Integrated Nutrition Project (Suaahara- Building Strong and Smart Families)

Case Studies
Agriculture, Food Security, Nutrition
Save the Children, Helen Keller International, JHPIEGO, NTAG, NPCS, NEWAH, JHUCCP
South Asia
Resource Publication Date:
December, 2013
Content Format:

This is one of 50 Harvesting Nutrition project case studies. Harvesting Nutrition was a contest held in 2012 and 2013 that showcased active projects working to improve the impact of agriculture and/or food security on nutrition outcomes. Co-sponsors were SecureNutrition, Save the Children UK, and the Global Alliance for Improved Nutrition (GAIN). Learn More.

Project Description: ​​

The overall goal of Suaahara program is to improve and sustain the health and well-being of the Nepali people. Specific objective of the program is to improve the nutritional status of women and children less than two years of age. The program uniquely integrates nutrition, hygiene, agriculture, family planning, reproductive health and child health activities at household and community level in 20 rural districts with poor nutrition indicators. Suaahara focuses upon first 1000 days, directly addressing the vulnerable points of development which result in stunting. Suaahara will focus on improving health and nutrition behaviors at the household level through promotion of the ENA, particularly IYCF, and addressing other determinants of under-nutrition, such as availability of and access to food, quality of health care, child spacing, and socio-cultural factors including gender and marginalization. Suaahara will support the GoN to institute nutrition interventions and policies enabling achievement of goals in the National Nutrition Action Plan. Suaahara will assist the government to build capacity of health workers, as well as staff from the Departments of Agriculture, Local Governance, Education, and Water. This will create multi-sectoral collaboration and synergy to address the pervasive problem of under-nutrition.  

The project will employ the USAID-developed ENA as the foundation of the technical approach. Suaahara will incorporate Essential Hygiene Actions (EHA) into the project‘s ENA framework, along with promotion of child spacing and family planning and activities to discourage smoking among women. All components will be integrated creating the ENA Plus (ENA+) package. A behavior change (BC) strategy using multiple approaches will be developed after conducting rapid formative research around barriers and facilitating factors for BC among the target population. BC approaches will range from interpersonal communication (such as counseling by health workers), to mass media (e.g. radio). Suaahara will inventory existing curricula and materials in Nepal, making revisions as needed for ENA+.  

To improve access to nutritious food for a varied diet, Suaahara will implement HKI‘s HFP model in food insecure districts. This model promotes small-scale poultry production and home gardening to increase year-round HH-level availability of micronutrient-rich foods and animal foods. The on-going USAID-funded AAMA project has fully integrated HFP with ENA in two Far West districts. In other districts, Suaahara will introduce less-intensive efforts to increase local poultry production and raising micronutrient-rich vegetables in collaboration with the district agriculture staff. Suaahara will pilot a larger-scale poultry production as a social enterprise in some districts and will facilitate public-private partnerships to make fortified foods or supplements accessible.

Impact of project: ​

The primary determinants of under-nutrition in Nepal include care dimensions (poor feeding and care-related behaviors), health dimensions (including hygiene and sanitation; lack of potable water, and a high prevalence of infections that reduce food absorption and utilization); and food dimensions (inadequate food availability, access, affordability, quality, and nutrient density). With the project interventions at household level, awareness among beneficiaries has significantly increased in terms of above mentioned dimensions. The highlighting factor of the program is involvement of caretakers and decision makers in community level trainings which has resulted in behavior change among beneficiaries. Earlier to project interventions, mothers didn't care much upon hand-washing before feeding their babies. Baby feces was not disposed properly. If baby fell sick, first option was to see the baby to traditional healers. Families laid emphasis upon staple food production with negligible vegetable production and consumption. Food security meant stomach full food with no knowledge upon nutritional requirement. Nutritious foods such as milk, eggs and animal sources were sold in local markets. The most striking factor of the program is the knowledge upon babies' mental development that takes place within 1000 days period.  

Project intervention is slowly impacting change in health, care and food behaviors. Each of mothers wishes their babies to be healthy and smart. Organized beneficiaries now sit every month to discuss upon nutrition and share experiences. They proudly show homestead food gardens displaying nutrient dense vegetables and poultry coops. They now understand the importance of colors in food recipe such as orange fleshed, green, brown and white and practice food behaviors.

In the meantime, absence of strategy to addressing under nutrition among new 1000 days mothers is creating a sort of conflict in the community. However, the project envisions the regeneration strategy, it takes time for agriculture interventions to produce results and by then, 1000 days households/ beneficiaries cross the duration. It is too early to talk about impact but behavior change is being reflected among project beneficiaries which are an encouraging factor in itself. 

Why this project is a Good Practice example:

​In terms of food dimensions, improvements in agricultural productivity have not maintained pace with population growth, particularly among small landholders and female farmers, the latter constituting over 60% of the agricultural labor force. In rural areas, particularly in the more inaccessible hill and mountain regions, year-round HH food security is a critical obstacle to achieving optimum nutrition in young children and women. HHs are unable to produce a variety of adequate food or do not have resources to purchase high-nutrient foods from the local market. The most recent WFP surveillance data indicate that 10 out of 18 Suaahara districts surveyed were food insecure in 2009, including four of six mountain districts, two of six hill districts, and three of five Terai districts. IFPRI‘s 2008 Global Hunger Index Report categorized nine Suaahara hill districts as having a serious hunger problem, two hill, eight mountain, and five Terai districts as being alarming and one mountain district as extremely alarming. Fortified foods, which also can provide critical benefits to young children and women of reproductive age, are not yet available in remote areas where under-nutrition is greatest. The relationships between household (HH) food insecurity and under-nutrition are inconsistent and complicated by multiple determinants. A recent study in Kailali (Terai), found no significant association between HH food insecurity and stunting, underweight, or anemia among preschool children. Conversely, in Baitadi (hill), a significant association was found between HH food insecurity and stunting in children and anemia among mothers. However, this association was not seen with wasting, underweight, or anemia in children and BMI in mothers. This underscores the need to better understand, classify, and address the local determinants of under-nutrition that vary by such factors as geographic area, socio-economic groups, and by HH, as a critical step towards effective programming. In addition, the project will consider social and cultural dynamics of community and intra-HH food distribution and behaviors.

With project interventions catching up pace, mothers and children have increased access to locally produced nutrient dense vegetables and animal source foods. They now have knowledge of nutrition of locally available food materials as well.

Impact Evaluation:

Impact evaluation in progress

Lessons Learned: ​

Convergence of nutrition sensitive and specific interventions in district/VDC level planning: While Suaahara has facilitated good coordination among health and non-health sectors, nutrition has not been a priority for non-health sectors. Nutrition objectives have been diluted during absorption into maternal and child health, poverty reduction, and food security programming. As a result, continuous and creative advocacy, education and communication are required at the district and VDC-level to drive integration.  

Beneficiary Reach: During year two, Suaahara relied heavily on the use of established community-level groups in order to quickly establish a broad reach with program activities. While this has been very important during the introductory phase of program implementation, group interactions may not be sufficient in order bring about the desired behavior change required to achieve Suaahara objectives. Suaahara has already initiated increased interpersonal communication activities through home visits by Field Supervisors. These types of visits are particularly important for disadvantaged households and those that do not attend group meetings. In addition, Suaahara will explore the use of peer educators in year three.  Low levels of hand washing at critical times and disposal of child feces (from LQAS study findings): The initial results from the LQAS studies revealed low levels hand washing at critical times and disposal of child feces. More focus is needed on scaling up and improving the coverage of hygiene and sanitation promotion by integrating it more fully into other project activities. Suaahara will continue to monitor these key indicators through the annual LQAS studies.

Rolling out of PDQ and HTSP training: Following the approvals of the PDQ and HTSP training manuals, Suaahara rapidly initiated preparing master trainers (Government health workers) and arranging logistics for district-level trainings. However, the availability of the master trainers to conduct the trainings became an issue, resulting in progress for both of these activities being stalled. Suaahara is exploring alternative mechanisms, possibly through national NGOs, in order ensure trainer availability and rapidly roll out these activities.

Logistical challenges of chick distribution: Chicks logistics in the back yard poultry program has been a challenging task because it is a live commodity. A back up-contingency plan has been developed that includes rescheduling the distribution plan, additional production of chicks, counting mortality rate during brooding and transportation, brooding the chicks at district level (if necessary due to outbreaks of diseases), exploration and shifting parent stock hatcheries, outsourcing technical experts from regions/district for inspection during brooding/transportation, development of health certificates of flock from authentic source and exploration of potential vendor/supplier of chicks during emergency.

Monitoring of key HFP interventions: Intensive monitoring and supervision is needed for key HFP interventions like monitoring building chicken coops and fenced in areas around coops in each household, germination of seeds and growing status in each household garden. This type of monitoring is resource intensive, both in terms of financial cost and personnel time. Suaahara is considering using a participatory monitoring through 1,000 days mothers groups to make each chick and seed recipient household accountable for practicing improved HFP actions.

Window of opportunity for agriculture interventions: To achieve nutrition outcomes through agriculture interventions, the age bar is critical within each child’s1,000 days window. Seed and chicks support to the household having a 22-month old child will not be able to address the window of opportunity, because agriculture interventions require at least a six to nine month timeframe for demonstrating outcomes


Funders: USAID

Primary Contact: Karan Singh Thapa, Helen Keller International, Cluster Agriculture Coordinator

Country: Nepal

Project Dates: August, 2011 to September, 2016

Interventions: Assess the context at the local level, Collaborate and coordinate with other sectors, Facilitate production diversification, Incorporate nutrition promotion and education,

Target Population: Pregnant/lactating women (PLW), Children under 3,

Project Stage: Ongoing activities

Geographic Coverage: State/Province