1
SUAAHARA II 
GOOD NUTRITION PROGRAM
EVALUATING A DECADE OF MULTISECTORAL NUTRITION INTERVENTIONS:
IMPACT EVALAUTION REPORTS
March 2023
This publication was produced for review by the United States Agency for International Development. 
It was prepared by Helen Keller International under the terms of cooperative agreement number AID￾367-A-16-00006.
SUAAHARA II 
GOOD NUTRITION PROGRAM
Evaluating a Decade of Multisectoral Nutrition 
Interventions: Impact Evaluation Reports 
DISCLAIMER:
This report is made possible by the generous support of the American people through the United 
States Agency for International Development (USAID). The content of this report is produced by 
Helen Keller International, Suaahara II Program and does not necessarily reflect the views of 
USAID or the United States Government.
The Suaahara II Good Nutrition Program is supported by the United States Agency for 
International Development (USAID) under Cooperative Agreement No. AID-367-A-16-00006. 
Suaahara II is managed by:
Helen Keller International
In partnership with:
Cooperative for Assistance and Relief Everywhere, Inc. 
(CARE)
Family Health International 360
(FHI 360)
Digital Broadcast Initiative Equal Access
(DBI EA)
Environmental and Public Health Organization 
(ENPHO)
Nepali Technical Assistance Group 
(NTAG)
Vijaya Development Resource Center 
(VDRC)
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Contents
Acknowledgements 6
List of Tables 7
List of Figures 9
List of Annex 9
List of Acronyms 10
Foreword 12
Executive Summary 15
Part 1 – Evaluating Intermediate Results – Improved household nutrition, WASH, and health 
behaviors (IR1) 18
Executive Summary 19
Background and Rationale 19
Study Design and Analysis 22
Results 23
Dietary Outcomes 26
Results for Impact Stratified by Wealth and Caste 40
Discussion 42
References 44
Part 2 – Evaluating Intermediate Results – Increased use of quality nutrition and health services 
by women and children (IR2) 45
Executive Summary 46
Introduction 47
Objectives and Evaluation Questions 48
Evaluation Method 48
Data Management and Analysis 50
Results 54
Discussion and Conclusion 57
Part 3 – Evaluating Intermediate Results – Improved access to diverse and nutrient-rich foods 
by women and children (IR3) - Quantitative 58
Executive summary 59
Introduction 60
Evaluation Aim and Research Questions 62
Methods 63
Findings 66
Discussion 70
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Conclusions 71
References 73
Appendices 77
Part 4 – Evaluating Intermediate Results – Improved access to diverse and nutrient-rich foods 
by women and children (IR3) - Qualitative 78
Executive Summary 79
Recommendations 80
Background 81
Rationale 83
Research Questions 84
Study Design 84
Training 85
Data Management and Analysis 85
Ethical Consideration 86
Results 86
Discussions 98
Conclusions 102
Recommendations 103
Funding Sources 104
References 105
Annex 107
PART 5 – Evaluating Intermediate Results – Accelerated rollout of Multi-Sector Nutrition Plan 
(MSNP) through strengthened local governance (IR4) 127
Executive Summary 128
Introduction 130
Methods 131
Findings and Discussion 135
Conclusion and Recommendations 150
References 153
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Acknowledgements 
Principal Investigator 
Edward Frongillo, University of South 
Carolina, USA
Nutrition Governance Evaluation 
Principal Investigator 
Sarah Eissler, (Independent Consultants)
Evaluation Researchers
Shalini Suresh (Independent Consultants)
Deependra Kaji Thapa (Independent 
Consultants)
Shiva Bhandari (Independent Consultants)
Evaluation Researchers
Shraddha Manandhar (Independent 
Consultants)
Kabita Shah (Independent Consultants)
Evaluation Manager
Ramesh Prasad Adhikari (Helen Keller INTL)
HFP Qualitative Evaluation 
Subas Risal, PhD (Independent Consultant)
Evaluation Advisory Committee
Debendra Adhikari (USAID /Nepal)
Pooja Pandey Rana (COP, Suaahara II)
Elaine Gray (Global Health/USAID Washington)
Kedar Parajuli (MoHP/GoN)
Lila Bikram Thapa (MoHP/GoN)
Dr. Madhu Devkota (Independent)
Dr. John Hoddinott (Cornell University?)
Silvia Alayon (JSI, USAID Advancing Nutrition) 
Dr. Patrick Webb (Tufts)
Dr. Purnima Menon (IFPRI)
Dr. Edward Frongillo (USC)
Dr. Steve Hodgins (University of Alberta)
Dr. Rolf Klemm (Helen Keller INTL)
Dale Davis (Helen Keller INTL)
Dr. Bibek Kuma Lal (MoHP/GoN)
Protocol Contributors
Kenda Cunningham (IMANNA, Helen Keller 
INTL)
Ruchita Rajbhandary (Consultant) 
Sagun K.C (Helen Keller INTL)
Pooja Pandey Rana (COP, Suaahara II)
Ramesh Prasad Adhikari (Helen Keller INTL)
Dr. Ed Frongillo (USC)
Shalini Suresh (Consultant)
Deependra Kaji Thapa (Consultant)
Shiva Bhandari (Consultant) and
Shraddha Manandhar (Consultant)
Baseline and endline Data Collection
Nira Joshi (New Era)
Kiran Acharya (New Era)
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List of Tables
Table 1.1: Sample Demographics of Comparison and Intervention Districts at Baseline and Endline
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Table 1.2A: Primary Outcomes for the Overall Sample 22
Table 1.2B: Primary Outcomes for Respondents with Children Between 0-5.9 Months of Age 22
Table 1.2C: Primary Outcomes for Respondents with Children Between 6-23.9 Months of Age 23
Table 1.2D: Primary Outcomes for Respondents with Children Between 24-59.9 Months of Age 23
Table 1.3A: Secondary Outcomes: Dietary Diversity & Anthropometry for the Overall Sample 25
Table 1.3B: Secondary Outcomes: Dietary Diversity & Anthropometry for Respondents with 
Children Between 0-5.9 months of age 26
Table 1.3C: Secondary Outcomes: Dietary Diversity & Anthropometry for Respondents with 
Children Between 6-23.9 Months of Age 26
Table 1.3D: Secondary Outcomes: Dietary Diversity & Anthropometry for Respondents with 
Children Between 24-59.9 Months of Age 27
Table 1.4A: Secondary Outcomes: Child Nutrition Practices for the Overall Sample 28
Table 1.4B: Secondary Outcomes: Child Nutrition Practices for Respondents with Children Between 
0-5.9 Months of Age 29
Table 1.4C: Secondary Outcomes: Child Nutrition Practices for Respondents with Children Between 
6-23.9 Months of Age 29
Table 1.4D: Secondary Outcomes: Child Nutrition Practices for Respondents with Children Between 
24-59.9 Months of Age 30
Table 1.5A: Secondary Outcomes: Health & WASH Practices for the Overall Sample 31
Table 1.5B: Secondary Outcomes: Health & WASH Practices for Respondents with Children 
Between 0-5.9 Months of Age 31
Table 1.5C: Secondary Outcomes: Health & WASH Practices for Respondents with Children 
Between 6-23.9 Months of Age 32
Table 1.5D: Secondary Outcomes: Health & WASH Practices for Respondents with Children 
Between 24-59.9 Months of Age 32
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Table 1.6A: Secondary Outcomes: Knowledge of Nutrition, Health and WASH Practices for the 
Overall Sample 34
Table 1.6B: Secondary Outcomes: Knowledge of Nutrition, Health, and WASH Practices for 
Respondents with Children Between 0-5.9 Months of Age 35
Table 1.6C: Secondary Outcomes: Knowledge of Nutrition, Health, and WASH Practices for 
Respondents with Children Between 6-23.9 Months of Age 35
Table 1.6D: Secondary Outcomes: Knowledge of Nutrition, Health, and WASH Practices for 
Respondents with Children Between 24-59.9 Months of Age 36
Table 2.1: Health System Level Indicators Assessed in the Endline Survey 48
Table 2.2: Impact of Suaahara Intervention on Capacity Building of Health Workers and FCHVs 52
Table 2.3: Impact of Suaahara Intervention on Service Delivery in Health Dacilities 53
Table 2. 4: Impact of Suaahara Intervention on Service Delivery Among FCHVs 54
Table 3.1: Socio-demographics of Households Before and After Implementation of HFP Intervention
in Darchula district, Nepal, 2012-2022. 64
Table 3.2: Comparison of Outcome Variables Before and After Implementing the HFP Intervention 
in Darchula, Nepal, 2012-2022. 64
Table 3.3: Changes in outcomes among households before and after receiving the HFP 
interventions in Darchula, Nepal, 2012-2022.a 66
Table 4.1: Sample allocation of respondents by municipality 82
Table 5.1: Study Areas in Nepal 126
Table 5.2: Types of Stakeholders Sampled at Each Government Level and by Data Collection 
Activity 127
Table 5.3: Total Number of Data Collection Activities by Government Level 129
Table 5.4: Illustrative Examples of Multi-sector Programming to Address Nutrition 130
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List of Figures
Figure 1: Suaahara – Components of Evaluation 13
Figure 2. Intervention and comparison districts selected for the survey 45
Figure 3: Reach by HFP component of Suaahara program in Nepal (Quant.) 58
Figure 4: Reach by HFP Component of Suaahara Program in Nepal (Qual.) 79
Figure 5: Nutrition Budget Allocation and Utilization in Suaahara II between 2016 and 2021 136
List of Annex
Annex 1.1: Interview with 1000 Day Mothers 104
Annex 1.2: Interview with Villager Model Farmer (VMF) 107
Annex 1.3: Interview with Female Community Health Volunteers (FCHV) 110
Annex 1.4: Interview with government officials (eg. agri-extension workers) 114
Annex 1.5: Interview with NGO workers/private sector representatives 116
Annex 1.6: FGD with 1000-day Mothers 118
Annex 2.1: Team Structure 121
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List of Acronyms
ANC Antenatal Care
BCC Behavior Change Communication
BMI Body Mass Index
CAPI Computer Assisted Personal Interview
CARE Cooperative for Assistance and Relief Everywhere
CB-IMCI Community-based Integrated Management of Childhood Illness
CSA Climate Smart Agriculture
DAGs Disadvantaged Groups
DD Dietary Diversity
DGLV Dark-green Leafy Vegetables
EHFP Enhanced Homestead Food Production
FANTA Food and Nutrition Technical Assistance
FAO Food and Agriculture Organization
FCHV Female Community Health Volunteer
FGD Focus Group Discussion 
FHI Family Health International
FP Family Planning
FWD Family Welfare Division
GESI Gender Equality and Social Inclusion
GMP Growth Monitoring and Promotion
HAZ Height for Age Z-score
HFIAS Household Food Insecurity Access Scale
HFP Homestead Food Production
HH Household
HKI Helen Keller International
HMG Health Mother’s Group
HMIS Health Management Information System
HTSP Healthy Timing and Spacing of Pregnancy
IFA Iron and Folic Acid
IMAM Integrated Management of Acute Malnutrition 
IR Intermediate Results
IYCF Infant and Young Child Feeding
JHPIEGO Johns Hopkins Program for International Education in Gynecology and 
Obstetrics
JTA Junior Technical Assistance
KII Key Informant Interview
LARC Long-Acting Reversible Contraceptive
MAM Moderate Acute Malnutrition
MARM Malikaarjun Rural Municipality
MER Monitoring, Evaluation, and Research
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MIYCN Maternal, Infant, and Young Child Nutrition
MoHP Ministry of Health and Population
MSNP Multi-Sectoral Nutritional Plan
MUAC Mid-upper Arm Circumference
MUM Mahakali Urban Municipality
NDHS Nepal Demographic and Health Survey
NE New ERA
NEWAH Nepal Water for Health
NHRC Nepal Health Research Council
NPCS National Promotion and Consultancy Service
NTAG Nepali Technical Assistance Group
ODK Open Data Kit
ORS Oral Rehydration Solution
PIP Program Impact Pathways
PNC Postnatal Care
PNGO Partner Non-Government Organization
PPS Probability Proportion to Size
RM Rural Municipality
RUTF Ready-to-use Therapeutic Food
SABAL Sustainable Action for Resilience and Food Security
SAM Severe Acute Malnutrition
SATH Self-Applied Technique for Health
SBCC Social and Behavior Change Communication
SD Standard Deviation
SRM Shaileshekhar Rural Municipality
TEM Technical Error of Measurement
TOT Training of Trainers
UM Urban Municipality
USAID United States Agency for International Development
USC University of South Carolina
VDCs Village Development Committee
VDCs Village Development Committees
VMF Village Model Farm
WASH Water, Sanitation and Hygiene
WAZ Weight for Age Z-score
WHO World Health Organization
WHZ Weight for Height Z-score
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Foreword 
The Government of Nepal (GoN) and international development partners recognized the 
importance of tackling a relatively high burden of maternal and child undernutrition and devised 
strategies to implement its Multisectoral Nutrition Plan (MSNP). The Suaahara – Good Nutrition 
program funded by the United States Agency for International Development (USAID) is one such 
program that supported the GoN’s MSNP. Spanning through two phases over ten years, 
Suaahara I (2011-2016) and Suaahara II (2016-2023), aimed to reduce the high burden of 
maternal and child undernutrition in Nepal. Initially launched in 20 of the 75 districts, the program 
was later scaled-up to cover 42 of 77 districts in Nepal spanning across three distinct 
agroecological zones -- mountains, hills, and terai. 
In Phase I (2011-2016), Suaahara was led by Save the Children International in partnerships with 
Helen Keller International (HKI), JHU Center for Communications Programs, JHPIEGO, Nepal 
Water for Health (NEWAH), the National Promotion and Consultancy Service (NPCS), and the 
Nepali Technical Assistance Group (NTAG). Since the beginning, Suaahara II deployed 
comprehensive monitoring, evaluation, and research systems for data driven planning, learning 
and adaptation, and for generating evidence through research. Thus, prior to the start of Suaahara 
interventions, an impact evaluation with cluster randomized quasi-experimental design was 
conceived. The baseline and counterfactual for program evaluation was set at the beginning of 
the program in 2012. The baseline data was collected by an independent external evaluation 
agency (New Era) from eight matching intervention and eight comparison districts thereby setting 
the counterfactuals. 
The endline survey was originally planned at the end of Phase 1 (2016), however, due to the 
massive Nepal earthquake in 2015, the evaluation could not take place. Since Suaahara 
continued for Phase II (2016-2023) implementation, the endline evaluation was postponed to 
2020. Again, due to the COVID-19 pandemic related lockdowns and movement restrictions 
throughout 2020, the evaluation was further delayed. Therefore, the final endline evaluation 
survey was conducted in 2022, by the same research agency (New Era), during the same months 
to minimize research bias, from the same intervention and comparison areas.
In Phase II of the program (2016-2023), Suaahara was led by Helen Keller Intl in partnership with 
Cooperative for Assistance and Relief Everywhere, Inc. (CARE), Family Health International 360 
(FHI360), NTAG, Digital Broadcast Initiative Equal Access (DBIEA), Environmental and Public 
Health Organization (ENPHO), and Vijaya Development Resource Center (VDRC) and was 
implemented by more than 40 local NGOs and CBOs. Since any evaluation of a multisectoral 
program must be juxtaposed against its objectives, it is important to reflect on the objectives with 
which Suaahara was introduced. 
Suaahara’s primary aim was to reduce the prevalence of stunting, wasting, and underweight 
among children under 5 years of age, and to reduce the prevalence of anemia among women of 
reproductive age (WRA) and children 6-59 months. To achieve this goal, Suaahara adopted a 
multi-sectoral approach to achieve four key intermediate results (IRs): 
1. Improved household nutrition, sanitation, and health behaviors; 
2. Increased use of quality nutrition and health services by women and children; 
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3. Improved access to diverse and nutrient-rich foods by women and children; and 
4. Accelerated roll-out of the MSNP through strengthened local governance. 
To achieve the above four IRs, Suaahara’s inputs and interventions spanned across health and 
family planning (FP); women’s and child’s nutrition; agriculture and homestead food production 
(HFP); and water, sanitation and hygiene (WASH). A wide range of social and behavior change 
communication (SBCC) interventions were used, primarily to generate demand for and access to 
improved services, and to motivate households to adopt optimal health, nutrition, and WASH 
practices. All Suaahara interventions were supported by a crosscutting theme of gender equity 
and social inclusion (GESI), in part by targeting women and disadvantaged groups (DAGs), and 
by conducting activities that addressed GESI-related barriers to optimal health, nutrition, and 
WASH behaviors.
Figure 1 below presents Suaahara’s theory of change, and how specific components of evaluation 
were conceived and designed to attain a deeper understanding about the program interventions, 
and their pathways to impact. From the figure we can observe, there are three separate pieces of 
evaluation corresponding with four IRs:
1. For IR1 and IR2, a quantitative evaluation with matching case-control design was 
conceived. This is because over 70% of the program’s key performance indicators fell 
under IR1 and IR2. Initially, baseline data was collected from eight matching intervention
and comparison areas. However, since the program was later scaled to cover four 
additional comparison districts, the endline data was collected from four matching 
intervention and comparison areas. The overall objective of this part of the impact 
evaluation is to assess whether Suaahara reduced maternal and child undernutrition and 
improved household behaviors related to health, nutrition, and WASH, and whether 
Suaahara interventions improved health services. The detail description about the 
evaluation methods and design is available in the first part of this evaluation report.
Figure 1: Suaahara – Components of Evaluation 
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2. For IR3, the evaluation consisted of a quantitative study and a separate qualitative study 
– both conducted by two separate external evaluators. The quantitative study was 
conducted with a small sample of a cohort of village model farmers adopting a simple pre￾post research design. However, due to its smaller sample size, a separate qualitative 
evaluation in the same district, with some of the same village model farmers was 
conducted. An integral part of Suaahara’s intervention was Homestead Food production
(HFP) through which Suaahara promoted production and consumption of nutrient-rich 
foods towards improving household food security and nutritional outcomes among children 
and mothers. The interventions aimed to improve access to and consumption of diverse 
nutrient-rich foods by women and children. Adopting two separate methods of evaluation 
to assess the effectiveness of this intervention therefore has improved the robustness of 
the study and has helped corroborate the findings and the results. The details about this 
evaluation is available in the second part of this report.
3. Finally, to assess Suaahara’s impact on accelerated rollout of MSNP through 
strengthened local governance (IR4), a separate qualitative evaluation by an independent 
researcher was conceived. Suaahara supported the Nepalese government at local, 
provincial, and national levels to implement Nepal’s MSNP, which includes attention to the 
allocation and utilization of government funds for nutrition-specific and nutrition-sensitive 
interventions. The qualitative evaluation was aimed at assessing the effectiveness of 
Suaahara II in improving multi-sectoral coordination for implementing MSNP at the 
national, provincial, and municipal levels in Nepal. The qualitative evaluation aimed to 
answer what was the status of decentralized implementation of Nepal’s MSNP? how have 
Suaahara II interventions contributed to this decentralized implementation; and what were 
the gaps barriers in the decentralized MSNP implementation? Details about this evaluation 
are available in the third part of this report. 
For the reader, it is important to keep in mind that every step of the evaluation were designed in 
consultation with a wide range of stakeholders by a well-established Evaluation Advisory 
Committee that included reputed academics, researchers, and policy makers on board. All the 
individual pieces of evaluation had a well-established research protocol designed in consultation 
with various stakeholders and approved by USAID. It is also important to be mindful of the 
complexity in evaluating a large scale and highly complex, multisectoral nutrition program. It was 
therefore prudent to evaluate the IRs separately. Moreover, having separate pieces of evaluation 
for each program goal also provides greater flexibility in terms of research designs and 
approaches – such as quantitative, qualitative or mix methods; or experimental design versus 
simple pre-post assessments. This provides robustness and greater reliability in results and 
findings. The results will be used to inform and design future nutrition policies and programs in 
similar contexts. 
What follows next are the individual pieces of evaluation of a decade of multisectoral nutrition 
intervention. We hope you enjoy reading them. 
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Executive Summary
Suaahara, funded by USAID, is a comprehensive multi-sectoral nutrition program. Implemented 
in two phases – Suaahara I (2011-2016) and Suaahara II (2016-2023) – the program aimed to 
improve maternal and child nutrition in 42 of Nepal’s 77 districts. To achieve this goal, Suaahara 
delivered interventions in 3,353 wards/communities depending on local needs across nutrition, 
health and family planning, agriculture and markets, water, sanitation, and hygiene, and nutrition 
governance. Through these interventions, Suaahara aimed to achieve four Intermediate Results 
(IRs): IR1) Improved household nutrition, WASH, and health behaviors; IR2) Increased use of 
quality nutrition and health services by women and children; IR3) Improved access to diverse and 
nutrient-rich foods by women and children; and IR4) Accelerated rollout of Multi-Sector Nutrition 
Plan (MSNP) through strengthened local governance. Suaahara was extensively built upon 
government structures, community platforms and national programs to target marginalized and 
socially vulnerable groups.
To evaluate the impact of Suaahara, a series of independent impact evaluation studies were 
conducted. This report presents each of the evaluation studies separately. Each evaluation was 
geared towards assessing the impact of Suaahara on each of the intermediate results (IRs) as 
outlined in the foreword. The evaluation of IR1 observed that Suaahara improved mother’s lives 
as manifested by improved maternal dietary diversity, weight, and rate of institutional delivery. 
Possibly reflecting improved prenatal conditions, the length of infants 0-5.9 months improved. 
Complementary feeding of infants and young children ages 6 to 23.9 months improved as 
reflected in improved dietary diversity, minimum acceptable diet, minimum meal frequency, and 
offering children more food when sick. Availability of soap and water at handwashing stations 
improved. These improvements in intervention districts relative to comparison districts were 
achieved despite substantial challenges Suaahara faced during the ten years of intervention. 
The evaluation of IR2 assessed Suaahara’s impact on health system strengthening. This 
evaluation observed that health facility workers and FCHVs in the intervention districts reported 
better knowledge on CB-IMCI, and GMP than in comparison districts. In terms of improved service 
delivery, the mean scores for service availability were higher in the intervention districts for 
maternal nutrition services, child nutrition services, ANC services, and FP services. Health
facilities in intervention districts, compared to comparison districts, had better availability and use 
of reference materials and guidelines for GMP service, and counseling aids to provide nutrition 
assessment and GMP, FP, ANC, and PNC services. Also, a higher proportion of FCHVs from the 
intervention districts (36% vs. 4%) mentioned implementing the Self-Applied Technique for Health 
(SATH) approach in the mother groups they facilitate. In short, Suaahara interventions contributed 
to strengthen the health system across the two components (capacity building and improved 
quality service delivery). 
For evaluating IR3, two separate studies were conducted – quantitative and qualitative. The 
quantitative study aimed to understand the role of the HFP program in improving availability, 
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accessibility, and consumption of diverse nutrient-rich foods in the marginalized and food insecure 
communities in Darchula. The evaluation observed that vegetable production diversity increased 
by 49% after the households received the HFP program. In addition, the likelihood of production 
of dark-green leafy vegetables and beans and pulses increased for the households after receiving 
the HFP program. Income from the sale of surplus vegetables was about USD 69 greater among 
the households after participating in the HFP program than before the program. Women’s 
knowledge on child nutrition and health improved after receiving the HFP program. Women were 
more empowered after being enrolled into the HFP program as indicated by their improved 
decision-making power over the use of income and the control of productive assets in the 
households. 
To substantiate the findings of the quantitative evaluation, a qualitative study was conducted in 
the same district (Darchula) with participating HFP members. This qualitative evaluation also 
observed that knowledge and practice related to homestead gardening improved among program 
participants. The knowledge HFP-participants had on consumption of nutrient-rich foods was also 
being translated into practice. For example, the knowledge and practice on child’s dietary diversity 
was quite high. The evaluation found the increased availability of nutrient-rich food at both 
household and community levels. There was increased income among HFP households through 
selling of surpluses which was largely due to growing off-season vegetables. However, a few 
barriers that prevented from yielding better results were lack of necessary materials (building 
fences, constructing semi-intensive coops etc.), lack of financial resources (purchasing 
polyhouses, purchasing materials for fence or coops etc.), lack of skilled manpower (installing 
polyhouses, constructing semi-intensive coops etc.) and lack of space (constructing semi￾intensive coops, land availability to undertake tunnel farming etc.). The qualitative evaluation 
suggests that there’s need to establish strong linkages between farmers and local markets. Also, 
one of the key criteria for VMF selection should be based on their dedication and commitment for 
full engagement. 
The final part of the evaluation assessed Suaahara’s impact on improving multi-sector 
coordination for implementing the MSNP at the national, provincial, and municipal levels in Nepal. 
This study followed a rigorous qualitative design. The study observed that most multi-sector 
stakeholders understand their role in implementing the MSNP to promote nutrition in Nepal and 
can articulate specific programs within their sector that advances multi-sector nutrition activities. 
Suaahara II has positively contributed to building stakeholders’ capacity and facilitating an 
effective implementation of the MSNP, however challenges remain. Suaahara II has been 
particularly effective at promoting awareness for multi-sector roles, leadership, and coordination 
for promoting nutrition; demanding budgets for multi-sector nutrition activities; and nutrition￾related concepts and practices across sectors and government levels. Suaahara II was effective 
at navigating and adapting to the shift to federalism and leveraging existing networks to 
strengthen their implementation of nutrition-focused activities, particularly at the local level. Yet, 
there exist gaps and challenges that hinder the effective implementation of the MSNP. Such 
challenges include insufficient human resources at the provincial level to adequately coordinate 
implementation at the municipal level and the lack of a formal reporting mechanism to enable 
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provincial and municipal level stakeholders to effectively monitor progress towards goals and 
implementation activities. Additionally, the lack of a formal coordination mechanism hinders 
productive provincial and municipal level stakeholder collaboration, as does the limited capacity 
of available trained, technical specialists at the municipal level to design and implement activities. 
The study observed that the GoN heavy relied on Suaahara II to implement nutrition-focused 
awareness raising and promotion activities, to strengthen capacity building, facilitate multi-sector 
coordination, and to enable vertical coordination. Suaahara II was effective at reaching local 
communities to promote nutrition, as evidenced by the differences in nutrition knowledge and 
awareness reported by municipal-level stakeholders in intervention and comparison areas. 
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Part 1 – Evaluating Intermediate Results –
Improved household nutrition, WASH, and 
health behaviors (IR1)
Principal Investigator: Edward A. Frongillo, University of South Carolina, USA
Evaluation Research Team: Shalini Suresh, Independent Consultant
Deependra Thapa, Independent Consultant
Ramesh P. Adhikari, Helen Keller INTL
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Executive Summary
Suaahara uses multiple sectors to achieve four key intermediate results: (1) improved household 
nutrition, sanitation, and health behaviors; (2) increased use of quality nutrition and health 
services by women and children; (3) improved access to diverse and nutrient-rich foods by women 
and children; and (4) accelerated roll-out of the MSNP through strengthened local governance. 
Suaahara interventions span health and family planning, nutrition, agriculture/homestead food 
production, and water, sanitation, and hygiene. 
This evaluation study was designed to evaluate key measures and indicators of the impact of the 
Suaahara interventions by including comparison districts to allow us to identify, quantify, and 
plausibly attribute changes in outcomes to Suaahara interventions. The endline survey was 
originally planned for the end of Suaahara I but could not be conducted due to the Nepal 
earthquakes in 2015. It was then postponed to 2020, and then had to be delayed further due to 
the COVID-19 pandemic. Thus, the impact evaluation endline survey was conducted in 2022, in 
the same season and sites and by the same survey firm as was done in 2012. This report focuses 
on the first three key intermediate results.
Suaahara improved mother’s lives as manifested by improved maternal dietary diversity, weight, 
and rate of institutional delivery. Possibly reflecting improved prenatal conditions, the length of 
infants 0-5.9 months improved. Complementary feeding of infants and young children ages 6 to 
23.9 months improved as reflected in improved dietary diversity, minimum acceptable diet, 
minimum meal frequency, and offering children more food when sick. Availability of soap and 
water at handwashing stations improved. These improvements in intervention districts relative to 
comparison districts were demonstrated with plausible evidence despite the substantial 
challenges that Nepal and Suaahara faced during the ten years between baseline (2012) and 
endline (2022) and the limitations in statistical power that resulted from the small number of 
districts that then could be included in the evaluation study.
Background and Rationale
Over the last several decades, Nepal substantially reduced undernutrition in children under five 
years of age; yet, Nepal has among the highest prevalence of child undernutrition in the world. 
According to the Nepal Demographic and Health Survey 2016, about the time when Suaahara II 
began, approximately 36% of children below five years were stunted, 27% were underweight, and 
10% were wasted (NDHS 2016). Food insecurity, inadequate access to nutrient-rich foods and 
health services, inappropriate infant and young child feeding (IYCF) practices and inappropriate 
water, sanitation and hygiene facilities and practices are the primary causes of malnutrition in the 
country. Only two-thirds of Nepalese children under the age of 6 months were exclusively 
breastfed. Only about 20% of children between the age of 6 and 23 months received a minimum 
acceptable diet. Less than half (47%) of children ate food from at least 4 of 7 food groups to attain 
minimum dietary diversity (DD), whereas less than 10% consumed egg (Nepal DHS 2016). 
Furthermore, the Nepal NDHS 2016 found that 17% of women of reproductive age (15-49 years) 
were underweight (BMI<18.5) and 41% of women of reproductive age were anemic. There was 
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also substantial variation across nutrition indicators, for example, by socio-economic status, 
caste/ethnicity, and agroecological zone of residency (e.g., plains, hills, or mountains). 
The Government of Nepal and development partners have prioritized multi-sectoral (integrated) 
nutrition as a key development agenda [1]. The Suaahara program funded by the United States 
Agency for International Development (USAID) is one of the programs that supports the 
Government of Nepal’s multi-sectoral nutrition plan (MSNP). It aimed to improve maternal and 
child nutrition behaviors and health services over a period of more than ten years, spanning two 
phases: Suaahara I (2011-2016) and Suaahara II (2016-2021, extended until 2023). Initially 
launched in 20 of 75 districts, the program has scaled-up to 42 of 77 districts that span across 
Nepal’s three agroecological zones and from east to west of the country too. 
Suaahara I was led by Save the Children International in partnership with Helen Keller 
International (Helen Keller), JHU Center for Communications Programs, JHPIEGO, Nepal Water 
for Health (NEWAH), the National Promotion and Consultancy Service (NPCS), and the Nepali 
Technical Assistance Group (NTAG). Suaahara II was led by Helen Keller in partnership with 
Cooperative for Assistance and Relief Everywhere, Inc. (CARE), Family Health International 360 
(FHI360), NTAG, Digital Broadcast Initiative Equal Access, Environmental and Public Health 
Organization, and Vijaya Development Resource Center and was implemented by more than 
40 local NGOs and community-based organizations. 
Suaahara’s primary aim is to reduce the prevalence of stunting, wasting, and underweight among 
children under 5 years of age and to reduce the prevalence of anemia among women of 
reproductive age and children 6-59 months of age. For this, the program uses multiple sectors to 
achieve four key intermediate results (IRs): (1) improved household nutrition, sanitation, and 
health behaviors; (2) increased use of quality nutrition and health services by women and children; 
(3) improved access to diverse and nutrient-rich foods by women and children; and (4) 
accelerated roll-out of the MSNP through strengthened local governance. Suaahara interventions 
span health and family planning (FP), nutrition, agriculture/homestead food production (HFP), and 
water, sanitation, and hygiene (WASH). Suaahara also strengthened nutrition policies and 
governance. Diverse social and behavior change communication (SBCC) interventions are used, 
primarily to generate demand for access to improved health services and to motivate households 
to adopt optimal health, nutrition, and WASH practices. All Suaahara interventions are supported 
by a crosscutting theme of efforts to improve gender equality and social inclusion (GESI), in part 
by targeting women and disadvantaged groups (DAGs) and conducting activities that address 
reducing GESI-related barriers to optimal health, nutrition, and WASH behaviors. 
Suaahara has a comprehensive monitoring, evaluation, and research for learning plan and related 
data systems. Prior to the start of Suaahara I interventions, an impact evaluation with a quasi￾experimental design was planned and baseline data collection was conducted in the 8 earliest 
intervention districts and 8 matched (based on agro-ecology as well as socio-economic 
characteristics) comparison districts in 2012. In 2014, after two years of implementation Suaahara 
conducted a mixed-methods process evaluation to assess progress in implementation and effects 
at the household, frontline worker, and policy levels. 
In Suaahara II, a program-representative quantitative annual monitoring survey was carried out 
annually in (2017, 2018, 2019 and 2022) to monitor progress and enable assessment of Suaahara 
21
II progress over time in intervention districts at the input, output, and outcome levels and assess 
change over time in anthropometry and hemoglobin as well (2017 and 2022 surveys). These 
monitoring surveys also included performance indicators at the health facility and FCHV level data 
in 2017 and 2020 to assess Suaahara II progress over time in strengthening the health system 
level. In addition to the quantitative surveys, several qualitative studies were conducted, including 
two external mid-term assessments, formative research on five key behaviors, and an 
assessment of municipal-government allocation and utilization of nutrition-related funds. 
This evaluation study was designed to evaluate key measures and indicators of the impact of the 
intervention by including comparison districts to allow us to identify, quantify and plausibly 
attribute changes in impacts and outcomes to Suaahara interventions. The endline survey was 
originally planned for the end of Suaahara I but could not be conducted due to the Nepal 
earthquakes in 2015. It was then postponed to 2020, and then had to be delayed further due to 
the COVID-19 pandemic. Thus, the impact evaluation endline survey was conducted in 2022, in 
the same season and sites and by the same survey firm as was done in 2012.
Study Objectives and Primary and Secondary Research Questions 
The overall objective of the impact evaluation is to assess whether Suaahara improved household 
behaviors related to health, nutrition, and WASH and reduced maternal and child under-nutrition 
as well as whether Suaahara interventions improved health services. The primary research 
questions for Suaahara’s impact evaluations at household and health system level include: 
1. What is Suaahara’s impact on reducing child stunting (0-23 months and 24-59 months) 
and improving maternal and child (6-23 months) dietary diversity?
2. What is Suaahara’s impact on improving health, nutrition, and WASH knowledge and skills 
among health workers and FCHVs?
This report focuses on the primary research questions around impacts on mothers and children. 
In addition to stunting and dietary diversity, the analysis in this section of the report seeks to 
answer the following secondary research questions:
1. What is Suaahara’s impact on reducing maternal underweight and anemia and child 
underweight, wasting, and anemia?
2. What is Suaahara’s impact on reducing equity gaps in maternal underweight and anemia; 
child stunting, underweight, wasting, and anemia; and maternal and child dietary diversity?
3. What is Suaahara’s impact on improving other maternal and child health, nutrition and 
WASH practices (e.g., ANC, PNC, modern family planning, breastfeeding, complementary 
feeding, handwashing with soap and water at critical times, and appropriate drinking water 
treatment methods and frequency)?
4. What is Suaahara’s impact in reducing equity gaps in other maternal and child health and 
nutrition and WASH practices (e.g., ANC, PNC, modern family planning, breastfeeding, 
complementary feeding, handwashing with soap and water at critical times, and 
appropriate drinking water treatment methods and frequency)?
22
Study Design and Analysis 
Design
The impact evaluation endline was conducted in four interventions and four comparison districts. 
Only a total of eight districts could be used because half of the original comparison districts 
became intervention districts in Suaahara II. The intervention districts were Sindhupalchowk, 
Syangja, Rupandehi, and Darchula whereas the pair-matched comparison districts in the 
corresponding order were Ramechhap, Tanahu, Chitwan, and Jumla. Sampling at the endline 
was done in 120 of the same old (i.e., pre federalism) wards as was at baseline. At baseline, 17 
households were sampled per old ward for a total sample of 2,040. At the endline, 20 households 
were sampled from each of 40 old wards and 21 households were sampled from each of 80 old 
wards, for a total of 2,480. The study is registered at clinicaltrials.gov with identifier 
NCT05448287.
Statistical Analysis
Data were checked for the assumption of normal distribution when relevant. Multivariable linear 
and logistic regression models were used to assess impact with the dependent variable for each 
model being a primary or secondary outcome. The models were used to compare changes in 
each outcome from baseline to endline between the intervention and comparison arms of the 
study. Impact was estimated and tested using an intent-to-treat, difference-in-differences analysis 
in which survey (baseline vs. endline), arm (comparison vs. intervention), and their interaction 
were specified as fixed effects. The interaction terms provided the estimate and test of impact. 
That is, the interaction term estimated the difference between arms in the differences between 
baseline and endline. Specifically, difference-in-differences estimates were the endline minus 
baseline difference for the intervention districts minus the endline minus baseline difference for 
the comparison districts. The analyses conducted inherently adjusted for any differences at 
baseline through the incorporation of the baseline measure for each outcome. The analyses 
accounted for clustering at the district level (i.e., the unit of assignment for intervention vs. 
comparison), ignoring the old wards, using a cluster sandwich estimator of the standard errors 
with data at the household level. The sandwich estimator accounts for the clustering of 
households within districts. This analytic method was appropriate because districts were assigned 
to receive either the intervention and or comparison, and the variation among districts within arms 
and the number of districts determined the standard errors and p-values used for testing estimates 
of the difference in differences. That is, the amount of variation among districts within each arm 
and the number of districts are the major determinant of the standard errors and the p-values. 
Estimates and corresponding exact p-values are presented in line with the 2019 
recommendations from leading scientists [2] and the American Statistical Association [3] to not 
use p-value cut-offs or the term “statistical significance.” The analyses were done for children 0-
59.9 months combined and then stratified by three age categories: 0-5.9 months, 6-23.9 months, 
and 24-59.9 months. The sample sizes for these three age categories were at baseline 201, 702, 
and 1,137 and at endline 453, 1,587, and 440 at endline, respectively.
23
In addition to the confirmatory analyses of impact just described, we conducted exploratory 
stratified analyses to examine whether impact appeared to differ by social and economic 
variables. Socio-economic status was measured descriptively using the Equity Tool. The 2011 
version was used for the baseline dataset and the 2016 version was used for endline. Due to the 
difference in versions, discrepancies were found between the results in baseline and endline with 
important differences in the socio-economic status distribution. To address this issue, for the 
exploratory analyses, a wealth index was constructed with principal components analysis using 
overlapping household asset items that were observed in the baseline and endline surveys. This 
wealth index was used for stratified analyses to assess any differences in the results between low 
wealth and high wealth households. Caste was also used as an equity measure, and stratified
analyses were conducted between socially disadvantaged households (i.e., Dalits, Muslims, and 
disadvantaged Janajatis) and non-socially disadvantaged households (i.e., Brahmin/Chhetri, 
Newar, Gurung/Thakali non-dalit terai castes). The pattern of the results from these exploratory 
analyses are summarized, but the large number of results (i.e., about 7,500 numerical values) are 
not tabulated in this report. 
Results 
Sample Demographics
The demographic makeup of the sample of respondents at baseline and endline in the 
comparison and intervention districts are presented in Table 1.1. 
Primary Outcomes
The results for the primary outcomes for the overall samples are listed in Table 1.2A. Tables 1.2B￾D present the data disaggregated by child age groups: 0-5.9 months, 6-23.9 months, and 24-59.9 
months. Descriptive data about prevalence of outcomes at baseline and endline are presented 
as percentages for binary outcomes and means with standard deviations for continuous 
outcomes. Difference-in-difference analyses were conducted to assess the strength of the 
differences in outcomes at baseline and endline between the intervention and comparison 
districts. The differences are presented in percentage points for binary outcomes and coefficients 
with standard errors for continuous outcomes. The outcomes with evidence of impact are 
highlighted in red font.
Table 1.1: Sample Demographics of Comparison and Intervention Districts at Baseline and 
Endline
Demographic 
Variables
Comparison Districts Intervention Districts
Baseline 
(N= 1020)
Endline
(N=1240)
Baseline
(N=1020)
Endline 
(N = 1240)
Mean (SD) / % Mean (SD) / % Mean (SD) / % Mean (SD) / %
Mothers’ age (years) 26.67 (6.39) 25.84 (5.37) 26.85 (5.98) 26.22 (5.46)
Child Age (months) 27.14 (16.82) 16.63 (12.65) 28.30 (16.69) 16.96 (12.70)
24
0-5.9 month 10.78% 19.60% 8.92% 16.94%
6-23.9 month 34.90% 62.66% 33.92% 65.32%
24-59 month 54.31% 17.74% 57.16% 17.74%
Child sex: female 46.27% 44.68% 46.76% 46.69%
Caste/ethnicity
Disadvantaged Group (
(Dalit, Muslim, 
Disadvantaged, Janajati)
42.55% 46.05% 43.04% 42.34%
Brahmin/Chhetri 46.18% 42.98% 45.29% 39.68%
Other 11.27% 10.97% 11.67% 17.98%
Socioeconomic status (quintiles using the Equity Tool for 2011 and 2016)
Quintile 1 (lowest) 47.84% 30.56% 22.35% 17.42%
Quintile 2 19.31% 19.73% 19.61% 17.26%
Quintile 3 15.59% 23.12% 27.75% 21.53%
Quintile 4 9.80% 21.42% 21.96% 37.66%
Quintile 5 (highest) 7.45% 5.17% 8.33% 6.13%
Agroecological zone
Terai 25% 25% 25% 25%
Hills 50% 50% 25% 25%
Mountains 25% 25% 50% 50%
Table 1.2A: Primary Outcomes for the Overall Sample
Primary Outcomes
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Coefficien
t (SE) or 
%
p-value
Child Dietary Diversity Score 
(7 food groups, 6-59.9 
month)
3.51 (1.13) 3.81 
(0.99)
3.62 
(1.12)
4.00 
(1.06)
0.070 
(0.14) 0.619
Maternal Dietary Diversity 
Score (IDDS 9 food groups) 3.80 (1.21) 3.82 
(1.05)
3.94 
(1.05)
4.17 
(1.09)
0.211 
(0.22) 0.372
Stunting (H/LAZ < -2) 43.51% 22.40% 40.47% 19.60% 0.24% 0.757
Underweight (WAZ <-2) 33.66% 14.41% 33.14% 14.19% 0.30% 0.978
Wasting (W/LAZ < -2) 8.91% 6.38% 13.75% 8.64% -2.58% 0.629
Child Anemia (6-59.9 month) 55.32% 59.28% 48.87% 61.07% 8.24% 0.143
Maternal Underweight (BMI < 
18.5) 19.82% 12.98% 25.59% 10.32% -8.43% <0.001
Maternal Anemia 38.54% 36.61% 37.78% 34.52% -1.33% 0.816
Table 1.2B: Primary Outcomes for Respondents with Children Between 0-5.9 Months of Age
Primary Outcomes
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Coefficien
t (SE) or 
%
p-value
25
Maternal Dietary Diversity 
Score (IDDS 9 food groups) 3.78 (1.28) 3.88 
(1.18) 4.0 (1.15) 4.29 
(1.20)
0.187 
(0.24) 0.470
Stunting (H/LAZ < -2) 10.48% 6.36% 10.99% 5.77% -1.10% 0.786
Underweight (WAZ <-2) 13.89% 5.39% 16.48% 5.24% -2.74% 0.735
Wasting (W/LAZ < -2) 6.54% 2.99% 6.98% 6.37% 2.94% 0.447
Maternal Underweight (BMI < 
18.5) 8.18% 8.23% 23.08% 4.29% -18.84% <0.001
Maternal Anemia 50.91% 34.16% 36.26% 33.33% 13.82% 0.136
Table 1.2C: Primary Outcomes for Respondents with Children Between 6-23.9 Months of Age
Primary Outcomes
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Coefficien
t (SE) or 
%
p-value
Child Dietary Diversity Score 
(7 food groups)
3.40 
(1.18)
3.78 
(0.99) 3.27 (1.23) 3.95 
(1.07)
0.294 
(0.140) 0.072
Maternal Dietary Diversity 
Score (IDDS 9 food groups)
3.87 
(1.19)
3.84 
(1.01) 4.00 (1.04) 4.15 
(1.07)
0.185 
(0.210) 0.396
Stunting (H/LAZ < -2) 39.83% 25.19% 37.39% 21.66% -1.09% 0.584
Underweight (WAZ <-2) 33.99% 16.54% 31.88% 15.31% 0.88% 0.981
Wasting (W/LAZ < -2) 11.83% 7.15% 17.89% 9.08% -4.13% 0.565
Child Anemia (6-59 month) 75.93% 65.38% 65.90% 68.40% 13.05% 0.071
Maternal Underweight (BMI < 
18.5) 20.85% 14.54% 28.32% 11.85% -10.16% 0.008
Maternal Anemia 39.55% 38.35% 41.91% 34.20% -6.51% 0.292
Table 1.2D: Primary Outcomes for Respondents with Children Between 24-59.9 Months of Age
Outcomes
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Coefficien
t (SE) or 
%
p-value
Child Dietary Diversity Score 
(7 food groups)
3.58 
(1.09)
3.91 
(1.01)
3.83 
(0.99) 4.17 (0.99) 0.007 
(0.15) 0.965
Maternal Dietary Diversity 
Score (IDDS 9 food groups)
3.77 
(1.20)
3.70 
(1.01)
3.90 
(1.04) 4.15 (1.05) 0.310 
(0.20) 0.158
Stunting (H/LAZ < -2) 52.30% 29.95% 46.97% 25.11% 0.49% 0.898
Underweight (WAZ <-2) 37.32% 16.82% 36.49% 18.64% 2.65% 0.482
Wasting (W/LAZ < -2) 7.48% 7.31% 12.31% 9.13% -3.01% 0.422
Child Anemia (6-59 month) 42.10% 37.73% 38.77% 34.19% -0.21% 0.916
Maternal Underweight 
(BMI < 18.5) 21.48% 12.73% 24.36% 10.45% -5.16% 0.083
Maternal Anemia 35.44% 33.18% 35.57% 36.82% 3.51% 0.657
26
Dietary Outcomes
Child Dietary Diversity: Dietary diversity scores for children between 6 to 59.9 months of age 
were calculated using the child dietary diversity instrument consisting of 7 food groups: 1) grains, 
white roots and tubers, and plantains; 2) legumes and nuts; 3) dairy; 4) meat, poultry, and fish; 5) 
eggs; 6) vitamin-A rich fruits and vegetables; 7) other fruits and vegetables. These scores were 
computed based on the dietary recall data collected in the mothers’ survey. Child dietary diversity 
in the 6-23.9 months age group improved more in intervention districts than comparison districts 
by 0.294 food groups (p=0.072).
Maternal Dietary Diversity: Dietary diversity scores for mothers were calculated using the 
Individual Dietary Diversity Score (IDDS) instrument that categorizes diets into nine categories: 
1) starchy staples; 2) beans, lentils, and nuts; 3) dairy; 4) meat and poultry; 5) eggs; 6) fish; 7) 
dark green leafy vegetables 8) vitamin-A rich fruits and vegetables; 9) other fruits and vegetables. 
These scores were computed based on the dietary recall data collected in the mothers’ survey. 
Minor improvements were noted in the maternal dietary diversity scores that were not different 
between intervention and comparison districts.
Anthropometric Outcomes: The data collection instruments included anthropometric 
measurements of all the children and mothers in the evaluation samples. The measures included 
hemoglobin levels for mothers and children, weight of mothers, and weight and height for children. 
Each measurement was taken twice, and the average of the measurements was calculated for 
each indicator. 
Stunting: Child stunting was calculated using height for age z scores (HAZ). Children were 
considered stunted if their HAZ was lower than -2. For the overall sample, there was a 
reduction in stunting between baseline and endline of about 21 percentage points for both 
intervention and comparison districts, but there was no difference in this reduction between 
the intervention and comparison districts.
Underweight: Child underweight was calculated using weight for age z scores (WAZ). 
Children were considered underweight if their WAZ was lower than -2. For the overall sample, 
there was a reduction of about 19 percentage points between baseline and endline for both 
intervention and comparison districts, but there was no difference in this reduction between 
the intervention and comparison districts.
Wasting: Child wasting was calculated using weight for height z scores (WHZ). Children were 
considered underweight if their WHZ was lower than -2. For the overall sample, there was a 
reduction between baseline and endline for both intervention and comparison districts but little 
difference in this reduction between the intervention and comparison districts.
Child Anemia: Child anemia was calculated based on children’s hemoglobin levels adjusted 
for altitude and was defined as hemoglobin levels <11 g/dl. Children under the age of 6 months 
were excluded from this sample. Child anemia increased by 13.05 percentage points 
(p=0.071) in the intervention districts relative to the comparison districts for children 6-23.9 
months of age.
Maternal underweight: Maternal underweight was defined by BMI values <18.5. The 
difference in differences for maternal underweight in the overall sample was -8.45 percentage 
27
points (p<0.001), meaning that the intervention districts had reduced maternal underweight 
by 8.45 percentage points more than the comparison districts. This effect was consistent 
across mothers of the three child age categories, with the largest difference-in-difference 
being -18.84 percentage points among mothers of children aged 0-5.9 months.
Maternal Anemia: Maternal anemia was calculated based on mothers’ hemoglobin levels 
adjusted for altitude and pregnancy. For pregnant women, anemia was defined as hemoglobin 
levels <11 g/dl and for non-pregnant women, anemia was defined as hemoglobin levels <12 
g/dl. There were no differences between baseline and endline between the intervention and 
comparison districts.
Secondary Outcomes: Dietary Diversity & Anthropometry
The results for the secondary outcomes around dietary diversity and anthropometry for the overall 
sample are listed in Table 3A. Tables 3B-D present the data disaggregated by child ages and are 
separated into the following age groups: 0-5.9 months, 6-23.9 months, and 24-59.9 months. 
Descriptive data about prevalence of outcomes at baseline and endline are presented as 
percentages for binary outcomes and means with standard deviations for continuous outcomes. 
Difference-in-difference analyses were conducted to assess the differences for each outcome at 
baseline and endline between the intervention and comparison districts. The differences are 
presented in percentage points for binary outcomes and coefficients with standard errors for 
continuous outcomes, and p-values are noted for all. The outcomes with evidence of impact are 
highlighted in red font.
Table 1.3A: Secondary Outcomes: Dietary Diversity & Anthropometry for the Overall Sample
Secondary Outcomes: 
Minimum Dietary 
Diversity & 
Anthropometry
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Coefficien
t (SE) or 
%
p-value
Child Minimum Dietary 
Diversity (≥ 4 of 7 groups 
for 6 – 59.9 month)
49.01% 62.59% 56.51% 70.00% -0.09% 0.882
Maternal Minimum 
Dietary Diversity 
(≥ 5 of 9 groups)
26.76% 23.47% 28.04% 36.77% 12.02% 0.167
HAZ
-1.75 
(1.31)
-0.93 
(1.39)
-1.75 
(1.12)
-0.81 
(1.41)
0.125 
(0.132) 0.375
WAZ
-1.53 
(1.06)
-0.73 
(1.23)
-1.64 
(1.05)
-0.80 
(1.19)
0.039 
(0.133) 0.780
WHZ
-0.73 
(1.00)
0.32 
(1.21)
-0.90 
(1.04)
-0.56 
(1.14)
-0.071 
(0.155) 0.662
Maternal BMI
20.68 
(2.70)
22.40 
(6.70)
20.45 
(2.88)
22.73 
(3.77)
0.571 
(0.546) 0.330
Maternal Hemoglobin
12.25 
(1.59)
12.45 
(3.71)
12.33 
(1.57)
12.81 
(6.17)
0.268 
(0.354) 0.474
Child Hemoglobin
10.50 
(1.98)
11.67 
(10.09)
10.96 
(1.41)
11.44 
(9.19)
-0.694 
(0.458) 0.174
28
Table 1.3B: Secondary Outcomes: Dietary Diversity & Anthropometry for Respondents with 
Children Between 0-5.9 months of age
Secondary Outcomes: 
Dietary Diversity & 
Anthropometry
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Coefficien
t (SE) or 
%
p-value
Maternal Minimum 
Dietary Diversity 
(≥ 5 of 9 groups)
30.91% 25.51% 32.97% 40.48% 12.9 0.209
HAZ
-0.45 
(1.28) -0.11 (1.29) -0.77 
(1.14)
0.33 
(1.51)
0.761 
(0.18) 0.004
WAZ 0.70 (1.12) -0.06 (1.11) -1.00 
(1.15)
-0.01 
(1.20)
0.355 
(0.255) 0.206
WHZ 0.38 (1.11) 0.03 (1.18) -0.46 
(1.20)
-0.37 
(1.25)
-0.313 
(0.310) 0.347
Maternal BMI
21.24 
(2.27)
23.23 
(12.85)
20.87 
(2.92)
23.25 
(3.43)
0.391 
(1.169) 0.748
Maternal Hemoglobin
11.98 
(1.59)
12.75 
(5.65)
12.49 
(1.58)
12.34 
(1.44)
-0.913 
(0.549) 0.140
Table 1.3C: Secondary Outcomes: Dietary Diversity & Anthropometry for Respondents with 
Children Between 6-23.9 Months of Age
Secondary Outcomes: 
Dietary Diversity & 
Anthropometry
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean (SD) 
/ %
Mean (SD) 
/ %
Mean 
(SD) / %
Mean 
(SD) / %
Coefficient 
(SE) or % p-value
Child Minimum Dietary 
Diversity (≥ 4 of 7 groups) 46.07% 61.90% 43.06% 68.40% 9.51% 0.028
Maternal Minimum 
Dietary Diversity 
(≥ 5 of 9 groups)
28.09% 23.29% 30.06% 35.93% 10.67% 0.258
HAZ
-1.67 
(1.24)
-1.05 
(1.38)
-1.68 
(1.13)
-0.97 
(1.30)
0.090 
(0.148) 0.562
WAZ
-1.57 
(1.00)
-0.81 
(1.23)
-1.57 
(1.16)
-0.90 
(1.16)
-0.090 
(0.146) 0.557
WHZ
-0.95 
(0.95)
-0.37 
(1.20)
-0.93 
(1.18)
-0.58 
(1.13)
-0.223 
(0.173) 0.238
Maternal BMI
20.70 
(2.93)
22.09 
(3.96)
20.24 
(2.78)
22.53 
(3.70)
0.903 
(0.531) 0.133
Maternal Hemoglobin
12.13 
(1.66)
12.39 
(3.38)
12.22 
(1.42)
13.04 
(7.54) 
0.565 
(0.394) 0.195
Child Hemoglobin 9.85 (1.90) 11.45 
(10.06)
10.44 
(1.32)
11.36 
(9.87)
-0.679 
(0.512) 0.226
29
Table 1.3D: Secondary Outcomes: Dietary Diversity & Anthropometry for Respondents with 
Children Between 24-59.9 Months of Age
Outcomes
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean (SD) 
/ %
Mean (SD) 
/ %
Mean 
(SD) / %
Mean 
(SD) / %
Coefficient 
(SE) or % p-value
Child Minimum Dietary 
Diversity (≥ 4 of 7 groups) 50.90% 65.00% 64.49% 75.91% -2.68% 0.914
Maternal Minimum 
Dietary Diversity 
(≥ 5 of 9 groups)
25.09% 21.82% 26.07% 36.36% 13.56% 0.090
HAZ
-2.06 
(1.19)
-1.41 
(1.12)
-1.96 
(1.02)
-1.29 
(1.16)
0.011 
(0.161) 0.950
WAZ
-1.66 
(1.00)
-1.18 
(1.04)
1.78 
(0.91)
-1.18 
(0.98)
0.110 
(0.083) 0.230
WHZ
-0.66 
(0.99)
-0.53 
(1.21)
-0.94 
(0.91)
-0.68 
(1.06)
0.136 
(0.125) 0.310
Maternal BMI
20.56 
(2.61)
22.55 
(3.85)
20.50 
(2.93)
22.95 
(4.24)
0.461 
(0.604) 0.471
Maternal Hemoglobin
12.38 
(1.53)
12.34 
(1.35)
12.38 
(1.65)
12.37 
(1.57)
0.026 
(0.269) 0.925
Child Hemoglobin
10.92 
(1.93)
12.46 
(10.17)
11.27 
(1.37)
11.72 
(6.02)
-1.09 
(0.751) 0.191
Child Minimum Dietary Diversity: Child minimum dietary diversity is defined by children eating 
foods from at least 4 of the 7 food groups that make up the child dietary diversity score. This was 
calculated for children aged 6-59.9 months in the sample. Among children aged 6-23.9 months, 
we see evidence of differences in the prevalence of meeting minimum dietary diversity between 
the intervention and comparison districts at baseline and endline, with a 9.51 percentage point 
greater improvement in the intervention districts (p=0.028).
Maternal Minimum Dietary Diversity: Minimum dietary diversity for mothers was measured 
using the IDDS maternal dietary diversity score and is defined as intake of foods from at least 5 
of the 9 food groups. In the overall sample, we observe more improvements in the intervention 
districts compared to the comparison districts, with the Intervention districts improving 13.56 
percentage points more than the comparison districts (p=0.090) in the 24-59.9 age group.
Child HAZ: There were large differences in HAZ scores between baseline and endline in both 
intervention and comparison districts. For the overall sample, there was a reduction of 0.94 z￾scores in the intervention districts and 0.82 z-scores in the comparison districts. For children aged 
0-6 months, HAZ improved 0.761 z-scores more in the intervention districts than in the 
comparison districts (p=0.004). 
Child WAZ: There were large differences in WAZ scores between baseline and endline in both 
intervention and comparison districts. For the overall sample, there was no substantial difference 
in the reduction between the intervention and comparison districts; the intervention districts had 
a reduction of about 0.84 z-scores, and the comparison districts had a reduction of about 0.80 z￾scores.
30
Child WHZ: There were large differences in WHZ scores between baseline and endline in both 
intervention and comparison districts. For the overall sample, there was no substantial difference 
in the reduction between the intervention and comparison districts; the intervention districts had 
a reduction of about 0.34 z-scores, and the comparison districts had a reduction of about 0.41 z￾scores.
Maternal BMI: There were minor differences in maternal BMI between baseline and endline in 
both intervention and comparison districts. For the overall sample, there was no substantial 
difference between the intervention and comparison districts. The intervention districts had an 
average increased BMI of about 2.28 units, and the comparison districts had an average 
increased BMI of about 1.72 units.
Maternal Hemoglobin: There were minor differences in maternal hemoglobin between baseline 
and endline in both intervention and comparison districts. For the overall sample, there was no 
substantial difference between the intervention and comparison districts; the intervention districts 
had an average increased hemoglobin of about 0.48 g/dL, and the comparison districts had an 
average increased hemoglobin level of about 0.20 g/dL.
Child Hemoglobin: There were minor differences in child hemoglobin between baseline and 
endline in both intervention and comparison districts. For the overall sample, there was no 
substantial difference between the intervention and comparison districts; the intervention districts 
had an average increased hemoglobin of about 0.48 g/dL, and the comparison districts had an 
average increased hemoglobin level of about 1.17 g/dL.
Secondary Outcomes: Child Nutrition Practices
The results for the secondary outcomes around child nutrition practices for the overall samples 
are listed in Table 4A. Tables 4B-D present the data disaggregated by child age groups: 0-5.9 
months, 6-23.9 months, and 24-59.9 months. Descriptive data about prevalence of outcomes at 
baseline and endline are presented as percentages for binary outcomes and means with standard 
deviations for continuous outcomes. Difference-in-difference analyses were conducted to assess 
the strength of the variations between outcomes at baseline and endline between the comparison 
and intervention districts. The differences are presented in percentage points for binary outcomes 
and coefficients with standard errors for continuous outcomes, and p-values are noted for all. The 
outcomes with evidence of effects are highlighted in red font.
Table 1.4A: Secondary Outcomes: Child Nutrition Practices for the Overall Sample
Secondary Outcomes: 
Child Nutrition 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / % % p-value
Exclusive breastfeeding 
(0-5.9mo only) 57.27% 57.61% 50.00% 60.00% 9.66% 0.422
Early initiation of 
breastfeeding (0-24mo 
only)
46.57% 67.00% 35.01% 67.33% 11.89% 0.307
31
Introduction of 
complementary feeding 
(6-23.9mo only)
18.70% 28.48% 12.12% 32.20% 10.30% 0.154
Sick child feeding 
(among children who had 
illness)
25.07% 31.38% 15.56% 32.44% 10.57% 0.025
Minimum meal frequency 
(6-23.9 month only) 78.93% 80.95% 66.76% 83.83% 15.05% 0.004
Minimum acceptable diet 
(6-23.9 month only) 39.33% 48.13% 32.28% 55.43% 14.35% 0.022
Table 1.4B: Secondary Outcomes: Child Nutrition Practices for Respondents with Children 
Between 0-5.9 Months of Age
Secondary Outcomes: 
Child Nutrition 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / % % p-value
Exclusive breastfeeding 57.27% 57.61% 50.00% 60.00% 9.66% 0.422
Early initiation of 
breastfeeding 49.09% 68.05% 29.67% 64.90% 16.27% 0.190
Sick child feeding 
(among children who had 
illness)
28.95% 24.39% 16.13% 26.67% 15.10% 0.281
Table 1.4C: Secondary Outcomes: Child Nutrition Practices for Respondents with Children 
Between 6-23.9 Months of Age
Secondary Outcomes: 
Child Nutrition 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / % % p-value
Early initiation of 
breastfeeding 45.79% 66.67% 36.42% 67.96% 10.66% 0.366
Introduction of 
complementary feeding 18.70% 28.48% 12.12% 32.20% 10.30% 0.154
Sick child feeding 
(among children who had 
illness)
28.95% 34.39% 12.59% 34.77% 16.74% 0.002
Minimum meal frequency 78.93% 80.95% 66.76% 83.83% 15.05% 0.004
Minimum acceptable diet 39.33% 48.13% 32.28% 55.43% 14.35% 0.022
32
Table 1.4D: Secondary Outcomes: Child Nutrition Practices for Respondents with Children 
Between 24-59.9 Months of Age
Secondary Outcomes: 
Child Nutrition 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean (SD) 
/ % % p-value
Sick child feeding 
(among children who had 
illness)
21.77% 26.83% 17.92% 26.15% 3.17% 0.698
Exclusive breastfeeding: Exclusive breastfeeding was defined as feeding the infant only breast 
milk until the child is 6 months of age and was measured only among children in the sample who 
were younger than six months of age. Descriptively, a moderate increase (10%) in the prevalence 
of children being exclusively breastfed was observed in the intervention districts from baseline to 
endline, while this prevalence remained almost identical at baseline and endline in the comparison 
districts. The p-value for the difference in differences between intervention and comparison 
districts was 0.422, and therefore there was no evidence of impact.
Early initiation of breastfeeding: This outcome was defined as the initiation of breastfeeding 
within one hour of birth and was measured only among children in the sample who were younger 
than 24 months of age. For the overall sample, there was an increase of about 20 percentage 
points for the comparison district and 32 percentage points for the comparison district between 
baseline and endline. The difference in differences, however, had p-value of 0.307.
Introduction to complementary feeding: This outcome was defined by the introduction of all 
types of complementary foods during the appropriate age window of 6 to 8.9 months. For the 
overall sample, there was an increase of about 10 percentage points for the comparison district 
and 20 percentage points for the comparison district. The difference in differences, however, had 
a p-value of 0.154.
Sick child feeding: This outcome was defined as offering more food than usual during the child’s 
illness and was only measured among children who had an illness in the two weeks prior to data 
collection. The difference in differences for the overall sample was 10.57 percentage points 
(p=0.025), providing plausible evidence of the positive impact of Suaahara interventions on this 
outcome. This effect was largest for children aged 6-23.9 months with a difference in differences 
of 16.74 percentage points (p=0.002).
Minimum meal frequency: Minimum meal frequency was defined as consuming solid, semi￾solid, or soft foods at least the minimum number of times in the previous day and was assessed 
only for children aged 6 to 24 months. Within this sample, the difference in differences for having 
an appropriate minimum meal frequency was 15.05 percentage points (p=0.004), which provides 
plausible evidence of the positive impact of Suaahara interventions on this outcome.
Minimum acceptable diet: Minimum acceptable diet, consuming minimum dietary diversity and 
minimum meal frequency in the previous day, was assessed only for children aged 6 to 23.9 
months. Within this sample, the difference in differences for having an appropriate minimum 
33
acceptable diet was 14.35 percentage points (p=0.022), which provides plausible evidence of the 
positive impact of Suaahara interventions on this outcome.
Secondary Outcomes: Health & WASH Practices
The results for the secondary outcomes around health and WASH practices for the overall sample 
are listed in Table 5A. Tables 5B-D present the data disaggregated by child age groups: 0-5.9 
months, 6-23.9 months, and 24-59.9 months. Descriptive data about prevalence of outcomes at 
baseline and endline are presented as percentages for binary outcomes and means with standard 
deviations for continuous outcomes. Difference-in-difference analyses were conducted to assess 
the strength of the variations between outcomes at baseline and endline between the comparison 
and intervention districts. The differences are presented in percentage points for binary outcomes 
and coefficients with standard errors for continuous outcomes, and p-values are noted for all. The 
outcomes with evidence of effects are highlighted in red font.
Table 1.5A: Secondary Outcomes: Health & WASH Practices for the Overall Sample
Secondary Outcomes: 
Health & WASH 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean
(SD) / % % p-value
Adequate antenatal care 
(0-23.9 month only) 62.88% 85.82% 69.34% 91.94% -0.34% 0.485
Adequate postnatal care 
(0-23.9 month only) 14.38% 24.31% 17.16% 34.71% 7.62% 0.300
IFA supplementation (0-
23.9 month only) 38.63% 56.15% 35.93% 58.45% 5.00% 0.557
Modern family planning 33.57% 35.40% 38.96% 35.81% -4.98% 0.405
Institutional delivery (0-
23.9 month only) 48.93% 81.18% 42.76% 90.49% 15.48% 0.074
Handwashing station with 
soap and water 40.51% 80.08% 34.77% 88.29% 13.95% 0.067
Handwashing at 6 critical 
times (mothers) N/A 23.31% N/A 23.06% -0.25% 0.980
Appropriate drinking 
water treatment methods 
(observation)
5.69% 21.13% 5.78% 28.23% 7.01% 0.371
Table 1.5B: Secondary Outcomes: Health & WASH Practices for Respondents with Children 
Between 0-5.9 Months of Age
Secondary Outcomes: 
Health & WASH 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / % % p-value
Adequate antenatal care 59.09% 85.96% 72.53% 93.20% -6.20% 0.718
Adequate postnatal care 13.64% 25.51% 20.88% 39.05% 6.30% 0.834
IFA supplementation 36.36% 52.67% 32.97% 58.85% 9.57% 0.337
Modern family planning 1.82% 11.93% 14.29% 17.14% -7.26% 0.051
Institutional delivery 53.64% 85.19% 57.47% 90.95% 1.93% 0.487
34
Handwashing station with 
soap and water 37.61% 79.25% 31.11% 87.62% 14.87% 0.034
Handwashing at 6 critical 
times (mothers) N/A 20.58% N/A 19.52% -1.06% 0.910
Appropriate drinking 
water treatment methods 
(observation)
4.55% 22.22% 5.49% 25.71% 3.49% 0.990
Table 1.5C: Secondary Outcomes: Health & WASH Practices for Respondents with Children 
Between 6-23.9 Months of Age
Secondary Outcomes: 
Health & WASH 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / % % p-value
Adequate antenatal care 64.04% 85.77% 68.50% 91.61% 1.38% 0.429
Adequate postnatal care 14.61% 23.94% 16.18% 33.58% 8.07% 0.210
IFA supplementation 39.33% 57.24% 36.71% 58.34% 3.72% 0.655
Modern family planning 27.91% 40.28% 32.93% 39.88% -5.42% 0.294
Institutional delivery 47.47% 79.92% 39.00% 90.37% 18.92% 0.048
Handwashing station with 
soap and water 43.94% 80.00% 36.71% 88.86% 16.09% 0.081
Handwashing at 6 critical 
times (mothers) N/A 24.58% N/A 23.09% -1.49% 0.870
Appropriate drinking 
water treatment methods 
(observation)
5.34% 20.85% 8.09% 30.00% 9.15% 0.911
Table 1.5D: Secondary Outcomes: Health & WASH Practices for Respondents with Children 
Between 24-59.9 Months of Age
Secondary Outcomes: 
Health & WASH 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / % % p-value
Modern family planning 44.10% 44.09% 46.77% 38.64% -8.12% 0.391
Handwashing station with 
soap and water 38.88% 81.28% 34.19% 86.82% 10.23% 0.049
Handwashing at 6 critical 
times (mothers) N/A 21.82% N/A 26.36% 4.54% 0.699
Appropriate drinking 
water treatment methods 
(observation)
6.14% 20.91% 4.46% 24.09% 3.18% 0.351
Adequate antennal care (ANC): Adequate ANC was defined as a mother having at least four or 
more antenatal care visits during pregnancy prior to delivery. For the overall sample of mothers 
with children 0 to 23.9 months, there was an increase of about 23 percentage points for both 
intervention and comparison districts between baseline and endline, but there was no difference 
in this increase between the intervention and comparison districts.
35
Adequate postnatal care (PNC): Adequate PNC was defined as a mother having at least three 
postnatal care visits in the week after delivery. For the overall sample of mothers with children 0 
to 23.9 months, there was an increase of about 10 percentage points for the comparison districts 
and 18 percentage points for the intervention districts between baseline and endline. The p-value 
for the difference between intervention and comparison districts was 0.300, so no evidence of 
impact.
Iron Folic Acid (IFA) supplementation: Appropriate IFA was defined as a mother taking IFA 
supplementation tablets for at least 180 days during her pregnancy. For the overall sample, there 
was an increase of about 18 percentage points for the comparison district and 23 percentage 
points for the intervention comparison district between baseline and endline. The p-value for the 
difference between intervention and comparison districts was 0.557, so no evidence of impact.
Modern family planning: The use of modern family planning methods was defined as using 
female sterilization, male sterilization, IUCD, implants, injectable, pills, or condoms. Among 
mothers of children aged 0-5.9 months, the difference in differences was -7.26 percentage points 
(p=0.051), indicating a reduction in the use of modern family planning among mothers with babies 
in this age group in the intervention districts relative to the comparison districts.
Institutional delivery: This outcome was defined as the delivery of the child at a health facility. 
The increase in institutional delivery was larger in the intervention districts, with a difference in 
differences for the overall sample of 15.5 percentage points (p=0.074); among mothers of children 
aged 6-23.9 months the difference-in-differences result was even larger. 18.92 percentage points 
(p=0.048). That is, the increase in institutional delivery was larger in the intervention than 
comparison districts.
Handwashing stations with soap and water: This outcome was measured by observation. The 
availability of handwashing stations with soap and water doubled or more in both the comparison 
and intervention districts. The difference was larger in the intervention district, and the difference 
in differences for the overall sample was 13.95 percentage points (p=0.067). The difference in 
differences was 14.87 percentage points (p=0.034) for mothers of children aged 0-5.9 months, 
16.09 percentage points (p=0.081) for mothers of children aged 6-23.9 months, and 10.23 
percentage points (p=0.049) for mothers of children aged 24-59.9 months. That is, the increase 
in handwashing stations with soap and water was larger in the intervention than comparison 
districts.
Handwashing at 6 critical times: This outcome was measured as mothers’ practicing 
handwashing at six critical times. The baseline survey did not have data around handwashing at
all critical times; at endline, there was no difference between the comparison and intervention 
districts, with about 1 in 4 mothers in the sample practicing handwashing at 6 critical times.
Appropriate drinking water treatment methods at all times: Appropriate treatment methods 
for drinking water were defined as boiling, adding bleach or chlorine, using a water filter (ceramic, 
sand, and composite), or using solar disinfection (Sodis method); this was measured as a 
household always engaging in these appropriate methods, without the use of any inappropriate 
treatment methods. This practice increased from baseline to endline in both the comparison and 
intervention districts, but the difference in differences had p-value of 0.371.
36
Secondary Outcomes: Knowledge of Nutrition, Health, and WASH Practices
The results for the secondary outcomes around maternal knowledge of nutrition, health, and 
WASH practices for the overall samples are listed in Table 6A. Tables 6B-D present the data 
disaggregated by child ages and are separated into the following groups: children between the 
ages of 0-5.9 months, 6-23.9 months, and 24-59.9 months. Descriptive data about prevalence of 
outcomes at baseline and endline are presented as percentages for binary outcomes and means 
with standard deviations for continuous outcomes. Difference-in-difference analyses were 
conducted to assess the strength of the variations between outcomes at baseline and endline 
between the comparison and intervention districts. The differences are presented in percentage 
points for binary outcomes and coefficients with standard errors for continuous outcomes, and p￾values are noted for all. The outcomes with evidence of effects are highlighted in red font.
Table 1.6A: Secondary Outcomes: Knowledge of Nutrition, Health and WASH Practices for the 
Overall Sample
Secondary Outcomes: 
Knowledge of Nutrition, 
Health, and WASH 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / % % p-value
Knowledge of key nutrition/IYCF behaviors (among mothers)
Exclusive 
breastfeeding N/A 73.23% N/A 86.61% 13.38% 0.014
Early initiation of 
breastfeeding N/A 85.65% N/A 85.97% 0.32% 0.948
Introduction of 
complementary 
feeding
21.67% 49.35% 32.65% 51.69% -8.64% 0.476
Sick child feeding 
(offering more food 
during illness)
37.65% 44.52% 39.02% 55.89% 10.00% 0.488
Knowledge of key health behaviors (among mothers)
Adequate antenatal 
care
N/A 66.29% N/A 74.35% 8.06% 0.266
Adequate postnatal 
care
N/A 20.73% N/A 25.40% 4.67% 0.397
IFA supplementation N/A 75.97% N/A 80.48% 4.51% 0.405
Modern family planning N/A 98.71% N/A 99.35% 0.64% 0.188
Knowledge of key WASH behaviors (among mothers)
Handwashing at 6 
critical times N/A 6.05% N/A 12.98% 6.93% 0.094
Appropriate drinking 
water treatment 
methods
N/A 94.52% N/A 97.82% 3.30% 0.214
37
Table 1.6B: Secondary Outcomes: Knowledge of Nutrition, Health, and WASH Practices for 
Respondents with Children Between 0-5.9 Months of Age
Secondary Outcomes: 
Knowledge of Nutrition, 
Health, and WASH 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / % % p-value
Knowledge of key nutrition/IYCF behaviors (among mothers)
Exclusive 
breastfeeding N/A 75.31% N/A 85.71% 10.40% 0.278
Early initiation of 
breastfeeding N/A 87.65% N/A 85.71% -1.94% 0.745
Introduction of 
complementary 
feeding
21.82% 48.97% 37.36% 48.10% -16.41% 0.296
Sick child feeding 
(offering more food 
during illness)
38.18% 48.97% 43.96% 54.76% 0.01% 0.993
Knowledge of key health behaviors (among mothers)
Adequate antenatal 
care
N/A 68.72% N/A 72.86% 4.14% 0.139
Adequate postnatal 
care
N/A 22.63% N/A 25.24% 2.61% 0.571
IFA supplementation N/A 77.37% N/A 81.90% 4.53% 0.443
Modern family planning N/A 98.35% N/A 100% 1.65% --
Knowledge of key WASH behaviors (among mothers)
Handwashing at 6 
critical times N/A 5.35% N/A 10.95% 5.60% 0.176
Appropriate drinking 
water treatment 
methods
N/A 97.12% N/A 96.67% -0.45% 0.876
Table 1.6C: Secondary Outcomes: Knowledge of Nutrition, Health, and WASH Practices for 
Respondents with Children Between 6-23.9 Months of Age
Secondary Outcomes: 
Knowledge of Nutrition, 
Health, and WASH 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / % % p-value
Knowledge of key nutrition/IYCF behaviors (among mothers)
Exclusive 
breastfeeding N/A 72.07% N/A 85.80% 13.73% 0.007
Early initiation of 
breastfeeding N/A 85.59% N/A 87.16% 1.57% 0.719
Introduction of 
complementary 
feeding
22.75% 50.84% 36.99% 52.59% -12.49% 0.374
Sick child feeding 
(offering more food 
during illness)
39.61% 44.02% 54.76% 56.42% -2.75% 0.445
Knowledge of key health behaviors (among mothers)
38
Adequate antenatal 
care
N/A 66.67% N/A 74.81% 8.14% 0.196
Adequate postnatal 
care
N/A 20.59% N/A 26.91% 6.32% 0.277
IFA supplementation N/A 77.61% N/A 82.22% 4.61% 0.411
Modern family planning N/A 98.71% N/A 99.26% 0.55% 0.381
Knowledge of key WASH behaviors (among mothers)
Handwashing at 6 
critical times N/A 5.79% N/A 13.21% 7.42% 0.053
Appropriate drinking 
water treatment 
methods
N/A 94.47% N/A 98.27% 3.80% 0.080
Table 1.6D: Secondary Outcomes: Knowledge of Nutrition, Health, and WASH Practices for 
Respondents with Children Between 24-59.9 Months of Age
Secondary Outcomes: 
Knowledge of Nutrition, 
Health, and WASH 
Practices
Comparison Districts Intervention Districts Difference in 
Baseline Endline Baseline Endline differences
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / %
Mean 
(SD) / % % p-value
Knowledge of key nutrition/IYCF behaviors (among mothers)
Exclusive 
breastfeeding N/A 75.00% N/A 90.45% 15.45% 0.001
Early initiation of 
breastfeeding N/A 83.64% N/A 81.82% -1.82% 0.787
Introduction of 
complementary 
feeding
20.94% 44.55% 29.33% 51.82% -1.12% 0.813
Sick child feeding 
(offering more food 
during illness)
36.28% 41.36% 37.39% 55.00% 12.53% 0.309
Knowledge of key health behaviors (among mothers)
Adequate antenatal 
care
N/A 62.27% N/A 74.09% 11.82% 0.089
Adequate postnatal 
care
N/A 19.09% N/A 20.00% 0.91% 0.898
IFA supplementation N/A 68.64% N/A 72.73% 4.09% 0.497
Modern family planning N/A 99.09% N/A 99.09% 0.00% >0.999
Knowledge of key WASH behaviors (among mothers)
Handwashing at 6 
critical times N/A 7.73% N/A 14.09% 6.36% 0.303
Appropriate drinking 
water treatment 
methods
N/A 91.82% N/A 97.27% 5.45% 0.149
Knowledge of exclusive breastfeeding: Data around knowledge of exclusive breastfeeding 
were not available in the baseline survey, and the data collected at endline are presented. At 
endline, the difference in differences for knowledge of exclusive breastfeeding for the overall 
sample was 13.38 percentage points (p=0.014), with a difference in differences of 13.73 
percentage points (p=0.007) for mothers of children aged 6-23.9 months and 15.45 percentage 
points (p=0.001) for mothers of children aged 24-59.9 months. That is, knowledge about 
exclusive breastfeeding improved more in the intervention than comparison districts.
39
Knowledge of early initiation of breastfeeding: Data around knowledge of early initiation of 
breastfeeding was not available in the baseline survey, and the data collected at endline are 
presented. At endline, the prevalence of knowledge around early initiation of breastfeeding was 
almost identical for the comparison and intervention districts in the overall sample.
Knowledge of introduction of complementary feeding: Knowledge of complementary feeding 
increased substantially from baseline to endline for both the comparison and intervention districts. 
For the overall sample, there was an increase of about 28 percentage points for the comparison 
districts and 19 percentage points for the intervention comparison districts. The difference in 
differences, however, had p-value of 0.476. meaning that the increase in knowledge of 
complementary feeding was not different between intervention and comparison districts.
Knowledge of sick child feeding: There was evidence of differences in knowledge of sick child 
feeding between baseline and endline in both intervention and comparison districts. For the 
overall sample, there was an increase of about 11 percentage points for both intervention and 
comparison districts.
Knowledge of adequate ANC: Data around knowledge of adequate ANC were not available in 
the baseline survey, and the data collected at endline are presented. At endline, the prevalence 
of knowledge around ANC was similar for the comparison and intervention districts in the overall 
sample, with 68.72% of the comparison districts and 72.86% of the intervention districts having 
knowledge around adequate ANC.
Knowledge of adequate PNC: Data around knowledge of adequate PNC were not available in 
the baseline survey, and the data collected at endline are presented. At endline, the prevalence 
of knowledge around PNC was similar for the comparison and intervention districts in the overall 
sample, with 22.63% of the comparison district and 25.24% of the intervention district having 
knowledge around adequate PNC.
Knowledge of adequate IFA supplementation: Data around knowledge of IFA supplementation 
were not available in the baseline survey, and the data collected at endline are presented. At 
endline, the prevalence of knowledge around PNC was high and similar for the comparison and 
intervention districts in the overall sample, with 77.37% of the comparison districts and 81.90% of 
the intervention districts having knowledge around adequate IFA supplementation.
Knowledge of modern family planning: Data around knowledge of modern family planning 
were not available in the baseline survey, and the data collected at endline are presented. At 
endline, the prevalence of knowledge around modern family planning was high and similar for the 
comparison and intervention districts in the overall sample, with 98.35% of the comparison district 
and 100% of the intervention district having knowledge around modern family planning.
Knowledge of handwashing at 6 critical times: Data around knowledge of handwashing at 6 
critical times were not available in the baseline survey, and the data collected at endline are 
presented. At endline, the difference in differences for mothers’ knowledge of handwashing at 6 
critical times was 7.42 percentage points (p=0.053) for mothers of children aged 6-23.9 months, 
meaning that the knowledge in the intervention districts was greater than in the comparison 
districts. The difference in differences had high p-values for the overall sample and other age 
categories.
40
Knowledge of appropriate drinking water treatment methods: Data around knowledge of 
appropriate drinking water treatment methods were not available in the baseline survey, and the 
data collected at endline are presented. At endline, the prevalence of knowledge around drinking 
water treatment was high and similar for the comparison and intervention districts in the overall 
sample, with 94.52% of the comparison districts and 97.82% of the intervention districts having 
this knowledge.
Results for Impact Stratified by Wealth and Caste
Because tabulating all the results of outcomes stratified by wealth and caste would require 
enumerating about 7,500 values, we instead summarize by stratum the outcomes that changed 
differently in intervention than comparison districts.
Analysis by Wealth
These outcomes changed (i.e., increased or decreased) more in intervention than comparison 
districts in the high-wealth category but not in the low-wealth category:
● Child dietary diversity score increased in the 6-23.9 month group 
● Child wasting decreased in the full sample 
● Child anemia increased in the 6-23.9 month group 
● Maternal anemia decreased in the 0-5.9 month group
● Child minimum dietary diversity improved in the 6-23.9 month group
● Child HAZ increased in the 0-5.9 month group
● Child sick feeding increased in the overall sample
● Child minimum diet increased in the overall sample
● IFA supplementation increased in the 0-5.9 month group
● Modern family planning increased in the 0-5.9 month group
● Institutional delivery increased in the 6-23.9 month group
● Knowledge of adequate ANC increased in the overall sample and in the 24-59.9 month 
group
● These outcomes improved more in intervention than comparison districts in the low-wealth 
category but not in the high-wealth category:
● Child hemoglobin in the 24-59.9 month group
● Women’s BMI for the overall sample and the 6-23.9 month group
● Handwashing station with soap and water for the overall sample and all the age groups 
41
● Knowledge of handwashing at six critical times in the overall sample and 6-23.9 month 
group
● Knowledge of appropriate water treatment methods in the 24-59.9 month group
Other outcomes did not have differential changes by wealth category.
Analysis by Caste
The following outcomes improved more in intervention than comparison districts in the socially 
disadvantaged castes category but not in the non-socially disadvantaged castes:
● Stunting in the 24-59.9 month group
● Child underweight in 24-59.9 month group
● Child anemia 6-23 month group
● Maternal underweight of mother with children 0-5.9 month and 6-23.9 month group
● Child WAZ in the 0-5.9 month group
● Exclusive breastfeeding in the overall sample
● Sick child feeding in the overall sample
● Child minimum meal frequency of the overall sample and 6-23.9 months group
● Modern family planning in the 24-59.9 month group
● 4 ANC during pregnancy in the overall sample
● Handwashing with soap and water in the 0-5.9 month group and 6-23.9 month group
The following outcomes improved more in intervention than comparison districts in the non￾socially disadvantaged castes but not in the socially disadvantaged castes:
● Women’s dietary diversity score in the 6-23.9 month group
● Stunting in the 6-23.9 month group
● Child anemia in the 24-59.9 month group
● Maternal underweight in the overall sample
● Child WAZ in the 0-5.9 month group 
● Child WHZ in the 24-59.9 month group
● Women’s BMI in the overall sample and the 6-23.9 month group
● Introduction to complementary feeding in the overall sample and 6-23.9 month group
● Modern family planning in the 0-5.9 month group
● Introduction to complementary feeding in the overall sample
● Introduction to complementary feeding in the 6-23.9 month group
42
● Sick child feeding in the 6-23.9 month group
● Handwashing with soap and water in the overall sample
Other outcomes did not have differential improvements by caste category.
Discussion 
The data from this evaluation demonstrate substantial impacts on multiple child and maternal 
outcomes plausibly attributable to the Suaahara interventions. The intervention districts, relative 
to comparison districts, reduced maternal underweight, consistent with improvements in maternal 
and fetal condition that were manifested in the early post-natal period as greater linear size of the 
young infant 0 to 5.9 months. Complementary feeding practices with children between 6 and 23.9 
months of age improved more in intervention districts than comparison districts, including child 
dietary diversity, sick child feeding, minimum meal frequency, and minimum acceptable diet. 
These improvements are consistent with the content and focus of the Suaahara’s interventions
on enhancing child nutrition for this age group through improving infant and young child feeding 
practices. 
Several outcomes had improvements in both intervention and comparison districts, aligning with 
the general trends in the population in Nepal over the past ten years. For example, stunting 
reduced in both arms from baseline to endline from about 40% to 20%, a large reduction of about 
2 percentage points per year. Other data support this trend in the reduction of stunting in children 
under five over the past decade as well as secular changes in other maternal and child metrics. 
For example, comparing the Nepal DHS surveys in 2016 and 2022, stunting, underweight, and 
wasting were reduced from 36% to 25%, 27% to 19%, and 10% to 8%, respectively, from 2016 
to 2022. Exclusive breastfeeding was reduced from 66% to 56% during the same period. Children 
having minimum dietary diversity increased from 47% to 78%, and the prevalence of anemia in 
women of reproductive age went from 41% to 34%. Similar secular trends have been observed 
in other countries. For example, during the first phase of Alive & Thrive in Bangladesh, exclusive 
breastfeeding [4] and complementary feeding [5] improved more in intensive (i.e., intervention) 
sub-districts than in non-intensive (i.e., comparison) sub-districts but child stunting prevalence 
was reduced in both intervention and comparison sub-districts, reflecting the underlying secular 
trend in improved child linear growth.
The exploratory analyses by wealth and caste showed that differences between intervention and 
comparison districts can depend on wealth and caste categories. The patterns of these 
dependencies were inconsistent and difficult to interpret, however, and this evaluation study was 
not designed to provide confirmatory conclusions about such dependencies on conditions. 
Therefore, this report does not provide interpretations or programmatic implications for the 
patterns of results from these exploratory analyses. These exploratory results may suggest 
opportunities for further research into conditions that enable improved outcomes.
In summary, Suaahara improved mother’s lives as manifested by improved maternal dietary 
diversity, weight, and rate of institutional delivery. Possibly reflecting improved prenatal 
conditions, the length of infants 0-5.9 months improved. Complementary feeding of infants and 
43
young children ages 6 to 23.9 months improved as reflected in improved dietary diversity, 
minimum acceptable diet, minimum meal frequency, and offering children more food when sick. 
Availability of soap and water at handwashing stations improved. These improvements in 
intervention districts relative to comparison districts were demonstrated with plausible evidence 
despite the substantial challenges that Nepal and Suaahara faced during the ten years between 
baseline (2012) and endline (2022) and the limitations in statistical power that resulted from the 
small number of districts that then could be included in the evaluation study.
44
References
1. Houston, R., Shresha, M.B., Pomeroy, A., Wun, J., Sharma, I., 2014. Pathways To Better 
Nutrition Case Study: Nepal Strategic Background Report. Arlington, VA.
2. Amrhein V, Greenland S, McShane B. Scientists rise up against statistical significance. 
Nature 2019;567:305–7.
3. Wasserstein RL, Schirm AL, Lazar NA. Moving to a World Beyond “p<0.005". Am Statist 
2019;73:1–19.
4. Menon P, Nguyen PH, Saha KK, Khaled A, Kennedy A, Tran LM, Sanghvi T, Hajeebhoy N, 
Baker J, Alayon S, Afsana K, Haque R, Frongillo EA, Ruel MT, Rawat R. Impacts on 
breastfeeding practices of at-scale strategies that combine intensive interpersonal 
counseling, mass media, and community mobilization: Results of cluster-randomized 
program evaluations in Bangladesh and Vietnam. PLoS Medicine 13:e1002159, 2016.
5. Menon P, Nguyen PH, Saha KK, Khaled A, Sanghvi T, Baker J, Afsana K, Haque R, 
Frongillo EA, Ruel MT, Rawat R. Combining intensive counseling by frontline workers with a 
nationwide mass media campaign has large differential impacts on complementary feeding 
practices but not on child growth: Results of a cluster-randomized program evaluation in 
Bangladesh. Journal of Nutrition 146:2075-84, 2016.
45
Part 2 – Evaluating Intermediate Results –
Increased use of quality nutrition and health 
services by women and children (IR2)
Analysis of end-line surveys of health facilities and Female 
Community Health Volunteers
Principal Investigator: Edward A. Frongillo, University of South Carolina, USA
Evaluation Research Team: Deependra Thapa, Independent Consultant
Shalini Suresh, Independent Consultant
46
Executive Summary
Suaahara’s primary aim is to reduce the prevalence of stunting, wasting, and underweight among 
children under 5 years of age and to reduce the prevalence of anemia among women of 
reproductive age and children 6-59 months of age. The program uses multiple sectors to achieve 
four key intermediate results: (1) improved household nutrition, sanitation, and health behaviors; 
(2) increased use of quality nutrition and health services by women and children; (3) improved 
access to diverse and nutrient-rich foods by women and children; and (4) accelerated roll-out of 
the MSNP through strengthened local governance. Suaahara interventions span health and family 
planning, nutrition, agriculture/homestead food production, and water, sanitation, and hygiene. 
This report focuses on the second intermediate results related to the quality nutrition and health 
services from the health system perspective. In line with the program impact pathway of 
Suaahara, the evaluation at the health system level aimed to assess the impact of Suaahara
interventions on improving quality health and nutrition services, which was measured in terms of 
improved capacity building (knowledge and skills of health facility workers and FCHVs), and 
increased availability of health, nutrition, and family planning services at facility and community 
level.
The endline evaluation included a quantitative quasi-experimental design where data were 
collected from four intervention (Darchula, Syangja, Rupandehi, and Sindhupalchowk) and four 
pair-matched comparison (Jumla, Tanahu, Chitwan, and Ramechhap) districts employing a multi￾stage cluster sampling. One health facility from each of the survey clusters (altogether 40 health 
facilities) and one FCHV per (old) (ward (altogether 120 FCHVs) were included in the survey. 
Although the overall evaluation included a quasi-experimental design, the health system 
component of the evaluation was a cross-sectional comparative. Surveys were administered 
using an android version of the ODK programming for Computer Assisted Personal Interview 
(CAPI) by trained field researchers. Composite indices for different indicators for capacity building 
and service delivery were developed. Regression models appropriate for each outcome variable 
were used to compare between intervention and comparison districts and estimate the effect of 
Suaahara interventions. These models accounted for clustering at the district level to address the 
variation among the sample districts.
Health facility workers and FCHVs in the intervention districts reported better knowledge on CB￾IMCI, and GMP than in comparison districts. Although the score was higher in the intervention 
districts for both health facility workers and FCHVs, the differences between the intervention and 
comparison districts were not estimated confidently on the number of health and nutrition training 
received and knowledge on IYCF, maternal health and family planning. In terms of improved 
service delivery, the mean scores for service availability were higher in the intervention districts 
for maternal nutrition services, child nutrition services, ANC services, and FP services. Health 
facilities in intervention districts, compared to comparison districts, had better availability and use 
of reference materials and guidelines for GMP service, and counseling aids to provide nutrition 
assessment and GMP, FP, ANC, and PNC services. The differences were not important in the 
availability of PNC services, and availability and use of reference materials and counseling aids 
for FP, ANC, and PNC services. FCHVs in the intervention districts more often reported providing 
GMP services and had better availability of job aids and BCC materials on nutrition counseling. A 
47
higher proportion of FCHVs from the intervention districts (36% vs. 4%) mentioned implementing 
the Self-Applied Technique for Health (SATH) approach in the mother groups they facilitate.
Suaahara interventions contributed to strengthen the health system across the two components 
(capacity building and improved quality service delivery). Both health workers and FCHVs in the 
intervention districts received training in a higher number of topics and had better knowledge on 
GMP, CB-IMNCI and identifying malnourished children. Impacts of the Suaahara interventions 
were observed in improving service delivery as the scores for the availability and delivery of 
services for maternal nutrition, GMP, ANC, and FP, as well as the availability and use of reference 
materials and guidelines and counseling aids were better in the Suaahara intervention facilities.
Introduction
Helen Keller International in partnership with different international, national, and local level 
organizations have implemented the Suaahara II program in 42 districts of Nepal from 2016 to 
2023. Suaahara II is the continuation of the first phase of the Suaahara program implemented 
from 2011- to 2015. Suaahara is a USAID funded multisectoral nutrition program with an overall 
aim of reducing undernutrition among women and children, particularly those in the 1000-day 
period between conception and a child’s second birthday, with a special focus on poor and 
marginalized communities. Suaahara works closely with the government stakeholders to 
strengthen programs and policies to improve the health and nutritional status of women and 
children. The program has employed a multi-sectoral approach across four key intermediate 
results (IRs) themes: 
(1) improved household nutrition, sanitation and health behaviors;
(2) increased use of quality nutrition and health services by women and children;
(3) improved access to diverse and nutrient rich foods by women and children; and 
(4) accelerated roll-out of the Multi-sectoral Nutrition Plan (MSNP) through strengthened local 
governance.
This report focuses on the second intermediate results related to the quality nutrition and health 
services. The program worked within the government system, primarily through community health 
workers in local health facilities and Female Community Health Volunteers (FCHVs). The program 
aimed to improve the capacity of these frontline health workers, as well as overall health system 
to disseminate health and nutrition messages and provide quality health and nutrition services at 
the household, community, and health facility level.
An independent research group carried out the endline impact evaluation of the Suaahara II
interventions in April – December 2022. As a part of the endline impact evaluation of the Suaahara 
program, surveys with health workers and FCHVs were conducted. 
48
Objectives and Evaluation Questions
The evaluation of Suaahara at the health system level aimed to assess the impact of Suaahara
interventions on strengthening the health system in providing quality health and nutrition services. 
In line with the program impact pathway for Suaahara, the assessment looked at the contribution 
of Suaahara to improve quality of nutrition and health services, which has been measured in terms 
of improved knowledge and skills of health facility workers and FCHVs on health and nutrition, 
and increased availability of health, nutrition, and family planning services at facility and 
community level. 
Overall Evaluation Question
What is the impact of Suaahara in strengthening health and nutrition services at local health 
system?
Sub-questions
1. To what extent is Suaahara successful in building the capacity of the health facility workers 
and FCHVs?
2. What is the effect of Suaahara on delivering improved nutrition, health, and family planning 
services at local health facilities?
Evaluation Method
Design
The endline evaluation included a quantitative quasi-experimental design where data were 
collected from four intervention (Darchula, Syangja, Rupandehi, and Sindhupalchowk) and four 
comparison (Jumla, Tanahu, Chitwan, and Ramechhap) districts employing a multi-stage cluster 
sampling.
49
Figure 2. Intervention and comparison districts selected for the survey
Although the overall evaluation included a quasi-experimental design, the health system 
component of the evaluation was a cross-sectional comparative –compared intervention districts 
with pair-matched comparison districts at endline only, as the baseline survey did not include 
survey with health facility workers.
Participants and Sample Size
Health facility workers and FCHVs from the same wards where the household surveys were 
conducted were chosen as survey respondents for the endline evaluation at the health systems 
level. Each survey cluster (VDC) has only one health facility. Therefore, a total of 40 health 
facilities (Primary Health Care Centers and Health Posts) from each of the 40 sample VDCs were 
included in the survey (5 VDCs X 8 districts), which were divided evenly between intervention and 
comparison districts). One FCHV per old ward was included in the survey. Most wards had only 
one FCHV but if a ward had more than one FCHV, an FCHV was randomly selected by the field 
supervisors using a lottery method. The sample included 40 health facility workers and 120 
FCHVs.
Data Collection
Surveys with health facility workers and FCHVs were administered using an android version of 
the ODK programming for Computer Assisted Personal Interview (CAPI). 
The health facility questionnaire included 4 different modules – identification and background 
information of the facility, family planning services, maternal health and nutrition services, child 
health and nutrition services, knowledge on integrated nutrition, exposure to Suaahara
interventions -- as well as an observation on the availability of health and nutrition related logistics 
and supplies. The first module also included information on the health facility’s supervision 
50
structure, and other basic information on facility management, and was asked to the facility in￾charge, while modules related to services were administered with the relevant health facility 
workers. The FCHV questionnaire included 10 different modules related to background 
information, FCHV related work activities, exposure to health and nutrition training, knowledge on 
integrated nutrition, supervisory support, and exposure to Suaahara interventions as well as an 
observation checklist on the availability of health and nutrition related logistics and supplies.
Data Management and Analysis
The e-data submitted in the KoBo collect was downloaded (in Excel) and imported in the SPSS 
for data cleaning, and then exported to the Stata for analysis. Composite indices for different 
indicators under each of the two research questions were developed as shown in Table 2.1.
Table 2.1: Health System Level Indicators Assessed in the Endline Survey
SN Indicator Indicator definition Measurement
Possible 
score 
range
HF FCHV
1 Capacity building
1.1
Received 
training on 
different 
aspects of 
health and 
nutrition
Training received on different 
aspects of maternal and child 
health and nutrition (MIYCN, IMAM, 
CB-IMCI, HTSP, WASH, 
counselling methods, GESI, etc.) 
during the past 5 years. 
1 for training on 
each topic 
received within 
the past 5 years.
23 different 
topics were 
included. 
0 – 23 √ √
1.2 Knowledge on 
IYCF
IYCF components related to 
breastfeeding and complementary 
feeding. 
1 for correct 
knowledge on 
each 
component.
7 different IYCF 
components.
0 – 7 √ √
1.3 Knowledge on 
CB-IMCI
Diagnosis of PSBI, pneumonia, and 
diarrhoea.
A summative 
score ranging 
from 1 to 17 with 
a higher score 
indicating better 
knowledge.
0 – 17 √ √
1.4 Knowledge of 
maternal health
ANC check-ups, TT/TD vaccine, 
iron/folic acid tablets during 
pregnancy and postpartum, PNC 
check-ups, and vitamin A capsule.
1 for correct 
knowledge on 
each of the six 
components.
0 – 6 √ √
1.5 Knowledge on 
HTSP 
Birth spacing, pregnancy interval 
after a miscarriage or induced 
1 for correct 
knowledge on 0 – 3 √ √
51
SN Indicator Indicator definition Measurement
Possible 
score 
range
HF FCHV
recommendati
ons
abortion, and age at first 
pregnancy.
each of the three 
components
1.6 Knowledge on 
GMP
Process of measuring weight, 
height/length; and use and 
interpretation of GMP card.
A summative 
score ranging 
from 0 to 20 with 
a higher score 
indicating better 
knowledge
0 – 20 √ √
1.7
Knowledge on 
identifying 
SAM and MAM
Identifying SAM and MAM children, 
which included weigh the child 
properly as per protocol; measure 
length/height of child as per 
protocol; calculate WHZ score; 
correctly classify child’s WHZ 
score; measure MUAC and classify 
as per protocol; and check edema 
on foot.
1 for correct 
knowledge on 
each of the six 
components
0 – 6 √ -
2 Improved service delivery
2.1 Availability of health and nutrition services
2.1.1
Availability of 
maternal 
nutrition 
services
HFs providing five services during 
ANC: maternal weight 
measurement, MUAC assessment, 
screening for anemia, nutrition 
counseling, provision of IFA 
supplements and 
Albendazole/deworming
HWs were asked 
how often they 
provide four 
different 
maternal 
nutrition services 
during ANC as a 
part of routine 
ANC check-up. 
Response 
options included 
0 (Never) to 
Always (4).
0 - 20 √ -
2.1.2
Availability of 
child nutrition 
services
Nutrition assessment services for 
children: measure weight, height, 
and MUAC; record measurement in 
the child health card; discuss 
result/child growth with child 
caregiver; counsel caregiver to 
attend GMP every month, and 
interpretation of growth curves; 
counsel caregiver about child 
health and nutrition; provide 
services or refer for treatment, if 
SAM/MAM discovered; checking 
for oedema; and provide 
therapeutic foods.
Each of the 
services 
included 
response 
options 0 
(Never) to 4 
(Always). There 
were 12 services 
for health 
facilities and 8 
for FCHV.
0 – 48 for 
health 
facility 
and 0 -32 
for 
FCHVs
√ √
2.1.3 Availability of 
ANC services
Iron/folic acid supplementation; 
TT/Td vaccine; deworming; 
Misoprostol; fundal height 
14 different ANC 
services 
recorded as 
0 - 56 √ -
52
SN Indicator Indicator definition Measurement
Possible 
score 
range
HF FCHV
examination; MUAC assessment; 
weight monitoring; vital signs 
check; counseling about the 
importance of ANC visit; counseling 
on maternal health and nutrition; 
counseling on child health and 
nutrition; counseling on WASH; 
Screening for anaemia (Hb test); 
and blood glucose test
providing Never 
(0) to Always (4).
2.1.4 Availability of 
PNC services
Weighing the lactating mother; 
Counseling about the importance of 
at least 3 PNC visits; Counseling 
about maternal health and nutrition; 
WASH counseling; and family 
planning counseling
5 different PNC 
services 
recorded as 
providing Never 
(0) to Always (4)
0 - 20 √ -
2.1.5 Availability of 
FP services
FP counseling, Condoms, 
Depo/injectables, Pills, Implants, 
IUCD, Minilap, Vasectomy, 
Emergency Contraception, and 
referral
9 different 
neonatal health 
services (4 in 
case of FCHV) 
recorded as 
providing Never 
(0) to Always (4)
0 – 40 for 
health 
facilities 
and 0 to 
16 for 
FCHVs
√ √
2.1.6
Health facilities 
providing any 
LARC services
% of health facilities providing any 
LARC (implants or IUCD) services - √ -
2.2 Availability and use of reference materials/job aids
2.2.1
Availability and 
use of 
reference 
materials and 
guidelines for 
GMP services
MIYCN Manual; MIYCN flip chart; 
CNSI manual/flip chart; and 
CBIMCI manual.
4 different 
reference 
materials
0 - 16 √ -
2.2.2
Availability of 
reference 
materials/job 
aids for FP
National Medical Standard for 
Reproductive Health (Volume III); 
FP clinical Protocol for health 
workers; Reference manuals 
(CoFP/C, Implant, IUD, VSC); 
Decision Making Tool (DMT) tools/ 
FP Flip Chart; and MEC wheel
Availability of 5 
different 
reference 
materials and 
guidelines
0 - 5 √ -
2.2.3
Availability of 
reference 
materials/job 
aids for ANC 
and PNC 
services
RH clinical protocol for medical 
officers; Maternity guideline 
(National Medical Standard Volume 
III); and ICC/BCC materials (danger 
sign posters, BPP flipchart, 
ANC/PNC job aids, pamphlets)
3 reference 
materials and 
guidelines
0 - 3 √ -
2.2.4
Availability of 
counseling 
aids/materials 
used to provide 
MIYCN flip chart; Complementary 
feeding (CF) wheel cards; Nutrition 
Assessment, Counseling, and 
Support (NACS) wheel cards; 
9 counseling 
aids/materials 0 - 9 √ -
53
SN Indicator Indicator definition Measurement
Possible 
score 
range
HF FCHV
nutrition 
assessment/G
MP services
Letter to the father; Poshan 
Sandesh Card; Breastfeeding 
poster; CNSI flip chart; Growth 
chart examples; and Other 
Posters/brochures/pamphlets.
2.2.5
Availability of 
counseling 
aids/materials 
used to provide 
FP services
Decision Making Tool (DMT) tools/ 
FP Flip Chart; FP Method Specific 
Brochures; FP Informed Choice 
Poster; FP Tool Kit Box; Medical 
Eligibility Criteria Wheel (WHO); 
and FP/Tihart Poster.
6 counseling 
aids/materials 0 – 6 √ -
2.2.6
Availability of 
counseling 
aids/materials 
used to provide 
ANC and PNC 
services
Letter to the father; Jeewan 
Surakshya (BPP) Flipchart; BPP 
flyer; ANC Leaflets; Poshan 
Sandesh Card; Breastfeeding 
Charts; PNC Danger Signs Charts; 
FP Charts and Real Objects; 
Immunization Card/Charts; 
Maternal and newborn care flip 
chart.
10 different 
counseling 
aids/materials
0 – 10 √ -
2.2.7
FCHVs 
providing 
health and 
nutrition 
services to 
pregnant 
women
Iron/folic acid; deworming; MUAC 
assessment; counseling about the 
importance of at least 4 ANC; 
counseling on maternal health and 
nutrition; counseling on child health 
and nutrition; and WASH 
counseling.
7 different ANC 
services 0- 28 - √
2.2.8
Availability of 
BCC materials 
and job aids 
among FCHVs
HMIS 4.2: FCHV register; ARI 
classification card; Zinc card; Home 
therapy card; 
Chlorhexidine/Kawach card; 
Chlorhexidine doll; Basic flip chart; 
FCHV sign board; FCHV Manual; 
BPP flip chart; BPP action card (to 
pregnant women); MIYCN flip 
chart; Complementary feeding (CF) 
wheel cards; Nutrition Assessment, 
Counseling, and Support (NACS) 
wheel cards; HMG monthly 
calendar; Letter to the father; ANC 
leaflet; Poshan Sandesh Card; 
Breastfeeding Charts; PNC Danger 
Signs Charts
Availability of 20 
different SBCC 
materials and 
job aids
0 – 20 - √
2.2.9
FCHVs 
implementing 
SATH in HMG
% of FCHVs implementing SATH in 
HMG - √
Descriptive data are presented in counts and % for categorical variables and mean (+/- SD) for 
continuous variables. Linear or logistic regression models appropriate for each outcome variable 
were used to compare between intervention and comparison districts and estimate the effect of 
Suaahara interventions. These models accounted for clustering at the district level using a 
54
sandwich estimator of standard errors that recognizes the number of districts and the variation 
among them.
Results
The results of the endline survey have been presented under each of the two research questions. 
The detailed tables of the findings have been attached in Annex I.
Capacity Building of health facility workers and FCHVs
The evaluation assessed whether health facility workers and FCHVs received training on 23 
different aspects/topics related to maternal and child health and nutrition (MIYCN, IMAM, CB￾IMCI, HTSP, WASH, counseling methods, GESI, etc.) and family planning during the 5 years prior 
to the survey. A mean score, with a possible range from 0 to 23 was calculated. On average, 
health facility workers from the intervention group reported having received training on 14 different 
topics (13.85±5.71), while health workers from the comparison group received training on 12 
different topics (11.90±6.38), with a p-value of the difference of being 0.474 (Table 2.2).
In terms of knowledge, health facility workers from intervention districts showed better knowledge 
on CB-IMCI (difference of 1.94, p = 0.005), GMP (difference of 1.75, p = 0.030), and identification 
of malnourished children (difference of 0.85, p = 0.090). There was no difference in knowledge 
scores between the intervention and comparison groups in terms of knowledge on IYCF, HTSP, 
and maternal health and nutrition, and HTSP among health facility workers.
Table 2.2: Impact of Suaahara Intervention on Capacity Building of Health Workers and FCHVs
Indicators Possible 
range
Health workers FCHVs
Intervention 
(n = 20)
Compar
ison
(n = 20)
Difference
p￾value
Intervention 
(n = 20)
Compar
ison 
(n = 60)
Difference
p￾value Mean 
(SD)
Mean 
(SD) B (SE) Mean 
(SD) 95% CI B (SE)
Received 
training on 
different 
aspects of 
health and 
nutrition
0 - 23 12.90
(5.75)
10.45
(6.94)
2.45
(2.78) 0.408 12.95
(7.59)
8.18
(8.02)
4.77
(2.33) 0.080
Knowledge 
on IYCF 0 - 7
6.55
(0.51)
6.40
(0.60)
0.15
(0.14) 0.322 6.30
(0.81)
6.48
(0.62)
-0.18
(0.17) 0.315
Knowledge 
on CB-IMCI 0 - 17 11.30
(1.98)
9.35
(2.64)
1.95
(0.77) 0.050 8.20
(1.79)
6.72
(2.64)
1.48
(0.54) 0.029
Knowledge 
on maternal 
health
0 - 6
5.50
(0.76)
5.30
(0.92)
0.20
(0.35) 0.587 5.77
(0.59)
5.53
(1.05)
0.23
(0.15) 0.176
Knowledge 
on HTSP 0 - 3
3.00
(0.00)
3.00
(0.00) 0.00 1.000 2.95
(0.22)
2.98
(0.13)
-0.03
(0.05) 0.518
55
recommendat
ions
Knowledge 
on GMP 0 - 20 13.00
(3.36)
11.25
(3.11)
1.75
(0.65) 0.030 7.33
(2.45)
4.93
(2.12)
2.40
(0.55) 0.003
Knowledge 
on identifying 
SAM and 
MAM
0 - 6
4.10
(1.29)
3.25
(1.02)
0.85
(0.43) 0.090 - - - -
FCHVs in the intervention district reported receiving training on a greater number of topics related 
to health and nutrition (mean scores of 12.95) compared to comparison districts (mean scores of 
8.18; p = 0.080). FCHVs from the intervention districts had better knowledge on CB-IMCI 
(difference 1.48, p = 0.029), and GMP (difference 2.40, p = 0.003). There was no difference in 
knowledge scores between the intervention and comparison groups in terms of knowledge on 
IYCF, HTSP, and maternal health and nutrition among FCHVs.
Service Delivery
Health facilities were assessed on the availability of different types of maternal and child nutrition, 
ANC, PNC, and FP services. Mean scores for service availability were higher in the intervention 
districts for maternal nutrition services (difference of 3.60, p = 0.010), child nutrition services 
(difference of 8.20, p = 0.016), ANC services (difference of 5.95, p = 0.021), and FP services 
(difference of 5.10, p = 0.056). The proportion of facilities providing Long-Acting Reversible 
Contraceptive (LARC) services was higher in intervention districts (75.0%), compared to 
comparison districts (60.0%), with the difference of 15 percentage points (p = 0.306). Health 
facilities in intervention districts, compared to comparison districts, had better availability and use 
of reference materials and guidelines for GMP services (difference of 3.60, p = 0.042). The 
availability of counseling aids to provide nutrition assessment and GMP services (difference of 
2.10, p <0.001), FP services (difference of 0.095, p = 0.008), and ANC and PNC services 
(difference of 2.45, p = 0.003) was also higher in intervention districts than in comparison districts. 
(Table 2.3).
Table 2.3: Impact of Suaahara Intervention on Service Delivery in Health Dacilities
Indicators
Possibl
e score 
range
Intervention 
(n = 20)
Comparison
(n = 20) Difference
p-value
Mean (SD) Mean (SD) B (SE) or %
Availability of maternal nutrition 
services 0 - 20 16.1 (2.17) 12.5 (2.06) 3.60 (1.02) 0.010
Availability of child nutrition 
services 0 - 48 37.85 (7.49) 29.65 (8.89) 8.20 (2.59) 0.016
Availability of ANC services 0 - 56 43.65 (4.7) 37.7 (4.74) 5.95 (2.01) 0.021
Availability of PNC services 0 - 20 13.80 (7.61) 15.85 (3.36) -2.05 (1.74) 0.279
Availability of FP services 0 - 40 22.15 (5.43) 17.05 (5.67) 5.10 (2.23) 0.056
% of health facilities providing 
any LARC services - 75.00% 60.00% 15.00% 0.306
56
Availability and use of reference 
materials and guidelines for 
GMP services
0 - 16 10.5 (3.27) 6.90 (3.21) 3.60 (1.45) 0.042
Availability of reference 
materials/job aids for FP 0 - 5 2.35 (1.04) 1.95 (1.08) 0.40 (0.30) 0.220
Availability of reference 
materials/job aids for ANC and 
PNC services
0 - 3 1.30 (0.86) 1.45 (0.6) -0.15 (0.25) 0.571
Availability of counseling 
aids/materials used to provide 
nutrition assessment/GMP 
services
0 - 9 4.60 (1.46) 2.50 (1.15) 2.10 (0.301) <0.001
Availability of counseling 
aids/materials used to provide 
FP services
0 – 6 3.40 (1.31) 2.45 (1.15) 0.95 (0.258) 0.008
Availability of counseling 
aids/materials used to provide 
ANC and PNC services
0 – 10 6.45 (2.16) 4.00 (1.62) 2.45 (0.548) 0.003
Most of the service delivery indicators assessed for FCHVs were found higher in the intervention 
districts compared to the comparison districts (Table 2. 4:). The mean scores for FCHVs providing 
GMP services were higher in the intervention districts (scores of 19.23 in intervention vs. 11.18 in 
comparison, difference of 8.05, p = 0.015). There was also a better availability of job aids and 
BCC materials on nutrition counseling among FCHVs from the intervention districts (scores of 
7.32 in intervention and 4.00 in comparison), with the difference of 3.32 (p = 0.015). More than 
one-third (35.71%) of FCHVs reported implementing the Self-Applied Technique for Health 
(SATH) program in HMGs in the intervention district, while compared to only 3.77% of FCHVs 
reported implementing SATH in the comparison districts (difference of 31.94 percentage points, 
p = 0.010). 
Table 2. 4: Impact of Suaahara Intervention on Service Delivery Among FCHVs
Indicators
Possibl
e score 
range
Interventio
n (n = 60)
Compariso
n
(n = 60)
Difference
p-value
Mean (SD) Mean (SD) B (SE)/%
FCHVs providing health and nutrition 
services to pregnant women 0- 28 18.83 (4.40) 17.50 
(4.16) 1.33 (1.34) 0.353
FCHVs providing child nutrition services 0 -32 19.23 (5.97) 11.18 
(6.80) 8.05 (2.51) 0.015
Availability of BCC materials and job 
aids 0 - 20 7.32 (4.07) 4.00 (3.00) 3.32 (1.04) 0.015
FCHVs providing FP services 0 - 16 9.45 (3.50) 8.78 (3.26) 0.67 (1.21) 0.599
% of FCHVs implementing SATH in 
HMG - 35.71% 3.77% 31.94% 0.010
57
Discussion and Conclusion
The comparison with comparison districts showed that both health facility workers and FCHVs in 
the intervention districts had received training in a higher number of topics related to maternal 
and child health, and nutrition. Health workers and FCHVs in the intervention districts also had a 
better knowledge particularly on CB-IMCI, GMP, and identification and management of SAM and 
MAM among children. Impacts of the Suaahara interventions were observed in improving service 
delivery as the scores for the availability and delivery of services for maternal nutrition, child 
nutrition including GMP, ANC, and FP, as well as the availability and use of reference materials 
and guidelines and counseling aids for GMP, FP, ANC and PNC services were better in the 
Suaahara intervened facilities. FCHVs in the intervention districts had better availability of job aids 
and BCC materials, and were more often providing GMP services, and counseling on 
breastfeeding and complementary feeding. The implementation of SATH was also higher among 
HMGs in the intervention districts. Overall, the end-line survey showed that the Suaahara 
interventions have contributed to strengthen the health system by improving the knowledge of 
health facility workers and FCHVs and improving service delivery. 
58
Part 3 – Evaluating Intermediate Results –
Improved access to diverse and nutrient-rich 
foods by women and children (IR3)-
Quantitative
Quantitative Evaluation of Homestead Food Production 
Program in Darchula district, Nepal, 2012-2022
Principal Investigator: Edward A. Frongillo, University of South Carolina, USA
Evaluation Research Team: Shiva Bhandari, PhD, Independent Consultant
59
Executive summary
Suaahara II is a multisectoral nutrition program being implemented in 42 of Nepal’s 77 districts 
from 2016 to 2023. SII aims to reduce the prevalence of stunting, wasting and underweight among 
children under five years of age and to reduce the prevalence of anemia among women of 
reproductive age and children 6-59 months of age. As one of SII’s thematic areas is agriculture, 
the program implements homestead food production (HFP), promoting the production and 
consumption of nutrient-rich foods and to improve household food security and nutritional 
outcomes among children and mothers among marginalized communities.
In 2013, HFP was initially implemented in nine highly food-insecure districts, but the HFP program 
gradually scaled-up into all 42 SII districts. Darchula, one of the four intervention districts selected 
for the Suaahara impact evaluation, is a district in the far-western region of Nepal where the HFP 
interventions have been implemented since 2013. 
A separate evaluation of HFP program was not part of the evaluation design at the baseline but 
given interest in understanding this component's contribution in reducing malnutrition among 
mothers and children, and the realization that in one of the districts for the evaluation there was 
baseline data on about 70 households, an evaluation study was designed.
The goal of the evaluation was to understand the role of the HFP program in improving availability, 
accessibility, and consumption of diverse nutrient-rich foods in the marginalized and food insecure 
communities in Darchula. To achieve this goal, a pre-test/post-test design without a comparison
group was used. The primary outcomes of the evaluation were household food insecurity and 
women’s dietary diversity. Secondary outcomes were gardening practices, poultry-raising 
practices, vegetable production diversity, chicken and egg production, income by selling surplus 
vegetables and poultry, women’s knowledge on child nutrition and health, and women’s 
empowerment. To assess gardening and poultry-raising practices, a summed score was 
calculated based on several individual gardening or poultry-raising practices performed by the 
households. Out of 70 households present at the baseline, 53 households reached at the endline 
nine years after the HFP program was implemented in 2013. Random-effects models with 
households as the random effect were developed to estimate the coefficients for the differences 
in outcome variables before and after the HFP program within households.
Vegetable production diversity increased by 49% (p < 0.001) after the households received the 
HFP program. In addition, the likelihood of production of dark-green leafy vegetables and beans 
and pulses increased for the households after receiving the HFP program. Income from the sale 
of surplus vegetables was about USD 69 greater among the households after participating in the 
HFP program than before the program. Women’s knowledge on child nutrition and health 
improved after receiving the HFP program. Women were more empowered after being enrolled 
into the HFP program as indicated by their improved decision-making power over the use of 
income and the control of productive assets in the households. On the other hand, the chances 
of households being food insecure increased after they were enrolled into the HFP program. The 
HFP program did not affect women’s dietary diversity, gardening practices, and chicken poultry 
production. 
60
Further research using in-depth interviews and experimental designs might be helpful to 
understand these changes in outcomes associated with the HFP program. 
Introduction
Vegetables, fruits, meat, and eggs are important sources of nutrients and often referred to as 
nutrient-rich foods. Consuming them daily, however, in Nepal, is still difficult for many families. 
Low consumption of such nutrient-rich foods is partly because of lack of knowledge of the 
importance of such foods,1 and less accessibility and availability, from either household 
production or market purchase.2,3 Lack of markets in rural settings leave those populations with 
limited options for purchasing nutrient-rich foods. Often, if there are markets, they sell mainly 
staples, such as oils, sugar, and spices/condiments that people want to buy frequently. In addition, 
the cost of nutrient-rich foods is higher in low- and middle-income countries as shown by a study 
done analyzing price data from 2011 from across 176 countries revealed that the cost of nutrient￾rich foods is considerably higher than staples in low- and middle-income countries. For example, 
in Asia, caloric prices of dark green leafy vegetables were 5-9 times higher in Asia than staple 
cereals.4 Even the most affordable diet proposed by EAT-Lancet commission5 cost a global 
median of about US$ 3 per day in 2011, of which the largest share was the cost of fruits and 
vegetables (31%).6
In Nepal, the cost of optimal diet that includes nutrients-rich foods is about 
US$ 8 in the mountains and about US$ 6 in the hills and Terai.7
One important way to deal with issues of poor availability, affordability, and accessibility of food 
items is to promote household food production. Helen Keller International has been working to 
promote diversified homestead gardens and small-animal production in several Asian and African 
countries.8 Helen Keller’s Homestead Food Production (HFP) programs are designed to empower 
women from poor households in Africa and Asia with agriculture, nutrition, and health education 
and together with agricultural resources needed to produce and consume their own nutritious 
foods such as vitamin A -rich fruits and vegetables, iron-rich green leafy vegetables, and vital 
protein sources like poultry, goat, and fish. These HFP programs have proven successful at 
improving health outcomes like dietary diversity,9,10 growth of children,11 household food 
security,11 and hemoglobin levels.12
HFP Program in Nepal
In Nepal, Helen Keller Intl has been implementing HFP programs for well over a decade, including 
through Suaahara II, a USAID-funded multi-sectoral integrated nutrition program. In Suaahara II, 
it is currently implemented in 42 out of 77 districts, and the project has a specific intermediate 
result related to HFP: to improved access to diverse and nutrient-rich foods by women and 
children, especially among marginalized communities. To achieve this outcome, in 2013, this HFP 
component was initially launched in 9 highly food-insecure districts. HFP was scaled up and 
implemented in an additional 11, 5, and 16 districts in 2013, 2014, and 2015, respectively. In 2015 
and 2016, during the transition from Suaahara I (2011-2016) to Suaahara II (2016-2023), HFP 
activities were expanded to all remaining intervention districts, with HFP reaching the 2 additional 
61
Suaahara II districts by 2017. The list of districts added in different years is presented in Appendix 
A. As the HFP intervention is intended for marginalized, food-insecure communities within the 
target districts only, the specific HFP program catchment areas within the target districts are 
shown in Figure 3. 
Suaahara II’s HFP program consists of interventions with Village Model Farmers (VMFs), selected 
to be the lead trainers and suppliers, and groups of households they support. Helen Keller 
International collaborated with local farmers and community organizations to establish 1 VMF per 
ward, the smallest administrative unit in Nepal (pre-federalism). A total of 5,686 VMFs were 
initially trained for five days and given the responsibility of establishing their model farm for 
demonstration purposes, providing ongoing technical assistance to beneficiary households, and 
organizing the household beneficiaries into groups of about 20-25 members. VMFs also 
coordinate with the District Agriculture Development Office, District Livestock Services Office, and 
other local community development partners. The HFP program targets households within the 
first 1000-days period. The first 1,000 days refers to a child's life from the moment they are 
conceived until they reach 2 years of age (24 months). This is a time when their brain, body and 
immune system grows and develops significantly. Households were selected for inclusion in the 
HFP program if they: (1) had a pregnant woman or a mother of at least 1 child less than 2 years 
old residing in the household at the time of the listing for the training and (2) had at least 40 to 75 
m2 of land near the home suitable for cultivation. These households received a 2-day basic HFP 
training, distribution of seasonal seeds for 3 seasons (dry and rainy) during the year immediately 
following the basic HFP training, distribution of 5 chicks to 1000-day mothers, and linkage with a 
VMF for further technical support and inputs. In total, an estimated 114, 000 HFP beneficiaries 
participating households across 1, 001 VDCs of 42 districts were reached. As the basic HFP 
training and seeds and chick distribution was a one-time effort per community, new households 
meeting these criteria later were not direct beneficiaries of the HFP program provided to one 
cohort of households at the time the project first began activities in that community.
The HFP program targets women among marginalized communities as they are most likely to 
contribute to improved household diet and health. In addition, in rural Nepal, women provide most 
of their labor force in agricultural production in addition to their traditional household chores.13
Empowering women with input and training contributes to improved farm productivity and 
household food security, among farms managed by women.14 In addition, HFP program 
empowers women,15,16 which in turn help to improve household dietary diversity,17 health care 
utilization,18 and growth of children.16,19,20 Women need trainings, inputs and information on 
agriculture to improve agricultural practices.21 Training, inputs, and information improves women’s 
knowledge on agricultural practices, which increases agricultural productivity.22
HFP is based on 4 programming principles: (1) ensuring households’ access to diverse and 
nutrient-rich foods throughout the year; (2) focusing on production of nutrient-rich foods￾vegetables, egg, meat; (3) promotion of low-cost but easy to adopt technologies; and (4) 
empowerment of small-holder farmers to build resilient and sustained household food production. 
Applying these principles, HFP is implemented at three levels: household, community, and 
structural. At the household level, the program targets families within first1000-day period with an 
aim to increase production and consumption of diverse nutrient-rich foods throughout the year. At 
the community level, the program establishes VMFs to support the household beneficiaries with 
62
agricultural practices training and production inputs, particularly when there is limited access to 
agricultural extension services and production inputs. At the structural level, the program 
collaborates with agricultural/livestock offices at the VDCs and works to upscale, mainstream, 
and sustain HFP through mainstreaming and leveraging resources. 
Figure 3: Reach by HFP component of Suaahara program in Nepal (Quant.)
Evaluation Aim and Research Questions
The overall goal of the study is to understand whether the HFP program improved availability, 
accessibility, and consumption of diverse nutrient-rich foods in these remote, marginalized 
communities. The specific primary research questions for evaluation of Suaahara’s HFP program 
include:
1. Did Suaahara HFP interventions improve household food security among HFP 
households? 
2. Do HFP households have improved dietary diversity compared to before the intervention? 
3. The secondary research questions include:
4. Do HFP households have improved relevant agricultural, especially HFP, practices after 
the HFP intervention? 
5. Do HFP households have greater production diversity of vegetables and increased 
quantity of poultry (eggs and chicken) after the HFP intervention? 
6. Do HFP households sell their HFP surplus and, if so, how does this influence their income 
after the HFP intervention?
63
7. Do HFP households, particularly mothers, have improved knowledge related to child 
health and nutrition after the HFP intervention? 
8. Are women from HFP households more empowered after the HFP intervention?
Methods
Study Setting
The HFP evaluation was conducted in Darchula, one of the four impact evaluation districts. The 
district was selected among the four evaluation intervention districts, because it had the highest 
number of households with baseline data that participated in the HFP interventions. Darchula, a 
mountainous district in western Nepal, has an area of 2,322 km2
, 24,618 households, and a total 
population of approximately 133,274. The district borders with India in the west, China in the north, 
Bajhang district in the east, and Baitadi district in the west. The elevation ranges elevation from 
532 meters to 7,132 meters, with 90% of the population practicing subsistence agriculture. This 
district has higher rates of food poverty (61%) (defined as expenditure on food is insufficient to 
meet the established basic food requirements), stunting (50%), underweight (40%), and wasting 
(11%).23
Study Design
A pre-post design without a comparison group was used. Households with a child 0-5 years of 
age randomly selected as participants in the evaluation baseline survey who started receiving the 
HFP intervention in 2013 (n=70) were followed and again interviewed in the evaluation endline 
survey. 
At the time of data collection for the endline survey, 53 of the 70 households were present in the 
district. Thirteen households had migrated to another district, one household had no female 
respondent due to death of mother, and three households were not available at the time of the 
endline survey. The primary respondent was an adult female present in the household. 
Primary Outcomes 
Household food security: The Household Food Insecurity Access Scale (HFIAS) score was 
used to measure the prevalence of household food security. This measure is based on the 
guideline by the Food and Nutrition Technical Assistance (FANTA) Project questionnaire, which 
ask about the severity and frequency of food insecurity experienced over the previous 30 day 
period.24 The nine occurrence questions asked whether a specific condition associated with the 
experience of food insecurity ever occurred during the past 30 days. Each severity question was 
followed by a frequency-of-occurrence question, which asked how often a reported condition 
occurred during the past 30 days.
64
Women dietary diversity score: Women’s dietary diversity score was measured as defined in 
the questionnaire of the guideline on dietary diversity by Food and Agricultural Organization.25
Among the nine food groups defined by the guideline, information on “organ meat” (e.g., any liver, 
kidney, heart, lungs) was not collected separately at the baseline survey. Therefore, we modified 
the score by merging information on “organ meat” with “meat and fish” food group at the endline 
and calculated the score based on a total of eight food groups. 
Secondary Outcomes
Gardening practices: Gardening practices were assessed by examining five individual practices 
that were collected at both baseline and endline. A summed score of the total number of following 
individual practices that were collected at both baseline and endline was created, with 1 point for 
each practice reported. If the respondents reported practice of the activities, a score of 1 was 
given for each, otherwise 0 was given. Then, a total score was created by summing the individual 
scores for each practice (range 0 to 5). Higher score reflects better gardening practices, which 
could result in improved production of vegetables. These practices were:
(i) Growing local crop/vegetables varieties 
(ii) Using improved seed/saplings/crops
(iii) Using hand tools (e.g., axe, sickle)
(iv) Using mechanized tools (e.g., thresher, harvester, tractor)
(v) Using plough
Poultry-raising practices: Poultry raising-practices were assessed by examining individual 
seven practices as well as creating a summed score of following individual practices only for the 
endline, as this information was not collected at the baseline. If the respondents reported practice 
of the activities, a score of 1 was given for each; otherwise, 0 was given. Then, a total score was 
created by summing the individual scores for each practice (range 0 to 7). Higher score reflects 
better gardening practices, which could result in improved production of poultry. The practices 
evaluated were:
● Use of chicken coop for rearing chicken
● Maintaining fresh air and ventilated space
● Facility of clean water and pot
● Clean or fresh chicken feed and pot
● Proper security of the chicken coops
● Deworming chickens 
● Vaccination against NewCastle Disease
Vegetable production diversity: Based on the major nutrients present in the vegetables and 
adapted from the groupings used in a study of homestead food production program in 
Bangladesh,26 vegetables produced were grouped into five types: dark-green leafy vegetables 
65
(DGLV), other vitamin A-rich vegetables, beans and pulses, roots and tubers, and other 
vegetables. This grouping is aligned with those of dietary diversity for children 6 to 23 months of 
age as guided by World Health Organization27 and for women as guided by Food and Agriculture 
Organization.25
Number of chickens produced: Respondents were asked how many chickens the households 
had at the time of survey. Information on three different chicken types: improved (e.g., New 
Hampshire, Black Australorp); local (e.g., Sakini, Ghanti Khuile); and boilers/layers was obtained 
at the endline. For the analyses, regardless of the types of the chicken raised, the numbers were 
combined. At baseline, information on number of chicken was not collected separately from other 
birds like ducks. Raising of other birds with chicken might be rare in the district, hence allowing 
for the potential comparison before and after the intervention.
Number of eggs produced: At the baseline, the number of eggs produced were measured by 
asking respondents the number of eggs produced in the last 12 months. The total number of eggs 
produced was divided by 12 to get an average number of eggs produced in one month. At the 
endline, respondents were asked how many eggs were produced in the last one month. 
Income by selling vegetables: Income was measured from the information provided by the 
respondents on earnings by selling vegetables in the last 12 months. Price of 2012 was adjusted 
to price of 2021 to account for the inflation using the guidance provided by USAID.28 The formula 
used is: real price(2021) = (CPI2012 ÷ CPI2021) x nominal price(2021), where CPI is the consumer price 
index. The data on consumer price index was obtained from the World Bank Data Repository 
(CPI for 2012 = 119.6 and CPI for 2021 = 206.4).29 Finally, the price in Nepalese rupees was 
converted into United States dollars (USD) (1 USD = 85.23 Nepalese rupees (NPR) in 2012 and 
118.13 NPR in 2021).30
Income by selling poultry: Income was measured from the information provided by the 
respondents on earnings by selling chicken and eggs in the last 12 months. Price of 2012 was 
adjusted to price of 2021 to account for the inflation using the guidance provided by USAID.28 The 
formula used is: real price(2021) = (CPI2012 ÷ CPI2021) x nominal price(2021), where CPI is consumer 
price index. The data on consumer price index was obtained from the World Bank Data Repository 
(CPI for 2012 = 119.6 and CPI for 2021 = 206.4).29 Finally, the price in Nepalese rupees was 
converted into United States dollars (USD) (1 USD = 85.23 Nepalese rupees (NPR) in 2012 and 
118.13 NPR in 2021).30
Women’s knowledge on child nutrition: Knowledge was measured based on information on a 
questionnaire covering colostrum feeding, appropriate age for feeding certain foods, knowledge 
on causes of malnutrition, and feeding of a child during her/his illness was assessed. All the 
responses were dummy coded, and the correct responses were scored one. A summed score 
was calculated to measure the overall knowledge on child nutrition.
Women’s empowerment: Women’s empowerment was assessed by adapting and modifying the 
Women’s Empowerment in Agriculture Index (WEAI).20 This index measures the empowerment, 
agency, and inclusion of women in the agriculture sector in an effort to identify ways to overcome 
those obstacles and constraints. Due to insufficient information in both the rounds to create WEAI, 
the index was modified to include information collected at both baseline and endline, and 
therefore, women’s empowerment was measured through these covered three domains: (i) 
66
decisions about agricultural production, (ii) decisions over use of income, and (iii) decisions over 
control of productive assets in the households. A greater score in these domains indicated greater 
empowerment. 
Note: A description of information used to measure these outcome variables is explained in Appendix B.
Covariates
Socio-economic status and whether the households received agricultural assistance from any 
organization were treated as time-variant covariates, and household caste/ethnicity as time￾invariant covariate. Principal component analysis was conducted based on a list of household 
assets using the method described by Ruestein and colleagues.31 Tertiles of this scale were then 
created. Agricultural assistance was measured by assessing if any member of the households 
received agricultural assistance from the government, NGO, etc. in the last 12 months preceding 
the survey in both baseline and endline. The agricultural assistance included seeds, fertilizer (e.g., 
chemical, organic), agricultural tools, other agricultural inputs other than seeds, fertilizer, or 
agricultural tools (e.g., pesticides); animals (e.g., livestock/poultry/fish), and inputs for care of 
animals (e.g., fodder, medicine, shelter). Socially disadvantaged caste groups consisted of Dalits, 
Muslims, and disadvantaged Janajatis while advantaged caste groups consisted of Brahmins or 
Chhetri, Gurung, Thakali, Newar, and non-Dalit Terai caste based on the caste/ethnicity defined 
by the Government of Nepal Health Information and Management System.32
Statistical Analysis
Descriptive statistics were calculated for the outcomes at baseline and endline. Linear and logit 
random-effects models with households as the random effect were developed to estimate the 
coefficients for the differences in outcome variables before and after the HFP intervention within 
households. For the number of chickens and eggs produced, and income from the sale of 
vegetables, chickens, and eggs, left-censored regression models were run that incorporated the 
zeros representing no production. First, bivariate random-effects models were run. Second, the 
models were adjusted using socio-economic status (rich, middle, poor) and whether the 
households received agricultural assistance from any other organization (binary) as time-varying 
covariates, and household caste/ethnicity as a time-invariant covariate. All the analyses were 
done using Stata version 14.2 and accounted for clustering using a robust sandwich estimator of 
standard errors.
Findings
The demographic makeup of the sample of respondents before and after the HFP intervention 
are presented in Table 3.1.
Women’s dietary diversity remained almost the same from baseline to endline (Table 3.2). 
Households experiencing food insecurity increased at the endline. Overall, improved gardening 
67
practices remained constant from baseline to endline. Production of vegetables, chicken, and 
eggs improved at the endline. Income from selling surplus vegetables and eggs increased from 
baseline to the endline. 
Table 3.1: Socio-demographics of Households Before and After Implementation of HFP 
Intervention in Darchula district, Nepal, 2012-2022.
Socio-demographic variables
Baseline
(2012)
N (%)
Endline
(2022)
N (%)
Household size (mean, SD) 6.0, 2.2 5.2, 1.9
Caste/Ethnicity
Socially advantaged 48 (50.0) 48 (50.0)
Socially disadvantaged 5 (50.0) 5 (50.0)
Household wealth
Poor 25 (58.1) 18 (41.9)
Middle 16 (45.7) 19 (54.3)
Rich 10 (38.5) 16 (61.5)
Household received agricultural assistance 17 (38.6) 27 (61.4)
Table 3.2: Comparison of Outcome Variables Before and After Implementing the HFP Intervention 
in Darchula, Nepal, 2012-2022.
Outcomes
Baseline
(2012)
N (%)
Endline
(2022)
N (%)
Women's dietary diversity score (8 food groups) (mean, SD) 4.0, 1.1 3.9, 1.0
HFIAS score (mean, SD) 1.8, 3.6 3.7, 4.4
Gardening practices
Growing local crop/vegetables varieties 53 (100.0) 49 (92.5)
Using improved seed/saplings/crops 34 (64.2) 37 (69.8)
Using hand tools (e.g., axe, sickle) 0 53 (100.0)
Using mechanized tools (e.g., thresher, harvester, tractor) 53 (100.0) 0
Using plough 51 (96.2) 45 (84.9)
Overall summed score (mean, SD) 3.6, 0.5 3.5, 0.6
Production of vegetables
Dark-green leafy vegetables 31 (58.5) 52 (98.1)
Other vitamin A-rich vegetables 31 (58.5) 33 (62.3)
Beans and pulses 2 (3.8) 17 (32.1)
Starchy roots and tubers 3 (5.7) 46 (86.8)
Other vegetables 52 (98.1) 52 (98.1)
Summed vegetable production diversity score (0-5) 
(mean, SD) 2.2, 0.8 3.8, 1.0
Chicken produced (at present)
No 43 (81.1) 39 (73.6)
68
Yes 10 (18.9) 14 (26.4)
Number of chicken produced (at present) (mean, SD) 1.0, 2.5 1.3, 3.5
Eggs produced (in last 1 month)*
No 46 (86.8) 43 (81.1)
Yes 7 (13.2) 10 (18.9)
Number of egg produced (in last 1 month) (mean, SD) 0.5, 1.3 4.3, 9.7
Income (in USD) in 12 months by selling** (mean, SD)
Vegetables 1.3, 8.0 8.9, 42.8
Chicken 3.5, 11.9 2.1, 8.2
Eggs 0.1, 0.3 0.2, 0.7
Total income 4.9, 1.9 11.2, 6.0
Mother’s knowledge regarding child nutrition and health (mean, SD) 10.4, 1.7 13.0, 2.4
Women’s Decision-making Power
Decision made about agricultural production (number of 
activities) 6.7, 0.7 6.8, 0.5
Decision made over the use of income (number of activities) 4.9, 0.8 6.7, 0.7
Decision made over control of productive assets (number of 
assets) 0.8, 1.3 1.3, 1.0
*in the last 12 months at baseline
**prices of 2012 (1 USD = 85.23 NPR) adjusted to price of 2021 (1 USD = 118.13 NPR) to account for 
inflation
In the bivariate random-effects models, the results showed that after receiving the HFP 
intervention, the chances of a household being food insecure increased by about 89% (Table 
3.2). Receiving the HFP intervention, however, increased the chances of vegetable production 
diversity increased by 53%, increased the number of eggs produced each month by 4, and 
increased the household’s income from the sale of surplus vegetables, chicken, and eggs by 
about USD 6. Mother’s knowledge on child nutrition and health improved from baseline to endline 
and mothers had improved decision-making power over the use of all household income and 
greater control of productive assets in the households.
In the regression models that adjusted for socio-economic and other covariates, the overall results 
remained the same with household food insecurity worsening, but vegetable production diversity, 
production of eggs, income from sale of surplus vegetables and eggs, mother’s knowledge on 
child nutrition, and women’s decision-making power increasing from baseline to the endline (Table 
3). In addition, chances of production of dark-green leafy vegetables and beans/pulses increased 
from baseline to endline. Overall gardening practices decreased after the implementation of the 
HFP program.
69
Table 3.3: Changes in outcomes among households before and after receiving the HFP interventions in Darchula, Nepal, 2012-2022.a
Outcomes
Bivariate random-effects model Multivariable random-effects model
Coefficient (95% CI) Standard error P-value Coefficient (95% CI) Standard error P-value
Women's diet diversity -0.15 (-0.50, 0.20) 0.18 0.397 -0.20 (-0.57, 0.17) 0.19 0.297
Household food insecurity access scale 1.89 (0.48, 3.29) 0.72 0.008 2.26 (0.69, 3.82) 0.80 0.005
Overall summed score of gardening 
practices -0.13 (-0.36, 0.10) 0.12 0.263 -0.21 (-0.43, 0.01) 0.11 0.053
Vegetable production
Vegetable production diversity score 1.53 (1.17, 1.89) 0.18 <0.001 1.49 (1.11, 1.86) 0.19 <0.001
DGLV 3.61 (-13.62, 20.83) 8.79 0.681 3.54 (1.34, 5.75) 1.13 0.002
Other vitamin-A rich vegetables 0.16 (-0.71, 1.03) 0.44 0.723 0.06 (-0.86, 0.98) 0.47 0.902
Beans and pulses 2.77 (0.73, 4.81) 1.04 0.008 2.78 (0.81, 4.75) 1.01 0.006
Roots and tubers 4.70 (-7.22, 16.61) 6.08 0.440 5.95 (3.50, 8.40) 1.25 <0.001
Other vegetables 0.01 (-2.85, 2.85) 1.46 >0.999 1.20 (-4.48, 6.88) 2.90 0.678
Chicken production 2.13 (-1.49, 5.75) 1.85 0.249 1.28 (-2.60, 5.16) 1.98 0.518
Egg production 14.6 (2.77, 26.42) 6.03 0.016 10.24 (-0.99, 21.46) 5.73 0.074
Income (in USD) from sale of surplus
Vegetables 70.15 (17.33, 122.97) 26.95 0.009 68.83 (13.47, 124.18) 28.24 0.015
Chicken -11.54 (-37.04, 
13.96) 13.01 0.375 -3.68 (-28.9, 21.54) 12.87 0.775
Egg 2.24 (-0.48, 4.96) 1.39 0.107 2.22 (-0.61, 5.05) 1.44 0.123
Women's knowledge regarding child 
health and nutrition 2.62 (1.77, 3.47) 0.43 <0.001 2.6 (1.68, 3.52) 0.47 <0.001
Women’s empowerment
Decision made about agricultural 
production (number of activities) 0.11 (-0.14, 0.37) 0.13 0.380 0.13 (-0.13, 0.38) 0.13 0.333
Decision made over the use of 
income (number of activities) 1.79 (1.50, 2.08) 0.15 <0.001 1.81 (1.51, 2.11) 0.15 <0.001
Decision made over control of 
productive assets (number of 
assets)
0.47 (0.09, 0.86) 0.20 0.016 0.38 (-0.04, 0.80) 0.21 0.073
a Entries that are bolded have p-values of about 0.1 or lower
70
Discussion
Overall, the findings suggest that the Suaahara program that included the HFP interventions in 
Darchula improved vegetable production diversity overall and specifically the production of dark￾green leafy vegetables and beans and pulses as well as the production of eggs and income from 
the sale of vegetables and eggs. Over nearly a decade of interventions, mother’s knowledge on 
child nutrition and health and women’s empowerment also improved. This study highlights that 
where availability, affordability, and accessibility of nutrient-rich foods is limited, promotion of 
improved production-related practices can improve production of vegetables and poultry and 
income from the sale of surplus production which might have important implications for nutritional 
outcomes. On the other hand, a result of increased prevalence of household food insecurity 
demands greater attention as food insecurity also links with nutritional outcomes.
Several studies corroborate our findings on improved vegetable and poultry production from HFP. 
For example, a study using nutrition-sensitive agriculture project that promoted production-related 
activities aimed to improve production, sales, and dietary diversity in Ethiopia, Kyrgyzstan, Nepal, 
Pakistan, and Peru showed an improved production of nutrients-rich foods including vegetables 
and fruits.33 Recent randomized controlled trials in Kenya, Tanzania, and Uganda also reported 
that home garden interventions improved vegetable production.34 A longitudinal study found that 
interventions that improved poultry-raising practices in four African countries was important for 
increasing egg and chicken production.35 Promotion of optimal production-related practices along 
with other types of trainings, inputs, and awareness-creation activities have been found to be 
important to promote improved food production and consumption choices.33,36
Further studies are necessary to understand the role of homestead gardening on household food 
insecurity, especially among hard-to-reach and disadvantaged communities. Since the HFP 
model targets smallholder farmers, with small plots for cultivation, improving vegetable and poultry 
production alone in such small plots might not be sufficient to improve household food security. 
HFP models along with other community-level interventions such as cash transfer programs that 
promote access to and availability of nutritious foods might be needed to improve household food 
security in marginalized communities.37 In addition, promoting livestock rearing along with poultry 
may be a means of improving household food security. For example, damage or loss of livestock 
(large, small, or poultry) in the last 12 months was positively associated with household food 
insecurity (p=0.199) in a supplementary analysis conducted for this study (Appendix C). In 
addition, there might be social and economic determinants such as increasing food prices, 
geographical constraints, and overall food policies which need to be further researched in relation 
to home gardening and household food security. 
Nutrition-sensitive agriculture interventions often have a goal to improve nutritional outcomes 
through household production of vegetables, fruits, and small livestock by promoting improved 
gardening and poultry-raising practices along with low-cost, easy to adopt technologies. It is also 
equally important to consider the number of improved practices to be taught to the farmers. 
Prioritization of topics and interventions might be needed for farmers, especially from 
marginalized communities, as there may be constraints in rapid adoption of multiple new 
practices due to no or limited awareness of the practices, poor motivation, and lack of access to 
and availability of resources.35
71
A strength of this study was the long measurement window, which is usually needed to see an 
impact of agricultural interventions. In addition, having a longer duration of interventions helped 
to understand the need for sustainable interventions and measurement of outcomes over a longer 
time rather than just 3-5 year periods. Findings from this externally designed and executed 
evaluation provide an estimate of the change over time in outcomes before and after Suaahara 
II’s implementation of HFP interventions, but non-randomization and lack of an appropriate 
counterfactual prevents establishing causality between the interventions and the outcomes. 
Social desirability bias, inherent with behavior-related questions, could not be avoided and might 
have affected the responses, particularly regarding whether the households remained engaged 
in the gardening and poultry-raising activities. Reliance on recall-based outcomes like assessing 
growth of vegetables in the past year might have introduced recall bias. Some of the information 
regarding improved gardening practices and poultry-raising practices was not collected at 
baseline, which limited the evaluation of some of the outcome variables. This study was not a part 
of the evaluation design at baseline, therefore, data collected at the baseline was not complete to 
compare the measures at the endline.
Although a long period after the intervention (almost a decade) is important to see the impact of 
agricultural interventions, such a period may have diluted the effects of the HFP program. For 
example, knowledge and skills received from the initial training might have diminished, despite
the household having received inputs from the HFP program staff and local organizations at 
certain intervals throughout the period. To explore in further depth whether initial and refresher 
trainings were helpful or not and what could be additional challenges over a long period, future 
studies, especially, qualitative studies, would be helpful. In addition, measurements of the 
outcomes at shorter intervals, rather than waiting at the end of the intervention, would be helpful 
for the programmers to modify and improve the program.
Conclusions
Participation in the HFP program was associated with several outcomes. Vegetable production 
diversity; production of dark-green leafy vegetables, beans and pulses; production of eggs; 
income from sale of vegetables and eggs; women’s knowledge on child nutrition and health; and 
women’s empowerment improved after the implementation of the HFP program. However, 
household food security and overall gardening practices decreased after the implementation of 
the HFP program. This could be due to several factors, such as, small, and unviable landholding 
size, the effect of Covid-19 and supply chain related disruptions especially in the mountainous 
areas, and rising cost of food and fuel. A detailed investigation into the factors is needed to better 
understand their impact. 
While understanding and interpreting the results, one must be mindful of the global disruptions in 
supply chain due to the twin effects of Covid-19 and Ukraine war. Both these global incidents 
affected poor and marginalized households in Nepal severely. The pandemic led to disruptions in 
global supply chains causing production slowdowns, leading to shortages and price increase for 
foodgrains. Additionally, movement restrictions made it difficult for farmers and other producers 
to transport their products to market, further exacerbating supply chain disruptions. Further, the 
72
conflict between Russia and Ukraine that started in February 2022, impacted global commodity 
markets, particularly for foodgrains and other agricultural products. Thus, the twin-effects of 
Covid-19-19 and Ukraine war aggravated phenomenal increase in food, fuel and fertilizer prices 
in Nepal leading to a shortage of food supplies, especially in remote and mountainous areas. In 
addition, Suaahara faced a challenging implementation context since the entire HFP program was 
targeted to smallholder farmers from marginalized communities in remote areas with poor access 
to markets. These factors potentially limit the effectiveness of HFP program. 
While designing and implementing nutrition‐sensitive agriculture interventions like HFP, the 
following points need to be considered for better outcomes.
First, sustaining participation and ensuring performance of improved agricultural practices over a 
long period is necessary to have improved nutritional outcomes. For this, understanding socio￾economic determinants might help to sustain the participation and performance of households in 
nutrition-sensitive agricultural interventions including HFP. Moreover, supporting activities 
delivered to the households should go deeper than vegetables, chickens, and eggs to address 
underlying cultural and gender norms that constrain women's active participation in homestead 
food production.38-40 Further research using in-depth interviews and experimental designs might 
be helpful to understand effect of these determinants in outcomes associated with the HFP 
program.
Second, while designing nutrition-sensitive agriculture programs like HFP, duration of program 
implementation needs to be considered in conjunction with the level of training, inputs, and 
resources provided to the farmers. If the farmers learn the practices quickly and perform them 
effectively to increase the productivity, even a shorter duration of implementation might suffice. A 
program implemented for a shorter duration, however, with fewer inputs or poorer quality will not 
necessarily result in improved productivity and nutrition outcomes.41
Finally, along with consumption of diverse nutrients-rich foods and nutritional outcomes, focus 
needs to be placed on training farmers, ensuring they learned the methods well, and are practicing 
correctly in the gardens. Trainings and methods for improved vegetable and poultry production 
are usually offered at lower cost and pose less risk, however, they are not easy, and more easily 
adopted practices for low‐resource settings are required.35
73
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77
Appendices
Appendix A: List of Districts where HFP Program was Implemented. 
Year of HFP 
implementation
Districts Number of 
districts
2013 Rasuwa, Dolakha, Taplejung, Sankhuwasabha, Manang, 
Mustang, Bajura, Bajhang and Darchula*
9
2013 Solukhumbu, Bhojpur, Baglung, Myagdi, Gorkha, Lamjung, 
Syangja, Parbat, Rupandehi, Nawalparasi, Sindupalchowk
11
2014 Accham, Dadeldhura, Baitadi, Doti and Nuwakot 5
2015 Banke, Bardiya, Dang, Salyan, Surkhet, Dailekh, Jajarkot, 
Pyuthan, Rolpa, Rukum, Kapilbastu, Argakhanchi, Palpa, Gulmi, 
Kailali and Kanchanpur
16
2017 Panchathar and Dhading 2
*District included in the present evaluation.
Appendix B: Association Between socio-economic Events and Household Food Insecurity Among 
Households in Darchula District at Endline, 2022.
Socio-economic 
events
Bivariate regression coefficients Multivariable regression coefficients
Coefficient 
(95% CI)
Standard 
error
P-value Coefficient 
(95% CI)
Standard 
error
P-value
Damage or loss of 
livestock (large, small, 
poultry) in the last 12 
months
1.63
(-0.77, 4.04) 1.2 0.178 1.63
(-0.89, 4.15) 1.25 0.199
Damage or loss of crops 
in the last 12 months
0.64
(-1.86, 3.13) 1.24 0.611 0.8
(-1.71, 3.31) 1.25 0.525
Chronic or short-term 
illness of household 
member in the last 12 
months
0.77
(-1.81, 3.34) 1.28 0.553 0.37
(-2.28, 3.01) 1.32 0.782
78
Part 4 – Evaluating Intermediate Results –
Improved access to diverse and nutrient-rich 
foods by women and children (IR3) -
Qualitative
Assessing the effectiveness of agricultural interventions 
under Suaahara: A Qualitative Evaluation of HFP Program in 
Darchula district, Nepal, 2012-2022
Principal Investigator: Subas Risal, PhD, Independent Consultant
Evaluation Research Team: Ramesh P. Adhikary, Helen Keller INTL
Rojee Suwal, Helen Keller INTL
79
Executive Summary
Hellen Keller International (HKI) has been implementing Suaahara II, a USAID-funded multi￾sectoral integrated nutrition program in Nepal over the last one decade. One of the integral 
components of the program was Homestead Food Production (HFP) that aimed to promote 
production and consumption of nutrient-rich foods towards improving household food security and 
nutritional outcomes of children and mothers. Additionally, the focus of the intervention was 
geared towards identifying and supporting the village model farmers (VMFs) who could serve as 
a local resource on homestead food production for the community. 
As an integral part of Suaahara’s monitoring, evaluation and research system, baseline and 
endline surveys for impact evaluation were conducted in 2012 and 2022 respectively. The impact 
evaluation primarily focused on health and nutrition aspects of the intervention, but did not cover 
the effectiveness of agricultural interventions under Suaahara II. This qualitative study aimed to 
fill this gap to generate knowledge and evidence on the effectiveness of Suaahara HFP 
interventions. The study was conducted in three municipalities of Darchula district, namely 
Mahakali Municipality, Malikarjun rural municipality and Shaileshekar rural municipality 
Four primary research questions formed the basis of overall research design. The research 
questions included: i. are the HFP intervention households’ practices and knowledge, and 
consumption of quality diet continuing over time? ii. how have HFP interventions impacted kitchen 
gardening and chicken rearing practices for increased production and crop diversity; iii. what are 
the key barriers and facilitators for improving household production practices; and iv. to what 
extent have VMFs delivered supports in their communities. The questions determined the 
methodology and guided all stages of inquiry, analysis and reporting. To answer the research 
questions two data collection methods were used: i. key informant interviews; and ii. focus groups 
discussions. The multi-module semi-structured checklists were used to collect the data (Annex￾1.1-Annex 1.6). The evaluation team consisted of 1 team leader, four interviewers and four 
translators. The data was collected in the month of November. As a part of the ethical 
consideration, the approval was obtained from Nepal Health Research Council (NHRC).
The following section presents the key findings of this qualitative study: 
● There was an improvement in knowledge and to some extent practice among the program 
participants with respect to homestead gardening. For example, the data indicates the 
increased use of fencing around their kitchen gardens. The scenario was quite similar to 
the backyard poultry rearing. For example, information collected suggests the increased 
use of semi-intensive chicken coops in the study location.
● The knowledge the study participants had with respect to consumption of nutrient-rich food 
was evidently being translated into practice. For example, the knowledge and practice on 
child’s dietary diversity, that is, feeding children from four different food groups was quite 
apparent from this evaluation.
● The evaluation found the increased availability of nutrient-rich food at both household and 
community levels. The information can to some extent suggests more production at the 
local level. 
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● The evaluation suggests the enhanced practice of growing diverse vegetables using 
technologies (machines, poly-houses etc.). There were however some locations where 
the production could have improved with training on the use of technology.
● One of the findings that emerged from the evaluation was the increased income among 
the beneficiary households through selling surpluses which was largely due to growing 
off-season vegetables. In some locations however, particularly those in remote parts 
where markets were not readily available, the surpluses rotted at homes.
● Some of the key barriers that could have prevented from yielding better results included 
lack of necessary materials (building fences, constructing semi-intensive coops etc.), lack 
of financial resources (purchasing polyhouses, purchasing materials for fence or coops 
etc.), lack of skilled manpower (installing polyhouses, constructing semi-intensive coops 
etc.) and lack of space (constructing semi-intensive coops, land availability to undertake 
tunnel farming etc.).
● With respect to enabling factors, local government units and non-government entities were 
providing support in form of materials or by providing training, or both. The support to a 
certain degree has contributed to improved practices.
● This evaluation suggests that social bonding, to some extent, has helped promote 
improved kitchen gardening and backyard poultry rearing practices. For example, a 
program participant in one of the study locations helped others by informing the latter 
about the places where improved seeds and appropriate pesticides could be obtained.
● Mixed responses were received about the services provided by the VMFs in the study 
locations. The findings suggest that the VMFs were quite successful in forming groups 
and imparting knowledge to the members. Additionally, VMFs in some study locations 
were able to leverage government resources through effective communication with the 
local authorities. Nevertheless, there were a few issues concerning VMFs and their roles: 
i. VMFs benefiting themselves from the interventions; ii. time management issue 
particularly for female VMFs; and iii. not communicating fully with the group members 
about obtaining appropriate materials associated with improved kitchen gardening and 
poultry rearing practices.
Recommendations
● The evidence from the evaluation emphasizes the need to promote kitchen gardening and 
backyard poultry rearing practices further which can be undertaken in collaboration with 
the local government units (support for materials and training). The units have resources 
at hand and decision-making power following the change in structure (shift to federalism).
● It is crucial to institute proper mechanisms for effective knowledge transfer. This is 
because, individuals directly involved with intervention, such as VMFs, were benefiting the 
most. The transfer of knowledge will help other program participants to understand the 
benefits of improved kitchen gardening and poultry rearing practices.
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● The findings suggest the importance of enhancing the availability of nutrient-rich foods 
particularly in rural markets. This can be achieved by collaboration between producers 
and local government units. 
● Cultivation of off-season vegetable farming should be encouraged as this was one of the 
leading reasons for income augmentation among program participants. It can be achieved 
by partnering with local governments and private sectors (such as agrovets, cooperatives 
and traders) for implementation.
● This study suggests the need to establish strong linkages between farmers and local 
markets. This is because the evaluation found that in remote areas surplus vegetables 
lied rotten as the farmers couldn’t find the markets to sell their produce. 
● The study recommends building capacity of the local communities through various formal 
and informal groups (such as women’s groups) for leveraging resources from local 
governments. Developing and fostering strategic partnerships between development 
interventions and local government units can help facilitate achieving this goal.
● It is important to promote all three types of social capital (bonding, bridging and linking) in 
locations where future initiatives would be undertaken.
● One of the key criteria for VMF selection should be based on their dedication and 
commitment of full engagement. The approach will further enhance the delivery of services 
such as distribution of seeds, chicks, impart knowledge etc. VMFs should communicate 
with the program participants about where important materials related to kitchen gardening 
and backyard poultry rearing are obtained. 
Background
In Nepal, Helen Keller International implemented Suaahara, a USAID-funded multi-sectoral 
integrated nutrition program for over a decade, ultimately covering 42 out of 77 districts. An 
integral part of the intervention was Homestead Food production (HFP) through which Suaahara
promoted production and consumption of nutrient-rich foods towards improving household food 
security and nutritional outcomes among children and mothers. Suaahara’s specific intermediate 
result related to HFP was to improve access to diverse and nutrient-rich foods by women and 
children. To achieve this outcome, in 2012, HFP was initially launched in 9 highly food-insecure 
districts and expanded to all 42 districts from 2013 to 2017. The HFP intervention targets 
disadvantaged food-insecure communities, thus its implementation varies by district. In some 
districts, the implementation was district-wide (i.e. all communities are targeted) and in other 
districts only selected communities are targeted (Figure 1). 
Women were the target for the HFP program because most are engaged in homestead 
agricultural production while also tending to household chores in most low- and middle-income 
countries including Nepal (Food and Agriculture Organization, 2011). Several studies have shown 
that empowering women can contribute to improved farm productivity (Diiro, Seymour, Kassie, 
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Muricho, & Muriithi, 2018). In addition, the HFP program has been shown to empower women 
(Heckert, Olney, & Ruel, 2019; Olney et al., 2016), which in turn can improve dietary diversity 
(Sinharoy et al., 2018), health care utilization (Sado, Spaho, & Hotchkiss, 2014), and growth of 
children (Cunningham et al., 2015; Heckert et al., 2019; Shroff et al., 2011). Also, the absence of 
extension services targeting women and providing technical support for horticulture and small￾animal raising, highlights the need to target trainings, inputs and information on agriculture to 
improve agricultural practices to women (Farinde & Ajayi, 2005). Research has shown that 
targeting women for training, agricultural inputs and information on improved horticultural and 
poultry improves their knowledge of agricultural practices and increases agricultural productivity 
(Rivera-Ferre, 2008). In addition to the household focus of the HFP program, which emphasizes 
a garden-to-plate model by encouraging consumption of home-grown production, Suaahara II 
(2016 onwards) also supported small producers (both VMFs and beneficiary households) to link 
with markets for the sale of excess production as a means to supplement household income. In 
this way, the HFP approach serves to both incentivize home production for home consumption, 
but also to sell and generate income to increase household purchasing power and well-being.
Suaahara’s HFP approach was to identify and support Village Model Farmers (VMFs) who could 
serve as a resource on homestead food production for households in the community. Through a 
collaborative process, Helen Keller identified local farmers and community organizations to 
establish one VMF per ward, the smallest administrative unit in Nepal (pre-federalism). A total of 
5,686 VMFs were established through training and other support to serve as model farms for on￾farm demonstrations, provision of technical extension assistance to beneficiary households, and 
for organizing the household beneficiaries into HFP groups (~20 members per group). 
Households were selected, at one point per community, for inclusion in the HFP program if they: 
(1) had a pregnant woman or mother of at least one child less than 2 years of age (1000-day 
women) residing in the household at the time of the listing for the training and (2) had at least 40 
to 75 m2 of land near the home. These households received a two-day basic HFP training 
consisting of (kitchen gardening, poultry rearing, diverse food consumption etc.). Immediately 
after the training, the households were given packets of seeds—one for each of the three growing 
seasons-- and five chicks. Households were also linked to the local VMF for further inputs and 
technical support. In total, the program served an estimated 114,000 beneficiaries across 1504 
wards in the 42 districts covered by the Suaahara program. It is important to note that the basic 
HFP support package (i.e. training, seed and chick distribution) was a one-time effort per 
community, and new households meeting these criteria at a later date did not directly receive 
inputs, but relied on VMF inputs and support. 
Suaahara adopted four fundamental principles of HFP programming: (1) ensuring households’ 
access to diverse and nutrient-rich foods throughout the year; (2) focusing on production of 
vegetables, eggs, and meat; (3) promotion of low-cost but easy to adopt technologies; and (4) 
empowerment of smallholder farmers to build resilient and sustained household food production. 
Applying these principles, HFP was implemented at three levels: household, community and 
structural levels. At the household level, the program targeted 1000-day women with an aim to 
increase production and consumption of diverse nutrient-rich foods throughout the year. At the 
community level, the program established VMFs to support the household beneficiaries with 
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agricultural practices and production, particularly when there is limited access to agricultural 
extension services and production inputs. At the structural level, the program worked with 
governmental agricultural/livestock offices at the local level and worked to scale-up and sustain 
HFP through mainstreaming and leveraging resources both from other development projects as 
well as the Nepal government. 
Figure 4: Reach by HFP Component of Suaahara Program in Nepal (Qual.)
Rationale
Suaahara had a comprehensive monitoring, evaluation and research (MER) for learning plan and 
related data systems. As a part of the larger MER, impact evaluation endline survey was 
undertaken in 2022. Both the baseline survey carried out in 2012 and the endline survey largely 
focused on health and nutrition aspects of the program. The surveys did not cover the agricultural 
component to the extent required. It was thus important to conduct the evaluation of Suaahara’s 
agricultural components that primarily focused on HFP. The HFP quantitative survey was 
conducted in Darchula district with the rationale that the district has the highest prevalence of 
households that participated in in HFP component at the baseline survey. Some of the key 
preliminary results1
(see Annex-2 for more details) of the quantitative survey included: i. women’s 
diversity remained the same between baseline and endline; ii. increased households’ 
experiencing food insecurity; iii. improved production of vegetables and eggs; iv. reduced chicken 
1 The results are based on the comparison between the baseline and endline surveys
84
production; and v. increased consumption of dark leafy vegetables, beans and pulses and starchy 
roots and tubers.
Although the quantitative survey did provide crucial information on HFP, it did not explore the 
intervention’s positive and negative impacts on the lives of the people. To gain insights into the 
impacts and to supplement the quantitative data collected, it was essential to have the evaluation 
guided by qualitative approach in place.
Research Questions 
The preliminary results from the HFP quantitative survey were taken into consideration to develop 
the following research questions:
1. Are the HFP intervention households’ practices and knowledge, and consumption of 
quality diet continuing over time?
2. How have HFP interventions impacted kitchen gardening and chicken rearing practices 
for increased production and crop diversity?
3. What are the key barriers and facilitators for improving household production practices?
4. To what extent have VMFs delivered supports in their communities?
Study Design 
The qualitative study was conducted in three municipalities of Darchula district. Darchula was the 
only district included in the HFP quantitative survey that was largely aimed at assessing changed 
in HFP knowledge, practices, production and market linkages. The municipalities where the study 
was carried out included: i. Mahakali Urban Municipalities; ii. Malikarjun Rural Municipality; and 
iii. Shaileshikar Rural Municipality. The municipalities were selected purposively based on 
urban/rural category and density of panel HFP households (high density M/RM were selected).
The study used key informant interviews (KIIs) among Village Model Farmers (VMFs), mothers, 
local government officials (eg. agri-extension workers), NGO/private sector representatives and 
Female Community Health Volunteers (FCHVs). In addition, focus group discussions (FGDs) 
were conducted with the beneficiaries mainly 1000 day mothers. The study participants were 
purposively selected on their basis of involvement (direct and indirect) in the Suaahara program. 
Their involvement was essential particularly to gain an in-depth understanding of purpose and 
impact of the HFP component. To facilitate the FGDs and KIIs, tailor made interview guides were 
developed (see annexes 1.1-.1.6). 
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Table 4.1: Sample allocation of respondents by municipality
KII FGD
Municipalities VMF Mother FCHV
Local government 
officials (agri￾extension worker)
PNGOs 
/Private 
sector 
(Agrovets)
Total FGD with 
mothers
Mahakali UM 2 2 2 2 2 10 2
Malikarjun RM 2 2 2 1 1 8 2
Shaileshikhar 
RM
2 2 2 1 1 8 2
Total 6 6 6 4 4 26 6
Training 
Prior to the actual field work, 2-day long training was provided to the interviewers (moderators 
and recorders/note takers led jointly by the HKI (Suaahara/USAID) representatives and the team 
leader. The team leader ensured that each interviewer participated actively in the entire period of 
the training. Adequate supply of required stationaries, training aids, manuals, recorder were 
ensured by the HKI.
The key focus of the training was to familiarize the interviewers with the objectives, methodology 
and tools in relation to the study. Additionally, the training included mock sessions that were aimed 
at making familiar the data collection team with questions to be administered and operational 
procedures of the field work.
Data Management and Analysis
The interviewer’s audio-recorded all the interviews that were later transcribed by the interviewers 
themselves. The transcripts were then translated from Nepali to English. 
Information collected through KIIs and FGDs was analyzed using thematic analysis method 
(Braun, Clarke and Terry, 2019). The key steps of the analysis included: i. reading and re-reading 
the data (translated transcripts) and noting of ideas; ii. generation of codes; iii. data organized into 
meaningful groups; and iv. revise coding scheme (eliminate and collapse codes). For the data 
management and analysis process, the software package called Nvivo was used.
For the data collection and analysis purposes, a number of variables related to kitchen gardening 
and backyard poultry rearing were used. Variables for homestead gardening included: i. fencing; 
ii. vegetable diversification; iii. climate smart agriculture (CSA); iv. insect pest management; v. 
water management; vi. integrated cultivation management; vii. seed production; and viii. solar 
drying. Likewise, variables for backyard poultry rearing included: i. use of semi-intensive coop; ii. 
providing nutritive feed and clean water; iii. coop hygiene and sanitation; iv. regular vaccination; 
and v. separate chicks and chickens if any diseases and consult with vet.
86
Ethical Consideration 
Ethical approval for this study was obtained from the Nepal Health Research Council (NHRC), 
Government of Nepal. 
Results
Research questions as in any other qualitative study occupied the central place (Onwuegbuzie & 
Leech, 2006). The questions framed for this evaluation determined the data collection methods, 
analysis techniques, sample size and sampling scheme. The section to follow attempts to present 
and summarize the findings of the study by putting them into context with research questions. 
The attempt is made to report all relevant results concisely and objectively in a logical order. The 
findings from the evaluation are presented under each research question.
1. Are the HFP intervention households’ practices and knowledge, and consumption of 
quality diet continuing over time?
2. How have HFP interventions impacted kitchen gardening and chicken rearing practices 
for increased production and crop diversity?
3. What are the key barriers and facilitators for improving household production practices?
4. To what extent have VMFs delivered supports in their communities?
Are the HFP intervention households’ practices and knowledge, and consumption 
of quality diet continuing over time?
The study explored the knowledge and practice among the study participants in relation to three 
key themes namely kitchen gardening, backyard poultry rearing and consumption of quality diet. 
Mainly for two themes (kitchen gardening and backyard poultry rearing), a number of variables 
(as discussed in data management and analysis section) were taken into account for investigating 
the research questions.
Knowledge and Practice in relation to kitchen gardening
Homestead gardening which is undertaken in a space set apart in the landscape for growing 
vegetables, herbs and fruits for everyday use was found to be gradually making headway in the 
study locations. This evaluation found that across almost all the kitchen gardening variables, the 
Use of quotes as a part of reporting
Study participants’ quotes for the reporting purpose are used as evidence more than as 
arguments. Additionally, they are used for a number of other purposes mainly including 
explanation, illustration and representation. To the extent possible, attention is paid in selecting 
quotes that reflect strong pattern of data. While discrepant examples served an important purpose, 
their use was mostly purposeful and explicit. Following quotations in the text, each participant is 
differentiated by: i. data collection instrument; ii. type of participant; and iii. geographical locations. 
For geographical location, initial of the municipality is used followed by initials of type of 
municipality (for urban municipality ‘UM’ and for rural municipality ‘RM’ are used).
87
knowledge and practice among the study participants were quite evident. The following presents 
some of the illustrative examples:
Fencing: There was an awareness by and large among the study participants about the 
benefits of having fencing in place around their kitchen gardens. There was a general 
agreement among the study participants about the damage to the garden that domestic and 
wild animals could cause. The practice of using sturdy and appropriate materials for fencing 
purpose was becoming more common unlike in the past. A 1000-Days mother commenting 
on the use of sturdy materials and its benefits:
“We did not use to install fence before but now we have it in place…Now we 
use wire for fencing. Previously, we did not use to plant vegetables, we used 
to buy vegetables from the nearby market. Use of sturdy materials has helped 
maximize the yield.” <KII_1000 Day Mother_SRM>
Vegetable diversification: The findings revealed that the program participants in the study 
locations for the most part were aware of vegetable diversification. They understood vegetable 
diversification as growing more than one crop in an area or adding more crops into an existing 
rotation. Some program participants had reflected that into practice. A statement below from 
a 1000-days mother suggested the knowledge she had on benefits of diversification 
particularly in terms of yield maximization and income it generated.
“We can plant potato, coriander, mustard greens, radish, garden cress, beans, 
carrot, spinach, and coriander. We can plant other vegetables also but due to 
fear that potatoes might get damage we don’t plant other vegetables. We plant 
dill leaves; it is useful. We can sell it at a high price, it is sold for R.s. 25-30 
rupees per bundle. We also plant beans and also various types of a gourd. We 
plant various types of vegetables.” <FGD_1000 Days Mothers_SRM>
Climate Smart Agriculture: Climate smart agriculture was largely perceived by the study 
participants as the use of available machines and equipment and poly-house/tunnel farming. 
In a wider sense, locals did possessed knowledge about the benefits of using machines and 
use of poly-houses for farming. The comment below from a VMF indicated that a few farmers 
were planting off-season vegetables adopting tunnel farming and generating income through 
the practice. An example:
“There are few people in Shaileshikhar municipality-3 who have planted off￾season vegetables with the help of advanced technology like growing 
tomatoes, cabbages and cauliflowers inside tunnels and have earned Rs. 
1,50,000-2,00,000 annually. Other people are also earning money by selling 
vegetables and are sustaining a living.” <KII_VMF_MARM> 
Although, the knowledge on the benefits of CSA was present, it is important to note that it was 
practiced by only a few. One of the key reasons informed by a respondent was the 
accessibility or in other words, it was accessible to the individuals who represented one group 
or other such as farmers’ group.
“This (poly-houses) is not available for everybody. Some people mainly those 
related to agricultural groups are given these things. They make poly-houses 
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and plant lots of green vegetables. I have seen people growing a lot of green 
vegetables.” <KII FCHV_SRM>
Knowledge and practice in relation to backyard poultry rearing
Backyard poultry farming has been one of Suaahara’s mainstream HFP activities with an 
overarching goal of increasing year-round access to diverse and nutritious foods at home. This 
evaluation found that the study participants had the knowledge on the poultry rearing variables 
and translating that into practice. Some of the examples included: 
Providing nutritive feed and clean water: The interviews conducted conveyed the 
impression that program participants were generally aware of the benefits of providing 
nutritive feed and clean water to chickens. There was a common understanding among the 
study participants that nutritive feed provides poultry the energy and material required for the 
development of bone, flesh, feathers and eggs. Further, particularly in relation to a laying 
flock, there was a general awareness about importance of clean water supply and its shortage 
can result in reduced egg production. The comments below from the study participants were 
examples indicating their awareness regarding the significance of providing nutritive feed and 
clean water to chickens.
“If we provide foods and clean water to chickens properly then only they lay 
eggs. If we have more eggs we can use both for our own consumption and 
selling purpose. This way we can be healthier and at the same time generate 
some income” <KII_FCHV_MARM>
Construction of semi-intensive coops: Introduction to semi-intensive coops in the project 
locations was one of Suaahara HFP’s important initiatives. The construction of semi-intensive 
coops is primarily intended to reduce poultry diseases and improve sanitation status of houses 
and their surroundings. The orientation provided by Suaahara has to some extent instilled 
awareness among the community people on the benefits of constructing semi-intensive 
coops. The comments below from an agro-vet suggested the improvement in practice of 
constructing semi-intensive coops:
“People have started to build semi-intensive coop in their houses. Yes, there 
are coops even if there are two or three chickens, there are small coops for 
them. It is not like at the large-scale chicken firms but is small.” <KII_Agro-vet_ 
MUM>
Regular vaccines to chickens: Those study participants in the study locations who were 
engaged in poultry rearing had the knowledge about the benefits of vaccinating chickens. 
Further, they were aware of the fact that minimizing the occurrence of diseases result in 
increased productivity. A 1000-Days mother stating on the benefits of regular vaccines:
“We are aware that the vaccination prevents chickens from contracting 
diseases. It is always good to have healthy chickens. More the chickens, more 
we can sell.” <KII_ 1000 Days Mother_MARM>
Coop hygiene: Maintaining good coop hygiene is critically important aspect of poultry rearing 
not just for chickens’ health but for family rearing them. If the cleaning is not done regularly, 
89
bacteria and other diseases can grow in the coop. The knowledge and practice among the 
study participants was apparent in relation to maintaining proper coop hygiene. The program 
participants who were maintaining the coop hygiene were found to use gloves instead of hand 
unlike in the past. The statement below from a 1000-days mother indicated the use of 
protective gears such as gloves while cleaning the coop. 
“We use gloves now. We need to clean by wearing gloves. There would be a 
lot of manures if we raise chickens.” <KII_1000 Days Mother_MUM>
However, there were variables such as chick reproduction that were not practiced as much. 
An example:
“We are aware that if we reproduce chicks, we do not have to buy from a 
market. It saves money. But we have heard that chicks die due to the lack of 
proper management. It is a costly affair for us.” <KII_FCHV_MARM>
Knowledge and practice in relation to consumption of quality diet
The findings to a large extent suggested that there’s been an improvement in knowledge and 
practices in relation to intake of quality diet among the beneficiaries. A statement below from one 
of the VMFs suggesting the change in practice in terms of consumption of quality diet. 
"There is a change. I have said earlier also, in the past people did not used to give 
enough food to pregnant women. They used to give one or two meals of flatbread or 
rice, they did not give vegetables, meat or fruits thinking that it would affect the child 
as they might get a common cold. Now they give everything. They now understand 
that they should provide four types of meals to small children and pregnant women. 
Everyone understands it. We also say these things about what they should do”
<KII_VMF_MUM>>
The knowledge among the program participants was not only possessed but imparted as well. 
The statement below from one of the FCHVs interviewed:
“I have seen this in many people around here. I will show you who Purnamaya 
(name changes) is. There was a two-year-old child who acted like 10 years old. I 
said that if a child gets all the nutrition then they would grow up to develop their 
brain and be smart. When people tell me that their child is slow, doesn’t know 
anything and forgets taught things easily, I tell them the same thing that their brain 
has not developed yet. If the child is not given proper nutrition when it is in the 
womb until they reach two years of age, then this happens so I tell them that there 
is a lack of proper food for the child. This really does happen so just giving them a 
stomach full of food is not enough.” <KII_FCHV_SRM >
How have HFP interventions impacted kitchen gardening and chicken rearing 
practices for increased production and crop diversity?
One of the key HFP goals is to encourage targeted community members to adopt improved 
gardening and poultry rearing practices that can result in increased vegetable production diversity 
and quantity, eggs and chicken production. Since there is a dearth of evidence that establishes 
90
positive correlation between improved practices and greater household production, a few proxy 
indicators were considered for this evaluation. The indicators mainly included availability of 
nutrient rich food particularly at the household level, awareness in relation to consumption of 
quality diet, production practices in general and improved income.
Availability of nutrient rich food: Availability of diverse nutrient rich food could likely be due to 
the increased production. Simply put, more the production more the food is available. The 
statement below from a study participant suggested the increased production and diversity of 
vegetables in the study locations:
“People grow green leafy vegetables and legumes in their fields. Green leafy 
vegetables, legumes, eggs, and lentils are available at home.” <KII_VMF_MUM>
For those who did not practice kitchen gardening and poultry rearing at the household level, they 
were dependent on a nearby market for nutrient rich food mainly including vegetables, meat and 
eggs. An example: 
“Meat and fish are not regularly available at the market. Some people don’t grow 
legumes so it is not available in all people’s home. That’s the problem. It could be 
better if these could be available easily at our local market. Shops should be opened 
for it. If everything is available locally then it would be easier. If a shop with all these 
products is opened, then we can buy them easily.” <KII_VMF_SRM> 
Consumption of quality diet: There is a strong association between consumption and 
production of nutrient rich food or in other words neither could exist without the other. Production 
creates the food for consumption, and consumption realizes/ actualizes production. The 
knowledge and practice in relation to consuming nutrient rich food was to a reasonable extent 
related to diverse production. An example:
“Without vegetables, how can we eat now, it is most essential. We follow saying each 
day four types of food “harek bar khana char”. Now, curd, and milk are not enough
to eat rice. Previously, people use to eat milk and curd only, they don’t use to care 
about vegetables. But now everything like green leafy vegetables, curd, and milk are 
required…Now, people also eat lentils along with vegetables. This knowledge and 
practice somehow is responsible for production of diverse vegetables in this 
location.”<KII_VMF_SRM>
Likewise, the knowledge and practice in relation to significance of having improved breed of 
chicken has affected the production positively. A FCHV in the course of an interview informed to 
have produced more improved breed of chicken due to its benefits:
“We got a good breed of chickens than before. We got good chickens which give 
more eggs and meats. It became good after getting chickens of good breed. Since 
such chickens give more eggs and meat, we have started to produce more.”
<KII_FCHV_MARM>
It is likely that the improved consumption of diverse vegetables, meat and eggs results in 
increased demand. To meet the demand, the production of chicken and vegetables is essential. 
A FGD participant commenting on the improved knowledge and practice about the consumption 
of vegetables, meat and eggs that could have resulted in increased production:
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“In the past people ate green vegetables and other things but now they eat meat 
as well as eggs. They also eat green vegetables now. Yes, they have started eating 
meat monthly as well as weekly. In the past, people only used to eat meat in 
Dashain and Tihar but nowadays they eat every other day and to meet the 
demand, chickens have to be produced in a large scale.” <FGD 1000 Days 
Mother_MUM>
Production practices: The change in production practices was noticed in the study locations. 
Production was not considered important by the program participants in the past. However, the 
trend appeared to be slowly changing. An example:
“Previously, they (program participants) don’t use to focus more on the production. 
They used to say that if it grows it’s good, if not then that is also fine. But now, 
cultivation and production are very important. Now, people plant daily. If you plant 
you can get lentils and vegetables. Likewise, if you raise chicken you can get eggs 
and meat.” <KII_VMF_MUM>
Program participants informed by the study participants were keen to grow diverse vegetables 
unlike in the past. To put in another way, the focus these days was more geared towards 
production of diverse vegetables. An example: 
"Its main positive point is people are growing more or fewer lentils, rice, wheat, and 
other vegetables in their homestead food production. As per our understanding in 
the rural area, people can increase some vegetables in their homestead food 
production. They have to make homestead food production near their houses for 
their families. They have to eat the vegetables of the homestead food production. 
They have to eat vegetables as well along with lentils, rice, and bread. They have 
to eat more legumes. They have the awareness that must produce some 
vegetables in their homestead food production. We can see that people have 
produced mustard greens, spinach, coriander, radish, carrot, garlic, and legumes 
though in fewer lands." 
However, it was reported that the production in the study locations such as remote parts of 
Shaileshekar Municipality could be better with training to the program participants on the use of 
advanced technology. A government staff commenting on the lack of training and knowledge 
about advanced technology: 
"Our Shaileshikhar municipality area is a geographical area where there is good 
production of everything from growing mushrooms to apples. We have areas 
where mushrooms are grown as well as apples. Everyone could not get that 
knowledge and skill. They have skills since they have been doing it, we have seen 
that. But also there is a lack of training and knowledge about advanced 
technologies. It would have been more effective if we could provide them with more 
training." <KII_Government staff_SRM>
One of the major impacts of the Suaahara’s HFP component that was noticed was the increased 
income among the beneficiary households through selling surpluses (after own consumption). A 
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key reason reported by the study participants was the practice of growing off-season vegetables. 
An example:
“On an average people earn 1 to 1.5 lakh yearly. Yes, they are doing modern 
vegetable farming (indicating off season vegetable farming) and increasing their 
income. Earning amount varies from person to person; some people earn even more 
than that amount. While some do not earn that much also.” <KII_Government 
staff_SRM>
In the study location, it is likely that use of modern farming and technology resulted in increased 
production. Additionally, availability of water, improved irrigation facilities and availability of hybrid 
seeds were also informed as factors that may have affected the production positively. The study 
participants commenting on the increased production due to modern farming techniques and use 
of technology that possibly could have increased their income.
The program participants were reported to engage in professional vegetable farming as well and 
generating income through it. 
"Yes, people in my community are doing professional vegetable farming and 
earning selling those products.” <KII_VMF_SRM>
With the income augmentation due to the increased production, program participants were 
supporting their children in buying useful materials such as notebooks and pens.
“Yes, they also have benefited from it. They had to buy vegetables to eat before. 
But, they don’t need to buy it. They can grow vegetables from their lands. It is good 
for all of us. We are getting enough money for the soaps, copy, and pen for our 
son and daughter and other necessary expenses.” <KII_FCHV_MUM>
Although improvement in terms of production was evident in the study locations, there were 
concerns expressed by some study participants with respect to selling vegetables for relatively 
low prices. An example:
“Sir, there is an improvement in the financial situation also. Whenever there is high 
market value we sell it later we have to sell in low price. A lot of vegetables remains 
at home. We feed them to buffalos.” <KII_VMF_SRM>
What are the Key barriers and facilitators for improving household production 
practices?
The study explored some of the key barriers and facilitators that contained or improved household 
production practices among the beneficiaries in the study locations. As previously mentioned in 
the relevant section, a number of variables were taken into account associated with kitchen 
gardening and backyard poultry rearing. It is important to note that although the knowledge and 
practice in relation to kitchen gardening and backyard poultry rearing have improved, barriers 
could have prevented from yielding better results.
Kitchen Gardening 
Barriers existed across all kitchen gardening variables. Some of illustrative examples include:
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Fencing: The findings suggested a couple of key barriers that could have prevented from 
beneficiaries in installing fences around the garden. The following statement from a VMF 
suggested the lack of materials in the study locations as a key related barrier:
“People are not much interested. They might not be doing it because it is 
difficult to manage bamboo as it is not easily available… Those who have 
money can only afford it, others cannot buy it” <KII_VMF_MUM> 
CSA: There was a general agreement among the study participants in relation to lack of skilled 
manpower to build tunnels in the study locations. An example:
“No, sir… And also, we need skilled people to build it (poly-house). If we have 
the knowledge and skills, we can also build it.” <KII_FCHV_MARM>
Likewise, to practice CSA, various materials are required which raises the question of 
affordability. The statement below from a two 1000-day mothers were examples of issues 
in relation to affordability:
“Cost of building poly-house is around 10 to 15 thousand which we cannot 
afford.” <KII_1000 Days Mother_MARM>
Integrated Cultivation Management: When the barriers concerning integrated cultivation 
management were explored, traditional thoughts particularly among the senior citizens were 
at times preventing the practice.
“Here agriculture is derived from ancestors so it is hard to change it. The old 
people are having difficulties adopting advanced agriculture here.”
<KII_Government staff_SRM>
Backyard Poultry rearing: 
Barriers existed across all backyard poultry rearing variables. Some of the important examples 
include:
Providing nutritive feed: the lack of sufficient amount of nutritive feed at the household level 
emerged as a barrier. The statement from a FCHV suggesting the same and also the lack of 
knowledge on the location where the feed can be obtained. 
“There is a Lack of sufficient amount of nutritive feed for the chickens at our 
home. What we lack is the understanding that to raise chicken we need 
everything like rice and pulses. But we do not know where one would get all 
the required things from.” <KII_FCHV_SRM> 
Semi-intensive coop: Lack of adequate space and lack of time and materials were informed 
as barriers. A VMF during the course of the interview informed the same as barriers:
“Some people don’t have enough space to build semi-intensive coops. it is a 
village and most of the houses are close to each other. So, if we raise chickens 
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openly, they might go to others’ houses which creates problems… we don’t 
have time to build it as well as it requires various materials too.”
<KII_VMF_MARM>
Chick reproduction: Barriers such as lack of insurance and lack of service centers existed 
with respect to chick reproduction. The comment below from a government staff highlighting 
the barriers:
“I have heard this, when they are small they die. If we get 1000 chicks then 
300 chicks die, this type of thing has occurred. There are cases where they die 
due to lack of management. There is a lack of insurance in this issue. If they 
are insured, then they would not have to carry its loss... Challenges may be, if 
the chickens get infected there is no place nearby for their timely treatment.” 
<KII_Government Staff_SRM> 
Regular vaccine: The lack of timely services provided by concerned government officials 
such as TA was a key barrier in relation to the chicken vaccination.
“They might get diseases but the timely vaccination was not given to them.” 
<KII_FCHV_SRM>
Enabling Factors:
One of the key facilitators that emerged from the evaluation was the support provided by the local 
government units. The support as reported by the study participants was in form of materials and 
also training. A statement below is a statement from a 1000-days mother suggesting the support 
being provided by the wards and municipalities:
"We got material support and training from the wards and municipalities. This has 
motivated us to construct fences around our gardens." <KII_1000 Days 
Mother_SRM>
Likewise, the knowledge itself emerged as another facilitator. For example, with respect to soil 
nutrient management, the knowledge on making soil thinner and less use of chemical fertilizers 
was present among the study participants. A 1000-Days mother commenting on the same:
“We need to make the soil clod small. We need to hit the soil with a small hoe to 
make the soil fertile. We need to make the same level of soil…we also should 
minimize the use of chemical fertilizers” <KII_1000 Days Mother_MUM>
Similarly, availability of resources such water can help significantly in improving practices. The 
regular flow of water appeared to have enabled the program participants to manage water in the 
kitchen garden appropriately which in turn has helped to certain degree to diversify vegetables. A 
1000-Days mother commenting on the benefit of having reading available water:
“We have a water facility now. There are one or two taps in the houses. There is 
a water facility in every house now. People could not access water even by 
spending money. So, they have to carry water from a distant place and managed 
to pour little into vegetable farming. We have water in all houses now and then, 
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and we will use that water on farms. We can eat different vegetables.” <KII_ 1000 
Days Mother_MARM>
The next facilitator reported was the changes in attitudes in relation to farming practices. The 
statement below from a government staff indicated the gradual change in attitudes particularly 
among the youths. The statement below from a government staff indicates the changes in 
attitudes particularly among the youths:
“…But the new generation of people are attracted to follow advanced agriculture. 
They are moving towards it and the production thus is improving”
<KII_Government staff_SRM>
Likewise, although a few there were program participants, who were helping other community 
members by getting the medicines and informing about the significance of regular vaccination in 
case of sick chicks. This could be indicative of the fact that bonding social capital2 can play a 
significant role in encouraging the improved practices in the study locations. A 1000-days mother 
commenting on the contribution she’s making in the community:
“Few people don’t vaccinate the chicken but are aware of the importance. 
Sometimes, they get sick at that time I bring medicine from the veterinary and give 
them. Till now chickens have not got serious sickness. In addition, I tell them about 
benefits of regular vaccination.” <KII_1000 Days Mother_MAUM> 
To What extent have VMFs delivered supports in their communities?
To gain deeper insights into the services delivered by VMF, four main variables were taken into 
account: i. lead HFP group; ii. provide agri-extension services including kitchen gardening, 
backyard poultry and CSA etc. to group members during the group meeting; iii. provide 
seeds/seedlings/chicks/eggs/vegetables to community members at free of cost or subsidized 
rate; and iv coordinate with government stakeholders to leverage government resources.
Lead homestead food production group
One of VMFs’ key roles included forming HFP group and conducting meetings with the members. 
The findings suggested that leading HFP group largely was associated with imparting knowledge 
to the members. In addition, VMFs were expected to set an example in the study locations. The 
mixture of responses was received from the study participants when asked about the services 
provided by the VMFs in the study locations. The general perception among the study participants 
was that VMFs to a large extent were successful in leading the HFP group and imparting 
knowledge to the members. Some of the typical responses from the study participants:
“The VMF here has done his duties sir. They have been working hard. If there are 
100 farmers, then 80-90 farmers learn new things because of the VMF. Hence, it 
can said they have been teaching.” <KII_Government Staff_SRM> 
2 Bonding social capital is derived from relationships among the people within the same community.
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“The VMF here has been Providing information and teaching mothers regarding 
types of food that should be fed to children below 2 years and also lactating 
mothers. In addition, she also has been providing information to the community 
people.” <KII_1000 Days Mother_SRM> 
VMFs were also found to be setting an example in the study locations. The statement below from 
a study respondent was a common response:
"We have appointed one village model farmer in every village. Model farmers can 
become an example for others. Other farmers become motivated to engage in 
farming by looking at their farms". <KII_Agri-Technician_MUM> 
However, the study revealed a number of issues concerning VMFs and their roles. One of the key 
issues that often was raised by the participants was that the VMFs were benefiting themselves 
by the initiative. A FGD participant commenting on the services provided by VMF:
"She (VMF) personally farms vegetables and sells them but what has she done for 
the group? She has not done anything." <FGD_1000 Days Mother_SRM> 
This could be substantiated to some extent by the information provided by a VMF, who stated to 
have learned a number skills mainly with respect to vegetable farming, writing applications and 
speaking with authority with confidence. 
“I learn about vegetable framing. I can write an application to local authorities 
asking for support. Now, I can openly talk with government staff and also can keep 
my thoughts.” <KII_VMF_MARM> 
There were other issues that emerged from the study such as VMFs’ unsuitability for the role and 
time management particularly for the female VMFs. The statements below were the common 
perceptions among the participants in relation to VMFs’ roles and challenges associated with 
female VMFs.
“Some female model farmers can't give more time. They have to give more time 
to the household chores if they have a big family. If the female has to work a lot as 
a daughter-in-law, and if we select them as a model farmer, she can't give time. If 
some women can take complete responsibility and she can convince others, they 
can work as Village Model Farmers effectively. But, some females don’t have 
convincing capacity. Some male farmers can work themselves hard but they might 
not have convincing capacity. So, we have to think a lot at the time of selecting 
Village Model Farmers. This is the situation. Most of the females are in agricultural 
fields. So, it would be better, if we could select energetic females as model 
farmers.” <KII_FCHV_MARM>
The communication gap between the VMFs and program participants was another issue that 
emerged from the study. A statement below from a 1000-day mother was an example:
“It is difficult, sir. We would not know if they (VMFs) would provide the necessary 
materials or not. We do not know when we would get it or where we get it from. 
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They tell us to go to a certain office and give documents. Sometimes they provide 
a little so it is difficult.” <KII_1000-Days Mother_MUM> 
Providing Agri-extension services
VMFs in some study locations were informed to be providing materials that largely included seeds 
and was motivating the program participants to undertake vegetable gardening. An example from 
a study participant:
“She motivates people to cultivate, helps people to spread seeds, and also shares 
her seeds with other people if it is not enough for all.” <KII_1000 Days 
Mother_MARM> 
VMFs seemed more active with the members of the farmers’ or women’s’ groups. A typical 
statement from a study participant. 
“Now they (VMFs) give information about things. There is an agriculture group that 
says that they have received certain training. Now there are also agriculture groups 
as well as women’s groups.” <KII_Agro-vet_MARM>
Providing seeds/ seedlings/chicks/eggs/vegetables to community members at free of cost 
or subsidized rate
Another VMFs’ key role was to distribute materials mainly including seeds/ 
seedlings/chicks/eggs/vegetables to community members at free of cost or subsidized rate. 
According to VMFs in the study locations, aforementioned materials were being provided free of 
cost to the community members. An example:
“I have been providing materials such as vegetable seeds to community members 
for free. I always distribute materials at free of cost.” <KII_VMF_MUM> 
However, not to be ignored, there were some study participants who mentioned not to 
have received any material from the VMF. As a common example, statement 1000-days mother:
“No, he (VMF) did not give me anything when I went there in the group meeting.” 
<KII_1000 Days Mother_MUM> 
Coordinate With government stakeholders to leverage government resources 
One of the activities that VMFs were actively engaged in was leveraging government resources 
with the local government authorities. The statement below from a VMF indicated the leveraging 
of resources through the local government unit:
“The group also does that and I also go there. We have talked with them about 
vegetables, equipment and requested to provide us with iron tunnels and hand 
held tractors. We go to the municipality and discuss this. ” <KII_VMF_MUM> 
Likewise, due to the VMFs’ effort in coordinating with municipal officials, program participants 
were able to receive grants for undertaking vegetable farming. The statement below from a FGD 
participant suggesting the receipt of the grant:
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“I ask for an agricultural tools grant with rural municipality. If they cannot provide 
that then I demand agricultural tools from a separate budget with local authorities. 
Previously, rural municipality did not to provide us grants but this year they did. 
They provide us a poly house. Rural Municipality have also provided us this fan 
which helps to blow dust from the paddy. It is used during the winnowing process.”
<FGD__1000-Days Mother_MARM>
Discussions 
This section provides the discussion of the study findings and an attempt has been made to put 
them into context with the research questions. Simply put, the section is geared towards 
discussion of findings that largely attempted to answer the research questions. As mentioned 
previously in the results section, the research questions played a significant role in steering the 
study. 
Knowledge and Practice 
Knowledge is often defined as information acquired largely through a number of sensory inputs 
such as reading, listening and watching. Additionally, it refers to familiarity with factual information 
and can be transferred or can be self-acquired through observation and study. Practice on the 
other hand is application of knowledge acquired.
The findings of the study suggested that with the exception of a couple of variables taken into 
consideration in relation to kitchen gardening and poultry rearing, there appeared to be an 
improvement in knowledge among the study participants. Improvement in knowledge was 
revealed particularly in terms of fencing, vegetable diversification, soil nutrient management and 
water management among other variables. Likewise, there was an improvement in knowledge 
regarding backyard poultry farming (mainly building semi-intensive coops, separating sick chicks 
from rest of the flock and regular vaccination to chickens). With reference to practice, although 
there was an improvement, there were opportunities for further progress. For example, many 
participants possessed knowledge about the benefits (protection from wild and domestic animals) 
of having a fence around their kitchen garden in place but were yet to install it. The findings were 
consistent with other variables including vegetable diversification or building semi-intensive 
coops. 
Evidence-based knowledge is crucial component for change (Ahmed et. al. 2018). In the study 
locations, there was a positive association between knowledge and practice supporting similar 
studies conducted in Nepal (Jones et. al, 2005). Individuals particularly those directly related to 
the project such as VMFs had higher odds of having adequate knowledge and adopting improved 
practices compared to participants who were indirectly benefiting (program participants in 
general). The higher level of practice among those directly related individuals was likely due to 
their direct access to different materials and knowledge imparted as a part of the program. 
Knowledge they had was the main modifier to bringing a positive practice towards kitchen 
gardening and backyard poultry rearing.
Impact of Improved Practices 
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Suaahara program is in its final year of implementation and it was important to gain an in-depth 
understanding of its impact. It is important for any development project that intended impact is 
achieved during or after the project period. This section discusses the findings in relation to impact 
of the improved practices. The study findings indicated the link between the production and: i. 
availability of food; ii. consumption of food; iii. improved practices; and iv. improved income.
Availability of Food and Production
The findings from the study revealed that the diverse nutrient foods particularly the vegetables 
were available at the household level which could likely be due to the increased production. 
However, there was a common concern expressed by those who were not engaged in household 
level vegetable farming and backyard poultry farming. According to these program participants, 
meat and eggs were not readily available at the market. The notion of production is premised on 
the belief that people will buy foods that are widely available (Kotler, 2000).
Consumption and Production
There is a strong association between consumption and production of nutrient rich food or in other 
words neither could exist without the other. Production creates the nutrient-rich food for 
consumption, and consumption realizes production. The findings suggested that there was an 
improvement in consumption of quality diet among the study participants. The improved 
consumption may suggest the increased demand which in turn tends to promote production.
Production Practices
The production practices are strongly influenced by the knowledge such as adoption of new 
technologies, application of alternatives for pesticides, undertake organic farming etc. There were 
program participants in the study locations lacking knowledge with reference to use of 
technologies to grow vegetables and rear chickens. It is often contended that use of technologies 
is an essential aspect in improving the farming yields (Suvedi, Ghimire and Kaplowitz, 2017). 
In some study locations, knowledge among the existed in relation to higher income vegetables 
could generate. They had the knowledge about significant role that factors such as availability of 
water, irrigation facilities and hybrid seeds can play in improved production. These factors are 
considered as fundamental requirement for any type of farming including the vegetable farming 
(Biswas, 1989 & Gauchan, 2017).
Improved kitchen gardening practices had to some extent contributed to the increased income of 
the program participants in the study locations. The improved income was largely due to selling 
surpluses. A key reason behind the existence of surpluses was the gradual popularity of off￾season vegetable farming. It was encouraging to note that although in a small scale, off-season 
vegetable production was making headway in the study locations. Generally, in Nepal the number 
of off-season vegetable growers is few with nominal production that barely can fulfil the demand 
(Kunwar, Dhakal & Panta, 2015).
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For improved income of the vegetable growers and the poultry rearers, it is crucial to have an 
efficient market network which some study locations lacked. Usually, households appeared to be 
linked to a vegetable collection centers that were established more informally. Further, for 
improved production, profitable supply chain (producers, distributors and marketers) is believed 
to be essential (Meijerink, 2010). There were program participants who informed that due to the 
lack of efficient market, the vegetables they grew lied rotten at home.
Barriers and Facilitators 
As discussed earlier, an improvement was noticed with respect to kitchen gardening and poultry 
rearing knowledge and practice. However, barriers in almost all the variables related to kitchen 
gardening and poultry rearing did exist that could have prevented from yielding better results. 
The process of translating knowledge into practice is often accompanied by barriers and 
challenges. Some of the typical barriers emerged from the study included: i. lack of materials; ii. 
lack of financial resources; iii. lack of skilled manpower; iv. lack to time; v. lack of knowledge and 
skills; and vi. lack of adequate space.
Lack of materials: It is often challenging for rural people particularly those from poorer
households to have the materials available. It is easier to explain the benefits of fencing or semi￾intensive coops but translating that into practice requires materials such as bamboo or wires 
which are not readily available. 
Lack of financial resources: Installing fences and building semi-intensive coops require financial 
resources which poorer household often lack. 
Lack of skilled manpower: Building fences, semi-intensive coops, poly-houses require 
investment of both capital and skilled manpower. The lack of skilled manpower often acts as a 
deterrent from installing fences or building coops and poly-houses.
Lack of time: Making home-made pesticides or making nutritive chicken feed at home can be 
time intensive. People particularly those engaged as daily wage labourers tend to be more 
focused on generating income rather than spending time making the pesticides and chicken feed.
Lack of adequate space: Many people mainly in rural Nepal do not possess private land that is 
adequate to build the semi-intensive coops and to undertake tunnel farming. 
Enabling Factors 
A leading enabling factor that could have motivated the kitchen gardening and backyard poultry 
rearing in some study locations was the support provided by the local government units in form 
of materials and training. For example, in one of the study locations, materials such as wires and 
bamboo were provided by the units. With the decision-making power in relation to resource 
mobilization that local government units have, the focus of any intervention should be geared 
towards leveraging the resources. To accomplish the leveraging of the resources, it is crucial for 
the local government leaders to possess knowledge on the benefits of improved kitchen 
gardening and poultry rearing practices.
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Social capital was another factor emerged from the study that could have motivated the improved 
kitchen gardening and poultry rearing practices. All three types of social capital namely bonding, 
bridging and linking (Claridge, 2018) were in place. The program participants were found to impart 
related knowledge to their neighbors and other villagers and also helping them by obtaining better 
and improved seeds and appropriate pesticides from a nearby market. 
The knowledge that the program participants possessed was also crucial component in motivating 
to undertake improved practices. For example, program participants in some study locations had 
knowledge to some extent about the soil nutrient management such as making soil thinner, less 
use of chemical fertilizers and pH testing that measures the soil acidity and alkalinity. 
VMFs’ Service Delivery
A key role of the VMFs in the study locations was forming the HFP groups and leading the same. 
Leadership quality was assessed from a number of perspectives mainly including self-awareness, 
relationship-building, empowering others, becoming role models and full engagement in the 
intervention (see Astin and Astin, 2000). There was mixture of responses from the study 
participants when asked about whether the VMFs were fulfilling the leadership role. 
VMFs in some study locations were leading the HFP group by imparting the knowledge in relation 
to improved kitchen gardening and poultry farming practices. This to some extent had helped 
empower the program participants with the knowledge. Some were translating the knowledge into 
practice. Likewise, for some program participants VMFs were setting an example or becoming 
role models in the study locations. One quality that a good leader has is setting an example by 
inspiring others to follow suit.
An important role that VMFs were fulfilling was coordinating with the local government units 
thereby leveraging resources. Although local government leaders have the authority, resources 
and political incentive to do more for the beneficiaries, they lack technical and managerial 
knowhow (USAID, 2019). Involving individuals such as VMFs particularly at the rural setting can 
contribute significantly in enhancing technical and managerial capacity of the leaders. 
Another quality that the good leader has to possess is to have self-awareness and the ability to 
transfer the knowledge to empower concerned others. The VMFs were aware of benefits of 
improved kitchen gardening and poultry rearing practices through the training they received. 
Possessing knowledge but not transferring the same will not enhance the practice at the 
community level. VMFs in some study locations were informed to be benefiting themselves or in 
other words not transferring the required knowledge to the program participants. 
Full engagement of a leader in any development initiative is considered as an important 
leadership quality. There were issues expressed by a number of study participants about lack of 
dedication among the VMFs. There were challenges informed particularly with respect to the 
female VMFs. Social expectations (caring for children and elderlies and take care of the 
household chores) for women mostly in rural areas often is a barrier for female VMFs to carry out 
their tasks efficiently. 
Another issue that emerged from the study was the gap in communication between the VMFs and 
the program participants. Effective communication is often considered as an important non-
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technical skill that every leader must possess. Without good communication skills, a leader would 
never be heard or understood by others. Program participants in the study locations reported that, 
they were barely informed about the venues where the materials required for the improved 
practices. The meetings are important for the particularly to gain knowledge about the improved 
practices.
Conclusions
The Home Food Production has been one of Suaahara’s integral component. The component is 
largely aimed at promoting production and consumption of nutrient-rich food. In addition, 
Suaahara intends to identify VMFs and equip them with the knowledge and skills about the 
improved kitchen gardening and poultry rearing practices. The VMFs had the roles to impart the 
gained knowledge to other beneficiaries and also to set themselves as an example in the 
community.
Suaahara is nearing its completion and it was important to undertake evaluations (quantitative 
and qualitative) of the HFP component mainly to gain insights into intervention’s achievements. 
This qualitative evaluation largely was intended to explore four key areas: i. improved knowledge 
and practices in relation to kitchen gardening; ii. impact of the intervention on production; iii. 
barriers and enabling factors; and iv. VMFs roles. The research questions framed were based 
primarily on these key areas.
The data collection was carried out in three municipalities of Darchula district namely Mahakali 
Municipality, Malikarjun rural municipality and Shaileshekar rural municipality. The data collection 
instruments included KIIs and FGDs with several types of respondents including MF, 1000-days 
mothers, female community health volunteer, local government officials, PNGO representatives 
and private sector. Use of multiple data sources and methods considerably contributed to data 
triangulation. 
Based on the evaluation findings, it can be argued that there was a significant improvement in 
knowledge about the benefits of improved kitchen gardening and poultry rearing practices. This 
was true across almost all the variables considered. Although the practice has improved, it was 
quite evident from the study that there was still room for improvement. This applied to some of 
the key variables in particular climate smart agriculture, integrated cultivation management and 
regular vaccine to chickens. The reasons for lower level of practice when compared to knowledge 
on the benefits were to a large extent tied to the barriers explored. The barriers such as lack of 
materials, lack of financial resources, lack of skilled manpower could have prevented from 
delivering better results. 
One of the key findings with respect to the motivating factor for practicing improved kitchen 
gardening and poultry rearing was the support from the local government units. This is particularly 
important when examined from sustainability perspective. Since Suaahara is approaching its end, 
it is entities such as local government units that can play a significant role in providing continuity 
to the practice. With the formal adoption of federalism, the state was restructured into federal 
government, seven provincial governments and 753 local governments (293 urban municipalities 
and 460 rural municipalities). The local government units now have the authority are solely tasked 
to deliver basic services including health and nutrition. Although in a few study locations, it was 
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quite encouraging to note the ability of the program participants to leverage resources through 
the local government units. 
Since there is a dearth of evidences that indicate the enhanced production due to adoption of 
improved kitchen gardening and poultry rearing practices, a few proxy indicators were considered. 
The indicators included availability of nutrient-rich food at the household and community levels, 
consumption practices, production practices and income augmentation. The responses were 
mixed from the study participants with respect to all the indicators. For example, in a few study 
locations growing off-season vegetables was generating more income than before while in some 
due to the lack of proper marketing management, the surpluses lied rotten. This to some extent 
warrants establishment of marketing mechanism such as linking farmers directly to buyers. 
There were mixed responses from the study participants in relation to roles and responsibilities 
of VMFs. It appeared from the findings that some VMFs were notably active and some lacked 
enthusiasm. The VMFs were active particularly in terms of forming the HFP groups. Although by 
a few, efforts were informed to be made to leverage resources from the local government units. 
There were however a few areas emerged from the evaluation that had potential for growth such 
as lack of full engagement. There were challenges informed particularly with respect to the female 
VMFs. There were certain expectations for the female VMFs such as caring for their children, 
taking care of the household chores etc. that may have prevented them from engaging fully in the 
interventions. 
Recommendations
Based on the evaluation findings, following recommendations are proposed:
● Although, there’s been an improvement in kitchen gardening and backyard poultry rearing 
practices, the evidence from the study underscores a need to promote them further 
through entities mainly including local government units given that they have resources at 
hand and decision-making power to use the resources rests with them. The awareness 
on the benefits of the practices generally existed among the participants. 
● In general, it was noticed that those individuals directly involved in the program (such as 
VMF.) were benefiting the most or in other words locals were not benefiting from the 
knowledge to the extent required. Therefore, the planning for effective transfer of 
knowledge which is sharing information, abilities and ideas across various areas is crucial. 
Since Suaahara program is nearing its completion, the transfer of knowledge relies on the 
knowledge and capacity of mainly local government units or the private entities to design 
and implement the plan to effectively transfer the knowledge. The plan could include short 
or long-term mentorship, people’s lived experiences and simulations. 
● It is important to make available nutrient rich food particularly meats and eggs at nearby 
markets. This will help both the parties namely producers and consumers benefit from the 
outcome. The producers will benefit from the increased income and consumers will have 
an opportunity to consume diverse nutrient rich food. Therefore, it is suggested that more 
promotion is needed in relation to production of meat and eggs. 
● It is recommended that a mechanism be in place to continue knowledge enhancement 
among program participants with respect to a number of factors that positively affect the 
production mainly including availability of water, irrigation facilities and hybrid seeds. 
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● It is suggested that the promotion of off-season vegetable farming be more vigorous. Off￾season farming was found to be one of the key reasons for income augmentation among 
the program participants. This can be accomplished by creating controlled environment 
for vegetables such as by making polyhouses or undertaking tunnel farming. Although 
ambitious, it is worthwhile to have local government units and private sectors such as 
agrovets, cooperatives and traders as implementing partners.
● Efficient market network is needed for both vegetable and poultry rearing farmers to sell 
their produces not only linking them to the collection centers but formally established 
entities such as market. This could be accomplished by contractual farming arrangements 
or through linking groups such as farmers’ groups directly with buyers. This approach can 
help in circumventing the middlemen.
● It is suggested that continued effort be made by the program participants through various 
formal and informal groups such as farmers’ groups and women’s groups to encouraging 
the local government units to provide them with necessary support (materials, training or 
financial). For achieving this, it is important to develop and foster strategic partnerships 
between any development initiatives and the local government units.
● It is also important to promote all three types of social capital (bonding, bridging and 
linking) in the locations where the interventions are undertaken. Building social capital is 
a part of the asset based community development approach that promotes utilization and 
strengthening of existing networks and relationship within the community. 
● It is suggested that continued effort be made in VMFs imparting knowledge and setting an 
example in relation to improved knowledge and practice. Transfer of knowledge however 
should be done in more systematic way that mainly involves effective mentorship and 
simulations. 
● The selection of VMFs should be done mainly based on their dedication and commitment 
of full engagement. The approach will further enhance the delivery of services such as 
distribution of seeds, chicks, impart knowledge etc.
● Communication skill is one of the crucial aspects of leadership. Approaches to develop 
communication skills among the VMFs would help them to convincingly interact with the 
program participants. In addition, information in relation to the meetings and venues to 
obtain materials should be provided in a clear manner. 
Funding Sources 
The study was commissioned and financially supported by Hellen Keller International 
(Suaahara/USAID)
105
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107
Annex 
Annex 1.1: Interview with 1000 Day Mothers 
Name (Pseudo)………………………………………
Province: ..……………………………………………
District: ……………………………………………….
Municipality: …………………………………………
Ward/ Old VDC name: ……………………………
Location: ……………………………………….......
Date: ………………………………………
Start time: …………………………………
End time…………………………………...
Q. No. Main Question Probe Questions
1. Perceptions on Homestead Gardening
1 How do you perceive vegetable 
farming or kitchen gardening? Has the 
practice of vegetable farming or 
kitchen gardening changed over the 
years? What are some of the areas 
that have changed? [If no response, 
ask the probe questions]
● What are some of the practices that you 
have been adopting in relation to the 
following components (instruction: also 
ask if there’s been any changes in the 
practices): i. vegetable diversification; ii. 
agri-extension services [related to kitchen 
gardening, backyard poultry, Climate 
Smart Agriculture (CSA)]; iii. soil nutrient 
management (examples include organic 
manure, compost, FYM, green manure, 
legume cropping etc.); iv. water 
management [drip, wastewater, rainwater 
etc.]; vi. insect pest management; v. seeds 
production; vi. solar-drying and post￾harvest management; and vii. integrated 
cultivation systems [mixed cropping, relay 
cropping etc.]
● Why have you been adopting the existing 
practices? 
● If there’s been a change in practice, why?
● What are associated challenges that you 
face? (for each component)? How are 
these challenges often tackled?
● How have the practices that you have been 
adopting impacting your lives (changes in 
income level leading to improved 
economic situation, consumption pattern)?
2. Perceptions on Chicken Rearing
2 Have there been any changes in 
practice in relation chicken rearing 
● What are some of the practices that you 
have been adopting in relation to the 
108
over the years (for the respondent and 
community in general)?
following components (instruction: also 
ask if there’s been any changes in the 
practices): i. semi intensive coop; ii. 
providing nutritive feed and clean water to 
chicken; iii. coop hygiene; iv. regular 
vaccine; v. separating sick 
chicks/chickens; vi. and vii. chick 
reproduction; 
● Why have you been adopting the existing 
practices? 
● If there’s been a change in practice, why?
● What are associated challenges that you 
face? (for each component)? How are 
these challenges often tackled?
● How have the practices that you have been 
adopting impacting your lives (changes in 
income level leading to improved 
economic situation)?
3. HFP’s Impact on Production, Consumption and incom
3 Has HFP improved the consumption 
of nutrient rich food (eg. vegetables, 
fruits, eggs, meat etc.)? How? Has it 
improved the income level (by selling 
the surplus)?
● What do you understand by nutrient-rich 
food? What are some of the main sources 
of such food? How do you/community 
members make such food available? 
● Have there been any changes in your 
practices in relation to consumption of 
nutrient-rich food over the years? If there 
are changes, why? What are some of the 
challenges associated with nutrient rich 
food availability?
● Do you members sell the surplus nutrient 
rich food (after consumption)? If yes, 
where and how do you sell the food? What 
are some of the main associated 
challenges in selling surplus? How do you 
tackle the challenges?
● Do you make more/less/around the same 
income selling the surplus nutrient rich 
food? Why? How can marketing of 
agricultural products be enhanced that can 
result in improved income level?
4. Village Model Farmers’ (VMFs) Roles 
4 What kind of support you are receiving 
from VMF (mainly in relation to kitchen 
gardening and poultry rearing)
● What is your perception on VMFs’ role as: 
i. a leader of HFP groups; ii. agri￾extension service providers; iii. providers 
of seeds 
/seedlings/chicks/eggs/vegetables to the 
community members at free of cost or 
subsidized rate; and iv. facilitators in 
coordinating with local government 
representatives; and v. facilitators of HFP 
group registration. [positive and negative 
perceptions]
109
● Do you face any challenges in receiving 
services (mentioned above) from the 
VMFs?
● How can the services provided by VMFs 
be improved?
5. Suggestions to Improve HFP program
5 What are some of your suggestions in improving the HFP component of the 
Suaahara program? Particularly, what areas need to be considered for its 
sustainability?
110
Annex 1.2: Interview with Villager Model Farmer (VMF)
Name (Pseudo)………………………………………
Province: ..……………………………………………
District: ……………………………………………….
Municipality: …………………………………………
Ward/ Old VDC name: ……………………………
Location: ……………………………………….......
Date: ………………………………………
Start time: …………………………………
End time…………………………………...
Q. No. Main Question Probe Questions
1. VMF Roles and Responsibilities
1 What are some of your key roles as a 
VMF? What are some of the 
opportunities/challenges in fulfilling 
your roles? 
● What are some of the opportunities/ 
challenges in leading the HFP? 
● What are some of the opportunities/ 
challenges in providing agri-extension 
services [related to kitchen gardening, 
backyard poultry, Climate Smart 
Agriculture (CSA)]
● What are some of the opportunities/ 
challenges in providing seeds/ seedlings/ 
chicks /eggs/ vegetables to community 
members at free of cost or subsidized rate;
● What are some of the opportunities/ 
challenges in forming HFP groups?
● What are some of the opportunities/ 
challenges in coordinating with the 
government stakeholders; 
● How the services you are providing have 
impacted the lives of the people (eg. 
changes in income leading to improved 
economic situation, consumption pattern)?
2. Homestead Gardening 
2 What are some of the key practices 
changed in relation to homestead 
gardening over the years? 
● Have the practices in relation to the 
following gardening components changed: 
i. fencing; ii. soil nutrient management; iii. 
water management (drip, wastewater, rain 
water etc.); iv. insect pest management 
(bio pesticide, integrated pest 
management etc.); v. Climate Smart 
Agriculture; vi. Seed production; vii. Solar 
drying and post-harvest management; and 
viii. Integrated cultivation systems (eg. 
mixed cropping, relay cropping etc.).
● If the practices have changed, how? 
(instruction to interviewers: ask for 
examples)
111
● What are associated challenges that 
community people face? (for each 
component)?How are these challenges 
tackled?
● How have the changed practices impacted 
the lives of the community people (eg. 
changes in income level leading to 
improved economic situation)?
3. Chicken Rearing Practice
3 What are some of the practices in 
relation to chicken rearing that have 
changed over the years?
● Have the practices in relation to the 
following chicken rearing components 
changed: i. semi intensive coop; ii. 
providing nutritive feed and clean water; iii. 
coop hygiene; iv. regular vaccine; v. 
separating sick chicks/chickens; vi. and vii. 
chick reproduction; 
● If the practices have changed, how? 
(instruction to interviewers: ask for 
examples)
● What are associated challenges that 
community people face (for each 
component)? How are these challenges 
tackled?
● How have the changed practices impacted 
the lives of the community people (eg. 
changes in income level leading to 
improved economic situation)?
4. HFP’s Impact on Production, Consumption and income 
4 Has HFP improved the consumption 
of nutrient rich food (eg. vegetables, 
fruits, eggs, meat etc.)? How? Has it 
improved the income level (by selling 
the surplus)? 
● What do you/community members 
understand by nutrient-rich food? What are 
some of the main sources of such food? 
How do you/community members make 
such food available? 
● Have there been any changes in 
your/group members/community members 
practices in relation to consumption of 
nutrient-rich food over the years? If there 
are changes, why? What are some of the 
challenges associated with nutrient rich 
food availability? How are these 
challenges often tackled?
● Do you/group members sell the surplus 
nutrient rich food (after consumption)? If 
yes, where and how do you sell the food? 
What are some of the main associated 
challenges in selling surplus? How are 
these challenges often tackled?
● Do you/community members make 
more/less/around the same income selling 
the surplus nutrient rich food? Why? How 
can there be a proper marketing of 
agricultural products that can result in 
improved income level?
112
5. Suggestions to Improve HFP program
5 What are some of your suggestions in improving the HFP component of the 
Suaahara program? Particularly, what areas need to be considered for its 
sustainability?
113
Annex 1.3: Interview with Female Community Health Volunteers (FCHV)
Name (Pseudo)………………………………………
Province: ..……………………………………………
District: ……………………………………………….
Municipality: …………………………………………
Ward/ Old VDC name: ……………………………
Location: ……………………………………….......
Date: ………………………………………
Start time: …………………………………
End time…………………………………...
Q. No. Main Question Probe Questions
1. Perceptions on Homestead Gardening
1 What is your perceptions towards 
Suaahara’s HFP component? What 
are some of the key practices 
changed in relation to homestead 
gardening over the years?
● Have the practices in relation to the 
following homestead gardening 
components changed: i. fencing; ii. soil 
nutrient management; iii. water 
management (drip, wastewater, rain water 
etc.); iv. insect pest management (bio 
pesticide, integrated pest management 
etc.); v. Climate Smart Agriculture (CSA); 
vi. Seed production; vii. Solar drying and 
post-harvest management; and viii. 
Integrated cultivation systems (eg. mixed 
cropping, relay cropping etc.).
● If the practices have changed, how? 
(instruction to interviewers: ask for 
examples)
● What are associated challenges that 
community people face? (for each 
component) ? How are these challenges 
often tackled? 
● How have the changed practices impacted 
the lives of the beneficiaries (eg. changes 
in income level leading to improved 
economic situation)?
2. Perceptions on Chicken Rearing
2 What are some of the practices in 
relation to chicken rearing that have 
changed over the years?
● Have the practices in relation to the 
following chicken rearing components 
changed: i. semi intensive coop; ii. 
providing nutritive feed and clean water; iii. 
coop hygiene; iv. regular vaccine; v. 
separating sick chicks/chickens; vi. and vii. 
chick reproduction; 
● If the practices have changed, how? 
(instruction to interviewers: ask for 
examples)
114
● What are associated challenges that 
community people face (for each 
component)?
● How have the changed practices impacted 
the lives of the beneficiaries (eg. changes 
in income level leading to improved 
economic situation)?
3. Maternal and Child Health Nutrition
4 What are some of the practices in 
relation to maternal and child health 
that have changed over the years?
● Have the practices in relation to the 
following maternal and child health 
changed: i. nutrient rich food to child; ii. 
food during pregnancy; iii. food for lactating 
mothers; iv. breastfeeding; and v. 
complementary food.
● If the practices have changed, how? 
(instruction to interviewers: ask for 
examples)
● What are associated challenges that 
community people face (for each 
component)
● How have the changed practices impacted 
the lives of the beneficiaries? (eg. changes 
in health situation)?
4. Village Model Farmers’ (VMFs) Roles 
4 What is your opinion towards roles 
and responsibilities of VMF?
● What is your perception on VMFs’ role as: 
i. a leader of HFP groups; ii. agri￾extension service providers; iii. providers 
of seeds 
/seedlings/chicks/eggs/vegetables to the 
community members at free of cost or 
subsidized rate; and iv. facilitators in 
coordinating with local government 
representatives; and v. facilitators of HFP 
group registration.
● Do community people face challenges in 
receiving services (mentioned above) 
from the VMFs?
● Do you suggest members of health 
mothers’ groups to visit VMFs if they 
require information in relation to kitchen 
gardening and poultry rearing? (materials, 
services, knowledge etc.)
5. Suggestions to Improve HFP program
5 What are some of your suggestions in improving the HFP component of the 
Suaahara program? Particularly, what areas need to be considered for its 
sustainability?
115
If FCHV is VMF herself, use the following checklist
Q. No. Main Question Probe Questions
1. Perceptions on Homestead Gardening
1 What is your perceptions towards 
Suaahara’s HFP component? What 
are some of the key practices 
changed in relation to homestead 
gardening over the years?
● Have the practices in relation to the 
following homestead gardening 
components changed: i. fencing; ii. soil 
nutrient management; iii. water 
management (drip, wastewater, rain water 
etc.); iv. insect pest management (bio 
pesticide, integrated pest management 
etc.); v. Climate Smart Agriculture (CSA); 
vi. Seed production; vii. Solar drying and 
post-harvest management; and viii. 
Integrated cultivation systems (eg. mixed 
cropping, relay cropping etc.).
● If the practices have changed, how? 
(instruction to interviewers: ask for 
examples)
● What are associated challenges that 
community people face? (for each 
component) ? How are these challenges 
often tackled? 
● How have the changed practices impacted 
the lives of the beneficiaries (eg. changes 
in income level leading to improved 
economic situation)?
2. Perceptions on Chicken Rearing
2 What are some of the practices in 
relation to chicken rearing that have 
changed over the years?
● Have the practices in relation to the 
following chicken rearing components 
changed: i. semi intensive coop; ii. 
providing nutritive feed and clean water; iii. 
coop hygiene; iv. regular vaccine; v. 
separating sick chicks/chickens; vi. and vii. 
chick reproduction; 
● If the practices have changed, how? 
(instruction to interviewers: ask for 
examples)
● What are associated challenges that 
community people face (for each 
component)?
● How have the changed practices impacted 
the lives of the beneficiaries (eg. changes 
in income level leading to improved 
economic situation)?
116
3. Maternal and Child Health Nutrition
3 What are some of the practices in 
relation to maternal and child health 
that have changed over the years?
● Have the practices in relation to the 
following maternal and child health 
changed: i. nutrient rich food to child; ii. 
food during pregnancy; iii. food for lactating 
mothers; iv. breastfeeding; and v. 
complementary food.
● If the practices have changed, how? 
(instruction to interviewers: ask for 
examples)
● What are associated challenges that 
community people face (for each 
component)
● How have the changed practices impacted 
the lives of the beneficiaries? (eg. changes 
in health situation)?
4. Suggestions to Improve HFP program
4 What are some of your suggestions in improving the HFP component of the 
Suaahara program? Particularly, what areas need to be considered for its 
sustainability?
117
Annex 1.4: Interview with government officials (eg. agri-extension workers)
Name (Pseudo):………………………………
Position: ………………………………………
Province: ……………………………………….
District: ………………………………………….
Municipality: …………………………………….
Ward/ Old VDC name: …………………………
Location: ………………………………………...
Date: 
………………………………………
Start time: 
…………………………………
End time: 
…………………………………..
Q. No. Main Question Probe Questions
1. General perception on HFP
1 What is your opinion towards Suaahara’s 
HFP component? 
● What are some of the key activities 
in relation to Suaahara’s HFP? 
● What are some of the key benefits 
of the HFP component? 
● How do villagers in general perceive 
the Suaahara’s HFP component?
● What are some of the associated 
challenges? How are these 
challenges often tackled?
● What are some of the areas that 
need improvement?
2. Homestead Gardening 
2 Have the practices in relation to homestead 
gardening changed over the years in this 
geographical community? (focus on fencing, 
soil nutrient management, water 
management, insect/pest management and 
seed production)
● If the practices have changed, how?
● What factors have caused the 
change?
● Are there any impacts (positive and 
negative) of HFP’s homestead 
gardening component over the lives 
of the community people? What are 
some of the impacts?
● What are some of the associated 
challenges that community people 
face?
3. Chicken Rearing Practice
3 Have the practices in relation to chicken 
rearing changed over the years? (focus on 
semi-intensive coop, nutritive feed, regular 
vaccination, separation of infected chicks and 
chick reproduction)
● If the practices have changed, how? 
● What factors have caused the 
change?
● Are there any impacts (positive and 
negative) of HFP’s chicken rearing 
component over the lives of the 
118
community people? What are some 
of the impacts?
● What are some of the associated 
challenges that community people 
face?
4. HFP’s Impact on Production, Consumption and income
4 Has HFP improved the consumption of 
nutrient rich food (eg. vegetables, fruits, 
eggs, meat etc.)? How? Has it improved the 
income level (by selling the surplus)? 
● What are some of the main sources 
of such food? How do 
you/community members make 
such food available? 
● Have there been any changes in 
community members’ practices in 
relation to consumption of nutrient￾rich food over the years? If there are 
changes, why? What are some of 
the challenges associated with 
nutrient rich food availability?
● Do community members sell the 
surplus nutrient rich food (after 
consumption)? If yes, where and 
how do you sell the food? What are 
some of the main associated 
challenges in selling surplus? How 
do you tackle the challenges?
Do community members make 
more/less/around the same income 
selling the surplus nutrient rich 
food? Why? How can there be an 
appropriate marketing of 
agricultural products that can result 
in improved income level?
5. VMF’s roles and responsibilities
5 What is your opinion towards VMF’s roles 
and responsibilities?
● Do you think VMFs are fulfilling their 
responsibilities as a leader 
effectively? If yes, how? If no, why?
● What are some of the key 
challenges that VMFs face? How do 
they deal with the challenges?
● How can their roles/responsibilities 
be improved?
6. Suggestions to Improve HFP program
6 What are some of your suggestions in improving the HFP component of the 
Suaahara program? Particularly, what areas need to be considered for its 
sustainability?
119
120
Annex 1.5: Interview with NGO workers/private sector representatives
Name (Pseudo):………………………………
Position: ………………………………………
Province: ……………………………………….
District: ………………………………………….
Municipality: …………………………………….
Ward/ Old VDC name: …………………………
Location: ………………………………………...
Date: ………………………………………
Start time: 
…………………………………
End time: 
…………………………………..
Q. No. Main Question Probe Questions
1. General perception on HFP
1 What is your opinion towards Suaahara’s 
HFP component? 
● What are some of the key activities 
in relation to Suaahara’s HFP? 
● What are some of the key benefits 
of the HFP component? 
● How do villagers in general perceive 
the Suaahara’s HFP component?
● What are some of the associated 
challenges? How are these 
challenges often tackled?
● What are some of the areas that 
need improvement?
2. Homestead Gardening 
2 Have the practices in relation to homestead 
gardening changed over the years in this 
geographical community? (focus on fencing, 
soil nutrient management, water 
management, insect/pest management and 
seed production)
● If the practices have changed, how?
● What factors have caused the 
change?
● Are there any impacts (positive and 
negative) of HFP’s homestead 
gardening component over the lives 
of the community people? What are 
some of the impacts?
● What are some of the associated 
challenges that community people 
face?
3. Chicken Rearing Practice
3 Have the practices in relation to chicken 
rearing changed over the years? (focus on 
semi-intensive coop, nutritive feed, regular 
vaccination, separation of infected chicks and 
chick reproduction)
● If the practices have changed, how? 
● What factors have caused the 
change?
● Are there any impacts (positive and 
negative) of HFP’s chicken rearing 
component over the lives of the 
121
community people? What are some 
of the impacts?
● What are some of the associated 
challenges that community people 
face?
4. HFP’s Impact on Production, Consumption and income
4 Has HFP improved the consumption of 
nutrient rich food (eg. vegetables, fruits, 
eggs, meat etc.)? How? Has it impacted the 
income level (by selling the surplus)? How?
● What are some of the main sources 
of nutrient-rich food? How do 
you/community members make 
such food available? 
● Have there been any changes in 
community members’ practices in 
relation to consumption of nutrient￾rich food over the years? If there are 
changes, why? What are some of 
the challenges associated with 
nutrient rich food availability?
● Do community members sell the 
surplus nutrient rich food (after 
consumption)? If yes, where and 
how do you sell the food? What are 
some of the main associated 
challenges in selling surplus? How 
do you tackle the challenges?
Do community members make 
more/less/around the same income 
selling the surplus nutrient rich 
food? Why? How can there be an 
appropriate marketing of 
agricultural products that can result 
in improved income level?
5. VMF’s roles and responsibilities
5 What is your opinion towards VMF’s roles 
and responsibilities?
● Do you think VMFs are fulfilling their 
responsibilities as a leader 
effectively? If yes, how? If no, why?
● What are some of the key 
challenges that VMFs face? How do 
they deal with the challenges?
● How can their roles/responsibilities 
be improved?
6. Suggestions to Improve HFP program
5 What are some of your suggestions in improving the HFP component of the 
Suaahara program? Particularly, what areas need to be considered for its 
sustainability?
122
123
Annex 1.6: FGD with 1000-day Mothers 
Province: 
………………………………………………
District: 
…………………………………………………
Municipality/ ward: 
…………………………………….
Old VDC name: 
………………………………………
Location: 
…………………………………………………
Date: ……………………………………
Start time: ………………………………
End time: ……………………………….
Participants’ Characteristics Table (need to add other relevant sections to the table)
S.N. Name Age Education
Group representation (self-help 
groups including 
mothers’/women’s/farmers’ 
groups)
124
Q. No. Main Question Probe Questions
1. Perceptions on Homestead Gardening
1 How do you perceive vegetable 
farming or kitchen gardening? Has the 
practice of vegetable farming or 
kitchen gardening changed over the 
years? What are some of the areas 
that have changed? [If no response, 
ask the probe questions]
● What are some of the practices that you 
have been adopting in relation to the 
following components (instruction: also 
ask if there’s been any changes in the 
practices): i. vegetable diversification; ii. 
agri-extension services [related to kitchen 
gardening, backyard poultry, Climate 
Smart Agriculture (CSA)]; iii. soil nutrient 
management (examples include organic 
manure, compost, FYM, green manure, 
legume cropping etc.); iv. water 
management [drip, wastewater, rainwater 
etc.]; vi. insect pest management; v. seeds 
production; vi. solar-drying and post￾harvest management; and vii. integrated 
cultivation systems [mixed cropping, relay 
cropping etc.]
● Why have you been adopting the existing 
practices? 
● If there’s been a change in practice, why?
● What are associated challenges that you 
face? (for each component)? How are 
these challenges often tackled?
● How have the practices that you have 
been adopting impacting your lives 
(changes in income level leading to 
improved economic situation, 
consumption pattern)?
2. Perceptions on Chicken Rearing
2 Have there been any changes in 
practice in relation chicken rearing 
over the years (for the respondent and 
community in general)?
● What are some of the practices that you 
have been adopting in relation to the 
following components (instruction: also 
ask if there’s been any changes in the 
practices): i. semi intensive coop; ii. 
providing nutritive feed and clean water to 
chicken; iii. coop hygiene; iv. regular 
vaccine; v. separating sick 
chicks/chickens; vi. and vii. chick 
reproduction; 
● Why have you been adopting the existing 
practices? 
● If there’s been a change in practice, why?
● What are associated challenges that you 
face? (for each component)? How are 
these challenges often tackled?
● How have the practices that you have 
been adopting impacting your lives 
125
(changes in income level leading to 
improved economic situation)?
3. HFP’s Impact on Production, Consumption and incom
3 Has HFP improved the consumption 
of nutrient rich food (eg. vegetables, 
fruits, eggs, meat etc.)? How? Has it 
improved the income level (by selling 
the surplus)? 
● What do you understand by nutrient-rich 
food? What are some of the main sources 
of such food? How do you/community 
members make such food available? 
● Have there been any changes in your 
practices in relation to consumption of 
nutrient-rich food over the years? If there 
are changes, why? What are some of the 
challenges associated with nutrient rich 
food availability?
● Do you members sell the surplus nutrient 
rich food (after consumption)? If yes, 
where and how do you sell the food? What 
are some of the main associated 
challenges in selling surplus? How do you 
tackle the challenges?
● Do you make more/less/around the same 
income selling the surplus nutrient rich 
food? Why? How can there be a 
appropriate marketing of agricultural 
products that can result in improved 
income level?
4. Village Model Farmers’ (VMFs) Roles 
4 What kind of support you are receiving 
from VMF (mainly in relation to kitchen 
gardening and poultry rearing)
● What is your perception on VMFs’ role 
as: i. a leader of HFP groups; ii. agri￾extension service providers; iii. providers 
of seeds 
/seedlings/chicks/eggs/vegetables to the 
community members at free of cost or 
subsidized rate; and iv. facilitators in 
coordinating with local government 
representatives; and v. facilitators of HFP 
group registration. [positive and negative 
perceptions]
● Do you face any challenges in receiving 
services (mentioned above) from the 
VMFs?
● How can the services provided by VMFs 
be improved?
5. Suggestions to Improve HFP program
5 What are some of your suggestions in improving the HFP component of the 
Suaahara program? Particularly, what areas need to be considered for its 
sustainability?
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Annex 2.1: Team Structure
Main responsibilities of the core research team and field team members 
Key Team Key Responsibilities
Team Leader i. Lead the overall study; ii. Coordinate with HKI and hold regular 
discussions and ensure feedbacks are addressed effectively; iii. 
oversee and provide feedback in study related procedures; iv. monitor 
the performance of interviewers; v. visits to the field for the 
supervision and monitoring purposes; vi. ensure that all deliverables 
are submitted within the proposed timeframe; and vii. share findings 
of the survey with HKI officials. 
Field Interviewers Attend training and conduct individual interviews and focus group 
discussions; and transcription of interviews and discussions.
127
PART 5 – Evaluating Intermediate Results –
Accelerated rollout of Multi-Sector Nutrition 
Plan (MSNP) through strengthened local 
governance (IR4)
Qualitative Evaluation of Suaahara II’s Impact on Nutrition 
Governance
Principal Investigator: Sarah Eissler, Independent Consultant
Evaluation Research Team: Shraddha Manandhar, Independent Consultant
Kabita Shah, Independent Consultant
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Executive Summary 
In Nepal, maternal and child malnutrition remain major public health problems. Both health and 
non-health interventions are important for reducing malnutrition, but few multi-sectoral programs 
have been implemented at scale and even fewer, rigorously evaluated. Suaahara (2011-2023) is 
a USAID-funded multi-sectoral program in Nepal that operates at scale, with the overall objectives 
to reduce the prevalence of: stunting, wasting and underweight among children under 5 years of 
age, underweight and anemia among mothers, and anemia among children 6 to 59 months of 
age. As part of its four strategic objectives, Suaahara II supports the Nepalese government at 
local, provincial, and national levels to implement Nepal’s MSNP, which includes attention to the 
allocation and utilization of government funds for nutrition-specific and nutrition-sensitive 
interventions to ensure sustainable improvements in nutrition. The primary purpose of this 
qualitative study is to assess the effectiveness and impact of Suaahara II in improving multi-sector 
coordination for implementing the MSNP at the national, provincial, and municipal levels in Nepal. 
This study follows a rigorous qualitative design and methods to answer the following primary 
research questions: 
1. What is the status of the decentralized implementation of Nepal’s MSNP?
2. How have Suaahara II interventions contributed to decentralized implementation of 
Nepal’s MSNP?
2.a. Are communities demanding for more funding for nutrition? What has been the 
influence of Suaahara II on this? 
2.b How has federalism contributed to or affected Suaahara II’s ability to achieve its 
nutrition governance goals? 
What are the Remaining gaps/barriers in the decentralized MSNP implementation?
This study drew on primary and secondary research with multi-sector stakeholders across three 
governance levels (national, provincial, and municipal) to understand the status of the 
decentralized MSNP implementation in Nepal, the contribution of Suaahara II on this 
implementation, and the remaining gaps and challenges regarding the MSNP implementation. 
Key informant interviews, group interviews, and focus group discussions were conducted with 
over 100 stakeholders in both Suaahara II intervention areas and comparison areas. Qualitative 
data were analyzed using inductive and deductive thematic qualitative analysis techniques. 
Additional secondary data collected through a thorough document review were analyzed under 
the research questions to inform and triangulate the qualitative findings. The findings were 
organized based on the three main research questions, presented below. 
Research Question 1: Most multi-sector stakeholders understand their role in implementing the 
MSNP to promote nutrition in Nepal and can articulate specific programs within their sector that 
advances multi-sector nutrition activities. And in summary, the findings of this study suggest that 
Suaahara II has positively contributed to building stakeholders’ capacity and facilitating an 
effective implementation of the MSNP, however challenges remain, as described below. 
129
Research Question 2: According to stakeholders, Suaahara II has been particularly effective at 
promoting awareness for multi-sector roles, leadership, and coordination for promoting nutrition; 
demanding budgets for multi-sector nutrition activities; and nutrition-related concepts and 
practices across sectors and government levels. Suaahara II was effective at navigating and 
adapting to the shift to federalism and leveraging existing networks to strengthen their 
implementation of nutrition-focused activities, particularly at the local level. And while there is an 
observable increased demand for nutrition budgets attributable to Suaahara II activities across 
sectors and levels, it is not met by sufficient allocation and utilization of budgets for nutrition, 
specifically in non-health sectors. 
Research Question 3: There exist remaining gaps and challenges that hinder the effective 
implementation of the MSNP. While Suaahara II was able to navigate the shift to federalism, it did 
present challenges that have and continue to effect strong vertical coordination of MSNP 
implementation. Such challenges include insufficient human resources at the provincial level to 
adequately coordinate implementation at the municipal level and the lack of a formal reporting 
mechanism to enable provincial and municipal level stakeholders to effectively monitor progress 
towards goals and implementation activities. Additionally, the lack of a formal coordination 
mechanism hinders productive provincial and municipal level stakeholder collaboration, as does 
the limited capacity of available trained, technical specialists at the municipal level to design and 
implement activities. 
Finally, a challenge raised by stakeholders in both intervention and comparison areas is the GoN’s 
heavy reliance on Suaahara II to implement nutrition-focused awareness raising and promotion 
activities, strengthen capacity building, facilitate multi-sector coordination, and enable vertical 
coordination. Suaahara II is very effective at reaching local communities to promote nutrition, as 
evidenced by the difference in nutrition knowledge and awareness reported by municipal-level 
stakeholders in intervention and comparison areas. Stakeholders in comparison areas requested 
support from Suaahara II to strengthen their ability to promote nutrition awareness and 
knowledge, suggesting that Suaahara II, instead of the GoN, leads in capacity building and 
strengthening nutrition in Nepal. This remains a challenge for future implementation of the MSNP 
and strengthening nutrition governance at each level, particularly as Suaahara II funding for 
implementation ends in 2023. 
Conclusion and Recommendations
In conclusion, these findings suggest that Suaahara II has been particularly effective at promoting 
awareness for multi-sector roles, leadership, and coordination for promoting nutrition; demanding 
budgets for multi-sector nutrition activities; and promoting nutrition-related concepts and practices 
across sectors and government levels. However, challenges remain for the effective 
implementation of the MSNP, mostly associated with limited vertical multi-sector coordination, 
insufficient human resource capacity at the provincial level and technical capacity at the 
municipality level, and an overreliance of the Government of Nepal on Suaahara II for 
implementing nutrition-related activities. Recommendations, are derived from the study findings 
130
and those suggested by stakeholders during primary qualitative data collection, are presented for 
consideration to improve future iterations or similar programming. 
Introduction 
In Nepal, maternal and child malnutrition remain major public health problems. Both health and 
non-health interventions are important for reducing malnutrition, but few multi-sectoral programs 
have been implemented at scale and even fewer, rigorously evaluated. Suaahara (2011-2023) is 
a USAID-funded multi-sectoral program in Nepal that operates at scale, with the overall objectives 
to reduce the prevalence of: stunting, wasting and underweight among children under 5 years of 
age, underweight and anemia among mothers, and anemia among children 6 to 59 months of 
age. Suaahara covers nearly 60 percent of the communities in Nepal using a blanket coverage 
approach for all households in the 1000-day period between conception and a child’s second 
birthday. The second phase of Suaahara, Suaahara II (2016-2023), is led by Helen Keller 
International with six core implementing partners: CARE, FHI360, Environment and Public Health 
Organization (ENPHO), Nepali Technical Assistance Group (NTAG), Vijaya Development 
Resource Center (VDRC) and Digital Broadcast Initiative – Equal Access Nepal (EAN); and more 
than 40 local partner organizations implementing community- and household-level activities. 
Suaahara II primarily implements social and behavior change interventions in nutrition, health, 
family planning, agriculture, and nutrition governance all underpinned with a gender and social 
equality lens and organized to achieve four intermediate results: 
● IR 1: Improved household nutrition, sanitation, and health behaviors
● IR 2: Increased use of quality nutrition and health services by women and children
● IR 3: Improved access to diverse and nutrient-rich foods by women and children
● IR 4: Accelerated roll-out of the Multi-sector Nutrition Plan (MSNP) through strengthened 
local governance.
In line with IR4, Suaahara II supports the Nepalese government at local, provincial, and national 
levels to implement Nepal’s MSNP, which includes attention to the allocation and utilization of 
government funds for nutrition-specific and nutrition-sensitive interventions to ensure sustainable 
improvements in nutrition. 
The primary purpose of this qualitative study is to assess the effectiveness and impact of 
Suaahara II in improving multi-sector coordination for implementing the MSNP at the national, 
provincial, and municipal levels in Nepal. This study follows a rigorous qualitative design and 
methods to answer the following primary research questions: 
1. What is the status of the decentralized implementation of Nepal’s MSNP?
2. How have Suaahara II interventions contributed to decentralized implementation of 
Nepal’s MSNP?
131
2.a. Are communities demanding for more funding for nutrition? What has been the 
influence of Suaahara II on this? 
2.b How has federalism contributed to or affected Suaahara II’s ability to achieve its 
nutrition governance goals? 
3. What are the remaining gaps/barriers in the decentralized MSNP implementation? 
For each of these 3 primary research questions, the following key themes are assessed: 
1) mainstreaming of nutrition in health and non-health systems, 2) budget allocation and 
utilization for nutrition, 3) multi-sector coordination mechanisms, and 4) capacity of leaders 
to advocate for nutrition-sensitive programming. 
Methods
This evaluation draws on secondary and primary data collected using mixed methods, including 
multiple qualitative data collection methods. Primary data collection included conducting key 
informant interviews, group interviews, and focus group discussions (FGDs) with purposively 
sampled participants from December 2021 to February 2022. Secondary data collection included 
reviewing Suaahara II monitoring data on budget allocation and utilization, and a comprehensive 
document review of key documents related to nutrition planning and programming. Descriptions 
of the methods and sampling strategies are presented below. 
Study Areas: The sampling approach targeted four Suaahara II intervention districts and four 
comparison districts, with two municipalities sampled within each district. Districts were selected 
in 2014 as a sub-sample of the overall 8 evaluation districts and to represent three geographic 
zones (mountains, hills, and plains/terai). The five respective provinces where the eight study 
districts fall were included. At the national level, multi-sector nutrition government bodies, 
Suaahara II program staff, development partners and the private sector bodies were sampled. 
Table 1 presents the comparison and intervention districts selected and the respective provinces 
included in this study. 
Table 5.1: Study Areas in Nepal
National Province Intervention / 
Comparison
District
Kathmandu
Bagmati Pradesh
Intervention Sindhupalchowk 
(upper hills/lower mountains)
Comparison Ramechhap
(upper hills/lower mountains)
Gandaki Pradesh
Intervention Rupandehi (terai)
Comparison Chitwan (terai)
Lumbini
Intervention Darchula (mountains)
Comparison Jumla (mountains)
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Sudurpaschim Intervention Syangja (hills) 
Karnali Comparison Tanahun (hills)
Sampling: At the national, province and municipal levels, key government stakeholders from 
nutrition sensitive and specific sectors including agriculture, livestock, health, planning, education, 
water sanitation and hygiene (WASH), and gender equality and social inclusion (GESI) were 
sampled. Additionally, Suaahara II staff were sampled at all three levels and non-governmental 
actors working on nutrition in Nepal were identified at the national and provincial levels, including 
those in the private sector and international donor partners. At the municipal level, key community 
members participating in nutrition planning and programming were also sampled, such as the 
municipal nutrition facilitator and CNV. See Table 2 for a list of the types of stakeholders sampled 
at each government level and by data collection activity.
Table 5.2: Types of Stakeholders Sampled at Each Government Level and by Data Collection 
Activity
National Province Municipal Community
Individual 
Interview
-MoFAGA
-National Planning 
Commission
-Family Welfare 
Division
-Ministry of Health
-Child Health and 
Immunization
-Epidemiology 
Disease and Control 
Division 
-Ministry of Agriculture 
and Livestock
-Ministry of DWSSM
Ministry of Education
-USAID
-Suaahara Staff 
-NFSSC Expert
-Policy and Planning 
Commission
-Provincial Health 
Directorate
-Agriculture and 
Livestock Ministry
-WASH Coordination 
Committee
-Ministry of Education
-Social Development 
Ministry
-Ministry of Health 
and Population
-MSNP Coordinator
-Suaahara staff 
(intervention only) 
Group 
Interview
-World Food Program 
and UNICEF
-Private Sector
-Deputy Chief, Chief 
Administrative Officer, 
and Ward Chairperson
-CNV and Municipal 
Nutrition Facilitator 
(intervention only)
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Focus 
Group 
Discussion
-Health Coordinator
-Agriculture Coordinator
-Livestock Coordinator
-WASH Focal Person
-Education Coordinator
-Women Development 
Officer
-Female 
Community 
Health Volunteer 
-Agriculture 
Extension Staff
-Village Model 
Farmer
-Women’s 
Group 
Representatives 
Research Ethics: This study was approved by the Nepal Health Research Council (NHRC) prior 
to the start of data collection. The interviewers received training on research ethics, including the 
process for seeking informed consent. Prior to being interviewed, the benefits and risks of 
participation, along with the purpose of the study, were explained to participants. All participants 
provided written informed consent for participation, and specifically for audio recording. All data 
have been de-identified/anonymized during analysis and reporting. Interview participants 
received a diary as a token of appreciation, whereas FGD participants were provided tea and 
snacks. 
Data Collection
Data were collected by an external team of trained, Nepalese qualitative researchers with 
experience conducting qualitative data collection activities. The research team was trained by two 
of the authors over a two-week period. The training covered topics including background on 
Suaahara II, the interview guides, the sampling selection, best practices for qualitative data 
collection, data management, research ethics, and transcription and translation. The research 
teams were organized into small groups and the designated team leader held frequently check￾ins with one of the authors throughout the data collection period. 
Primary data collection: Primary data collection activities included semi-structured in-depth 
interviews with 48 stakeholders, 23 group interviews, and 30 focus group discussions with key 
stakeholders described above (Table 3). Group interviews were conducted with purposively fewer 
numbers of individuals (approximately 2 to 3 per interview) and are extractive in nature, where 
they aim to elicit information from participants without encouraging collaboration or discussion 
amongst the participants. Focus group interviews are participatory in nature, where they aim to 
encourage a facilitated discussion amongst participants regarding the discussion questions and 
their lived experiences. 
Secondary data collection: Secondary data collection methods included a comprehensive 
document review of key documents related to nutrition planning and programming, as well as 
reviewing Suaahara II monitoring data for intervention districts. Two authors fluent in Nepali 
reviewed 58 relevant nutrition planning and policy documents at the provincial and municipal 
levels. Examples of documents reviewed include periodic plans, annual health & nutrition review 
reports, municipal annual policy and programs, documents evidencing investment in nutrition 
(e.g., budget allocation or utilization) and Nutrition and Food Security Steering Committee 
134
(NFSSC) meeting minutes. The research team also collected and analyzed municipality-level data 
on budget allocation and utilization for nutrition-related activities. Data were collected on 
municipality-level budget allocation and utilization figures. 
Table 5.3: Total Number of Data Collection Activities by Government Level
National
Provincial Municipal + Community
Total
Intervention Compari
son
Intervention Comparis
on
KII 16 27 5 48
GI 16 7 23
FGD 16 14 30
Interview and focus group discussion question guides were developed for each category of 
stakeholder based on their role and government level. These guides followed a semi-structured 
approach to ask relevant questions about the participants’ experience and perception of 
coordinating with other stakeholders to plan and implement nutrition-related activities in Nepal, 
and to assess their engagement and perspective of Suaahara II’s effectiveness in strengthening 
nutrition governance at each level. Qualitative data were collected by 15 hired facilitators who 
were trained by two authors on research ethics, best practices for qualitative data collection, and 
the interview/discussion guides. 
Data Analysis: The audio recordings were transcribed into Nepali by the data collection team 
and then were translated into English by a translation team. All interviews and FGDs were used 
for analysis to avoid selectivity bias. A single codebook was developed by the three authors that 
included deductive codes (established themes in the literature and predetermined themes 
stemming from the research questions) and inductive codes (developed from a preliminary review 
of the data) to guide qualitative analysis. The research team employed thematic qualitative 
analysis (Guest et al. 2012) using NVIVO Qualitative Analysis software (QSR International Pty 
Ltd, 2020). Three authors led the data coding and established inter-rater reliability prior to full 
coding. The research design and analysis team includes local experts with native Nepali language 
skills and contextual knowledge, as well as cultural outsiders. 
Data limitations: The research team acknowledges limitations to the data collected as part of 
this evaluation. First, several key stakeholders that were initially identified to participate in the 
data collection were either not available to conduct an interview or not able to due to COVID-19 
restrictions (n=3), or the specific post was vacant and therefore was dropped from the sampling 
strategy (n=8). Additionally, as this study focuses on questions related to nutrition governance, 
135
intended community-level participants in Suaahara II program activities are not included in this 
sample nor are represented in the findings. Next, data collection from comparison municipalities 
related to budget allocation and utilization was unable to be verified as municipalities only offered 
some documents that did not record all related budget allocation and utilization figures across 
sectors. Therefore, the comparison data on budget allocation and utilization cannot be considered 
comprehensive. Finally, response bias may have influenced the qualitative data collected. The 
authors took steps to mitigate response bias, including to articulate to participants that their 
responses would be kept confidential and reported only in the aggregate. 
Findings and Discussion 
This section presents the findings and discussion synthesized across all data collected to answer 
each research question. When applicable, comparisons are made between intervention and 
comparison areas, as well as to the findings from the 2015 study conducted on nutrition 
governance, specifically budgeting, commissioned by the Suaahara activity to demonstrate 
change over time (Khatri et al. 2015). Findings and discussion are organized around the three 
research questions. While this is primarily a qualitative study that draws on stakeholders’ 
perceptions and experiences, it cannot attribute change or draw conclusions with statistical 
significance. The authors intentionally utilize words of salience, such as “most”, “several”, “few” 
to signify the prevalence of themes across the many stakeholders consulted for this study. 
Research Question 1: What is the status of the decentralized MNSP 
implementation?
This section presents the findings that address Research Question 1. These key findings include 
that most multi-sector stakeholders understand their role in implementing the MSNP to promote 
nutrition in Nepal and can articulate specific programs within their sector that advances multi￾sector nutrition activities. Second, stakeholders articulated how awareness of the MSNP and its 
implementation has increased across multi-sector stakeholders. And finally, stakeholders 
explained mechanisms, such as the NFSSC fora, for facilitating the implementation of the MSNP.
The Nepal MSNP II for 2018-2022 takes a multi-sector approach to tackling malnutrition and sets 
out guidance for the integration of both nutrition-specific and nutrition-sensitive interventions 
(Manandhar et al. 2020). Multi-sector stakeholders at each governance level (national, province, 
municipal) recognized and articulated the role they play in advancing nutrition and elaborated on 
how nutrition-focused or related programming is integrated across and within respective sectors 
in both intervention and comparison areas. Multi-sector stakeholders articulated how they 
contribute to implementing the MSNP, indicated they are aware of the MSNP and their role in its 
implementation. This level of awareness by stakeholders of the MSNP is a key improvement since 
2015, where stakeholders had only a basic understanding of the MSNP, its purpose, and their 
role in its implementation (Khatri et al. 2015). Stakeholders in this study provided examples of 
nutrition-focused programs within their respective sector. An illustrative list of examples provided 
by stakeholders regarding nutrition-focused programs within their respective sector is presented 
136
in Table 4. Additionally, private sector stakeholders at the national level shared that contribute to 
nutrition by promoting fortified food supplies and products. Other donor partner stakeholders at 
the national level also explained that they contribute to nutrition agendas by generating evidence 
to inform policy development and supporting key programs, like the Mother Baby Friendly Hospital 
Initiative (MFFHI) to promote breastfeeding, among other examples. 
Table 5.4: Illustrative Examples of Multi-sector Programming to Address Nutrition 
Sector Example
Education (province and 
municipal)
School Meals programs for grades 1-5. 
WASH (province and municipal) Programs promoting drinking clean water and hygiene practices, 
such as handwashing. 
GESI (province) Programs at the household level to target behavior change to 
address equal food consumption patterns (for example, so that 
families do not favor sons over daughters for nutritious food 
consumption). 
Agriculture and Livestock 
(province and municipal)
Programs targeted at the community level to promote kitchen 
gardens, production and consumption of indigenous crops, 
increased seed distribution, and poultry rearing. 
Most stakeholders observed that there is good horizontal coordination to implement the MSNP. 
The MSNP structure that intentionally integrates multi-sector stakeholders to advance policies 
and programming to address nutrition gaps and promote good nutrition practices, is a key enabler 
of the MSNP implementation. A stakeholder from the municipal level in a comparison area shared, 
“Coordination plays a pivotal role in it. It's not that everyone will do the same work. 
We need to find out our roles to improve the overall condition of nutrition of the 
community. Some departments work in some sectors and others in another sector. 
Like, the health sector also works with the education sector. The other sectors will 
support the poor families in their own way. We will discuss the improvement level 
of our nutrition condition in the meantime and discussed at which level we are in”
(Comparison, Municipality, Planning). 
Another stakeholder at the province level shared,
“This multi-sectoral system is itself an opportunity. Single effort can't make it 
successful. Single effort can't achieve the goal. It needs collective efforts. The 
MSNP came to expose collective efforts. It is a beautiful concept itself because 
there are resources. There are many sectors, many thematic ministries, many 
stakeholders, many external development partners, many donors, and many 
parties participate there as a partner” (Comparison, Province, Health). 
Several provincial-level stakeholders elaborated that the MSNP coordinator is an extremely 
important role at the province level to manage, monitor, and support the implementation MSNP 
at the municipal levels, although this role is under capacitated in most provinces, according to 
137
stakeholders (The findings under Research Question 3 address remaining gaps and persistent 
challenges to the MSNP implementation). 
The Provincial Policy and Planning Commission under the Provincial Ministry of Federal Affairs 
led and formulated provincial Nutrition and Food Security Steering Committees (NFSSC). 
Participants reported that the provincial NFSSC is responsible for overall management of nutrition 
programs including budget allocation, planning and implementation. Stakeholders at every level 
and in both intervention and comparison areas noted that the NFSSC fora are critical to enabling 
the horizontal multi-sector coordination at both the province and municipal levels. One 
stakeholder from an intervention province explained how the NFSSC meetings work, 
“There is a Province Planning Commission, we sit and discuss there, and each 
sector give a presentation about their subject matter. Based on that, the agriculture 
sector makes their own plans, the livestock sector makes their own plans, the 
education sector does it their own way, and the health sector make their own plans”
(Intervention, Province, Health). 
The extent to which these fora are effective at facilitating multi-sector coordination varies by level 
and area. For example, some stakeholders noted that the NFSSC forum are effective at bringing 
multi-sector stakeholders together to discuss ideas and plan collaborations, but actual realization 
of these plans beyond the forum is limited. Different stakeholders, including Suaahara II staff at 
the province level, observed that collaboration during the NFSSC meetings is not always effective 
as stakeholders do not appreciate the purpose of such coordination and attend the meetings to 
“check a box”. While there is room to improve the effectiveness of the NFSSC meetings to enable 
horizontal coordination, the functioning of the NFSSC meetings overall in 2022 demonstrates 
positive improvement since 2015 when the meetings at certain levels were essentially non￾functional or irregular, at best (Khatri et al. 2015). 
While stakeholders observed strong horizontal coordination to implement the MSNP, they noted 
variable strength in vertical coordination between government levels to implement the MSNP. 
Specifically, municipal level stakeholders described strong coordination between the two levels 
to implement the MSNP activities at the local level. However, stakeholders at all three levels 
described weak vertical coordination between national and provincial, and provincial to municipal 
levels, the dynamics of which are further described in the findings presented under Research 
Question 3. 
Most stakeholders at the municipal and provincial level explained that MSNP awareness raising 
activities have contributed to improved diets at the local level. While many municipal level 
stakeholders in comparison areas observed changes to an extent, almost all municipal level 
stakeholders in intervention areas noted observable change. Such changes include, but are not 
limited to, increased variation in the number of crops being grown or livestock being raised 
compared to prior years, and increased purchasing and consumption of more nutritious foods for 
themselves and their households. A stakeholder from the municipal planning commission in 
Karnali said, 
“I have seen it has improved a lot. If I talk about the earlier days, there wasn’t the 
trend of major farming for fishes, meat, egg, green vegetables, or vegetables. 
138
Moreover, it wasn’t like fishes, meat and eggs also should be taken regularly, it 
was like they would eat when they got it, else they wouldn’t. Now, people have 
started to eat by buying as well, they believe it, the nutritional food must be eaten, 
balanced diet should be taken” (Comparison, Province, Planning Commission). 
A female community health volunteer (FCHV) from an intervention community observed changes 
in behavior related to nutrition in her community, 
“Also, they used to feed green vegetables bought outside before but now, they 
make a kitchen garden at home and produce whatever little they can and feed their 
children and consume themselves as well. They didn’t use to raise chickens, which 
they do now and feed eggs to their kids. It wasn’t there before” (Intervention, 
Municipality, FCHV). 
Research Question 2: How have Suaahara II interventions contributed to 
decentralized implementation of MSNP?
This section presents the key findings that address Research Question 2. These key findings 
include Suaahara II’s influence on increased awareness related to nutrition that has led to 
observable increases in funding, training, and technical support for nutrition across sectors. The 
technical and financial support provided by Suaahara II has led to direct, observable increases in 
behavior change within communities around nutrition. Second, stakeholders from comparison 
areas were aware of Suaahara II’s role in advancing nutrition and providing support to key 
stakeholders to implement nutrition-related programming. Finally, stakeholders described how 
Suaahara II interventions were essential to facilitating stronger horizontal, and to an extent, 
vertical coordination among multi-sector stakeholders to implement the MSNP. 
At every level, stakeholders from intervention areas attributed observable increases in nutrition 
awareness to Suaahara II funding, training, and technical support. This high level of awareness 
and appreciation for Suaahara II interventions and activities is similar to that found in 2015 (Khatri 
et al. 2015). Municipal level stakeholders specifically attributed their own increased awareness of 
nutrition to their participation in Suaahara-led trainings and activities. A FCHV shared, “The 
making of jaulo from time to time is happening because of Suaahara. It’s not been given from the 
health-related government to us. It is only happening because Suaahara has been providing these 
trainings” (Intervention, Municipality, FCHV). 
Stakeholders mentioned other Suaahara II trainings and activities that have been particularly 
useful, including trainings on how to prepare jaulo and how to breastfeed, providing vegetable 
seedlings to promote their production, helping to facilitate meetings with stakeholders and 
community members, and forming groups to exchange knowledge on nutrition-related activities 
with multi-sector stakeholders and community members. Some provincial level stakeholders 
mentioned that Suaahara conducted two-day sustainability workshops at the municipal level, 
which supported them to incorporate nutrition in their current and future planning. A community 
level stakeholder shared, “When we did not know how to prepare a balanced diet in the village, 
the Misses from Suaahara came here and taught us and gave us. They have given support to 4 
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months’ pregnant women, mothers to 6 months’ child, one-year-old child till the age of two” 
(Intervention, Municipality, GESI). 
Most province and municipal level stakeholders cited Suaahara II as a key source of nutrition 
information and support. Many stakeholders particularly cited the IEC materials as key 
communication tools to promote raising awareness about nutrition among community members 
and across sectors. Specifically, the MSNP coordinator in an intervention province shared that 
the IEC materials had a significant, observable impact in raising awareness about best nutrition 
practices. 
While municipal level stakeholders in comparison areas do not engage with nor benefit from 
Suaahara II interventions and activities, they were keenly aware of Suaahara II’s role in improving 
awareness and action for advancing nutrition-sensitive and focused interventions. Several 
stakeholders at the municipal level in comparison areas explained that they knew of Suaahara II 
as a focal point for MSNP implementation. A WASH stakeholder from a comparison province 
shared their understanding of Suaahara II, 
“Suaahara means, it is related to nutrients. The children who are recently born 
[infants] and from the time before they were born, they should be protected. They 
should be provided with a nutritious diet, and then they would be clean and healthy. 
I think that’s the concept. If we take care of post-partum women, [babies] will be 
born healthy. That’s the understanding” (Comparison, Province, WASH).
Another stakeholder from a comparison municipality explained they were aware of Suaahara and 
where it was working, “Suaahara is one project. It will do nutrition-related work. I have heard that 
this project is especially working in the eastern part, and it is not in our Karnali” (Comparison, 
Municipality, Planning). 
In addition to Suaahara II’s strength in promoting awareness and knowledge of nutrition, 
stakeholders also indicated that Suaahara II’s outreach and engagement at the municipal level is 
particularly strong. Suaahara II has enabled larger scale outreach to implement activities utilizing 
their strong and extensive network of staff and relationships at the community level, compared to 
government assistance, which is lacking, according to stakeholders. A donor partner observed, 
“I think Suaahara must have implemented that in a large scale in the community, 
whereas the training component of the government itself has not been able to 
reach beyond female community health volunteers. In such condition, Suaahara 
has created an environment to interact with the mothers. Suaahara has a number 
of district bodies, municipal bodies, and thus has a large catchment area and is 
able to reach…They have even worked closely with the Family Welfare Division 
which is a key implementation body of the Ministry of Health and Population. 
Looking at the human resource as well, they are present up to the grass root level, 
and if you look up program, Suaahara shows up. Even if you have to do a pilot 
program, you need to turn to Suaahara because only they have the staffs at the 
ground level” (National, Donor Partner). 
This is particularly evident by the difference shared from stakeholders at the municipal level in 
comparison and intervention areas regarding the levels of support and information they’ve 
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received about nutrition. A municipality level stakeholder in an intervention area described an 
example of support received from Suaahara II, 
“Earlier we did not know about what we should eat to keep our health in good 
shape. After the arrival of Suaahara program, we were taught that if we eat four 
types of food in a balanced way we could prevent illness, there would be 
development of mental health, we get immunity to fight against illness by 
consuming pulses and green vegetables, it could also prevent night-blindness. We 
received good information about these things” (Intervention, Municipality, FCHV).
In comparison, a stakeholder from a non-intervention community described, 
“We keep saying that we need to discuss, but we have not had any discussion 
since the establishment of the new rural municipality. We have not received 
training; we have not received any budget either, neither from agriculture, nor from 
the cooperatives or from the mother’s group, volunteers, or chairperson of the 
mothers group. We have not received anything from anyone. We used to receive 
when there was no local government before; we used to get it when there was a 
provincial government, district government. We used to get trainings; they had 
provided us with a lot of seeds from agriculture [sector] as well. But now when 
there is local government, we have neither received any training, nor any seeds, 
nor anything else, so how would we know anything? There is no one to teach us, 
no one we can ask. We don’t have anyone who would guide us to gather people 
as we have registered. We have registered [the group], but we don’t know 
anything, where can we know it from?” (Comparison, Municipality, Agriculture).
This difference in descriptions of experience shared between intervention and comparison 
stakeholders at the municipality level suggests that Suaahara II’s assistance is much stronger 
and more effective compared to the Government of Nepal (GoN) stakeholders at raising 
awareness and providing support to municipality level stakeholders. 
Finally, stakeholders at all levels and in both comparison and intervention areas described 
Suaahara II’s positive contribution to improving horizontal and, to an extent, vertical coordination 
among each policy level to implement and prioritize the MSNP. Khatri et al. (2015) had observed 
that Suaahara’s coordination with multi-sector stakeholders was weak in 2015, highlighting a 
meaningful change in outcomes of Suaahara’s engagement since 2015 with multi-sector 
stakeholders. As noted by several stakeholders at the provincial and some stakeholders at the 
municipal level, Suaahara II has helped to support areas where human resources are lacking, 
specifically for providing technical support. For example, one NFSSC member at the province 
level shared, 
“Specially, when we look into the Suaahara program through the health sector, 
they have supported immensely good with technical support. We brought it 
theoretically, but all the technical support in coordinating and bringing it into action 
was done by them. They gave us trainings, plans and program designs or we 
created them together. They have played a major role” (Intervention, Province, 
NFSSC Member, Health). 
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Suaahara II staff and many stakeholders in intervention areas described the role Suaahara II staff 
contribute to facilitate coordination via their participation in NFSSC meetings. Several 
stakeholders noted that Suaahara II staff are strong participants of these meetings at the province 
and municipal levels, where they communicate upcoming nutrition-related activities and actively 
facilitate linkages between multi-sector stakeholders at the meetings to identify opportunities to 
collaborate outside of the meetings. Province-level stakeholders noted that Suaahara II staff are 
also vocal in encouraging more frequent meetings at the province level stakeholders to continue 
multi-sector collaboration and coordination. A Suaahara II staff member at the province level 
explained, 
“We work to facilitate the implementation of the NFSSC action plan, and we reach 
one NFSSC meeting in most palikas almost every year. At the province level, they 
hold NFSSC meetings. Sometimes we even constantly poke them to hold 
meetings. And in the meeting held by them, Suaahara reflects upon the work done 
from door-to-door level to the community level and in the palika wards, what 
activities have been carried out to strengthen the committee are also reflected and 
then advocacy for the solutions of existing problems” (Intervention, Province, 
Suaahara II staff).
Stakeholders at the province and municipal levels in comparison areas shared their desire to 
emulate Suaahara II’s approach for facilitating multi-sector coordination for nutrition and to 
strengthen the capacity of multi-sector stakeholders in their province to promote nutrition 
awareness and activities. In addition, stakeholders from comparison areas want Suaahara II 
activities to expand and directly support them in their design and implementation of activities. For 
example, a member of the Planning Commission from a comparison province shared, 
“Yes, if Suaahara gets implemented in all the districts, nutrition education, nutrition 
importance, nutrition benefits, nutrition brought changes can aid more 
improvement. There is a big role of Suaahara in bringing sustainable development 
in the Karnali province and to reach the goals of the Karnali province” 
(Comparison, Province, Planning Commission). 
Another stakeholder from the comparison province shared, 
“Our objective is to make a completely nourished Karnali province, not only 
Naugad rural municipality. Our vision is to make nutrition-centered work areas with 
the help of Suaahara. As they have the same objective, we can say it supportive 
organization” (Comparison, Province, Health). 
Research Question 2a: Are communities demanding for more funding for nutrition? 
What is the influence of Suaahara II on this?
This section presents the key findings that address Research Question 2a, specifically that there 
is an observable increased demand for funding for nutrition across sectors and that this increased 
demand is positively influenced by Suaahara II. However, stakeholders note that despite the 
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increased demand, actual allocation and utilization of budgets is not sufficient to meet nutrition 
needs. 
Across each governance level and sector, almost all stakeholders pointed to an increased 
observable demand for budgets for nutrition-related activities. Many stakeholders noted that 
nutrition has been increasingly receiving prioritization as an agenda item at each level. Several 
stakeholders noted that the GoN is increasingly prioritizing nutrition at both the provincial and 
local levels, where local groups, mothers’ groups, farmers’ groups, among others, have become 
empowered and aware of how government, non-governmental organizations (NGOs) and 
community are working together for nutrition.
According to Suaahara II monitoring data from Year 5 of implementation, investment in multisector 
nutrition programming has increased by more than 10-fold between 2016 and 2021. Figure 1 
presents the increased allocation and utilization of budgets for nutrition between 2016 and 2021, 
highlighting incremental increases in both allocation and utilization in budgets for nutrition (except 
for utilization between FY19 and FY20). 
Figure 5: Nutrition Budget Allocation and Utilization in Suaahara II between 2016 and 2021
Source: Suaahara II monitoring data. *Note that this figure only presents data on intervention areas and 
not the budgeting allocation and utilization data from comparison areas due to limitations discussed. 
Stakeholders at both the provincial and municipal levels noted that there has been an increased 
utilization of funds on nutrition-sensitive programming across sectors. While the health sector still 
represents the largest share of allocated budget (22 percent), other sectors have been increasing 
their percent of allocated budget, such as WASH (15 percent), agriculture (13 percent), nutrition 
(12 percent) and strengthening the NFSSC (0.43 percent), respectively, according to Suaahara II 
monitoring data from Year 5. Stakeholders shared examples of types of multi-sector nutrition￾related activities implemented under multisector budgets. For example, education sector 
stakeholders shared the example of the School Meals program for Grades 1-5 as an activity where 
funds were newly spent to support nutrition activities, whereas agriculture and livestock 
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stakeholders gave several examples of such activities, including kitchen garden programs, 
indigenous crops programs, increased and targeted distribution of seeds, and those that promote 
poultry rearing. Stakeholders from the WASH sector shared examples of programs focused on 
promoting drinking water and hand washing as those that support nutrition goals. 
The only exception includes private sector stakeholders at the national level, who did not observe 
an increase in demand for nutrition-related budgets; other stakeholders observed that there 
remains limited private sector investment in nutrition at the national level and that this is an area 
for improvement. A private sector stakeholder at the national level shared, 
“While talking about the investment of the private sector in nutrition, it's almost 
zero. While saying clearly, it is a different thing, if they invest without knowing. But, 
in Nepal's case, there is no private sector in Nepal that invests to improve the 
nutrition condition as much as I know” (National, Private Sector).
In intervention areas, participants attribute the increased demand for budgets to support nutrition￾related activities to Suaahara II interventions. Stakeholders from comparison areas also noted 
that nutrition is increasingly becoming a priority agenda item and that people are asking for more 
money to implement their programming, but the extent to which stakeholders strongly shared this 
view varied across comparison areas. Participants from intervention municipalities noted that 
Suaahara II programming was so well received that there is strong motivation to replicate and 
continue certain activities under the municipal budget. Such activities include the health baby 
competition and the nutritious food recipe demonstration. Participants noted that certain programs 
have already been included in the municipal red book joint programming, indicating a government 
commitment to continue the programming under the government budget. 
Stakeholders described how budgets are utilized at the provincial and municipal levels. At the 
province level, stakeholders explained that their budgets are allocated and utilized for monitoring 
nutrition-related activities, rather than for implementation. A stakeholder in an intervention 
province shared, 
“Now, the Provincial Policy and Planning Commission has allocated Rs. 1 million 
($ 8,403,361) for nutrition. And the next is from the National Planning Commission 
on behalf of the federal government. However, the Ministry of Federal Affairs had 
allocated the budget and sent it to us, around Rs. 1 million ($ 8,403,361). Budgets 
will come again for the monitoring and other support, like logistic support to 
implement the program. Now we are thinking about making a profile, by collecting 
a few samples from any of the rural municipalities to make a nutrition profile using 
that Rs. 1 million ($ 8,403,361) budget. Asking, how is the situation of nutrition, 
how is our food security status, how is the level of nutrition in our foods, or whether 
the food is enough or not? How much food is available for nutrition?” (Intervention, 
Province, Planning Commission). 
Budgets at the municipal levels are allocated and utilized to design and implement programs 
related to nutrition activities. 
However, stakeholders note that while there is increased demand for budgets for nutrition related 
activities and programming, the total budgets allocated and utilized in intervention and 
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comparison areas still not sufficient from all sectors (except health) to meet demand for nutrition 
related activities. According to Suaahara II monitoring data, only 53 percent of total allocated 
budgets are effectively utilized. Additionally, a very low percentage of the overall budgets are 
earmarked for strengthening the NFSSC (approximately 0.4 percent in FY2020/2021), which has 
not improved since 2016, representing a gap in funding for strengthening the implementation of 
the MSNP. 
Several stakeholders from national, provincial, and municipal levels helped to explain the low 
utilization and allocation for nutrition-related activities across budgets at the municipal level. 
Several stakeholders observed that there is still a heavy focus on infrastructure programming 
when allocating and utilizing budgets for “development” activities compared to programs that 
focus on supporting nutrition or health, which is similar to challenges raised by stakeholders in 
Khatri et al. (2015). A private sector stakeholder observed, 
“While talking about financing, there is no budget code of nutrition. The next thing 
is that nutrition is not in the prioritization. The government might say that we don't 
need nutrition, but we need roads. The people say that we don't need anything 
except soil and roads” (National, Private Sector). 
And as a result, many stakeholders at all three levels and in both comparison and intervention 
areas noted that there were insufficient budgets allocated to implement the needed and desired 
programs at the municipal level. One stakeholder at the municipal level shared, “There is no one 
to develop programs. They are all competent here…to make program for nutrition, but the concern 
is related to finances” (Intervention, Municipality, Planning). A stakeholder from a comparison 
municipality explained that insufficient budgets are a key challenge faced when trying to 
implement their programs, 
“We can't get organic foods for twelve months in our places. There might be a lack
of financial sources to do a nutritious Lito porridge exhibition. We can't cover 
[creating] nutrition programs with sufficient money. I think that financial issues are 
also an obstacle, mainly the lack of budget” (Comparison, Municipality, GESI).
Research Question 2b: How has federalism contributed to or affected Suaahara II’s 
ability to achieve its goal of strengthening nutrition governance?
This section presents the key findings that address Research Question 2b. Stakeholders at all 
levels shared examples for how the national shift to federalism had created both opportunities 
and challenges for the implementation of the MSNP, and specifically, for Suaahara II to achieve 
its goal in strengthening the GoN’s nutrition governance. Overall, participants reflected on how 
Suaahara II was able to leverage its existing position to respond well to the shift to federalism. 
Some Suaahara II staff explained some challenges that came with this shift, while several 
participants noted persistent challenges in the restructured GoN to effectively implement the 
MSNP, described below. 
Most participants noted challenges that persist to hinder the implementation of the MSNP, beyond 
Suaahara II’s influence or implementation. As a result of federalism, the GoN’s governance 
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structure shifted; previous VDCs combined to form municipalities. This specific change resulted 
in vacuums of leaders with sufficient capacity, as well as trained technical specialists at the local 
level to proactively manage the implementation of the MSNP, sufficiently coordinate with the 
provincial level, and to respond to challenges or specific needs as they arose. Additionally,
according to participants, prior to federalism, there was an established “chain of command” 
between the local and provincial levels for implementing the MSNP, which was disrupted after the 
shift to federalism as new governance structures were established and those who worked in the 
previous positions at the prior VDC level did not carry over. A province level stakeholder 
explained, 
“The current situation is not the same as before the federal structure in the district. 
After federalism, the channel has fragmented from upper-level. The information we 
used to get from grass-root level is now ruptured” (Intervention, Province, 
Agriculture). 
This challenge has contributed to the limited sufficient vertical coordination to implement the 
MSNP. While federalism has been noted as a challenge, prior to the shift to federalism, Khatri et 
al. (2015) found similar, but distinct, challenges associated with MSNP implementation, such as 
uncertainty over ownership of the MSNP, lack of elected representatives at the district and former 
VDC levels, and unfulfilled positions at the regional level, which exacerbated workloads and 
stretched the bandwidth of government staff, which effectively deprioritized the MSNP. 
Stakeholders observed that with the shift to federalism human capacity and staff bandwidth 
continues to be a major constraint, albeit under different circumstances, to effective 
implementation of the MSNP. 
Participants noted, however, that despite these challenges Suaahara II has been able to quickly 
and effectively adapt its implementation strategy to respond to the shift to federalism, and even 
sometimes finding opportunities from federalism for stronger Suaahara II implementation. All 
stakeholders from intervention areas noted that Suaahara II staff were quick to adapt their 
implementation strategy to the new structure. In response to a question about Suaahara II’s ability 
to adapt, a donor partner shared, “Suaahara is flexible…can adapt to any kind of change in 
environment. They have that skill and effort” (National, Donor Partner). Another stakeholder at 
the national level shared, 
“What to do through Suaahara program, the local government does not have 
design for that, the program is designed as the present federal structure. To 
implement the integrated nutrition program, specially related to nutrition and to 
implement the special nutrition program together, it has supported and contributed 
a lot” (National, Nutrition Expert). 
A Suaahara II staff member at the province level elaborated on how Suaahara II adapted to the 
federalism structure, 
“Then the country went through the federal system, Suaahara also changed its 
working modality and structure according to the model of the federal system. Now 
there was the formation of the province and likewise Suaahara also established a 
body for coordination at the provincial level. There some people were assigned the 
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responsibility for the coordination in each of the provinces. Likewise, people were 
also assigned at the local level and at municipalities… Before there was the village 
development committee but now there is the rural municipality. The local partner 
employees coordinated with the municipality level and have been doing their work. 
Suaahara has changed their model according to the model of the federal system. 
That is why there is a condition to work easily now” (Intervention, Province, 
Suaahara II staff). 
Prior to federalism, Suaahara had built strong relationships with actors at the previous VDC and 
district levels, which enabled Suaahara II’s effective adaptation during federalism to leverage such 
networks at the local level to continue implementing their activities, according to many 
participants. 
However, while Suaahara II was able to quickly respond to federalism, several Suaahara II staff 
noted difficulties they continue their activities, and most participants across governance levels 
described persistent challenges that hinder effective implementation of the MSNP, described 
below under Research Question 3. Suaahara II staff noted that they had to redefine their 
strategies and protocols, which represented a total shift in the operational structure of the 
program. Several staff also noted that the restructuring of government offices increased the 
number of coordination points (e.g., 359 municipalities rather than 42 districts) for each Suaahara 
staff member, which exacerbated their workloads. 
Research Question 3: What are the remaining gaps/barriers in decentralized MSNP 
implementation?
This section presents the key findings that address Research Question 3. These key findings 
include that vertical coordination between governance levels remains a key challenge for 
implementing the MSNP. Second, there is limited technical capacity at the municipal level and 
limited staff capacity at the provincial level to effectively implement the MSNP. These limitations 
in capacity are further detailed in the below sections. Third, stakeholders raised concerns that 
MSNP activities are not tailored designed to reach the most vulnerable groups or to address the
nuanced needs of the different geographic zones in Nepal. Finally, a challenge raised by 
stakeholders in both intervention and comparison areas is the GoN’s heavy reliance on Suaahara 
II to implement nutrition-focused awareness raising and promotion activities, strengthen capacity 
building, facilitate multi-sector coordination, and enable vertical coordination.
Vertical coordination between governance levels remains a key challenge according to many 
stakeholders that impedes the effective implementation of the MSNP. Post-federalism, the 
structure of governance levels changed, particularly at the local level when the previous VDCs 
combined to form municipalities, which spurred personnel changes and altered the chain of 
command between provinces and local level actors. As previously mentioned under Research 
Question 1, there continues to be limited to no formal mechanisms to facilitate effective vertical 
coordination, particularly between the national and province, and province and municipal levels. 
Stakeholders from both intervention and comparison areas raised this as a key challenge. One 
stakeholder from the health sector in the comparison province shared, “Coordination is lacking 
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among the three-level government after the federal restructuring” (Comparison, Province, Health). 
Another stakeholder from an intervention province explained in further detail, 
“Institutional coordination has not yet happened. Few people coordinating is a 
different thing. The institutional one, which is required, has not happened yet. 
[Maybe] because provincial and local bodies have not fully come into operation. 
Hence, it [the coordination] is necessary. Province should play the role of mediator 
between local body and federal state, and coordinate between them… A lot of 
times, works are discussed from lower-level to the higher authorities, which instead 
should have been directed from upper-level. The coordination is yet to reach such 
level. This is required.” (Intervention, Province, Health). 
Many national and provincial level stakeholders shared they felt they have limited authority or 
ability to directly coordinate with municipal level, and there is a perceived lack of motivation among 
municipal level actors to engage or coordinate with provincial level stakeholders. Many provincial 
level actors indicated that municipal level actors do not always coordinate with them and that they 
operate independently to develop their own policies or implement their programming. 
The decentralized MSNP allows for each government level to design their own policies related to 
nutrition programming, which has created challenges for vertical coordination. Several 
stakeholders observed that there is a misalignment between policies developed at the municipal 
level compared to those at the province and national level. A stakeholder at the province level 
shared, “If you see at present, some of the palikas have formulated their own health policy, they 
have their own, which is seemingly contradicting with the federal policy” (Intervention, Province, 
Health). Others observed that while many municipal level actors develop many policies related to 
nutrition, there is limited implementation of policies. 
Further exacerbating this challenge are the limited human resources available, particularly at the 
provincial and municipal levels, to effectively coordinate to implement the MSNP. At the province 
level, stakeholders indicated that one person is effectively responsible to coordinate with the 
municipal level actors to implement the MSNP, and with only one dedicated staff position, this 
person is often overly committed and has limited bandwidth to effective coordinate the 
implementation. National level stakeholders observe that the effectiveness of province level 
actors has not met expectations, as shared as one stakeholder, “the steering committees of the 
provincial level are not becoming quite effective as expected. They have been doing a minimum 
level of activities” (National, Government). This also contributes to poor oversight and 
coordination of activity implementation from the province to municipal levels. 
National and province level stakeholders also observed that there is limited staff capacity at the 
municipal level to be effective. They explained that current municipal level actors have not spent 
enough time in their position and or have not been properly trained, created an observable gap 
in sufficient technical capacity at the municipal level. This is similar to findings presented by 
Manandhar et al. (2020) in which limited or insufficient staff technical capacity at the municipal 
level hindered effective budgeting processes to ensure adequate budgets were allocated and 
utilized for nutrition programming. A donor partner shared, “I have heard discussion that [staff at 
the municipal level] are all new, they need to be provided with more modern trainings and 
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orientation on this, and how it can be taken be done functionally” (National, Donor Partner).
Another national level stakeholder shared, 
“There is the lack of technical capacity of local level or municipality, rural 
municipality, metropolitan city and previously we called it health post and public 
health office. There is the shift of roles and responsibilities. There is a lack of staff 
on the basis of roles and responsibilities. How can the two, three or four number 
of staffs handle this huge number of programs?” (National, Suaahara staff). 
This issue has been exacerbated by COVID-19 when many municipal level positions were left 
vacant and training activities were suspended during the pandemic. 
In addition to challenges related to vertical coordination, there remain challenges with effective 
multisector coordination. As previously mentioned under the findings associated with Research 
Question 1, the NFSSC meetings are key enablers of strong multi-sector coordination but there 
exist challenges to optimizing this coordination. First, several stakeholders who participate in 
NFSSC meetings observe that they can sometimes be ineffective at facilitating linkages for multi￾sector actors. Additionally, several stakeholders noted that it can be difficult to communicate to 
non-health sector stakeholders and ministries about the importance of promoting nutrition and for 
how to effectively coordinate to integrating nutrition into their programming. A WASH 
representative from the provincial level explained, “We go to the [NFSSC] meeting, discuss, and 
what we agreed is lost. And then again, we are asked, called. And again, we go. But after than 
we stay idle. That’s what is happening. If you are working with WASH, you need to work with us 
directly” (Intervention, Province, WASH). 
Several stakeholders at the provincial level in both intervention and comparison areas noted that 
the lack of a formal reporting mechanism to capture implementation and results for multi-sector 
nutrition activities hinders province-level stakeholders’ ability to effectively monitor progress 
towards or the impact of the MSNP implementation at the municipal levels. A few stakeholders 
explained that the reporting systems for each sector are different and do not easily overlap, which 
hinders province-level stakeholders from capturing real-time results across the sectors and to 
disaggregate results by nutrition-related activities that contribute to the progress of the MSNP 
implementation. One NFSSC member at the province level shared an example, “What we found 
was that, with the same amount of money, in some villages they have distributed 5 crates of eggs 
whereas in some only 1 crate, similarly, in some places distributed 25 kg of rice, whereas in some 
only 5 kg of rice was distributed” (National, NFSSC Expert). Another stakeholder from the 
Planning Commission at the province level explained that monitoring is required even after 
program implementation. He shared examples of two municipalities where there were outbreaks 
of water-borne diseases because of open defecations, although both had been declared ODF. 
He further elaborated that he didn’t have transportation to go to for monitoring visits, and he was 
therefore unable to sufficiently monitor the situation. However, one MSNP coordinator from an 
intervention province did share that there is a new web-based application that is being used to 
update and monitor progress on the MSNP implementation:
“Now, the Government of Nepal has started Web Based Reporting System under 
the MSNP. In the WBRS, there is an introduction of palika and everything needs 
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to be updated there. From that update, the monthly health aspects (indicators) 
which we have…. 26 aspects (indicators) related with nutrition……. 16 aspects 
need to be updated and now the update is going on. The provincial NFSSC have 
also presumed to publish a profile of nutrition and food security…. These things 
are included in the WBRS app. We used to do our own but from this year we have 
transferred this responsibility to the palika… We have provided Tab Plus apps and 
provided training by installing the app in the tab. From this fiscal year, an integrated 
plan will also come” (Intervention, Province, MSNP Coordinator). 
Many stakeholders observed that there was limited tailored design in the implementation of the 
MSNP to address the specific needs between the terai, hills, and mountains to reach the most 
vulnerable and meaningful include marginalized groups into activities. A Suaahara staff member 
at the national level explained, 
“Like if we talk about Nepal, there are hills, terai and mountain and seven 
provinces. There are lots of equity gaps between the rich and poor. If you look at 
the malnutrition rates, then it is triple if we compare rich and poor. The targeted 
approach needs to be followed, but it is lacking in the implementation and design” 
(National, Suaahara staff). 
Several stakeholders specifically noted that it is unclear to what extent the most vulnerable or 
poorest of the poor are reached and benefit from MSNP activities. Several stakeholders at the 
province level, specifically, explained that MSNP programs and services do not reach the poorest 
and marginalized, and that only a handful of community elites get all the services, 
raising speculation that these activities end up targeting higher socio-economic families. 
Additionally, a recent study by Pokharel and Pradhan (2020) found that women and marginalized 
groups are disproportionately excluded from meaningfully participating in local governance 
mechanisms and activities. Several stakeholders in this study from the NFSSC forum explained 
that although there is motivation to include marginalized groups, such as women and Dalits, into 
meaningful decision-making roles, in practice this has rarely occurred. For example, one NFSSC 
member said, 
“We are the ones who do it all. There are programs, which are done with our 
decisions rather than women/Dalits’ demands, targeting certain activities. To be 
honest, I don’t think we have conducted programs with discussions with 
[women/Dalits]. There are not many targeted programs in the palika. There should 
be but, in reality, there isn’t” (Intervention, Municipality, NFSSC Member). 
Another key challenge raised by stakeholders in intervention areas is the GoN’s heavy reliance 
on Suaahara II and NGOs with similar goals to promote nutrition awareness and facilitate MSNP 
implementation. According to stakeholders, the GoN overly relies on Suaahara II to conduct 
awareness activities, advocate with non-health sectors, and implement activities and reach 
targeted groups at the local level, specifically as Suaahara II is extremely effective at leveraging 
their extensive networks and strong human resources to achieve their goals. A member from the 
planning commission at the provincial level said, “Suaahara has supported the government and 
has been doing what government should be doing” (Intervention, Province, Planning 
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Commission). A national level Suaahara II staff shared, “sometimes we feel that we have made 
them a little dependent, when I went for field visit, I have observed that the coordination committee 
also calls the Suaahara coordination committee and for everything, they call [it] Suaahara” 
(National, Suaahara staff). A stakeholder from a province-level health ministry observed,
“As I said before, the people's representatives should be sensitized and clarified. 
While working at the field level, it feels like the targeted groups are still beyond the 
boundary, we seemingly failed to include them” (Intervention, Province, Health 
Ministry). 
To provide further evidence to suggest Suaahara II’s role in providing the necessary resources 
and support to implement the MSNP and related activities, several municipal stakeholders in 
intervention areas had requested that Suaahara expand their budgets to enable the municipality 
to implement their designed nutrition programs, suggesting stakeholders perceive nutrition 
budgeting coming from Suaahara II rather than the respective government budgets. The concern 
of government ownership over nutrition activities and facilitating multi-sector coordination to 
implement the MSNP was raised by Khatri et al. (2015) and continues to be of concern for the 
sustainable continuation of Suaahara II impacts. 
Stakeholders from comparison municipalities continue to struggle in promoting nutrition 
awareness that leads to behavior change, specifically promoting consumption of nutritious foods 
at the local level. Several stakeholders shared these challenges are associated with designing 
communication strategies to reach illiterate or uneducated community members, including 
women, quoting pushback they receive such as, “you do not need to teach me about eating or 
consuming foods,” according to stakeholders. Municipality-level stakeholders in comparison 
areas also noted that there are limited opportunities to learn about nutrition, as these discussions 
are typically limited to FCHVs and mother’s groups who receive municipality trainings. Other 
challenges include competition with marketing and preferences for packaged foods, although this 
was only mentioned by a few stakeholders, so it is unclear to what extent this is a serious 
impediment. A national level leader in nutrition shared, “the biggest challenge we are facing now 
is the promotion of local level foods and another is the advertisement of these foods. A number 
of children are attracted towards the packaged foods because of advertisements” (National, 
Nutrition Chief). 
Conclusion and Recommendations 
In conclusion, these findings indicate that Suaahara II has been particularly effective at promoting 
awareness for multi-sector roles, leadership, and coordination for promoting nutrition; demanding 
budgets for multi-sector nutrition activities; and nutrition-related concepts and practices across 
sectors and government levels. Suaahara II was effective at navigating and adapting to the shift 
to federalism and leveraging existing networks to strengthen their implementation of nutrition￾focused activities, particularly at the local level. And while there is an observable increased 
demand for nutrition budgets attributable to Suaahara II activities across sectors and levels, it is 
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not met by sufficient allocation and utilization of budgets for nutrition, specifically in non-health 
sectors. 
However, challenges remain for the effective implementation of the MSNP. The shift to federalism 
presented challenges that have and continue to effect strong vertical coordination of MSNP 
implementation. Such challenges include insufficient human resources at the provincial level to 
adequately coordinate implementation at the municipal level and the lack of a formal reporting 
mechanism to enable provincial and municipal level stakeholders to effectively monitor progress 
towards goals and implementation activities. Additionally, the lack of a formal coordination 
mechanism hinders productive provincial and municipal level stakeholder collaboration, as does 
the limited capacity of available trained, technical specialists at the municipal level to design and 
implement activities. Finally, the GoN’s heavy reliance on Suaahara II to implement nutrition￾focused awareness raising and promotion activities, strengthen capacity building, facilitate multi￾sector coordination, and enable vertical coordination is an ongoing challenge related to 
sustainability. The following section presents several recommendations for consideration. 
Recommendations 
Based on the findings and conclusions of this study, we present some suggestions for 
consideration to improve future iterations of the Suaahara II programming or similar programs 
that aim to strengthen nutrition governance. 
Future iterations of the program should aim to promote the improved capacity of various 
stakeholders to strengthen their ability to implement the MSNP and promote nutrition awareness 
and programming within their respective sectors. 
● At the provincial, municipal, and palika levels, interventions should advocate for increased 
resources, both human and financial, and capacity building for stakeholders who manage 
and coordinate the MSNP for their respective municipalities. 
● Promote increased capacity building for leaders in non-health sectors on nutrition 
education, awareness, and integration to facilitate their leadership in promoting nutrition￾sensitive and related activities at their respective levels.
● Advocate for a fixed budget percentage across sectors for nutrition-related activities and 
for increased budgets to strengthen the NFSSC coordination. 
Challenges for effective MSNP implementation could be addressed through the establishment of 
formal mechanisms that would enable stronger vertical coordination between relevant 
stakeholders. 
● Establish a formal reporting mechanism for MSNP activities that incorporates activities, 
outcomes, and outputs from multi-sector activities that fall under the MSNP. Use formal 
reporting mechanisms to identify those who are actually reached and benefit from MSNP 
activities. 
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● Establish a formal vertical coordination mechanism, especially between province and 
municipal levels, which enables provincial-level actors to engage more directly with 
municipal level stakeholders to plan, design, implement and monitor MSNP activities.
Continue to work with GoN stakeholders to ensure stronger government ownership over MSNP 
activity design, budgeting, funding, and implementation, particularly at the local level. 
● Increase ownership over and role of provincial level stakeholders and technical specialists 
at municipal level for MSNP implementation.
● Develop mechanisms for GoN stakeholders to expand their targeting at the local level to 
target the most vulnerable in MSNP activities to ensure their benefit. 
The program should intentionally target underrepresented stakeholders into activity design, 
planning, implementation, and assessment, monitoring, and review for accountability measures, 
and to promote their voice in decision-making around nutrition governance at each government 
level. 
● Encourage more private sector and civil society engagement in MSNP implementation at 
all levels. 
● Work with local level stakeholders to increase women, youth, Dalit, and other marginalized 
populations in meaningful decision-making positions. 
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References
1. Khatri, R., Manandhar, S., Bhatt, A., Dahal, K., and Baral, S. 2015. Suaahara Process 
Evaluation Policy Environment and Government Structures (PEGS) Study. Held Research 
and Social Development Forum (HERD), Kathmandu. 
2. Manandhar, S., Shrestha, P., Neupane, B., Acharya, S., Chand, H., and Rana, P. 2020. 
Municipal budget allocation and utilization for nutrition in Nepal. Field Exchange Issue, 62. 
Accessed online. 
3. Pokharel, B., and Pradhan, M. 2020. State of inclusive governance: a study on participation 
and representation after federalization in Nepal. Tribhuvan University. 
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DISCLAIMER:
This report is made possible by the generous support of the American people through the United States Agency for 
International Development (USAID). The content of this report is produced by Helen Keller International, Suaahara II 
Program and does not necessarily reflect the views of USAID or the United States Government.