Nepali Times

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Shambhu's father Dev Narayan Ram and mother Shanti Devi Ram sold land and spent all their savings to treat their son.

When Shambhu Kumar Ram died in November last year aged 17, he looked as emaciated as a drought victim (pictured, far right). While severe malnutrition appears to have been the immediate cause of death, there were underlying factors. The boy’s parents say they knew only that he appeared malnourished, and kept losing weight until he died at home.

How could his family, which had accessed the health system numerous times in the years before Shambhu died, know so little about what killed their son? Their experience illustrates some of the ways that the health system in Nepal can fail.

Sitting on a wooden bench outside of their bamboo and mud hut in the Dalit village of Danda, his parents describe a fruitless years-long quest to uncover the reason their healthy baby showed signs of malnutrition as a toddler and never seemed to recover. When he was four he spent a month at the Sagarmatha Zonal Hospital but there was no diagnosis.

Shambhu was healthy enough to go to a local school until he was 12, when he started to lose more weight. “I knew he wasn’t going to survive so I did my duty and took him to Biratnagar,” says his mother Shanti Devi Ram. But after 10 days they ran out of money and returned, no wiser about the cause of their son’s weight loss.

Dhruba Mandal

WASTED AWAY: Shambhu Kumar Ram looked as emaciated as a drought victim when he died last year.

During this period the family sold nearly half of its land to finance treatment. They borrowed from neighbours, to whom they still owe Rs 45,000. A month later, they travelled to Bir Hospital in Kathmandu but after 15 days they ran out of money again and returned home.

“I had to beg to feed my child in Kathmandu, but no one helped us,” says his mother. Shambhu remained at home till he died. The death made headlines in the media, with most indicating it was a death from starvation.

But here in Rajbiraj there is a different story. Shambhu being found on the streets of Saptari’s district capital by a nurse in July 2014 and taken to the Nutrition Rehabilitation Home (NRH), which is usually reserved for under-5 children with severe acute malnutrition. The boy was 13, says NRH Project Manager Rashmi Jha, and within days he had left, though doctors wanted to keep him for treatment.

“He didn’t like the food here so the family took him home,” District Public Health Officer Nagendra Chaudhary told Nepali Times. “The cause of death might be carelessness of family members, the doctor wanted to keep him in the hospital.”

Chaudhary says Shambhu had TB, was diabetic and might also have had HIV or AIDS. Back in their village, Shambhu’s mother says she knew nothing about their son having TB or other illnesses: “No doctor ever told me that.”

Both parents say they did not get any support from the local health post, and the Female Community Health Volunteer never came to visit. Chaudhary says the local mothers’ group led by FCHVs has meetings every month, and the system is working in every ward of every village.

He admits some poor families still do not know how to access the health system, but says the network is much stronger these days.

Stunted and wasted

Wasting affected 11.3% of Nepali children under five, according to the Nepal Multiple Indicator Cluster Survey three years ago. More than one-third (37.4%) had moderate malnutrition, or stunting (low height for age). Another survey in Saptari found that 15% of children showed signs of wasting.

Nepal’s malnutrition rate is among the world’s highest, with more than half of preventable under-5 deaths each year attributed to insufficent food. But the country took remarkable strides in reducing stunting during and immediately after the conflict, the figure coming down from 57% in 2001 to 37.4% in 2014. Nutrition Rehabilitation Homes (NRH) and a program called Community/Integrated Management of Acute Malnutrition (CMAM) contributed.

But nearing its halfway point, Multi-sectoral Nutrition Plan (MSNP), the blueprint for Nepal’s fight against malnutrition is being reviewed. Experts agree it hasn’t delivered as promised. Inspired by the global Scaling Up Nutrition (SUN) movement, the plan takes a multi-pronged approach to tackling malnutrition. Seven ministries are included in the MSNP which is coordinated by the National Planning Commission. It has been scaled up to 28 districts but is supposed to be effective in all 75 districts by year’s end also addressing acute malnutrition, or wasting (low weight for age).

A 2014 review of CMAM found that in the preceding four years 21,782 cases of severely malnourished children had been treated, and 86.5% of them cured. Of the 795 children treated at the NRH in Rajbiraj only two had died.

Yet, CMAM has only reached 32 of the 35 districts, and NRHs are operating in 18 instead of 35 planned districts. Nepal will probably not meet the MSNP target to cut wasting to below 5% by 2017.

“MSNP hasn’t been implemented as expected,” admits Raj Kumar Pokharel, Chief of the Nutrition Section in the Department of Health. “It should be reaching the household level but other sectors are not taking it seriously … there is no culture of coordination.” At UNICEF, the head of nutrition Stanley Chitekwe agrees. “The architecture is there, but the implementation has issues. We need to ensure that each ministry makes malnutrition a core part of its business. We’ve realised that this hasn’t happened enough.”

Nutritionist Aruna Uprety was named to one of two committees created by the National Planning Commission to address the problem, but says: “The plans have failed, implementation doesn’t exist. The problem is that programs are created without knowing the reality on the ground.”

Asked why stunting rates have declined but wasting rates persist, Chitekwe points to “inequities in the way that malnutrition manifests itself” including the effects of geography, wealth, ethnicity and caste.

Pokharel says it is difficult to address these factors using a health approach only, good governance is also essential. The Rs120,000,000 earmarked to reduce malnutrition in Saptari was recently returned unspent to the treasury.

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