Twelve-month-old Prapti KC has been battling severe acute malnutrition at the Nutrition Rehabilitation Home (NRH) in Butwal. Prapti, the daughter of Prajita Thapa KC of Madane in Gulmi, was admitted to the nutrition rehab a week ago. Despite receiving round-the-clock care, her recovery has been slow—not because of negligence, but due to an acute shortage of life-saving therapeutic food.

Like Prapti, 11-month-old Simran Paija and several other children admitted to the facility are being treated without the recommended therapeutic milk formulas, F-75 and F-100. The Nutrition Rehabilitation Home in Butwal, operated under Lumbini Provincial Hospital, has been without these therapeutic foods for over six months, leaving healthcare workers to rely on homemade alternatives such as buffalo milk, porridge and lentil soup. While these substitute diets offer some nutrition, they lack the scientifically balanced composition essential for rapid recovery in severe acute malnutrition cases.

“F-75 and F-100 are specially formulated powders rich in essential nutrients like zinc, vitamins, and minerals. They're proven to be highly effective in the initial and transition phases of malnutrition treatment. We've had to improvise with local foods, which are not as effective, but we can’t turn these children away,” said Pratiksha Thapa, chief nutrition officer at the home.

According to Thapa, over 75 children have been treated with homemade alternatives since the shortage began in February. The Nutrition Rehabilitation Home has a capacity of 10 beds, with six currently occupied. Children with severe malnutrition typically require residential care for 10-18 days, after which they are referred to local Outpatient Therapeutic Care (OTC) centers for follow-up.

The NRH in Butwal receives children from neighbouring districts, including Nawalparasi, Palpa, Gulmi, Arghakhanchi and Kapilvastu. Established in 2014, it is one of the few such facilities in Lumbini Province, alongside such homes in Dang and Nepalgunj.

The problem is not limited to Butwal in Rupandehi district. In Saptari, ten children are currently admitted to the NRH at Gajendra Narayan Singh Hospital in Rajbiraj. According to Rashmi Jha, chief at the Rajbiraj NRH, they too have faced a shortage of F-75 and F-100 since January. “We’ve been using purified dairy milk to simulate the formulas, but it’s not yielding the desired outcomes. Dairy milk lacks the necessary fat and protein content, slowing weight gain,” she explained.

Children admitted with severe acute malnutrition typically receive F-75 for the first three to five days to stabilise their condition, followed by F-100 to promote weight gain. Jha noted that three of the admitted children currently require F-75 and seven children need F-100.

According to Jha, the nutritional rehab has been forced to stretch a limited budget to purchase milk and has sent multiple requests to the Family Welfare Division under the Department of Health Services. None have been answered.

The procurement crisis stems from a pricing dispute in the federal tendering process. As a result, therapeutic food supplies have been stalled for months, even as demand remains critical.

Similarly, the malnourished children are deprived of proper treatment due to lack of therapeutic food in remote districts of Sudurpaschim province as well. In Bajura, the situation is even more alarming. In Swamikartik Khapar Rural Municipality’s Muktikot, perhaps Nepal’s most malnourished village, no Ready-to-Use Therapeutic Food (RUTF) has been available since March.

According to Brija BK, in-charge of Muktikot Community Health Centre, two severely malnourished children—16-month-old Santosh Nyaupane and 17-month-old Jamuna BK—died in July last year while receiving care in Muktikot.

“There was no RUTF, and they were too critical to be saved with only local diets,” said Auxiliary Nurse Midwife Mala Bam, who had referred both children for emergency care. “But their families couldn’t manage transportation to well facilitated hospitals, and both died at home.”

Bajura district health officials confirmed that RUTF and Sarvottam Pitho (fortified multigrain flour) have been out of stock for nearly five months. Some RUTF packets stored in the local warehouse were reportedly stolen.

According to BK, a rapid survey conducted last week identified 25 children suffering from malnutrition in Muktikot and other settlements in ward 1 of Swamikartik Khapar Rural Municipality. Eleven of them suffer from severe malnutrition and 14 with moderate cases. "We have informed the rural municipality that treatment cannot begin until RUTF is supplied," said BK.

The local government has promised delivery within a week, though the lack of roads and ongoing monsoon rains may delay transportation. “We have to rely on porters to carry supplies. It takes a full day to reach Muktikot,” said Bhakta Kaila, chief of the rural municipality’s health unit.

When contacted, Jhanak Dhungana, chief of the Provincial Health Supply Management Center in Dhangadhi, insisted that there is no current shortage of RUTF across the province. It shows that there are communication gaps within the public health system as the higher authorities are unaware of the ground-level health crises.

Severe acute malnutrition is a life-threatening condition, especially in children under five. The F-75, F-100 and RUTF are classified as essential, life-saving treatments by the World Health Organisation. The ongoing shortages not only compromise treatment but directly endanger the lives of the most vulnerable children.

Despite having the required budget, the Department of Health Services has failed to procure essential nutritional supplements and medicines crucial for treating severely malnourished children. Six months into the fiscal year, vital therapeutic foods like F-75, F-100, RUTF as well as Vitamin A, iron tablets, anti-rabies vaccines, and contraceptive implants remain out of stock across the country.

According to official data, there are around 40,000 children suffering from severe acute malnutrition nationwide. Last year alone, 52 children died due to malnutrition, with Kapilvastu district recording the highest number of new cases at 2,261.

The department has not yet finalised tenders for the purchase of these essential supplies. Reasons cited include delays in issuing tenders, price manipulation by suppliers, and mismatches between procurement staff and suppliers. Last year's prices for F-75, F-100 and RUTF stood at Rs851, Rs942 and Rs44 per packet, respectively. Officials blame frequent staff transfers and lack of coordination for the delay.