When 20-month-old Madan Sunwar was brought into the Achham District Hospital in the remote west of Nepal, he was severely malnourished and critically ill. He weighed just 4.5 kg and he was suffering from severe pneumonia. His mid-upper arm circumference was less than 11.5 cm, the same as an infant.
Dr Sharad Chandra Baral, a doctor at the hospital was the first to treat Madan when he arrived at the clinic. The young child looked months younger than his age, his limbs were wasted and his skin hung loosely from his body. “He was brought to us by his mother with severe pneumonia,” Dr Baral says. “We performed a physical exam and he was found to be severely malnourished.”
Madan travelled to the hospital with his mother from a remote village in the Achham district after a community health volunteer told her Madan was in desperate need of medical care. “We expect a child at that age to be 10-11kg,” said Dr Baral. “He was just 4.5kg. He was suffering from severe acute malnutrition with medical complications of severe pneumonia.” Unfortunately, Madan’s situation is not unusual. For children, illnesses like pneumonia are frequently linked with severe malnutrition.
Achham is one of the remotest districts in Nepal and also one of the poorest. It’s one of the six districts initially targeted for the implementation of the Multi-Sector Nutrition Plan by the Government of Nepal. As such, it received support from the EU-UNICEF Maternal and Young Child Nutrition Security Initiative in ASIA (MYCNSIA).
Dr Baral says the programme has given his team the ability to save the lives of severely malnourished children like Madan. He says that they see, on average, two severe cases every month. “We often meet such children in our district,” he continues. “With the help of the MYCNSIA programme, we are beginning to overcome such cases and we are able to handle such cases in one of the most remote districts of Nepal.”
Madan was treated at the hospital for more than two months. The young boy was initially treated with antibiotics and enriched milk formula and then with ready to use therapeutic food (RUTF). “With time he gradually improved,” Dr Baral says. “He was two months in our hospital. In that period, he gained 3kg.”
The EU-UNICEF project worked alongside the Government of Nepal on a raft of policy initiatives and district level initiatives aimed at reducing stunting and malnutrition in children. Anaemia and malnutrition in women were also targeted. All health workers from the MYCNSIA districts are now trained in the management of malnutrition, advising mothers on the introduction of food after the age of six months and the administering of micronutrient powders to children at risk of malnutrition.
Dr Krishna Paudel, Director of Child Health at the Ministry of Health and Population in Nepal, says this outcome in the targeted districts was made possible by a multi-sectoral approach that started at the local level. “We had a strong system in the villages backed by the female community health workers”, he explains. It was managed “through behaviour change communication, nutrition education, respecting the value of the local foods, appropriate supplementary feeding and timely identification and treatment of malnourished kids.”
In the targeted districts, stunting in children was reduced. “Stunting is a major challenge for us,” Dr Paudel continues. At the beginning, “41 per cent of kids under 5 were stunted [DHS 2011] but the survey last year [MICS 2014] was 37 per cent. We are not satisfied. We want to bring it to less than 30. We are working on it.”
But treatment at a local level is not enough. The MYCNSIA initiative aimed to provide assistance with multi-sectoral, government level programmes to manage nutrition and position nutrition at the heart of policy making. It was an initiative embraced by the Government of Nepal. “Nepal was the first country to have a multi-sectoral nutrition plan that was fully implemented in 2012 and it was formulated in 2012, one year after MYCNSIA came up,” Dr Paudel says.
There is still much work to be done. Nepal still faces many challenges to reduce malnutrition: 37 per cent of children are stunted, 18.6 per cent of mothers are undernourished, 24 per cent of babies are born with low birth weight and only 23 per cent of children aged 6-23 months have a diet considered nutritionally acceptable.
The MYCNSIA project in Nepal started with six districts but a further 10 additional districts are being added in 2015-2016. In addition 14 districts affected by the massive earthquake in April 2015 were able to benefit from the programme. An emergency nutrition response was able to reach these districts far more effectively due to the policy framework put in place by the ongoing MYCNSIA project.
Ambassador Jesus Miguel Sanz, head of the EU delegation to Thailand and Laos, says that the five-country MYCNSIA project has produced lots of learning for the region. “We have learned a lot about the region and challenges we face ahead,” he says. “We are quite proud of the outcome of this project but we need to realise that the situation is quite worrying in Southeast Asia and much more needs to be done.”
In Achham district in Nepal, there is one very happy outcome. Madan, the young boy who was brought to the clinic suffering from severe malnutrition and other related problems, was discharged two months after arriving at the district hospital. Health workers visited him at home for eight weeks following discharge. “He was so happy,” says Dr Baral. “We were so happy to see a smile on his face.”
The authors
By Anneliese Mcauliffe and Charlotte Pries Scheibel
