|How Nutrition Improves - Nutrition policy discussion paper No. 15 (UNSSCN, 1996, 106 p.)|
|Chapter 5: Local Level Action to Directly Improve Nutrition|
Figure 5.1 lays out the time frame of the National Food and Nutrition Policy (NFNP) in Thailand along with other related policies. The following is extracted from the case-study (Kachondham et al. 1992) from various sections.
NESDP = National Economic and Social Development Plan
NFNP = National Food and Nutrition Policy
PHC = Primary Health Care
PAP = Poverty alleviation Policy
BMN = Basic Minimum Needs scheme
Source: Kachondham et al. (1992) p.57
The first NFNP (1977-81) set out ambitious and comprehensive goals to improve the nutritional status of the population by tackling the problem from many angles, i.e., improvement of health care and hygiene; increasing food availability, nutrition education; and improving socio-economic conditions of the vulnerable groups. The plan targeted rural infants, preschool children (children under five), pregnant and lactating women, and, to a lesser extent, school children.
In reality, the nutrition programme was not fully implemented due to lack of inter and intra sectoral collaboration. Although some action plans were well defined, planning was entirely a top down approach. The planning, authorization and budget allocation were decided from the central or provincial level and vertically channeled to the grassroots, but no single agency was responsible for overall co-ordination and monitoring of programmes. There was no change in the programme planning and budget allocation structure to support multisectoral efforts. There was very little participation by the community. Many of the activities did not achieve the set objectives and depended totally on government-provided services, for example, the centrally produced supplementary food, and the nutrition rehabilitation in the villages.
It was not surprising that the first NFNP produced disappointing results. Malnutrition continued to be a serious problem, especially protein-energy malnutrition among infants and preschool children and iron-deficiency anaemia among children and pregnant and lactating women10. A 1980 nationwide survey showed that 53% of preschool children suffered from protein-energy malnutrition. However, the most significant accomplishment of this plan was the creation of a strong awareness of the nutritional problems both among the public and private sectors and at all levels, and led to a strong political commitment to the country's policy.
10 Quoted from National Economic and Social Development Board. The Fifth National Economic and Social Development Plan (1982-1986). Bangkok, Thailand: The Royal Thai Government, 1981.
The main thrust of nutrition policy in 1981-1986 (Fifth NESDP) lay in the broader policy of poverty alleviation programme (PAP) and development of backward areas, and the primary health care approach (PHC). This was the important turning point in the developmental approach in the country.
Both PAP and PHC policies have nutrition concerns as a component. Multi-sectoral collaboration was promoted through community-level training sessions involving personnel from each sector. Thus, village organization and planning at the community level were strengthened. These bottom-up efforts appeared to function more effectively, to promote greater integration of the efforts of the various government sectors, and to use the potential of the community - through village committees - to address needs and possible solutions. In addition, there was an organizational change for rural development by having only one national committee instead of too many sectoral developmental committees in charge of development policies, with infrastructure down to the village level. This was a striking organizational reform which combined macro- and micro-level structures to support both the top-down macro policy and bottom-up planning by the community and peripheral government resources.
Manpower development, management and community financing were facilitated. Village-based health volunteers called village health communicators (VHC) and village health volunteers (VHV) were trained nationwide. Growth monitoring programmes were carried out by health personnel and these volunteers in the villages. Simple and practical indicators and nutrition education for all age groups were introduced. The VHV and VHC were responsible for weighing, interpreting and communicating the results to mothers. The moderately and severely malnourished children received more attention, and their mothers were encouraged to participate in the activities. Supplementary food programmes were also financed through the MOPH, which introduced economic incentives by establishing village nutrition funds. Under this plan, MOPH provided target villages with a fixed amount of seed money for community efforts to improve nutrition. The community also determined whether the funding would assist people with immediate needs for supplementary foods (poor families with malnourished children) or would go towards starting a local supplementary food production unit. Development of village-based supplementary food processing allowed the communities to become self-reliant. Through these strategies, the community participation improved and people took more active roles in solving the problems within their own community.
By 1986, the nutrition situation of infants and preschool children had been dramatically improved, and severe PEM had practically been eliminated and only a small amount of moderate PEM remained. Weighing by simple beam balance and the use of growth charts by the village-based health volunteers (VHV and VHC, trained under the PHC strategy) and mothers were shown to be feasible and used for problem identification. Simple technology for village level processing of supplementary food was promoted to overcome the disruptive distribution of centrally produced supplementary food. Village self-financing schemes were also tried with some success.
An important feature of the NFNP from 1986 to 1991 was the basic minimum needs to approach to improve community participation and integration of sectoral development activities. This was implemented nationwide to strengthen the integration of sectoral efforts. Birth weight and weight-for-age of underfives and school-aged children were the nutritional indicators defined for measuring adequate nutrition. Thus, nutrition activities became a means to achieve the goal of quality of life. Through this iterative process, it was expected that villagers would increase their understanding and have confidence to participate. In these processes, local officers were expected to change their roles from being the agents of change to be facilitators or advisers.
By 1989, more than 500,000 village health communicators (VHC) and 50,000 village health volunteers (VHV) were trained, covering almost all the villages in the country. At the end of the Sixth NESDP, the most recent nutritional surveillance report (1991) has shown that the prevalence of severe malnutrition was almost nil, and moderate malnutrition had reduced sharply.
Four key programmes were implemented as part of the PAP, beginning in 1982:
Rural job creation programme: Jobs were created for rural people during the dry season to boost their income. Most of the employment was given to people in the locale so that rural people would remain in their communities and participate in community development activities.
Village development projects or activities: The activities included village fish ponds, water sources, prevention of epidemic diseases affecting poultry, cattle and buffalo bank, and other development projects focused on rural poor to improve their economic status and household food security.
Provision of basic services: Public services for rural poor such as health facilities and health services, nutrition, clean water supplies, and illiteracy education programmes were directed to the targeted areas.
Agricultural production programme: Important programmes included nutritious food production (especially crops used for supplementary feeding of young children), upland rice improvement projects and soil improvement projects. Income generation and household food security were the direct benefits.
To strengthen rural development, from 1986 on, the basic minimum needs approach (BMN) was used as the principle to achieve a good quality of life for rural people. In addition, the approach has been developed as a response to problems encountered in the course of actually implementing PHC programmes and projects. Two major problems were a lack of participatory orientation and the necessary skills among local government workers in promoting and supporting community participation; and inadequate opportunities for villagers to manage their own community development process i.e. data collection, planning and decision making. To overcome these obstacles, an Intersectoral Social Development Project was launched under the auspices of the NESDB in 1981. The project's outcome was a set of Basic Minimum Needs (BMN) and their indices to be used by the villagers themselves. The indicators are shown in Box 5.2.
The BMN approach may be succinctly defined as a socially-oriented, community-based, intersectoral and scientifically-sound development process. It is also a process carried out by the people and community with support from the government aimed at fulfilling basic human and community needs. Eight groups of BMN indicators (32 measurable indicators) were developed and used as the tools for problem identification and setting up goals for development in the community - see Box 5.2.
The results from the process are used to formulate a village proposal and submitted to the sub-district committee. The extension personnel from the government agencies serve as a supervisory committee to the sub-district committee. The proposals which have been approved by the sub-district committee are then submitted to the district and provincial levels, respectively. The provincial rural development committee makes the final decision as to which proposals in the province are to be supported. The approved proposals are sent to the central level. The proposals from all provinces are considered and the budget allocation decided.
Through this entire process of problem identification, planning, prioritization of the types of activities and support needed, implementation, and evaluation by re-survey of the BMN status of the village, villagers, by themselves, are aware of their own problems and the level of their achievement. At the same time the district and provincial administration are able to effectively carry out their supervisory and supportive tasks and closely interact with villagers in trying to respond to their needs.
At present, more than 95% of the total villages throughout the country are using BMN indicators to gauge their development status and achievements. There have been some modifications, especially in some rapidly improved areas. Either new indicators were added or the criteria of success were lifted to a higher level. However, long term success still needs constant and persistent government support. Quality improvement in data collection by the people themselves, enhancing local capacity in planning and management, utilizing MBM indicators and supervision by government officers are important issues for sustainable success.
Box 5.2: Basic Minimum Needs (BMN)
Eight groups of BMN indicators were originally developed to be used by villagers themselves as well as local government officials as tools for problem identification, analysis, goal setting and action programme implementation. The indicators below were developed into checklists as a way to determine problems and their priorities as a basis for planning intervention activities as well as to monitor and evaluate their results.
I. Adequate food and nutrition
1) Proper nutrition surveillance from birth to five years and no moderate and severe PEM.
II. Proper housing and environment
4) The house will last at least live years.
III. Adequate basic health and education services
8) Full vaccination with BCG, DTP, OPV and measles vaccine for infants under one year.
IV. Security and safety of life and properties
15) Security of people and properties.
V. Efficiency in food production by the family
16) Growing alternative crops or soil production crops.
VI. Family Planning
21) Not more than two children per family and adequate family planning services.
VII. People participation in community development
22) Each family is a member of self-help activities.
VIII. Spiritual or ethical development
39) Being cooperative and helpful in the village.
Source: Kachondham et al. (1992) p.110-111
11 In part edited from Ins, pp 6-7, 21-22.
Indonesia's commitment to improve the nutrition situation has been explicitly stated ever since the Second Five Year Development Plan (FYDP-1974). In the Fifth FYDP (1988-1994) the food and nutrition policies focussed on four objectives: (i) sustaining food self-sufficiency through increased food production; (ii) improving nutritional status for the population through increased diversification of food consumption; (iii) improving the nutritional status of infants, children and pregnant women; and (iv) improving the nutritional status of the population by reducing the prevalence of nutritional diseases such as protein and energy deficiencies, vitamin A deficiency, nutritional anaemia and goitre. National efforts to implement this policy involved intersectoral cooperation, particularly between health and agriculture. In particular, the fifth FYDP nutrition policy was indirectly related to poverty alleviation. Macro programmes to ensure food security by intensification, extensification, and diversification of food production had the following objectives: (i) to sustain rice self-sufficiency; (ii) to increase farmers' incomes; (iii) to provide sufficient and diversified food supplies to meet nutritional requirements.
These objectives were supported by a food marketing system that ensure stable food prices, both affordable for consumers and profitable for farmers.
Micro programmes in the agricultural sector were designed specifically to accelerate the poverty alleviation of small farmers in certain areas, as part of a national community nutrition programme called UPGK with emphasis on generating income from the family garden, as well as direct consumption purposes especially related to micro nutrient deficiencies.
One important precondition for the National Family Nutrition Improvement Programme (UPGK) (which started as the Applied Nutrition Programme in the 1970s) was the extensive grass-roots community participation - a natural outgrowth from a tradition known as gotong royong. This inherited cultural pattern of mutual help in the community was adopted as one of the 15 principal guidelines for the country's national development plan. In the early 1980s, the UPGK grew rapidly to cover 45,000 of the 65,000 villages in Indonesia. This growth was possible as a result of the active participation of a village women's organization known as PKK, which exists in most Indonesian villages. The members of PKK were responsible for establishing village nutrition centres called taman gizi, where growth monitoring, nutrition education and supplementary feeding activities were undertaken by village nutrition cadres, trained under the auspices of government nutrition programmes. Since 1984, the village nutrition centres have been gradually integrated with other primary health care services, and known as posyandu. The posyandus are designed to be managed by the community and serve as fora for communication, while the cadres are selected by the community and supported by sector workers. Interest is first aroused through the process of a baseline survey, before training and support from the health services is then used as a means of enabling full participation. By 1994, there were expected to be two posyandus per village in Indonesia. This rapid development was primarily due to the active participation of PKK and other women's organizations at village level.
A sustainable community nutrition movement such as UPGK is considered a necessary condition for dealing with complex nutrition problems (PEM, vitamin A and iron deficiencies). It requires a basic infrastructure for community participation, such as nationwide village women's organizations, like PKK, and a village-level community-initiated basic health and nutrition service such as posyandu, as the lowest referral system of district and sub-district health centres. Vitamin A capsules distributed via posyandu demonstrated cost effectiveness in a relatively "shorter" time in eradicating xerophthalmia and promoting child survival. Reducing the prevalence and incidence of PEM, especially of severe and moderate forms, seems possible without special supplementary feeding at a rehabilitation centre, provided there are sustainable economic activities benefitting the poor, coupled with the provision of basic services. In this case, growth monitoring as part of nutrition services at Posyandu is believed to play a key role as an entry point and for education purposes. The growth promoting "effect" of weighing is a complementary outcome of integrated inputs provided at Posyandu and the mother's care at home. Therefore, the effectiveness of growth monitoring should not be evaluated as an isolated activity. For iron deficiency anaemia however, there have been no significant benefits from using iron pills. A more effective delivery system will still have to be found.
Nutrition surveillance, developed in most critical areas on Indonesia in the 1970s is currently being redesigned for broader purposes such as the monitoring of children's growth at local, regional and national levels. This is to be part of the national social-economic household survey for national or regional policy and planning purposes.
Integrated nutrition and health programmes such as the Tamil Nadu Integrated Nutrition Programme (TINP) and the Integrated Child Development Services (ICDS) are particularly relevant although (particularly in the case of ICDS) their targeting, community involvement and implementation could be strengthened (Reddy et al. 1992, Ind pan II, p20). At present ICDS, like many other interventions in India, tends to exist and work best in those areas where it is in a sense least needed i.e. those areas with a more developed infrastructure for delivery. Area targeting to more remote, usually poorer, areas, could be supplemented with targeting to under-three year old children from the poorer households at village level. The case study suggests that the lessons learnt from TINP (regarding targeting, implementation, training, supervision, monitoring) could be utilized fully to optimize results. Both programmes are seeking ways of more effectively involving the community.
In Tamil Nadu during the 1980s, the Noon Meals Programme (NMP) was in operation, which is an example of an expensive, untargeted, top-down use of resources ostensibly allocated to nutrition. The NMP is a feeding programme for school children, not a nutrition programme for the malnourished. It does not start from the community's diagnosis of who are the malnourished. Rather, it disburses food to children at school, who therefore arc unlikely to be in the most nutritionally at-risk age groups nor from the most at-risk socio-economic class who cannot afford to send their children to school. It may on the other hand provide an incentive to retention in primary schools which is a valid objective with possible pay-offs for nutrition in the long-term.
The country review (Reddy et al. 1992) has also demonstrated the need to balance needs, potential demand and available resources in order to reduce the types of mismatches seen with both the Public Distribution System (PDS) and the ICDS (hid part n, p47). A stronger integration between macro planning (resource allocation) issues and micro-level (programme design) issues is recommended in the review, with the overall objective of ensuring adequacy and efficient use of resources allocated to nutrition. This seems all the more important given the relatively low percentage of combined Central and State direct expenditure allocated to nutrition (approx. 1 % in 1986/7).
Flexibility is important. A programme like the ICDS needs to look different in Bihar than it does in Tamil Nadu, for example. Apart from the prevalence, causes and location of child malnutrition, states will differ in such factors as, for example, female literacy levels. Hence the differing levels of priority for the health education component of ICDS. Such flexibility might be brought about through a decentralization of planning and decision-making - a move away from the uniform supply of a blueprint ICDS throughout India - in order to foster a more active involvement of beneficiaries in the design, implementation and evaluation of programmes. Such a system could be backed up by a regularly up-dated data base on nutrition to keep track of areas of need as well as assessing programme impact (Reddy et al. 1992).
Ongoing programmes in Tanzania show a number of important characteristics (Tan p170-77).
i) They are community-based with strong community participation and management through the Government and Party administrative structures. National, regional and district technical supportive mechanisms were strengthened or in some cases established.
ii) There is a strong component of social mobilization through advocacy, information and communication which has led to the creation of community concern with the problem of child deaths and malnutrition.
iii) Active participation has been sustained through improved management - the result of the systematic strengthening of the process of continuous assessment, analysis and action. The management systems emphasized improved information through quarterly child growth monitoring using growth cards and the understanding by both men and women of the child's growth pattern. Also management and decision-making was strengthened through training at all levels and discussing results from the information systems in the health and nutrition committees. More household and community resources are now being allocated towards the improvement of nutrition. Management was also strengthened through the provision of essential management tools like supervisory transport and other expendables. The management systems created helped also in monitoring programme impact.
iv) An integrated multidisciplinary approach was used. Actions on the improvement of household food security, caring capacity, health services, education and water were carried out at the same time. In many cases extension staff from the relevant sectors continued to do the same things they used to do; but with an understanding of the consequences of their actions on the nutrition situation, they did them better. The explicit conceptual approach used facilitated dialogue and analysis of the causes and problems of malnutrition by those affected. The emphasis on the triple A approach prevented the intrusion of external "magic" packages of solutions. As a result emphasis was initially placed on the development of the process for the reduction of child and maternal mortality and malnutrition. Coupled with extensive internal and external technical contacts, this resulted in the creation of confidence and capacity in community and national institutions.
The Child Supplementary Feeding Programme (CSFP) in Zimbabwe was initiated by a consortium of national and international NGOs together with two government ministries in late 1980, before the country was hit by drought in the years 1982-84. In early 1982 the Department of Nutrition (DNN) in the MOH took the lead in child supplementary feeding, with assistance from the Ministry of Labour and Social Welfare. The CSFP was successful in mobilizing various ministries, NGOs, and extension workers, to work with self-organized village committees to feed children in groups in the communal areas. The project also registered success in replacing imported biscuits and food products, traditionally used in emergency feeding programmes, with locally produced foods (groundnuts, beans, maize and cooking oil). The use of local foods to rehabilitate malnourished children had an important educational message for parents and informative posters placed at many feeding points and health facilities emphasized, and affirmed the value of, these local and cultivable foods. The CSFP also utilized locally-constituted committees to measure food quantities required, and receive and distribute the food to mothers who prepared the food at the group feeding points in the community. The success of community action led the programme to develop a production element, and the Supplementary Food Production Programme (SFPP) was born. Like the CSFP, the SFPP utilized a complex inter-ministerial management system (the National Steering Committee (NSC)) with equally structured community-based management committees (Food and Nutrition Management Teams (FNMTs)). Government extension workers (in health, community mobilization, agriculture, etc.) were mobilized and organized for this programme.
Targeting for the programme was achieved by using rates of malnutrition among under-fives. Initially, the CSFP used mid-upper-arm circumference measurements of less than 13 cm to include children in the programme; later weight-for-age measurements were recorded on master cards, identifying areas of high malnutrition prevalence. Extension staff responsible for managing the programme established community gardens where the rates of malnutrition warranted such action. Other components of the SFPP were i) nutrition education, ii) promotion of appropriate technologies for food preservation, processing and storage, iii) training of extension workers in planning and monitoring, iv) production of nutritious foods at communal gardens worked on by mothers of malnourished children, v) communal cooking and feeding of children using the food produced.
The mandate of the FNMTs evolved to go beyond food production; programmes on IDD, community-based nutrition surveillance, nutrition surveys etc. are handled by these committees. The NSC no longer coordinates the SFPP alone, but has taken the lead in the development of a National Nutrition Policy framework. These developments have taken place because as nutrition programmes developed, gaps became evident, and the NSC/FNMTs took up these roles. Evaluations by the NSC during the 1985-90 period indicated the need for the SFPP to address broader issues beyond community food production. The SFPP has thus now evolved into a Community Food and Nutrition Programme (CFNP) to reflect the broadening of its objectives. Community mobilization for nutrition, provision of agricultural extension support, nutrition and health education, linkages to local institutions for development planning, and extensive inter-sectoral collaboration remain the main features of this programme.
Brazil has had a diversified experience with food and nutrition programmes - from food subsidies to the direct distribution of foodstuffs, through market channels or from public facilities (B p20-21). Such programmes have been almost entirely supported by national resources. The monetary values and volumes involved are substantial: a single programme of food supplementation for pre-school children distributed more than 1.5 million tons of food between 1976 and 1987. Expenditures with food and nutrition programmes increased from 0.06% of the GDP in 1980 to 0.21% in 1989 - the fastest growing area of the social sector. Despite such impressive figures and ambitious goals however, there have been several problems: firstly, programmes have not reached the poorest regions and income groups and the most vulnerable age groups (rather they target workers in the urban modern sector, and primary school children), and secondly programmes have been disassociated from health and educational efforts. Thus Iunes and Monteiro (1992) claim that food entitlements acquired through non-income channels have had a limited influence on the nutritional improvement observed in Brazil, due largely to the low effectiveness of these programmes (B p27). The behaviour of food prices, in aligning very closely to inflation, while not a contributing factor to the improvements, did not represent an obstacle either.
While food and nutrition programmes in Brazil were therefore not community-based, they provides an interesting example of the power of public action by the people for adequate basic social services. The rapidly growing urban population during the last two decades put pressure on the public sector not only to provide adequate social services and infrastructure, but also for political change, demanding political freedom and the restoration of democracy. As a consequence it became increasingly difficult for the government to contain the movements in opposition to the military dictatorship established in 1964. An example is the labour and grassroots movements that gradually, throughout the second half of the seventies, provided the freedom and voice to fight for better wages and public infrastructure; and the fight of the civil society for free elections. While each and every government, even during the military dictatorship, stated that social areas were priorities, Brazil lacked a strategy to integrate its several social programmes into a consistent and coherent scheme that could be defined as a social policy. Areas such as food and nutrition, health, education, water and sanitation, housing, social security, etc. tended to fight for the same resources. This in turn led to the lobbying in the Congress for laws that would establish floors of expenditures as percentages of the government revenue or even the GDP.