Drivers of stunting reduction in Nepal: a country case study

BACKGROUND: Chronic child malnutrition represents a serious global health concern. Over the last several decades, Nepal has seen a significant decline in linear growth stunting – a physical manifestation of chronic malnutrition – despite only modest economic growth and significant political instability. OBJECTIVE: This study aimed to conduct an in-depth assessment of the determinants of stunting reduction in Nepal from 1996 to 2016, with specific attention paid to national-, community-, household-, and individual-level factors, as well as relevant nutrition-specific and -sensitive initiatives rolled out within the country. METHODS: Using a mixed-methods approach, 4 types of inquiry were employed: 1) a systematic review of published peer-reviewed and gray literature; 2) retrospective quantitative data analyses using Demographic and Health Surveys from 1996 to 2016; 3) a review of key nutrition-specific and -sensitive policies and programs; and 4) retrospective qualitative data collection and analyses. RESULTS: Mean height-for-age z-scores (HAZ) improved by 0.94 SDs from 1996 to 2016. Subnational variation and socioeconomic inequalities in stunting outcomes persisted, with the latter widening over time. Decomposition analysis for children aged under 5 y explained 90.9% of the predicted change in HAZ, with key factors including parental education (24.7%), maternal nutrition (19.3%), reduced open defecation (12.3%), maternal and newborn health care (11.5%), and economic improvement (9.0%). Key initiatives focused on decentralizing the health system and mobilizing community health workers to increase accessibility; long-standing nationwide provision of basic health interventions; targeted efforts to improve maternal and child health; and the prioritization of nutrition-sensitive initiatives by both government and donors. National and community stakeholders and mothers at village level highlighted a mixture of poverty reduction, access to health services, improved education, and increased access to water, sanitation, and hygiene as drivers of stunting reduction. CONCLUSIONS: Improvements in both nutrition-specific and nutrition-sensitive sectors have been critical to Nepal's stunting decline, particularly in the areas of poverty reduction, health, education, and sanitation.