Investing in Nutrition

To Reduce Poverty

Nepal Quarterly Newsletter, April-June 2015


Excerpts from USAID/Nepal Mission Director Beth Dunford’s remarks at a panel discussion on “Programming to End Extreme Poverty: Evidence and Experience to Guide the Way Forward” at USAID’s Extreme Poverty Summit, Washington DC in May 2015.

The most commonly accepted measure of extreme poverty is monetary – namely minimal daily individual consumption after adjustment for purchasing power. But we know that poverty is more complicated than that, and as is recognized in the Agency’s definition of extreme poverty, it often entails hunger and malnutrition as well.



  • Poor nutrition during a child’s first 1,000 days can have a lifelong impact, resulting in 20 percent lower lifetime earnings and the unexpected costs of care, which divert savings from productive investments.
  • Under nutrition reduces a nation’s economic advancement by at least eight percent because of losses in direct productivity, poorer cognition, and via reduced schooling.

Given the direct impact of malnutrition on earnings, nutrition needs to be a critical component of any poverty reduction effort. The Agency has recognized the multi-dimensional aspect of poverty, and nutrition is one of the dimensions. But the importance of nutrition when addressing poverty is often overlooked. And malnutrition is a difficult problem to tackle.

Nepal has achieved one of the world’s fastest declines in the prevalence of stunting. In 2001, 57 percent of Nepali children were stunted – the fourth highest rate in the world. By 2011, this was reduced to 41 percent. But this still means that we have over 1/3 of the population in Nepal that is stunted. That means that 1/3 of the population is less productive, less able to reach their full potential, and less able to pull themselves out of poverty. If we are going to contribute to the goal of ending extreme poverty, we will need everyone to be able to achieve their full potential. And thus combatting malnutrition is a big focus for us at USAID/Nepal.

What we have done is take the recommendations from the 2013 groundbreaking Lancet series on nutrition and translate all of the recommended actions – every single one – into one comprehensive, integrated program to improve the health and nutrition status of pregnant and lactating women and children under two years of age – the so-called 1,000-day households – to address the vulnerable points of development which result in stunting.

This program, called Suaahara or “good nutrition”, is implemented by Save the Children, in conjunction with the Government of Nepal, Helen Keller International, and other partners. It is unique in that it applies the latest evidence-based interventions in health; nutrition; family planning; water, sanitation and hygiene (WASH); backyard poultry; and homestead food production at scale in over half of the districts in Nepal.

So, for example, the same families that receive nutritional counseling and support also plant small, diversified gardens; learn about the importance of skilled birth attendance; access animal-source protein through chicken breeding; raise incomes through livestock rearing and homestead gardens; build latrines; learn how to wash hands well and dispose of solid waste; and benefit from messages on the healthy timing and spacing of pregnancies. And this integrated approach is working.

But as we look at malnutrition, we have to also focus on social exclusion. Nepal’s “layers of exclusion” are deeply entrenched and are primary determinants of a household’s level of wealth and nutritional status. In Nepal, traditionally excluded groups include Dalits, who were historically considered an “untouchable” caste, as well as Muslims and Janajatis, or indigenous groups.

While 25% of all Nepalis live below the poverty line of $1.25/day, this figure is much higher for disadvantaged groups, particularly Dalits. In the hills, 44% of Dalits live below the poverty line. Disadvantaged groups are also more likely to be among the extreme poor; for example, the poverty gap--or average distance below the poverty line--for poor Dalits is more than six times higher than the gap for poor Brahmins (high-caste groups). The rate of stunting among the disadvantaged group population is often as high as 60 percent.

Thus, if we want to address malnutrition as a key factor in the elimination of extreme poverty, we need to ensure that we are reaching socially excluded groups. However, targeting these groups is not easy, as they are often the poorest of the poor and have historically suffered discrimination through the caste system or are cut off from access to basic services due to social exclusion or to their geographic remoteness. The discrimination they face means that development interventions don’t often reach them.

To ensure that all 1,000-days households are reached by the Suaahara program, including the disadvantaged households, the program has fully mapped all 1,000 day households in targeted districts. Once identified, Suaahara uses multiple entry points to bring about behavior change among these households, including:

  • Female Community Health Volunteers, mother’s groups and local community structures.
  • It’s Bhanchhin Aama radio serial and call-in programs. Discussions on the Bhanchhin Aama radio program are facilitated at Citizen Awareness Centers, which are specifically established in disadvantaged communities.
  • Suaahara field staff are equipped with smartphones in order to track coverage of disadvantaged households and conduct annual surveys to monitor the degree to which it has reached these households with interventions.

And this deliberate outreach to disadvantaged groups is working. Data from 2013 and 2014 show that the gap in dietary diversity narrowed. In 2013, 38 percent of Dalit children ate a minimum acceptable diet compared to 52 percent of non-Dalits.

In 2014, that gap had narrowed to two percent, with 52 percent of Dalits eating a minimal acceptable diet compared to 54 percent of non-Dalits. And if we look at data since the beginning of the program three years ago, we have seen an overall increase in those eating a minimum acceptable diet of over 18 percent. These data show that we are on track to see significant reduction in stunting in next year’s Demographic Health Survey.

Thus, we are seeing that the two-pronged approach of Suaahara is paying off. It integrates all recommended efforts of the Lancet series into one program and focuses on including disadvantaged groups.

But listen to this. In addition to having a dramatic impact on malnutrition, we have found that incomes have gone up as well! In 2014 -15, the sale of excess vegetables and poultry provided by Suaahara have helped Dalit families earn an additional average of $3,500/year in Suaahara focus districts. This is in addition to their existing income. Data also suggest that beneficiaries are building assets – acquiring insurance, investing in livestock, diversifying crops – that will multiply their wealth and provide security and resilience to shocks and stresses that could push families back into extreme poverty.

The cumulative effect of these interventions through everyday improvements is what can propel extreme poverty reduction at scale, sustainably, over the long run.



And this week, as Nepal and its people marked the first month since the April 25 earthquake that killed almost 9,000 Nepalis and destroyed or damaged over 760,000 homes, our work takes on a new sense of urgency and purpose. As we know, natural disasters of this scale and magnitude have a greater impact on the most vulnerable, typically pushing more people into poverty or deeper into poverty.

The Suaahara program is operating in much of the zone impacted by the earthquake, and used their established networks to immediately deliver emergency assistance to people in need. And as the much larger emergency response has stood up, these established networks that Suaahara has created to reach all 1,000-day mothers and families have worked well. They are proving to be important for all types of assistance delivery, to ensure that disadvantaged groups that are often bypassed by public and community networks also receive urgently needed assistance.

And although it is too soon to tell, our field visits have shown us that the 1,000-day mothers and families supported by the Suaahara program are proving to be more resilient and are starting the long road to recovery.

Issuing Country 
Tuesday, August 18, 2015 - 6:45am