|Essays on Food, Hunger, Nutrition, Primary Health Care and Development (AVIVA, 480 p.)|
Not as a surprise, this 5th Report shows a mixed picture of what we have achieved (or not achieved) in the world in terms of nutrition outcomes.
- Should we --the nutrition community-- blame ourselves in part for not having achieved more? The response to this question passes through asking ourselves another:
- Have we really tackled all major obstacles and opportunities to improve these nutrition outcomes? Here, we can probably say with confidence that we have not.
- Have we overlooked, neglected or consciously avoided tackling some of the non-nutrition obstacles and opportunities that could have maximized nutrition outcomes? Even if this is the most value-loaded question of the three, it is crucial we take it face-on when, from now to 2015, we engage new, more effective mechanisms to reach the goal of halving the <5 malnutrition rate worldwide.
It is to expand on these matters that this article now turns.
The Household Entitlements Revolution here proposed looks at the challenges we face in nutrition work from a more comprehensive perspective; it focuses not only on nutrition per-se, but on how to simultaneously address a host of related (non-upheld) household members rights.
Making this Revolution women-centered and focusing it on indicators of family security departs, on the one hand, from the principle that there is an array of household (HH) securities that are indispensable for the well-being of HH members in general and for the women in it in particular. On the other, the issue of providing such securities has remained unresolved in most past and current nutrition and development work --i.e. we have failed to secure poor women's actual access to and utilization of the resources and services they need to fulfill their basic entitlements (of which nutrition is only one).
The main rights HHs in general and women in particular are entitled to are those related to attaining minimum levels of security in:
- Food and nutrition (macro- and micro-nutrients).
- The care of children and the support of women to do so.
- Womens own gender-related needs and entitlements.
- Clean water supply and sanitation facilities/services.
- Housing (shelter).
- Income (in kind/in cash, including employment opportunities and access to credit/subsidies, especially for women).
- Education (pre-primary/primary with a focus on girls, female literacy/numeracy).
- Fuel (energy).
- Legal protection (mainly, but not only of children and women's rights).
- Physical environmental safety.
- Physical personal safety during armed conflicts.
- Women's personal safety from domestic violence.
For monitoring and accountability purposes, the minimum standards and the best indicators for each of these entitlements need to be set by community representatives themselves, together with experts, in each (of the many) different local context(s).
There is nothing terribly new in this HH and women-centered approach to overall family security. It just (re)packages well known basic children's and women's rights in a way that more explicitly emphasizes the need for a new set of priorities that transcends current development orthodoxy. The most important aspect of this approach is, perhaps, that it has the potential to bring us closer to (and to focus our work more on) the underlying and basic causes of neglect, abuse, ill-health, malnutrition and unnecessary mortality of women and children.
Under this approach, the major focus of attention in the search for solutions to the above causes, therefore, shifts: it now starts with a major and explicit effort to identify insecure HHs and women living insecure lives. Only then, does attention turn to devising a more comprehensive set of interventions that, as much as possible, simultaneously addresses several of the insecurities identified. [It is important to notice that some of the above insecurities are always 'limiting', in the same sense that a limiting amino-acid restricts the biological value of a protein: regardless of the ample supply of all other amino-acids needed to synthesize the protein, the absence of even one limiting amino-acid stops the synthesis of the protein altogether. This metaphor illustrates well what orthodox development work in nutrition has quite consistently neglected so far].
Locality by locality, the identification of vulnerable, insecure HHs and women is also to simultaneously be accompanied by the identification of the coping mechanisms proven successful as utilized by both HHs and women to get access to the different resources and services that help them fulfill their entitlements under given difficult local conditions and circumstances. These coping mechanisms will be very different in urban as opposed to rural settings and will have to be surveyed with different instruments.
The ensuing challenge is then twofold: On the one hand, one has to foster the needed community organization and consciousness raising to forcefully and persistently place womens claims and demands on selected duty bearers; this is necessary to create yet new conditions that will further expand the opportunities and remove the existing barriers for insecure HHs and women to attain the securities so far not available to them. On the other hand, together with the community, one has to find the interventions that support the adoption of the proven and successful coping mechanisms by a larger proportion of at-risk women and HHs in that particular environment.
This two-pronged approach then becomes the basis for directing interventions to the more vulnerable. The widespread organization of women for active lobbying and the communication and adoption of the positive coping mechanisms used by each local community become the key challenges for all of us; the use of participatory, consciousness-raising Education Information and Communication (IEC) techniques is key here.
All this, calls for a much heavier emphasis on local and national social mobilization programs and a better coordination among them. If and when the approach here proposed starts to be accepted by a growing number of development organizations, coordination among UN and bilateral donor agencies in the field --as well as among NGOs and grassroots organizations at local and national level-- will have to get more prominence and a greater sense of urgency so as to maximize their combined social mobilization capabilities.
In practical terms, what this revolution also means is that sectoral approaches --nutrition, health, water and sanitation, basic education, income generation, women's affairs, etc.-- need more integration. Such a drive for integration actually has to come from the HH and local women's organizations level up. This is helped by all technical sectors and programs, together with the local organizations, jointly embarking in the upfront identification of insecure HHs with women living insecure lives. Ideally, local organized groups should actually actively participate from the planning of the identification of vulnerable HH surveys on. If such community groups do not yet exist, preliminary efforts will have to be made to organize them.
If all sectors jointly start identifying these insecure HHs, as well as the successful coping mechanisms used by some of them, and then contribute their findings to a community participatory forum, a great contribution will be made to a more appropriate search for more workable and sustainable solutions to the problems at hand --and not only for those of malnutrition alone.
Interventions chosen do not need to (and probably will not) be new, but will be combined and focused in a way that different relevant causal levels are tackled, using some tried and perhaps some new approaches to solve old problems expressed as felt needs by community representatives, especially women. Some interventions will be manageable with the exclusive inputs (resources) and organization (mobilization) of community members and existing women's organizations, others will require some form of public pressure and lobbying that can translate womens felt needs into effective claims and demands. It is both of these, the internal and the external dynamization processes together that will ultimately lead to the indispensable empowerment of the organized community.
The approach here proposed does not lend itself for a grandiose national-scale scheme. Its focus has to be intensive rather than extensive. It calls for a gradually growing set of mostly local interventions that should perhaps start in the geographically most vulnerable region(s) or district(s) of the country.
The pilot implementation of this HH and women-centered approach could best be achieved through operations research activities: trying out different approaches and documenting their impact. The surveying of HHs and women for vulnerabilities and coping mechanisms will require working on some simple data collection tools that can be analyzed simply. The engagement of local organized groups and the sharing of the results of these surveys with them will then lead to local collective decision-making. NGOs and other organizations can help finding funds for some of these community-based interventions and can support womens lobbying since they often have the advantage of having a more national presence.
In conclusion, if towards 2015, we are to more significantly improve nutrition outcomes of women and children worldwide, we have to address a number of their more crucial unfulfilled entitlements at the same time. It is at this point, really, that the question raised at the beginning of this article comes up again: How effective is it to continue trying (sometimes so hard) to tackle one (or two) entitlement at a time..? Nutrition alone cannot be significantly improved without resolving the access questions related to other entitlements when these are limiting as well. So, if we want to engage more effective mechanisms to improve nutrition outcomes worldwide, this is the major challenge we simply have to confront: Jointly assess all the major HH level shortcomings with a geographical rather than a sectoral program focus and let communities have the final word on the better interventions.
Claudio Schuftan MD
IPO Box 369, Hanoi, Vietnam
Fax: 84 4 971 0802