational Age infants (relative risk: 0.69, 95% CI: 0.56 to 0.89). Pooled results showed that the bal-anced protein energy supplementation resulted in an overall significantly higher mean birth weight. (58.99 gm 95% CI: 33.09 to 86.68 gms). This effect was more pronounced in women with evidence of malnutrition

(74.90 gm 95% CI: 42.42 to 107.6 gm) compared to ad-equately nourished women (27.8 gm, 95% CI: 19.57 to 75.31 gm). The effect of balanced protein energy supplementation on neonatal mortality was not sta-tistically significant (relative risk 0.63, 95% CI: 0.37 to 1.06).

Primary Health Center in Deulekh VDC at Bajhang District providing MCHC service


Annex iv: Nutrient content of Fortified Food ‘Supercereal’ distributed under MCHC programme

Nutrients Vitamin and Mineral Requirements in Human Nutrition, FAO-WHO 2004

Nutrient content (Native plus Premix)in WFP Supercereal*

RNI/day for Pregnant women

RNI/day for Lactat-ing women

Per 100g

Kcal 380Protein, % of energy 16.4Fat 6.0Carbohydrates Iron, mg 23-27 30 8.2Folic 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 9.5Vitamin C, mg 50 70 101.2Vitamin K, µg 55 55 39.5Thiamine, mg 1.4 1.5 0.4Niacin, mg 18 17 9.1Vitamin B2, mg 1.4 1.6 0.6Vitamin B5, mg 6 7 2Vitamin B6, mg 1.9 2 1.1Vitamin B7, µg 30 35 Vitamin B12, µg 2.6 2.8 2Zinc, mg 11-20 14-19 6.6Copper, mg 0.4Selenium, µg 28-30 35-42 26.3Iodine, µg 200 200 40Sodium, mg 1.7Calcium, mg 1200 407.8Potassium, mg 498.3Phosphorous, mg 350.1Magnesium, mg 220 270 70.4Manganese, mg 1Biotin, ug 1.5


Annex v: Summary on reports of review of MCHC Programme

Date Title Reviewers Objectives Findings Recommendations

April 2005 (Nov 2004 to Feb 2005)

MCHC review mission’s report

Dr.Genequand

Dr.Gartaulla

Ms. Ghimire

Ms. Kudsk-Iversen

To assess the overall imp’tion process and to sug-gest actions for improve-ment

l No specific funding in DHS, frequent transfer of trained staff to non-programme districtsl Insufficient staff at NS of CHDl Lack of coordination between MoHP and FFEP of MoEl Inactive DCC, no pro-vision for NFPerson in the programme district l Inadequate equip-ment, instruments in ORCs and S/HPs, no staff for recording and reportingl MCHC members help in running ORCs but are not supported in any way with no budget for snacks or tea, the reports sent by MCHC committees to S/HPs and onward to DHOs are incomplete & irregularl No proper ORC build-ingsl No refresher training for the staff of S/HPs l UNICEF/DACAW-run areas showed marked reduction in UW preva-lence l GIZ had provided equipment to one ORC in Doti l Follow up survey re-ports showed lower UW rates in Makawanpur, less in Doti, red in ane-mia prevalence more in Makawanpur and less in Doti, ANC and PNC practices and GM rates increased

Ensure appropriate MoH funding (WFPN &ODB mission)Policy decision not to transfer staff (DHS)Strengthen the HR in NS, CHD to seek fund(WFPCO to help)

MoHP/DHS to have control over the log man of MCHC act (transport and food )Hold DCC meets regularly, NFP to be nominated from DHOWFP SO and DHO to train supervisors and NFP,DHS to develop minimum std for equip and services at S/HP & ORCs, allow money raised during food dist to be used by MCHCC or DHS funding for this purposeDCC to explore pos-sible NGO support for equipments to ORCMCHCC to be provided funds for tea & snacks, members to have exposure visits to well run prog areasRegularize recording and reportingWFP to seek sup-port for construction of ORC buildings or procure curtains to create privacy for ANC and PNCRefresher training for S/HP staff and FCHVLearn from DACAW exp; explore possi-


ble help form GTZ for equipmentWFP to organize a meeting of INGOs to discuss the possible col-laboration

UNFPA should continue to support S/HP with ANM, training and en-hance awareness about MCHC Expand collaboration to other VDCs

Better ownership by the health facility staffBetter coordination between MCHC and HFOMC neededMinimum stock level at FDP to last for at least 2 months, need for lead time between com-modity received and distributionWooden pellets recom-mended for some stor-age sitesConcerned about an exit strategy

May 2009

July 2008

MCHC activ-ity: A joint review of WFP and UNFPA col-laboration at commu-nity level, Jogbudha and Shirsha VDC, DDL

MCHC Activity: Re-view report on the NGO support

Ms.Meena Thapa

Mr.Ganesh Shahi

Madhav Sap-kotaMs.Elaine ReinkeBBAmatyaRaju NeupaneLB ThapaPrakash ShakyaNT SherpaNiraj Shrestha

To learn the lessons from the joint imple-mentation process an recommend actions for future effective col-laboration in common VDCs

To assess and review the NGO modality op-tions in ar-eas of food distribution, utilization and maximi-zation of ex-isting health services and facilities

Utilization of nutrimix at HH level: Health staff believed that the ben shared NM with other members; NM was consumed within 15-20 days though it was supposed to last for the monthThere was no problem with the distribution of NM in both VDCBen knew the content of NMA reduction in the prevalence of UW was reported from both VDCs according to DHO reportANC and PNC use has increased but home deliveries are still prevalent

Comprehensive re-cording and reporting system for monitoring system was designed and implemented which was very effectiveEffective utilization of MCHC funds available at S/HP for ANC and PNC services, better services at S/HP compared to ORCs.Staff members of awareness about pos-sible losses found to be high, better storage arrangements


• There was a general good feeling about the pro-gamme and it seemed that the beneficiaries ap-preciated the WFP, staff at health facilities, DPHO, DEO and other officials in the district. However, limited interventions, blanket coverage and its in-ability to make much impact were some of the con-cerns implied in some of the government officials’ conversation. The question of sustainability and the programme’s tendency to promote depend-ence were also voiced by different officials.

• Lack of adequate number of health staff at the health facilities was repeatedly brought up as one of the major limiting factors that would hinder the MCHC program to achieve its objective of improved utilization of health services. This has highly justi-fied the support being provided by the WFP for the MCHC through an NGO committed to the field of health and nutrition in Nepal and its continuity is sought for as per conversations.

• Inability to ensure consumption of the food sup-plement by the intended beneficiaries alone and not by other family members was another con-straint that would not allow the programme to achieve expected reduction in the prevalence of underweight and anaemia in the targeted popu-lation. This needs further clarification at policy level, such as an average kcal requirement per day for a child or an adult as being used by WFP glob-ally and within Nepal by Nepali authorities, and further interpretation of intra-household sharing information dissemination, and how this informa-tion should be disseminated at household level on proper food utilization at household level. Further reference should be made to the WFP’s policy document on ration size such as “the Right Food at the Right Time” for both treatment of MAM and prevention of stunting.

• Though it was repeatedly mentioned that the VAM was used to identify the benefiting VDCs, the reasons for selecting these VDCs for food supple-ment were not obvious. Their fields were full of ripening crops and looked fertile. However, some of the beneficiaries did mention that none of the households within the VDC that they lived in could manage to live on the produce of their land for the whole year. The lurking question was what would be the situation in those VDCs which did not have the programme.

• The FFEP managed logistics whereas the health services were the responsibility of the health facili-ties. DPHOs and Health facilities did not have a ma-jor role in the processes of resource mangement. It looks logical that the FFEP has been involved in this task as they seemed more experienced and have an existing network for the purpose. But the FFEP does not have anything to show in short term as the impact of their work. The DPHO has to manage the increased work-load created by the increased attendance of PLW for ANC and PNC and of chil-dren under 36 months of age for growth moni-toring. There is no support for them in terms of human resources and incentives to carry out this extra work. Local HFoMC has limited resources and these are not sufficient to strengthen the human resource situation. The current government rule that no participation fees can be charged by the health facilities has further limited the local com-munity’s ability to raise funds to support the pro-gramme.

• Using an NGO to support the programme looks like a short term measure. There is a need for in-stitutionalizing whatever the NGO has additionally been doing at VDC level in support of the MCHC on behalf of the donor agency so as to be able to show an impact in the long run. It just strengthens the argument that to provide effective services of good quality health services, the health facilities need human resources and VDCs have had the tendency of allocating their annual funds to other develop-ment areas than the health related areas.

• As these districts did not have a programme for management of acute malnutrition, we could not observe the relationship between the MCHC and CMAM. Field reports from Accham and Ba-jura could be reviewed to see how it works. This issue could be brought up during discussion with Ms.Saba Mabrehtu and Mr. Anirudra Sharma of the UNICEF at central level.

• Apparently, UNICEF and WFP had worked in collab-oration when the DACAW programme was opera-tional in Dadeldhura district. It would be a worth-while exercise to explore how that collaboration helped each other’s programme.

• Discussion with the Directors of the CHD and FHD should seek in an effort for opinion building and policy building about how they perceive the role

Annex vi: Summary of observations from the field mission


of the food supplement to improve maternal and child health and nutrition. A review of the inter-national experiences in food supplement usu-ally produces a mixed picture. It is a very difficult exercise to demonstrate a positive impact as the programme does not work under the rigours of a research. At this stage, extensive discussions with

the MoHP officials from CHD, FHD and LMD of the DoHS and Policy Division at the MoHP are very im-portant before proceeding further. The MoE have reportedly had no problem as regards the overall structure except the district level FFEP staff mem-bers having expected more support in operational areas from both the WFP and government.


Annex vii: Background to the HHESS and synopsis of its achievements at local levelHHESS began to work in Solukhumbu district for the MCHC programme in partnership with the WFP since 2007. The partnership happened following the visit of WFP Country Representative to Solukhumbu and overall observation of innovative ideas being used by HHESS in the promotion of health and nutrition as per reports. Main purpose of this partnership was to pilot NGO support into the ongoing MCHC and further scale up the system in the Far/Mid Western regions based on recommendations of the following joint review vis-its and do away with some of the observations made by concerned stakeholders prior to 2007 on issues of quality of service delivery. Further piloting was done in Dadeldhura and Salyan districts in 2008, and from 2009 onwards the NGO support system was scaled up in all programme districts.

It was considerably discussed at the outset whether the NGO support was to fill into specific human re-source gap at the government health facilities provi-sioning limited number of junior level health staff with some technical background or function as a short-term entity only for health and nutrition education/counseling. Joint reviews time and again recommend-ed that the existing gaps of human resource including social mobilization support would be the key in overall sustainability of the support system. As a result of this field level exercise, the support strategy was packaged in such a way that the NGO would have to help im-prove not only technical aspects of ANC, PNC, growth

monitoring, counseling and logistical components, but also social mobilization targeting utilization of lo-cally available resources; be it in the form of increasing funding from local government line agencies, collabo-ration, human resource or user contribution.

Ongoing support to the government health facilities has considerably helped improve quality of maternal and child health service delivery, logistic management and advocacy of food utilization. Monthly monitoring reports from July 2011 to January 2012 during the last six months have shown a significant progress on key output indicators; 94.85% progress on the number of children aged 6 to 36 months growth monitored, 95.40% progress achieved on ANC, 95.15% progress achieved on PNC, and underweight prevalence rate standing at only 4.12%, a huge step forward compared to the last year’s underweight prevalence rate at 9.9%. Even if queries may be raised on meeting minimal an-thropometric measurement parameters, overall pro-gress has been seen beyond expectations.

Support in financial terms is very minimal. One super-visor covers an area ranging from one VDC to two to three VDCs in the given district. With a focus more on sustainability of the MCHC at health facility level, the HHESS has been able to show some tangible results in line with mobilizing locally available resources in col-laboration with the government line agencies in the Far West as per the table shown below;


Annex viii: Contributions made at local level

Districts VDCs Contributions made from VDCs (NRS)

Purpose of contribution Remarks

Dadeldhura Gangkhet 200,000.00 ORC set-up in Hartola for wards 8 & 9

Birthing center established and an ANM hired.

Shirsha 140,000.00 Hiring of an ANM Birthing center established. Belapur VDC 400,000.00 (through

GIZ)Drinking water, hiring of 3 ANMs, ORC set-up

Through lobbying by HHESS and MCHC committee

Chipur Budget not specified yet

An additional ANM hired for MCHC

VDC secretary has commit-ted to propose a separate budget.

Jogbudha Budget not specified yet

2 ANMs being hired for SHP and ORC both.

VDC and PAF to support for two-room house for health initiated by HHESS.

Achham Kuntibandali Budget not specified yet

An ANM hired for MCHC Counseling session linked 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 post building

Ongoing two-year long lob-bying with the VDC and DHO on the need for improv-ing poor infrastructure by HHESS

Bajhang Kafalseri 36,000.00 Management of snacks during monthly clinics

Birthing center established at the initiative of com-mittee, HFoMC and HHESS together

Daulichaur 130,000.00 For construction of an ORC set-up

At the initiative of HHESS with VDC secretary

Dahabagar 250,000.00 For construction of sub-health post building

Through joint efforts of HFoMC and HHESS

Sunikot 150.000.00 Hiring of an ANM and management of snacks during monthly clinics

Birthing center established at the initiative of HHESS

Syandi 241,000.00 For construction of sub-health post building

HHESS has started sale of empty Super Cereal bags to raise budget for snacks dur-ing monthly clinics.

Deulekh 60,000.00 Hiring of an ANMDoti Simchaur Budget not specified

yetAn ANM hired and solar panel set up in addition to improved birthing center

HHESS played a key role for this arrangement over the past 2 years.


Chamarachau-tara

Budget not specified yet

An ANM hired and solar panel set up in addition to improved birthing center

HHESS played a key role for this arrangement over the past 2 years.

Daud Budget not specified yet

For management of snacks during monthly clinics in addition to an ANM for MCHC

Birthing center established through lobbying with VDC secretary by HFoMC and HHESS.

Bajura Chhatara Budget not specified yet

2 ANMs hired for MCHC in addition to birthing center and sub-health post building construc-tion

Lobbying with VDC secretary and local youth clubs still continuing through HHESS for MCHC

Budget not specified yet

1 ANM hired for MCHC in addition to birthing center and sub-health post building construc-tion

Lobbying with VDC secretary and local youth clubs still continuing through HHESS for MCHC

Baitadi Bhumiraj Budget being pro-posed

For ORC set-up in ward-7

Lobbying / advocacy going on for MCHC in order for locals to take ownership

Sakar Budget not specified yet

Hiring of an AHW and 1 MCHW for MCHC

Lobbying / advocacy going on for MCHC in order for locals to take ownership


Annex ix: MCHC Review Dissemination MeetingMCHC Review Dissemination MeetingNHICC Conference Hall, DoHS, Teku, Kathmandu10 February 2012

Note for RecordDissemination meeting on the MCHC programme review report was jointly organized by the WFP and CHD at the NHICC conference room, Teku, Kathmandu on 10 February 2012. Main objective of the dis-semination was to share key findings, major achieve-

ments, constraints and suggested measures for future directions.

A total of 28 participants representing the key NuTEC members attended the meeting on 10 February 2012 at the NHICC hall from 09:00 to 11:15 am at the invi-tation of the CHD earlier through formal correspond-ence. Following is the list of participants for further reference;

SN Names Designation Organization Email/contact1 Dr. Shyam Raj Upreti Director CHD/DoHS [email protected] Mr. Robin Houston Deputy Director NFHP [email protected]

3 Dr. Madhu Dixit Devkota Professor IOM [email protected] Natasha Mesko Maternal Health &

Nutrition AdvisorDFID [email protected]

5 Dr. Shilu Aryal Senior Obstetrician/Gynecologist

FHD [email protected]

6 Mr. Jibachh Mishra Director FFEP/MoE [email protected] Dr. Lhamo Sherpa ED HHESS [email protected] Mr. Ngima T. Sherpa Chairperson HHESS [email protected] Dr. Jaganath Sharma Coordinator NFHP II [email protected] Ms. Bhim Kumari Pun Programme Manager SC [email protected] Ms. Neera Sharma Sr. PC Nutrition SC Neera.sharma@savethechildren.

org12 Mr. Devendra Adhikari M & E Manger HKI [email protected] Mr. Anirudra Sharma Nutrition Specialist UNICEF [email protected] Mr. Madhukar Bdr

ShresthaSenior Programme Manager

HKI [email protected]

15 Ms. Nicole Menage Country Representa-tive

WFP [email protected]

16 Mr. Nicolas Oberlin Deputy Country Direc-tor

WFP [email protected]

17 Ms. Pramila Ghimire CP Coordinator WFP [email protected] Ms. Sophiya Upreti Programme Officer WFP [email protected] Ms. Shreejana Rana Vice Chair SCWEC [email protected] Ms. Pramila Acharya Rijal Chairperson SCWEC [email protected] Ms. Swastika Sirohiya SCWEC [email protected] Mr. Raj K. Pokharel Chief CHD/DoHS [email protected] Mr. Shankar P. Acharya Public Health Officer CHD/DoHS [email protected] Prof. Ramesh Kant Adhikari MCHC Review Team

[email protected]


Proceedings- Dr. Shayam Raj Upreti, Director, CHD chaired the

meeting. - Mr. Raj Kumar Pokharel, Chief, Nutrition Section

facilitated overall sessions. - Prof. Ramesh Kant Adhikari presented the report

on MCHC review. - Ms. Nicole Menage, Country Representative, WFP

shed closing overall remarks followed by Dr. Upreti closing overall meeting at the end.

Queries from the participants during plenary discussion- Baselines, mid-term follow-up and end line evalua-

tion. - Targeting strategy based on multiple indicators,

particularly food security and nutrition. - Sustainability to be high on the agenda, a top prior-

ity. - Alignment of food distribution with 4 ANC visits. - Strengthening linkages with the Family Health Divi-

sion (FHD). - Need for extra human resources and filling in the

existing gaps. - Food supplement to be a part of the health deliv-

ery system. - Programme implementation modality for supple-

mentary feeding programme in Karnali and be-yond, and ongoing MCHC activities.

- Workload for health workers, FCHVs and HFMCs/MCHC committees.

- Cost implications for the government and overall capacity of the government.

Response to queries from Prof. Adhikari and MCHC & Nutrition Team from the WFP, and concluding remarks from Nicole Menage, Country Representative, WFP Nepal and Dr. Shyam R. Upreti, Director, CHD, Teku

- There had been baselines and follow-up evalua-tions of the MCHC until 2006-2007. Results were then positive. This has been a top priority in the upcoming WFP CP period from 2013 to 2017.

25 Mr. Sumit Karn Programme Coordina-tor

CHD/DoHS [email protected]

26 Mr. Lila Bikram Thapa Senior PHO CHD/DoHS [email protected] Dr. Kedar Prasad Baral Professor PAHS28 Mr. Amrit Bdr Gurung SPA WFP [email protected]

- There will be more targeted approach in place for the next phase considering food insecurity and nu-trition indicators. Other social and political realities will also be considered while building up the over-all targeting strategy.

- Sustainability is being addressed by including more synergistic efforts in the 2013 – 2017 CP with more life cycle approach for food insecure areas. Sustainability is to be understood in terms of be-ing a part of fulfilling key requirements of health and nutrition related services by the government health workers involving local stakeholders by the local people themselves under the MCHC. How-ever, Nicole Menage, WFP Country Representative expressed her hope that the different aspects that play a crucial role sustainable livelihood through life-cycle approach will be the key in such highly food insecure areas.

- Work burden or extra human resource issue is be-ing dealt with by the locals, health workers and user committees themselves without much ex-ternal assistance, an example of which is ongoing contributions from VDCs and local user groups in hiring health workers, establishing ORC set-ups and improving infrastructure at the health facilities / ORCs within the programme VDCs.

- Need to explore the mechanism and evidence on how food supplement can be a part of national health delivery system.

- Costs become higher while providing support in the remote, food insecure areas in Nepal. MoHP’s ongoing supplementary feeding programme for children under-2 in Karnali and beyond indicates a priority being given to the supplementary feeding, and the government and WFP can further collabo-rate in joining hands in areas of logistics and tech-nical expertise and sharing of lessons learnt.

- Further discussion will be made at the next Pro-gramme Coordination Committee (PCC) meeting considering alignment with the 4 ANC visits.

- Prof. Adhikari stressed the need for further link-ages with the FHD considering maternal health and nutrition. In response to a specific question


- In closing, Dr. Upreti recognized the role of food supplement in improving the utilization of ANC, PNC and GM services by the PLM living in the pro-gramme VDCs, however, expected to see more valid data to demonstrate effectiveness of pro-gramme on other outcome indicators (prevalence of anemia, LBW, underweight etc). He suggested that the recommendations from the review that future implementation of the programme be car-ried out in such a way that the outcome indicators are collected in a rigorous way to demonstrate the impact. He also announced that MCHC activities will be included in the national multi sectoral nu-trition plan in such a way that its implementation would help generate more valid evidence.

about the role of food supplementation during pregnancy and lactation, Prof. Adhikari empha-sized the role of food particularly for pregnant and lactating mothers in food deficit households. He also stressed that every VDCs have three types of families: first: families with food sufficiency don’t need food supplement but still need nutrition education, second: those families which may need food supplement during lean seasons occasionally but will need nutrition education all the time and third: families which are chronically food deficient and would benefit from food supplementation along with nutrition education. The programmatic challenges lie in identifying the different categories of families and provide the services as needed.


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)

Annex x: References


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

WFP CouNTRy oFFICEChakupat, Patan Dhoka, LalitpurP.O. Box 107, Kathmandu, NepalTel: 977-1-5260607Fax: 977-1-5260201

Contact Information

WFP SUB-OFFICEAdarsha Nagar, NepalgunjP.O. Box 3, Banke, NepalTel: 977-81-525132Fax: 977-81-525133

WFP SUB-OFFICEKirtipur, DadeldhuraAmargadhi, NepalTel: 977-96-420469Fax: 977-96-420398

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