Expression of Interest (EOI): Anthropological assessment on access and coverage of nutrition services in Nepal

CALL FOR EXPRESSION OF INTEREST (EOI)

July 2024

Terms of Reference (ToR)

Project activity: Anthropological assessment on access and coverage of nutrition services in Nepal 

Project duration: maximum 45 days 

Background

Acute malnutrition is one of the leading causes of child morbidity and mortality. Acute malnutrition is a major threat to children’s long-term health and development, the impacts of which are seen in individuals, their communities, and their countries. The trend of acute malnutrition has remained consistently high with limited changes over the past decade. The prevalence of acute malnutrition in Nepal was recorded at 15% in 1996, 11% in 2001, 13% in 2006, 11% in 2011, 10% in 2016, and 8% in 2022. While the national indicator shows a recent decline in acute malnutrition, there are disparities across provinces with some provincial data continuing to be considerably high, surpassing the emergency threshold set by the World Health Organisation (WHO). 

According to NDHS 2022, still 1 in 4 children under 5 years of age in Nepal are stunted, 8% are wasted, and 43% of children and 34% of women are anemic. The prevalence of stunting is highest in Karnali Province (36%), followed by Madhesh Province (29%) and Sudurpaschim Province (28%), and lowest in Koshi Province (20%) (NDHS, 2022). Adolescent malnutrition is also emerging as a serious public health concern in Nepal. The burden of over-nutrition has also increased gradually in Nepal. Overweight/obesity among women age 20-49 is higher in urban areas (38%) than in rural areas (26%) 1. Overall, Nepal is facing the triple burden of malnutrition. Numerous SMART surveys conducted at the district level (including by ACF in Nawalparasi and Udayapur District) also reveal alarmingly higher rates of acute malnutrition than the provincial aggregate given by the national demographic health surveys mentioned above. 

Aligned with the Second Long-Term Health Plan (SLTHP) spanning from 1997 to 2017 (FY 2054-74), the Government of Nepal (GoN) aimed to bring down acute malnutrition to less than 5%. Additionally, the Multi-Sector Nutrition Plan (MSNP) I (2013-2017), MSNP II (2018-2023) and MSNP III (2024-2030) also focuses on implementing Multisectoral efforts to reduce acute malnutrition below 5%. Despite these targets, Nepal fell significantly short of achieving them. The Sustainable Development Goals (SDG) have set even more ambitious objectives to combat acute malnutrition, with the aim of reducing acute malnutrition to less than 5% by 2025, and further to 4% by 2030. However, without additional efforts, achieving these targets seems challenging in the years to come.

Community-specific approach for revising management of wasting in Nepal

Nepal is diverse with different geographical variations. The fluctuation in prevalence of malnutrition, different underlying causes in different population groups, and existence of specific vulnerable groups (such as children, pregnant women, and marginalized communities) all needs consideration during the revising of the Wasting Management Guideline in Nepal. As observed in IMAM gap analysis, provinces have analysed their priorities based on current implementation status of the IMAM program and needs of the communities. The approach will hence need consideration of policy and governance, multi-sectoral collaboration, community engagement, behaviour change communication and capacity building plan. Guidance on monitoring and evaluation system of IMAM to track progress, identify gaps, and make evidence-based decisions. The use of regularly collected data on key IMAM indicators following HMIS needs to be used for informing program adjustments and improvements.

Objectives

The overall objective of the assessment is to explore the local socio-cultural aspects in link with health and nutrition services and access,  understand people’s indigenous knowledge, practices and perspectives towards food and nutrition (specific and sensitive) services are built on or established in different socio-cultural and political contexts, and their experiences towards a range of delivery of nutrition-specific and nutrition sensitive services through health facilities or community services. In particular, in addition to general populations, especially poor, ethnic/indigenous, socio-economically, culturally, geographically and politically marginalized populations will be adequately represented as part of community engagement for this qualitative research. The evidences from the field research will complement and address the relevant issues or concerns at the community for consideration during the revision or update of protocols and technical guidelines such as IMAM and SAM  

In addition, the research also aims to understand specificities, power relations, identify influencers/change agents in the community, and explore adaptive approaches for community-based nutrition services at large.

Identifying research questions 

The research questions largely evolve from the anthropological inquiry to better understand the socio-cultural and political contexts of local people and their communities– in particular marginalized and vulnerable populations and their access to essential health and nutrition services in the communities. In the larger context of access to and utilization of nutrition services, the inquiry is particularly guided by fundamental questions like what do people in general, and in particular marginalized and vulnerable people do, are there any patterns to what they do, why do they do what they do and what causes differences in what they do? 

Methodological approach and process

1. Desk review: An in-depth review of the existing literature will be carried out in order to integrate an analysis of the secondary data available in the country (e.g. Nutrition related policies and strategies, Annual Reports of Department of Health Services, NGO reports, academic research including ACF publications, etc.)

2. Fieldwork: This will be primarily a qualitative research that uses some of the social and anthropological approaches with a clear focus on participatory methodologies such as observations, social and/or resource mapping, seasonal calendars, mapping of communication channels, case studies, Key Informant Interviews (KIIs) with community members, school teachers, female community health volunteers, health workers, community-based organizations’ (CBOs) representatives, representatives of marginalized communities and other social service providers (public and private). In addition, Focus Group Discussions (FGDs) with marginalized and vulnerable communities, health facility staff, female health volunteers and mothers’ groups will be conducted.

Primarily, qualitative data collection through interviews guides and participatory tools will focus on following topics:

• Representations of wasting / undernutrition including socio-cultural context
• Therapeutic itinerary of children, (barriers, solution, influence) and qualitative component of SLEAC
• Identification of MAM/SAM cases
• MAM/SAM cases comprehensive health and nutrition assessment.
• Case management of MAM/SAM cases in the health facilities as per the IMAM protocol
• Nutrition counselling on IYCF and on local recipes promoted in IMAM protocol
• Actual provision of nutritious home food by the families and use of local recipe
• Existence of preventative program/other solutions (included local/traditional) of high potential for supporting MAM/SAM children and their families
• Linkages with preventive program of high potential for supporting MAM/SAM children and their families reception and uses of nutrition services
• Community recommendations – policies, strategies, interventions etc.

Interviews, data and analysis 

All discussions will be conducted in the local languages of the interviewees, recorded, translated and transcribed into English. The data will then be encoded for text analysis.

Community feedback of the preliminary results will be organised in each area of the study in order to check the relevance of the data and to integrate the feedback of the people in the final analysis

The final analysis will be the result of a triangulation of the information from the secondary data analysis (desk review), the primary data analysis (data collection) and the feedback of the participants. Particular attention will be paid to the knowledge and recommendations of those involved in the study

Sampling of research areas and populations

In order to have a diversity to some extent in terms of gender, ethnicities and level of marginalization - -socio-economically, politically and geographically (rural/semi-urban) in terms of community engagement or participation in the research for information collection and analysis across the marginalized and vulnerable communities, three clusters - a ward or community from high mountain, hill and terai districts can be purposefully selected for primary and secondary data collection.

The districts and/or cluster shall include districts from  1) Karnali Province 2) Bagmati Province: and 3) Madhesh province, ensuring geographic and ethnical representation. 

So, in each three sites, below are the proposed methods for data collection in the communities. 

1. Participatory social/resource mapping and seasonal calendar (1) in each cluster 
2. FGDs with health facility staff (1), marginalized and/or vulnerable communities (2), and mothers’ groups (1) – each cluster 
3. KIIs with female community health volunteers (1), local government official (1), school teacher (1), health care provider (1 or 2 including private sector), representatives of marginalized or vulnerable  in each cluster 
4. Mapping of existing communication channels and approaches – from local governments/health institutions to communities, health staff or volunteers to communities, and others, means of communications, for example: community radio, public meetings, campaigns, training or other community events such as school education etc. 
5. Case studies – 2 or 3 from each cluster or ward

Ethical considerations: The research team is committed to ensuring the anonymity and confidentiality of discussions. Informed consent will be sought. Individuals are free to refuse or stop their participation at any time without any consequence to them or their family

Implementation modality

International Research Advisor provides overall guidance, technical lead and supervision with the support from national researcher for field research implementation, data collection, analysis and reporting. Two field researchers (one male and another female) will be recruited for each ward or cluster and oriented for methodological approach and data collection, recording, transcription, translation, and reporting.

Application procedure 

ACF Nepal will select applications from consultancy firms/teams or individual. Given the scope of the evaluation. Applications must include: 

• Curricula Vitaes (CV) for all proposed team or individual.
• In case of Organization (registration, VAT/PAN, profile, audited Financial Statement and Report)
• Cover letter outlining how the applicant meet the person specification, confirmation of availability in the timeframe indicated, and contact details for three professional referees 
• Technical proposal – outlining methodologies and with timeframe and an outline of the roles and responsibilities of each member of the consultancy team,
• Financial proposal – including daily rate and all costs in relation to travel, accommodation and other expenses related to evaluation 
• A sample of a similar piece of work previously conducted in the relevant field 

Interested consultancy firms/teams or individual should apply to procurement@np-actionagainsthunger.org with subject as “Application for anthropological assessment” by 24 July 2024, 17:00 hours Nepal Standard Time.  

Only shortlisted applicants will be contacted for further process. Action Against Hunger Reserves the right to reject any or all applications. Telephonic inquiries will not be entertained. 

Action Against Hunger | Action Contre la Faim is an equal opportunity employer and encourages applications from women, people with disabilities and members from disadvantaged /under represented ethnic groups.