|How Nutrition Improves - Nutrition policy discussion paper No. 15 (UNSSCN, 1996, 106 p.)|
|Chapter 1: Introduction|
A number of considerations applied to proposing and contacting countries for review. Firstly, there needed to be nutrition (anthropometric) trend data, in a majority of cases showing a significant improvement during the last decade or so. This was a primary criterion for "success". Secondly, there needed to have been an explicit governmental attempt to deal with the problem of malnutrition, manifested as nutrition-oriented programmes, a nutrition policy and/or explicit nutrition-related objectives built into broader developmental policies or programmes. UNICEF refers to the Triple A process of assessment, analysis and action (UNICEF, 1990). Applied to the problem of malnutrition, each country in these reviews can be said to have been undergoing such a process during the 1980s. Employing these criteria, and following discussion with UNICEF, the following six countries were contacted: India, Indonesia, Thailand, Tanzania and Zimbabwe and Brazil. As well as differing in context, the actions seen to determine the nutritional improvements ranged from large-scale targeted nutrition programmes (e.g. Tamil Nadu in India) to broader development policies (e.g. equitable growth in Indonesia).
A further four countries, for which recent detailed material had been commissioned for the ACC/SCN's Second Report on the World Nutrition Situation, are also considered in this synthesis. These are Pakistan, Egypt, Mexico and Nigeria. The work on Egypt was brought together to specifically look at policies and programmes. Seven case studies have thus been published, which provide the basis for this work. These are the following:
Iunes, R. and Monteiro, C. (1992) The Improvement in Child Nutritional Status in Brazil: How did it Occur?
Nassar, H. et al. (1992) Review of Trends, Policies and Programmes affecting Nutrition and Health in Egypt.
Reddy, V., Pralhad Rao, N., Shekar, M. and Gillespie, S.R. (1992) Nutrition in India.
Soekirman, Tarwotjo, I., Jus'at, I., Sumodiningrat, G. and Jalal, F. (1992) Economic Growth, Equity and Nutritional Improvement in Indonesia.
Kavishe, F. (1992) Nutrition-Relevant Actions in Tanzania.
Kachondham, Y., Tontisirin, K. and Winichagoon, P. (1992) Nutrition and Health in Thailand: Trends and Actions.
Jayne T., Tagwireyi, J. and Lenneiye, N. (1992) Nutrition-Relevant Actions in Zimbabwe.
Other case studies for the Second Report on the World Nutrition Situation have not been published but have also been drawn upon for many of the points in this synthesis. These are:
Chavez, A., A. Avila, S. Bermejo, J. Roldan, H. Madrigal (1992) The Food and Nutrition situation of Mexico: A Report of Trends in Food Consumption, Nutritional Status and Applied Programs, 1960-1990.
Agary, T. and S.R. Gillespie (1992) Trends in Nutrition in Nigeria.
Malik, N. and S. Malik (1992) Reporting on the World Nutrition Situation: Case Study on Pakistan (1976-1991).
In addition, at the workshops held in Adelaide in September 1993, when these were discussed, a further case study was presented from Malaysia, which has been most usefully included in this synthesis. The report is:
Karim, R., Zaman, K.F.K., and Yusoff, S.M. (1993) Review of Policies and Programmes that have an Influence on Nutritional Status in Malaysia During the 1980s.
Eleven case studies therefore form the basis of this work. Of these, the first seven listed above provide the most material, as they have specifically addressed policies and programmes in relation to nutritional trends. Over and above this, country level data from recent reports on the world nutrition situation (ACC/SCN 1992-94) are used to provide context.
The ideal would be that those who use this synthesis in detail have with them copies of the published case studies, as listed above. These are available on request from the ACC/SCN Secretariat. As appropriate, reference is made in the text below to these case studies where specific facts or opinions need to be referenced. They are abbreviated such that, for example, B p16 means Brazil case study page 16, as follows: Brazil-B; Egypt-E; India-Ind; Indonesia-Ins; Tan-Tanzania; Tha-Thailand; Zim-Zimbabwe. The other four case studies are unpublished, but used for the report, referenced as follows: Ma-Malaysia; Me-Mexico; Ni-Nigeria; and Pa-Pakistan. At the end of each chapter, relevant case study experience is summarized.
Finally, some limitations should be recognized. The range of country experiences reviewed is limited to eleven (where in-depth material has been compiled), with some reference to others where information is also available. Second, nationally representative data are in some cases not available at regular intervals. Third, sometimes it is not possible to directly attribute causes to outcomes. Rather, we aim to tell a story that makes some sense, by relying on the literature and on specific studies, to infer that an impact on nutrition should be expected resulting from changes in causal factors, deliberate or otherwise. The "story" is therefore subjective but nevertheless the consensus of many, including country representatives at the workshop in Adelaide.