Nepal

Key Messages

• Though Nepal’s Global Hunger Index score has improved in the past two decades, its 2020 score is 19.5, considered moderate. The current score reflects significant progress on reducing undernourishment, a declining—though still high—rate of child stunting, modest improvement in child wasting, and a substantial decline in child mortality.

• Poverty has fallen over time but remains a challenge, together with social and income inequalities.

• Interventions to improve children’s health have done a great deal to reduce child mortality and raise children’s nutritional status. In particular, Nepal has carried out a highly successful program of vitamin A supplementation.

• Most Nepalis are employed in agriculture, but small landholdings and low productivity keep many farmers at subsistence levels. Although some agricultural interventions have helped improve Nepalis’ food security and nutrition, more support and resources for farmers are needed.

• Nepal’s efforts to combat hunger would benefit from social sector investments that aim to improve the diets of young children, eliminate child marriage, promote gender equality, empower marginalized and excluded groups, establish a high-quality comprehensive health care system, and provide better-quality education for all.

Country Context

Nepal is an ethnically diverse South Asian country with a population of 28 million people experiencing multiple demographic changes.

Situated between China and India, Nepal has three major geographic regions: the mountains, hills, and Terai (plains). According to the latest national census conducted in 2011, Nepal has over 125 ethnic/caste groups, and each of its seven provinces is home to a unique combination of groups. Fertility and mortality rates have both decreased rapidly in recent decades, and life expectancy is increasing. The share of the population in the mountain and hill regions of the country is declining, while the proportion of the population in the Terai is increasing (UNFPA Nepal 2017). Though Nepal is predominantly rural, it is undergoing rapid urbanization. Migration, both within Nepal and internationally, plays an important role in the lives of Nepalis, contributing to urbanization, poverty reduction, and improved economic well-being (Brøgger and Agergaard 2019; Wagle and Devkota 2018). Remittances constituted 29 percent of GDP in 2018 (World Bank 2020a).

Nepal is experiencing a period of relative political stability and restructuring of political institutions after facing major upheaval in the recent past. The country was ruled by a king under what is known as the Panchayat system from 1960 until 1990, when, in response to large-scale protests, it transitioned to a constitutional monarchy (Nightingale et al. 2018). The early years of the new government were unstable. From 1996 through 2006, the country experienced a civil war characterized by a Maoist insurgency (Do and Iyer 2010). In the aftermath of the civil war, the country transitioned to a democratic regime and attempted to formulate a new constitution while still experiencing considerable civil strife. In 2015 a massive earthquake struck the country, killing approximately 9,000 people, injuring 23,000, and causing nearly US$7 billion in economic damage, equivalent to roughly one-third of Nepal’s GDP (Nightingale et al. 2018; Gauchan et al. 2017). The constitution, finalized later that same year, guarantees 31 fundamental rights to the Nepalese people. Since the passage of the constitution, Nepal has been solidifying its government structures and institutions, although political tensions still run high (World Bank 2019c; Strasheim 2019). Among the government’s key tasks are decentralization and the establishment of a federal system.

Poverty and inequality are major challenges for Nepal, although the situation has improved over time. GDP per capita was just $1,034 in current US dollars as of 2018, the third-lowest level in Asia (World Bank 2020a). As of 2019, 39 percent of the population lived in poverty at or below $3.20 per person per day, while 8 percent of Nepal’s population was estimated to live in extreme poverty at or below $1.90 per person per day, down from 50 percent living in extreme poverty in 2003 (World Bank 2020a, c). This reduction can largely be attributed to the increase in international migration, which has driven up wages for the remaining working population in Nepal; the dramatic increase in remittances sent to the country since the late 1990s; and decreases in the fertility rate and average household size (World Bank 2016b). The more holistic Multidimensional Poverty Index (MPI) likewise shows a decline, from 59.4 percent in 2006 to 28.6 percent in 2014 (GoN and OPHI 2018). The lowest multidimensional poverty rates are in Bagmati Pradesh and Gandaki Pradesh, while the highest rates are in Province 2 and Karnali Pradesh (GoN and OPHI 2018). There is inequality in employment opportunities and wages along multiple lines, including geography, ethnicity, caste, and gender (Mainali, Jafarey, and Montes-Rojas 2017; Yamamoto et al. 2019).

Agriculture is crucial to the economy, but farmers suffer from small landholdings and low productivity. Seventy percent of employment is in agriculture, while 13 percent is in industry and 17 percent is in services. Twenty-five percent of GDP comes from agriculture, 13 percent from industry, and 51 percent from services (World Bank 2020a). Nepal’s farmers grow mainly rice, maize, wheat, millet, barley, pulses, oilseeds, and sugarcane (CCAFS 2020). Overall productivity of rice and cereals has increased in recent decades, yet yields in Nepal continue to lag behind the average in South Asia, including in neighboring India (FAO 2020d). The provision of agricultural extension and advisory services in the country is limited, and the effectiveness of extension agents is often hampered by inadequate motivation and limited locality-specific knowledge and skills (Kyle and Resnick 2019). Mechanization of farming has increased over time, particularly in terms of tractor use, which is associated with increased yields of staple crops. However, these improvements have occurred mainly in the Terai, the most agriculturally productive region, and the benefits for resource-poor smallholders have been minimal (Takeshima 2017). Just over half of Nepal’s agricultural land is irrigated, leaving a large proportion of farmers reliant on rainfed agriculture and particularly vulnerable to the effects of climate change (Pradhan and Belbase 2018). The average farm size is just 0.7 hectare, and over half of Nepali farm households have less than 0.5 hectare of land, which limits the possibilities for farming above subsistence levels (GoN 2015a).

Nepal is extremely vulnerable in the face of the COVID-19 pandemic. The country has limited resources with which to respond to the pandemic, given its tight budgetary position, its still-developing governmental structures, and its lack of a robust health care system, particularly in terms of critical resources such as ventilators, hospital isolation units, and personal protective equipment (Bhattarai 2020). While the situation is rapidly evolving, food and nutrition security is jeopardized by both the global health crisis and the economic fallout, including a decline in remittances and lower GDP growth (Budhathoki 2020).

Nepal’s 2020 Global Hunger Index score is 19.5, considered moderate, down from 37.4 in 2000, showing that despite improvements, food and nutrition insecurity is still cause for concern. The prevalence of undernourishment—the percentage of the population with insufficient access to calories on a regular basis—fell from 23.6 percent in 2000–2002 to 6.1 percent in 2017–2019 (Figure 3.4). Food access is more limited in the mountains than in the Terai. Micronutrient deficiencies, low dietary diversity, and a high reliance on staple foods are common, reflecting that 75 percent of Nepal’s cultivated land is occupied by cereal crops (GoN NPC 2018). At the same time, obesity and overweight are increasing as people’s diets shift toward processed foods with higher energy, fat, and sugar (Subedi, Marais, and Newslands 2017). The diets of Nepali children aged 6–23 months are largely suboptimal: just 36 percent receive a minimum acceptable diet (MoH, New Era, and ICF 2017). Challenges to achieving food and nutrition security include natural disasters such as flooding, landslides, and earthquakes; climate change; poverty; poor infrastructure, particularly in remote and mountainous areas; urbanization and outmigration, leading to the feminization of agriculture; and volatile food prices (GoN NPC 2018; Tamang, Paudel, and Shrestha 2014).

Nepal’s under-five mortality rate declined from 20.8 percent in 1980 and 8.1 percent in 2000 to 3.2 percent in 2018. Data from 2001–2016 suggest that child mortality in Nepal is associated with mothers who reported the previous death of a child, did not receive tetanus toxoid vaccines during pregnancy, did not use contraceptives, were younger than 20 years old, reported having a first birth, or did not use antenatal iron and folic acid supplements (Ghimire et al. 2019).

Nepal’s rate of child stunting, an indicator of chronic undernutrition, declined significantly from 57.1 percent in 2001 to 36.0 percent in 2016, which is still unacceptably high. Child malnutrition rates vary widely by region, with 46.8 percent of children stunted in the mountains compared with 36.7 percent in the Terai and 32.3 percent in the hills (MoH, New Era, and ICF 2017). In the mountains, poor access to nutrient-dense foods and low dietary diversity correspond with higher rates of child stunting (GoN NPC 2018). Women’s empowerment in agriculture - specifically their access to and decision making regarding credit, satisfaction with leisure time, and autonomy in production decisions - is also associated with greater children’s height for their age (Cunningham et al. 2015).

Nepal’s child wasting rate, indicating acute undernutrition, has declined modestly, from 11.3 percent in 2001 to 9.6 percent in 2016. The ecological zone with the highest wasting rate is the Terai, at 12.2 percent, compared with 6.1 percent in the mountains and 6.4 percent in the hills (MoH, New Era, and ICF 2017). The high wasting rate in the Terai may be related to poor sanitation and hygiene (GoN NPC 2018). Furthermore, the proportion of children aged 6–23 months receiving the minimum acceptable diet is lowest in the Terai, even though that is the country’s most agriculturally productive region. At the provincial level, Province 2 has the highest wasting rate, at 14.4 percent (Table 3.2). This province also faces related social issues, such as the earliest age of first marriage for women and the lowest education levels in the country (MoH, New Era, and ICF 2017). A study of child nutrition in the eastern Terai found that caste played an important role, with Dalit (the most marginalized ethnic/caste group) children facing higher rates of both stunting and wasting than non-Dalit children (Kafle et al. 2017).

Gender inequality and the challenges facing girls, including young motherhood, increase food and nutrition insecurity. Within households, foods and nutrients are allocated inequitably, with women, including pregnant women, at a clear disadvantage relative to men (Harris-Fry et al. 2018). Although child marriage was banned in Nepal in 1963, the practice is still all too common. This reality has important implications for nutrition, given that the children of young mothers are less likely to receive proper diets (Na et al. 2018).

Adequate health care services are critical for nutrition, but the current system is insufficient. While Nepal has effectively instituted disease-centric and issue-specific health care programs, it still lacks a high-quality comprehensive health care system (Sharma, Aryal, and Thapa 2018). More than half of Nepali women report having problems accessing health care because they cannot get money for treatment or because the health care facility is too far away. About two-thirds of women report a reluctance to go alone to a health facility or a lack of female health service providers (MoH, New Era, and ICF 2017).

Improved food security - including decreasing undernourishment - in South Asia over the past 25 years is due mainly to rising cereal production and yields, declining population growth rates, and greater government spending as a share of GDP. Nepal has seen an increase in cereal yields from about 1,900 kg/ha in 1990 to about 2,800 kg/ha in 2017 - a significant improvement - yet the level is still lower than the average for South Asia as a whole (Mughal and Fontan Sers 2020). An analysis of data from Nepal from 1995–1996 and 2003–2004 found that increased agricultural productivity did indeed lead to an increase in household food security, particularly for lower-income households (Morioka and Kondo 2017).

Increases in wealth and improvements in health and nutrition programs, sanitation, and education largely account for recent improvements in child and maternal nutrition. Nepal’s reduction in child stunting from 57 percent in 2001 to 41 percent in 2011 is associated with, and likely attributable to, increased household assets (a proxy for household wealth), increased maternal education, improved sanitation, and implementation and use of health and nutrition programs, including antenatal and neonatal care (UNICEF, WHO, and World Bank 2020a; Headey and Hoddinott 2015). A related study found that these same factors led to improvements in child height-for-age, child weight-for-height, and maternal body mass index (BMI). In particular, toilet use at the community level - which reduces open defecation - was found to be a predominant source of improvement in children’s weight-for-height and maternal BMI (Cunningham et al. 2017).

Nepal has achieved its impressive reduction in child mortality largely by implementing a wide range of child health interventions. In the 1980s and 1990s Nepal scaled up interventions related to child survival: recognition and treatment of acute respiratory infection, vitamin A supplementation, routine immunization, control of diarrheal diseases, malaria control, and family planning (BASICS II, The MOST Project, and USAID 2004). Between 1991 and 2011, the reduction in child mortality was due, in part, to the high coverage of semiannual vitamin A supplementation and deworming, community-based integrated management of childhood illness, high rates of full child immunization, and increased coverage of interventions to promote exclusive breastfeeding of children under six months of age. Additional factors include improvements in nutrition, education, and infrastructure, such as health care facilities, paved roads, mobile phone networks, and WASH services (MoHP et al. 2014).

Agricultural programs, including home and school gardening programs, have shown beneficial outcomes. An intervention that promoted the planting of improved varieties of maize in the Nepali hills increased the number of months of food security for participating farm families by 1.6 months relative to when they used unimproved, local varieties of maize (Tiwari et al. 2010). An enhanced homestead food production program that included home gardening, poultry raising, and nutrition education in Baitadi District, Sudurpashchim Pradesh, lowered anemia among children aged 12–48 months and their mothers, and reduced underweight among the women, although it did not improve child growth (Osei et al. 2017). A multisectoral intervention in Dolakha and Ramechhap Districts, Bagmati Pradesh, that included school gardening; water, sanitation, and hygiene components; and nutrition and health promotion activities increased children’s fruit and vegetable consumption, decreased intestinal parasitic infections, and improved hygiene behaviors (Shrestha et al. 2020).

Livestock promotion interventions can also boost children’s nutrition. Children in households that participated in a livestock training and community development intervention run by Heifer International in the Terai and the hills exhibited greater improvements in height-for-age and weight-for-age than children in control households (Miller et al. 2014). A follow-up intervention showed the greatest improvements in child growth and nutrition for households that received a combination of community development activities along with nutrition education and livestock training (Miller et al. 2020).