|How Nutrition Improves - Nutrition policy discussion paper No. 15 (UNSSCN, 1996, 106 p.)|
|Chapter 5: Local Level Action to Directly Improve Nutrition|
Disentangling the relative effects on nutrition improvement of actions ranging from those in the domain of economic policy, through social service provision to direct nutrition programmes, not to speak of long-term factors such as fertility change, represents an important and difficult area of future study. In the present context, we have looked so far at the association of economic growth with nutrition improvement (Figure 3.1) and then the element of nutrition improvement not accounted for by economic growth, in relation to health and education expenditure, in Figure 4.1. These data, from varying periods, with uncertainties both in prevalence change and the determining factors, are only at best indicative, but do provide a basis for discussion.
The final step conceptually here is to try to understand the further improvement observed in those countries that did better in improving nutrition than would be expected from economic growth, and from health and education investment - that is, those countries falling below the average line in Figure 4.1 (which used a linear fit to the data shown in Figure 3.1). For example, if the data were accurate, it would be observed that Thailand had a further percentage point per year improvement to be accounted for, as did Malaysia and Zimbabwe; while India and Egypt, in this example, did worse than might have been expected. Some of the deviations seen in Figure 4.1 can be accounted for by known set-backs - as examples, in Ethiopia during the 1980s where there was widespread destitution due to the civil war; or in Kenya in the late 1980s and early 1990s, when economic recession and unfavourable prices, coupled with drought, contributed to nutritional deterioration. Nonetheless, it is probable that part of the improvement seen in those countries doing better than expected is in fact due to direct nutrition actions.
In principle, therefore, the results from the different countries studied are consistent with there being an impact of the programmes in Indonesia, Tanzania, Malaysia, Thailand, and Zimbabwe; with less impact in India, Egypt, and Brazil. This is in line with the impressions put forward in the case study reports - impressions only, because none has nation-wide programme impact evaluations.
One initial question concerns where in the historical process of economic development do nutrition programmes have their most important role. This depends to a considerable degree on the extent of administrative and physical infrastructure, its outreach, and the extent of local organizational capacity. These then can allow flows of resources to help support nutrition activities at the local level. An attempt at proposing priorities in relation to levels of development is made here.
For very poor regions within countries with extremely limited infrastructure8, the very first priority is likely to be to ensure access to adequate food, and to establish accessible and relevant preventive and curative health care. Nutrition activities as defined here are probably secondary to this. At one step above this minimal level of community or government resources and infrastructure, nutrition programmes can become an affordable priority, and accelerate progress (e.g. Tamil Nadu, Iringa, Indonesia, Zimbabwe). Such countries or regions generally have levels of nutritional deprivation which warrant direct forms of action. Moreover, programmes have a role whether or not the underlying trend is one of nutritional improvement. Normally improving underlying trends, as seen earlier, are still too slow to solve malnutrition within an acceptable time; and deteriorating trends need to be counteracted. An analogy can be drawn with public health measures, which are still essential even when health conditions arc tending to improve as a result of socio-economic development.
8 Infrastructure here generally refers to human, physical and organizational.
In lower-middle income countries (i.e. about per caput GNP US $725-3000), programmes are more feasible, but not so widely needed (as the magnitude of the problem is usually less). The social and regional targeting of well-organized, efficient, programmes is an increasing consideration, e.g. in Thailand, Malaysia and several Latin American countries such as Colombia, Chile and Costa Rica. Nutrition programmes in this group may also have important beneficial interactions (through human capital formation) with economic growth.
In higher income countries, nutrition programmes eventually merge with social welfare and health services. They may not be such a priority for the whole country, but will need to be targeted to reduce disparity where it exists and buffer any social groups marginalized during the economic growth process. As countries industrialize, food becomes more accessible and health care more extensive and better; social welfare and services and legislation will become relatively more important (and these may serve to nutritionally buffer vulnerable groups during economic shocks). In such countries, where there is the economic potential to do something about malnutrition, an overriding concern is often equity - both regional and social (this is certainly the case in the Brazil of the 1990s, for example).