|Reaching Mothers and Children at Critical Times of their Lives (WFP)|
15 September 1997
Third Regular Session
Rome, 20 - 23 October 1997
"The single most devastating news for developing countries is that widespread nutritional deficiencies are inflicting lasting damage on the physical and mental capabilities of their populations. Apart from mortality, the most serious consequence of nutritional deficiencies during pregnancy and infancy is interference with brain development at critical times....Malnutrition in infancy and early childhood...also means a lower physical work capacity as adults...and the earlier onset of chronic degenerative diseases in later life." (Scrimshaw, WFP/UNU Seminar, May 1997).
1. Individuals have special food needs at critical periods in their lives - most notably expectant mothers and their unborn babies, children under five, and nursing mothers. Inadequate nutrition in the first years of life and before is likely to damage health, mental development and future labour productivity. The high demands of reproduction deplete a womans nutrient stores, increasing her vulnerability to disease and reducing her capacity to work and care for her children. The consequences of "early malnutrition" reach beyond the individuals and families involved: society as a whole suffers losses when children cannot learn, when poor health restricts productivity, and when malnourished women give birth to the next generation that will also be malnourished.
2. Today, approximately 30 percent of children under five (i.e., over 200 million, according to a recent WHO estimate) are more vulnerable to sickness and more likely to die because they are undernourished. Most of them live in South Asia and sub-Saharan Africa. It is estimated that 50 percent of disease-related mortality among infants could be avoided if infant malnutrition were eradicated.
3. WFP can help end the inheritance of hunger through supplementary feeding programmes which provide the energy and nutrients missing from the basic diet of those who have special nutritional requirements. At present, WFP reaches over four million expectant and nursing mothers and children under five through primary health care centres. This assistance, which addresses early malnutrition, has important long-term pay-offs that cannot be achieved with later interventions. At the same time, there are challenges: past supplementary feeding programmes have not been without difficulties, particularly in the poorest countries where often food is needed most but sufficient complementary resources and capacities are lacking.
4. This paper examines the conditions under which WFP can better contribute to protecting poor women and children against lasting damage from early malnutrition. It will make recommendations on WFPs future policy and operational principles for supplementary feeding programmes, including measures required to increase these activities in the countries with the greatest needs. Recommendations will also be made for better meeting critical food needs during crisis and rehabilitation, bearing in mind the special circumstances involved.
5. Assistance to mothers and children "at risk" features prominently in the core policies and strategies that govern WFP activities. One of the strategic goals set by the WFP Mission Statement is to provide food aid "to improve the nutrition and quality of life of the most vulnerable people at critical times in their lives". The World Food Summit Plan of Action includes a similar commitment to "develop within available resources well targeted social welfare and nutrition safety nets to meet the needs of the food insecure, particularly needy people, children and the infirm" (Commitment Two, Objective 2.2c).
6. WFP has begun to elaborate this mandate and the strategic implications of increasing its focus on tackling early malnutrition:
7. WFP has acquired much experience and expertise in over 30 years of assistance to Mother and Child Health (MCH) and other projects that provide supplementary feeding. Major findings from the recent assessment of WFPs programmes, including a portfolio review of ongoing supplementary feeding projects, are as follows:
8. Research findings show that malnutrition is the outcome of an array of inter-linked risk factors: poverty (unemployment, landlessness); lack of education (illiteracy, poor child spacing); poor health (lack of clean water, poor hygiene, parasitic infections); low social status (tribes, castes, minorities); unfavourable traditions (taboos, low status of women); and/or a harsh environment, all leading to insufficient access to food and/or micronutrients.
9. Not surprisingly, then, a key finding of the thematic evaluation of WFP assistance to address the food needs of women and children at critical times of their lives is that the effectiveness of a food aid intervention is maximized when the achievement of a direct dietary effect is combined with indirect effects such as a better utilization of health and education services; increased household food security and mothers caring capacity; and empowerment of women. The full text of the thematic evaluation is contained in document WFP EB.3/97/5/Add.5.
10. In WFPs experience, food assistance to address early malnutrition will be most effective under conditions of widespread food insecurity. Supplementary feeding will usually be a less preferable option where malnutrition is primarily the result of factors such as inadequate weaning or caring practices and unfavourable social traditions, which can be better addressed through services such as nutrition education, training, growth monitoring and a build-up of referral systems.
11. To be fully effective, WFP assistance through supplementary feeding needs to be integrated with other components. This requires policy, planning and management resources, apart from the actual handling of the food itself. However, the ideal - integrated utilization of a substantial number of complementary activities - is frequently not attainable. There are situations in which WFP is faced with a very practical choice: supplementary feeding with very limited, but viable, complementary activities or no assistance at all.
12. The policy issues and operational challenges which emerged from WFPs recent review of experiences are discussed in the following section. Action on these issues will be crucial if WFP is to increase the share of food assistance programmed to contribute to a better nutritional status of mothers and children at critical times in their lives.
13. The topics examined below cover fundamental questions about the groups that should be eligible for assistance, the objectives and rationale for food aid, and the definition of project sustainability as well as more technical issues of intervention design such as targeting, food inputs, project support and the special conditions of early malnutrition during crisis and rehabilitation.
14. There are critical times in human life when the potential to break the inter-generational cycle of hunger is greatest. Many poor women cannot meet their additional food needs during pregnancy and nursing. Infants require nutritionally adequate and safe foods to complement breast milk after some six months. The critical food needs for women and children include nutrients such as protein and micronutrients (especially vitamin A and minerals such as iron and iodine) in addition to energy.
15. The key indicators to assess the magnitude of critical food needs of these groups include: incidence of low birth weight (LBW) and rates of maternal mortality (MMR), infant mortality (IMR), under five mortality (U5MR) and under five malnutrition. Nutrition and health indicators (including data on micronutrient deficiencies) are usually available from sources such as WHO, UNICEF or the national ministry of health.
16. To assess the need and scope for supplementary feeding in meeting critical food needs, food assistance must be considered in light of other possible interventions. Basic choices within the life-cycle of vulnerable groups include:
17. The nexus of causes underlying nutritional problems in any one country or region can be quite different from that in another. For supplementary feeding to be truly effective and food aid to be justified, the food security situation must be analysed. Levels of poverty and food production are important determinants of household food security. Data on household food insecurity are less frequently available and major efforts have been initiated in recent years to fill this gap, in particular through WFP-supported Vulnerability Analysis and Mapping (VAM) exercises. As a follow-up to the World Food Summit, FAO and WFP are coordinating the development of a worldwide Food Insecurity and Vulnerability Information and Mapping System (FIVIMS).
18. The Common Country Assessment and United Nations Development Assistance Framework processes and the formulation of the WFP Country Strategy Outlines provide the framework for WFP to engage in a dialogue with national partners and to define and communicate its focus on reaching malnourished children and mothers. Small investments in advocacy (expenses for meetings, workshops, publications, reports and educational posters) can do much to highlight the importance of food assistance in addressing early malnutrition and to identify potential complementary relationships with partners.
19. Almost all WFP projects that provide supplementary feeding to expectant and nursing mothers are designed to provide an incentive for more regular utilization of MCH services, namely prenatal and postnatal health care. Supplementary feeding for moderately malnourished or at-risk small children is provided to improve their nutritional status and/or promote their regular growth monitoring. Fewer of the supplementary feeding projects are aimed at the nutritional rehabilitation of severely malnourished children. The immediate objectives of WFP-assisted projects are usually well linked with government policies and goals on the health and nutritional status of mothers and children.
20. Food rations used in health and nutrition education programmes can be an effective means of achieving mutually reinforcing objectives. Provided in this way, food rations:
21. As food assistance can contribute to tackling several of the causes of early malnutrition, it may often be advisable to aim for a combination of objectives (i.e., improved dietary intake, better utilization of MCH services, and increased household food security and mothers caring capacity). When this is done, however, decisions regarding the size, composition and timing of food rations as well as the range of complementary inputs become more complicated. For example, women can be effectively encouraged to attend a clinic through the provision of a single high-value food commodity, such as vegetable oil. On the other hand, when intervening to meet a nutritional deficit, a larger, more complete food ration may often be required. Therefore, in designing a food intervention a hierarchy among individual objectives needs to be established to reflect the relative importance of the causes of nutrition and health problems faced by expectant and nursing mothers and infants in the specific situation.
22. Progress towards the attainment of programme objectives must be monitored. Budgets for monitoring and evaluation of the performance of WFP-assisted supplementary feeding projects range between 0.1 and 1.1 percent of the total WFP cost. It would not be appropriate or beneficial to spend the substantially larger amounts which would be needed to measure the long-term effects of WFP-assisted supplementary feeding on growth, cognition and/or work performance, as such benefits have been demonstrated through longitudinal studies. The plausible inference from the achievement of intermediate targets such as weight gain of malnourished children or fewer cases of low birth weight to the greater realization of the genetic potential should suffice. Effective monitoring of child growth and birth weight should therefore have priority. And, of course, input and activity indicators such as timely food distribution and the provision of health and education services need to be monitored in order to verify the link between these project activities and the weight gains. To the extent possible, generation and analysis of project data should be linked with national health and nutrition statistics.
23. Once a group of beneficiaries has been identified, the targeting strategy defines the most effective way to reach them, including how the needy can be separated from the not-so-needy with the least administrative and political friction.
24. Geographic targeting identifies the most vulnerable areas within the countries eligible for WFP food assistance. While administratively cheap, geographic targeting (without individual screening) is expensive in terms of the level of resources required. Individual screening of nutritional status, administratively more expensive, is used to target those actually malnourished or clearly at risk, thus reducing the level of resources needed. Moreover, several studies have shown that food supplementation has the greatest nutritional impact when targeted to moderately or severely malnourished children and expectant mothers. Continued monitoring of these individuals nutritional status will signal when food assistance is no longer needed. But, whatever the targeting strategy identified as most appropriate, it must also take into account operational aspects such as the available infrastructure, administrative capacity, presence of implementation partners, socio-cultural conditions and other practical issues.
25. Interventions that aim at preventing early malnutrition are best achieved through geographic targeting. Rehabilitation of acute cases of malnutrition is best organized on the basis of an individual, medical targeting strategy. In most supplementary feeding projects individual screening is combined with the geographic targeting of the most vulnerable areas. However, there are thresholds beyond which individual targeting may not be appropriate or cost-effective. For example, in areas with very high LBW rates, the provision of a nutritional supplement to all expectant mothers during at least the last trimester of pregnancy would combine prevention and treatment of malnutrition.
26. WFP provides a variety of food rations in supplementary feeding programmes. Most of the time, commodities include a basic cereal/pulse combination and edible oil. The nutritive value of a ration for expectant and nursing mothers varies from 300 to more than 1,200 kilocalories a day. Rations for malnourished children are designed in line with recommended feeding norms. Most expectant and nursing mothers receive assistance for one year or less. Therapeutic feeding of severely malnourished children lasts up to 90 days; food assistance for moderately malnourished children is provided for four months to a year.
27. Food-insecure people are also at risk of micronutrient deficiencies. Fortification of commodities with one or more micronutrients is a cost-effective approach to provide these essential nutrients. The actual cost of vitamin A, iron or iodine fortification is minimal, at most a small percentage of the commodity price. But fortification has implications for shelf-live and quality control.
28. Low-cost blended foods are fortified with essential micronutrients and are therefore well suited for the food basket of MCH interventions. In addition, they are easy to prepare (short cooking time), which lessens the household burden for mothers. More than half of the WFP-assisted supplementary feeding projects include a blended food. WFP assists countries to build national capacities in producing low-cost, safe and micronutrient-fortified blended foods. In addition, it will continue to support projects that encourage beneficiaries to grow the specific ingredients and prepare the weaning foods themselves. The local production of appropriate weaning foods can contribute to sustainable improvements in household food security and nutrition.
29. There are two ways in which supplementary food assistance can be provided: on-site feeding (normally in health centres) and take-home rations. These alternatives have marked trade-offs between the level of food resource required and administrative efficiency:
30. The majority of WFP food assistance is provided as a take-home ration. On-site feeding tends to be limited to cases of rehabilitation of severely malnourished children and to feeding of vulnerable under-fives attending day-care centres.
31. Potential negative effects such as disincentives and market displacement tend not to be an issue in food interventions that target malnourished or at-risk people because they are most likely to result in additional consumption. WFP uses locally produced foods procured through local purchases or commodity exchanges, importing only those commodities that are not produced in sufficient quantities in the recipient countries. FAO advice is regularly obtained in this regard.
32. Calculating the cost-benefit ratios of supplementary feeding expenditures is usually not attempted in WFP-assisted projects. Studies of a similar programme in the United States, however, have shown that prenatal participation by low-income women saves over three dollars in "Medicaid" costs for every dollar spent on the feeding programme.
33. The thematic evaluation found that as a result of carefully designed food baskets, the transfer-efficiency in the projects analysed was quite satisfactory. Where food is used as an incentive, the commodities should have a transfer value to the recipient which is not lower than the costs incurred by the donor. The cultural appropriateness of a food incentive and visibility of the resource have also been found to be important arguments in favour of food, particularly in countries with significant "leakage" problems.
34. WFP has demonstrated that cost-effective food strategies can be developed which make good use of available aid budgets for addressing early malnutrition. Inevitably, though, providing food assistance to malnourished individuals through a dispersed network of MCH centres cannot be expected to be the food aid intervention with the lowest cost per ton ratio. In addition, in the poorest countries where the level of early malnutrition is highest, provision of food assistance tends to be more expensive than in many of the better off countries.
35. Obviously, the costs involved in supporting supplementary feeding programmes targeted to the neediest regions in the world must be considered in the light of lasting benefits to the individuals and to the society. One of the implications of WFPs mandate is that food assistance is provided to those who need it most. However, choices must be made and a given benefit should be achieved with the least cost. Therefore, the cost implications of proposals for supplementary feeding interventions will be carefully analysed. Costs may be particularly high where essential non-food complementary inputs need to be included in order to make the project work. Funding of such interventions may only be possible if WFP can provide its assistance in collaboration with others.
36. To be fully effective, food assistance programmes require policy support, operational integration and a minimum level of administrative capacity and complementary inputs. Such support and coordination is normally expected from the government. In some of the poorest countries, however, gaps in national capacity are a reality. The poorest countries have scant resources for social purposes, even when national authorities are convinced of the importance of adequate nutrition. Partnerships with other United Nations agencies, bilateral donors and NGOs and, in some cases, WFPs flexibility to provide a limited amount of non-food support, are important means to make up for shortfalls in LDCs capacity to support effective nutrition programmes.
37. Nevertheless, government commitment is important and there are several ways in which even a poor country can provide support to a supplementary feeding programme. Governments can facilitate the collaboration and partnership of international donors with NGOs and local communities. Government commitment can also manifest itself through coordinating and directing other aid resources in support of the supplementary feeding programme and formulating appropriate food security and nutrition policies.
38. An insufficient capacity in governments to provide complementary inputs might be compensated by government-managed efforts to provide them through partnerships with other United Nations agencies, NGOs and bilateral assistance. In more than three quarters of WFP-assisted supplementary feeding projects, such collaboration occurs in areas such as training of health staff, national immunization programmes and control of micronutrient deficiencies, construction and/or upgrading of health centres, provision of equipment and supplies and nutrition education. UNICEF, the World Bank and WHO are the most frequent United Nations partners in this field. At the level of local operations, NGOs can be highly effective in motivating and leading beneficiaries towards participation. NGOs can also be instrumental in local institution-building.
39. WFPs partnership strategies to assure complementary inputs need to be pursued even more actively if WFP is to devote more of its programmes to the alleviation of early malnutrition. Contributions often turn out to be insufficient, not available on time or generally unreliable. Furthermore, what in official government documents may look like well linked programmes of external assistance may not be perceived that way by the individual aid agencies. The thematic evaluation includes more than one example in which United Nations partner agencies supporting MCH programmes made no reference at all to WFPs work in the very same sector. It is expected that the new United Nations Development Assistance Framework (UNDAF) will better facilitate collaboration and programming of complementary non-food inputs and services. WFP will clearly advocate its focus on addressing early malnutrition and communicate this to possible partners. Pilot activities can serve to better explore the scope for partnerships with local authorities and NGOs.
40. Yet, in post-emergency situations and in the poorest areas, WFP is often faced with the choice of helping needy people with food assistance or refraining from doing so until suitable partners can be found. Such a negative scenario can be overcome if WFP has the flexibility to meet a minimum of non-food expenditures that are required to make food assistance programmes effective. WFP should be able to meet some of the most basic non-food costs such as training, education materials, weighing scales, growth charts, etc. Such expenditures would be used to provide for minimum levels of non-food inputs and contribute to capacity-building for local partners. The flexibility to use direct support costs for such purposes would, however, be limited to interventions in which food costs still represent the major share of WFPs investment. Projects involving larger requirements for complementary assistance and activities beyond WFPs expertise would be undertaken only if appropriate partnerships could be established. Such joint programmes, including with bilateral donors, will be actively sought by WFP.
41. WFP-assisted interventions are expected to be "sustainable" and not "open-ended". This is usually interpreted to mean that the project objectives will continue to be met after food aid ends and that the external assistance, after some time, is replaced with national or local resources.
42. Almost without exception, WFP assistance to health and nutrition programmes has been planned in an open-ended way, usually for five years the first time, with the possibility, almost always used by the recipient country, for additional multi-year expansions. In this way many projects have continued for long periods.
43. This is justifiable, indeed almost inevitable. While each beneficiary may need WFP help only for a few months, there will be other children and expectant mothers needing help in the following years, especially in the poorest communities. Interventions to tackle early malnutrition are not a "once and for all" undertaking comparable to a resettlement scheme or a construction project. Adequate nutrition for these target groups brings important and enduring benefits for individuals and society as a whole. However, such programmes may involve high day-to-day running costs, which are usually defined as recurrent costs even though investment would be a more apt description. A rigid insistence on early government assumption of these "recurrent costs" would sometimes mean that a valuable investment would have to be prematurely terminated.
44. Regular reassessment of the magnitude of critical food needs (the key indicators were discussed above) must be the basis for determining when supplementary feeding programmes can be either discontinued or so reduced in scope that external assistance is no longer necessary. Moreover, there should be a clear indication of continued government commitment to tackling early malnutrition (demonstrated through its policy, administrative and financial support). This should be the subject of regular reviews and assessments of the country's capacity to gradually assume a higher share of financial and other support for the feeding programme. The key consideration is not how many years the programme has been in operation, but whether it continues to be a good investment, managed as cost-effectively as possible.
45. When an emergency strikes, expectant and nursing mothers and small children are at greater risk than others of malnutrition and mortality. Food relief in emergency situations is usually managed at two levels: general distribution (per capita ration for the whole population) and selective feeding (specific foods targeted to specific groups of malnourished individuals). In order to examine the appropriate balance between general distribution and supplementary feeding, it is useful to distinguish three phases in relief situations: the acute emergency phase, the intermediate phase and the longer-term rehabilitation phase.
46. In the acute emergency phase, i.e., during the first weeks after the arrival of refugees or displaced people in reception areas, there is often a need to complement the distribution of general rations with supplementary feeding of children under five and expectant and nursing mothers. Screening new arrivals to determine their food needs is crucial to reduce the risk of mortality and long-term damage related to malnutrition. Existing MCH services can play an important role in the planning and organization of selective feeding programmes. MCH centres have also been used to provide supplementary food rations for malnourished children in natural disasters.
47. In the intermediate phase of a relief operation, i.e., after appropriate feeding and health arrangements have been put in place, the general food ration is normally adequate to prevent any malnutrition problem. Supplementary food assistance is limited to short-term, curative interventions where pre-existing nutrition and/or specific health problems (epidemics, diarrhoea) lead to malnutrition in some children and mothers. Monitoring of nutritional status is nevertheless important during this phase. Where operational problems such as a break in the food pipeline or the lack of adequate donor support force aid agencies to prioritize and limit the distribution of available commodities, MCH structures will help to reach the neediest.
48. Relief operations often take place in remote, food insecure areas of very poor countries and require relatively large financial, technical and administrative resources. In managing these (temporarily) available funds and capacities there can be opportunities to also promote longer-term development in these areas. In particular, health/MCH facilities can benefit from rehabilitation measures and training of staff. WFP and its United Nations and NGO partners should pay more attention to the scope for creating lasting benefits in relief. For WFP this may require flexibility to use a small share of relief resources for supporting MCH facilities that benefit the local population (both immediately and in the longer term) as well as those acutely affected by emergencies.
49. During the rehabilitation phase, food assistance is progressively phased out. In this situation WFP sometimes provides food assistance through MCH centres, thereby creating a "safety net" for vulnerable women and children. MCH centres can play a strategic role in checking early malnutrition during phase-down/phase-out of general food rations in relief operations. Growth monitoring through MCH centres can also serve as an "early warning system", indicating when it is the time to switch (back) to other methods of ensuring minimum food security.
It is recommended that the Executive Board endorse the following eight policy and operational principles. WFP would then prepare operational guidelines on supplementary feeding interventions on this basis.
|NOTE TO THE EXECUTIVE BOARD|
Pursuant to the decisions taken on the methods of work by the Executive Board at its First Regular Session of 1996, the documentation prepared by the Secretariat for the Board has been kept brief and decision-oriented. The meetings of the Executive Board are to be conducted in a business-like manner, with increased dialogue and exchanges between delegations and the Secretariat. Efforts to promote these guiding principles will continue to be pursued by the Secretariat.
The Secretariat therefore invites members of the Board who may have questions of a technical nature with regard to this document, to contact the WFP staff member(s) listed below, preferably well in advance of the Board's meeting. This procedure is designed to facilitate the Board's consideration of the document in the plenary.
The WFP focal points for this document are:
Should you have any questions regarding matters of dispatch of documentation for the Executive Board, please contact the Documentation and Meetings Clerk (tel.: 6513-2641).
Revised: September 23, 1997©: 1997, World Food Programme. All rights reserved.