|How Nutrition Improves - Nutrition policy discussion paper No. 15 (UNSSCN, 1996, 106 p.)|
|Chapter 5: Local Level Action to Directly Improve Nutrition|
The next set of issues considered is:
- problem definition and analysis leading to programme design (triple A process)
- coverage and targeting
- intensity (expenditure/head)
Prior to design, relevant disaggregated information on who is malnourished, where and when will always be crucial. Also, how is malnutrition perceived locally? Is it even seen as important, a priority? This initial assessment of the problem, which should largely involve the community, leads to an analysis of its causes - why these children are malnourished -which in turn suggests relevant activities for incorporation in programme design. This "triple A" process then iterates, with the programme design being modified accordingly following later re-assessment of the malnutrition situation.
How often is this idealized process actually achieved? Again, and probably as no surprise, the more effective programmes do seem to be those that have achieved it. Thus in Thailand with the Basic Minimum Needs approach, and in Tanzania, through the village committees (which use growth monitoring data) there is a genuine involvement in local decision making. An earlier assessment (Shrimpton, 1995, based on observations up to 1988) considered that neither UPGK in Indonesia, nor Tamil Nadu in India had much involvement of the community in needs assessment, nor indeed in many other aspects (p.254, Table 13.2 in Shrimpton, 1995). However, we know that at least Thailand, also scored low by Shrimpton, has a local system, and it may be that the others have evolved as well.
An important aspect of design is thus flexibility. There can be no absolute statement about what programme works, no blueprint amenable to universal replication, because of the importance of the local context. Nevertheless, while the content of a community-based Iringa-style programme, for example, would be different in India, there are features of the process of designing community-based nutrition programmes which are replicable.
Experience remains that many programmes have outdated concepts underlying them. There is clearly a need for overhaul of messages for nutrition education, for priorities given for targeting different age groups, and a number of other concepts e.g. the importance of supplementary feeding practices in cases of chronic diarrhoea, energy density of weaning foods, etc. The experiences with social marketing offer some lessons regarding the importance of formative research (effectively an insider's perception of the problem) in clarifying the problem and hence design of remedial action. But the design should not then be done only by outsiders - a common shortcoming of the past.
Coverage can be extended either with a high degree of targeting, or with attempts at blanket coverage and less emphasis on targeting. In general programmes often start with some degree of targeting by area, whereby attempts are made to preferentially allocate resources to poorer regions. Often in practice the reverse occurs, as a consequence of the fact that areas with better infrastructure (facilitating implementation) are least likely to be those with the highest proportions of the worst-off groups. In cases such as ICDS in the two Indian States reviewed here, in the early 1990s the estimated coverage was less than one in three preschool children (and the targeting does not make these the malnourished). Thus, however effective, well-planned and managed the programme might be, its impact necessarily is constrained by such limited and non-targeted coverage.
While programmes may begin with some degree of geographical targeting to worse-off areas, they often evolve to aim for universal coverage. This is the case for all five of the countries summarized in Table 5.2. Thus in Thailand and Indonesia most villages had programmes going by the late-1980s; the expansion in Tanzania was to nearly half the regions in the country, based more on feasibility than targeting by need; equally, in Zimbabwe the aim was to cover as much as possible of the country although, in the early stages, the worst-affected areas were targeted. In India, with such a vast area and population, the ICDS of necessity began with a limited geographical outreach, but again, the intention is to cover as much of the country as possible. This is a change in emphasis from the previous conclusion, derived from the earlier review of targeting methods (ACC/SCN, 1991, p. 11) where almost all the programmes were reckoned to be geographically targeted.
A further progression can be seen, for example, in Thailand from late-1980s to early 1990s, of then evolving again from wide coverage to focussing resources on worst off areas. This happened with the Basic Minimum Needs approach (Kachondham et al. 1992), which involved self-assessment at village level using a series of predetermined indicators, followed by decisions within the national development plan to classify villages into three categories, as backward or poor (around 10%), intermediate, or advanced, with consequent focussing of resources on the backward areas. The lesson probably is that as programmes mature and achieve nearly universal coverage, malnutrition is reduced, and a relative focussing of resources becomes appropriate. In other words, at some stage during the process, almost all areas develop programmes, and improving conditions and organization then allow some renewed targeting.
The process of targeting at the second stage, of selecting individuals based on likely risk, and then the malnourished within these, is an important possibility (see ACC/SCN, 1991, p.11). A key decision may be the degree to which eligibility for supplementary feeding is based on screening for malnourished individuals. This is often a political issue, e.g. in ICDS where within project areas there is blanket coverage of certain age groups, versus TINP where there is selection with respect to a child's nutritional status. It can be seen, however, that where the community itself is aware of child nutritional status (e.g. Tanzania) there is apparently some degree of local level decision-making with respect to targeting children. There is no doubt that as the resources are still very limited for nutrition, decisions on targeting are among the most crucial; although where the prevalence of malnutrition is particularly high in the region, there may be less of a rationale for targeting individual children.
Concerning the level of resources allocated per caput, there seems to be some convergence (see ACC/SCN 1991) on around $5-10 per head per year being a workable, common level of expenditure in nutrition programmes, though generally not including supplementary food costs. ICDS, TINP, Iringa and UPGK all cost between $8-11 per child per year. The CDS projects in Tanzania run at around $2-3 per year (Kavishe, 1993, p.157). These are ongoing or recurrent costs (which also relate to a programme's financial sustainability); other costs include those incurred in starting and expanding programmes. It is unclear how far this level is adequate - just that it seems in practice to be what is allocated in many instances. Equally, relating the expenditures to outcome indicators (e.g. underweight prevalence reduction) is hardly feasible. It can be broadly observed that effective programmes, with these levels of expenditure, seem to be associated with reducing underweight prevalences by around 1-2 percentage points per year.
Supplementary food, where used, roughly doubles (or more) the expenditure. The evidence available is inadequate on whether supplementary food itself is cost-effective. There is a danger of the supplementary feeding component overshadowing other important aspects of programmes that might aim to deal with important health or care-related causes of malnutrition. For example, the ICDS programme in India, despite being intended as an integrated health, pre-school education and nutrition programme, is often perceived as a food hand-out scheme only (see e.g. USAID 1994).
Given a certain level of per caput expenditure per programme, management issues become crucial. The impression is clear: again community involvement in programme management makes it more effective; and poor targeting and implementation is at least in part a matter of management in those programmes having less of an impact. In brief, other management issues include consideration of leadership, training and supervision. The need is not just for an appropriate mix of components, but for effectively administered components. As well as a sufficient period for initial training e.g. 2 months (TINP) or 3 months (ICDS), re-training at given intervals needs to be undertaken. Staff-to-client and supervision ratios need to be realistic. TINP had a worker-client ratio of around 1:200-300 families and supervision ratios of around 1:10. Process monitoring and evaluation is integral to effective implementation. Programme re-appraisal should be based on the results of the monitoring, with flexibility to modify where necessary. A lack of periodic evaluations may lead to the continuation of ineffective programmes and the wastage of scarce resources. A fuller discussion of programme design and management issues - including targeting, staff selection, training, supervision, monitoring and evaluation - for the nutrition programmes in India, Tanzania, Zimbabwe, Thailand and Indonesia, is detailed in ACC/SCN 1991 which is based on the 1989 ACC/SCN workshop at the XIV IUNS Congress in Seoul.
Finally, with regard to nutrition programmes, the policy issue is not primarily whether or not to have them - once above the minimal level most countries do - and the indications are that they are sustainable and worthwhile. The issue is more how to make the best use of the resources, through appropriate programme design, targeting, management, etc. With economic development, experience has shown that certain population groups in certain areas tend to lag behind or are marginalized - for example, in much of Latin America, Thailand, or Egypt - where appropriate area-targeting becomes increasingly important. In sub-Saharan Africa on the other hand, where there is less activity, we can distinguish three situations: firstly, where programmes are established, they need to be supported (e.g. Tanzania and Zimbabwe); secondly, in marginal situations where the infrastructure is becoming adequate, nurturing embryonic programmes will be important, avoiding early mistakes, through learning from success. Finally, there are countries where programmes have not yet been conceived. In many such situations, e.g. parts of Bangladesh and India (particularly remote tribal populations), the very first priority will be to ensure access to appropriate health care and adequate food, to provide a quick response to urgent problems. Following this, the potential for building an appropriate nutrition programme can be nurtured. Sustainability then will relate very much to ongoing availability of required resources (human, financial, organizational) from whatever level - community or more central - as well as the degree to which the programme becomes embedded as a part of life which is valued by local involved communities.
The value and success of direct nutrition interventions will, in sum, depend on factors such as their historical timing, their relevance to the extent, type and causes of malnutrition, the degree of community ownership of the programme, the infrastructure and management capacity for implementation, and the political will and resources to ensure sustainability.