How Nutrition Improvesand What That Implies for Policy Decisions

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Introduction and Overview

Nutritionists generally believe that we have moved toward a better understanding of how to improve nutrition in poor countries over the past several decades. This understanding is based on country experiences with nutrition programs that often included external assistance. The uncertainty about our models of how nutrition improves is due to the serious lack of evaluation data. Thus the conclusions here and elsewhere are constructed from scattered clues.

The key factor in improving young child nutrition is to ensure that parents and children have contact with people who can help with focused interventions, many aimed at behavioral change. Community-based programs—owned and run by communities, with help from outside—are the essential organizational feature for achieving

* John Mason is the author of this section.

such contact. The core interventions include antenatal care, safe delivery, breastfeeding support, growth monitoring and promotion, complementary feeding, micronutrient supplementation, immunization, deworming, and referral to primary health services. Since communities tend to set a broad range of development objectives, nutrition must find a way to fit with a multifaceted local approach. The support needs—ratios of staff to supervisors, and of participating children to staff, and resources spent per child—derived from existing programs can guide new program development. At the same time, micronutrient supplementation and fortification strategies require national and regional as well as local action.

The design and implementation of interventions depends on context—factors such as women's status and education, social exclusion, and political commitment. Programs can be assessed in terms of coverage, intensity (resources per head), targeting, and content. As seems likely, a minimum level of intensity must be reached before significant impact takes place (the response is not necessarily linear), so spreading resources too thinly can simply be a waste. Similarly, programs should be targeted to those who can best respond, not just to those in need. Finally, insufficient implementation capacity commonly explains lack of impact. To accelerate improved nutrition, we need to improve—and then act upon—a better understanding of implementation capacity.

How this thinking developed is discussed in the next section. Then, country and agency experience and context are briefly described. Finally, some lessons are suggested.

Chronology

Threads at different depths are entwined in the evolution of policies for improving nutrition. Changes in thinking and related milestones—globally and within countries—can map progress. This can be seen first at the global level.

Nutrition as a discipline has always been linked to issues of identity and scope. As expressed in the 1960s, factors affecting nutrition range "from ribosome to combine harvester." In the 1970s, nutri-

rion planning embraced a vast scope of central and local actions—in fact, subsuming most national government international agency activities to the objective of nutrition. The FAO, among others, promoted this approach. Others, including USAID and the World Bank, supported the use of systems analysis to describe complex causal pathways, leading eventually to more limited (but feasible) interventions. A number of conferences and country projects explored these methods, leading for example to the TINP in India (described in chapter 5) and national planning efforts in Sri Lanka. Responding in part to food crises, nutritional surveillance introduced epidemiological methods for tracing nutritional outcomes. These were linked to food availability and health status as basic factors contributing to poverty. A high-level expert committee representing the FAO, UNICEF, and the World Health Organization (WHO) in 1975, and a follow-up through WHO in 1984 consolidated these ideas and led to the United Nations, through the ACC/SCN beginning to report on world nutrition trends in 1987.

The scientific understanding of child malnutrition evolved from its early medical focus, looking at syndromes such as kwashiorkor and clinical micronutrient deficiencies, to a central concern for protein sufficiency. Although the protein gap was discredited in the late 1970s, the perception that protein remains the central problem persists in some circles. But the swing from protein went to the other extreme; calories were viewed as the only concern, with effective demand for food (any food, really) as the key factor. Thus nutrition as an objective of economic planning became a central feature of the development approach promoted by many international agencies.

The issue of scope has not been fully resolved in this policy debate among the international agencies; however, the focus has now swung back toward direct programs and diet quality, often with the emphasis on micronutrients, rather than protein. WHO support for primary health care (PHC), which gained momentum in the 1980s, involved many of the concepts for local action now considered important in community-level nutrition programs. Starting in the early 1990s with "Investing in Health," these PHC programs were eventually eclipsed by newer health initiatives emphasizing minimum essential clinical services, integrated management of childhood illness, and so forth.

In practice, many nutrition programs were established during the 1970s and 1980s, based on local initiative. These are the ones that are most frequently used as examples of success, as in chapter 5. Available evidence suggests that programs with decisionmaking genuinely at the local level have had sustainable positive effects (Mason 2002). Though varying from country to country, an initiating feature in most cases was a decision to change radically from past efforts judged to have failed. Evaluation revealed that service delivery programs driven by external concepts and top-down planning methods simply had not worked very well. This was explicidy seen in Thailand and Indonesia in the 1980s, in Costa Rica earlier, and perhaps less starkly in the other countries reviewed for this paper (see Mason 2002). However, the timing is important: improvement accelerated in most cases with explicit decisions to foster community programs through local structures, deliberately rejecting previous organizational methods (rather than the program content, which changes less).

The World Bank was a major external supporter of nutrition programs, committing relatively high levels of resources to a few countries. UNICEF supported lower-profile programs in many more countries, and in a WHO program jointly supported with Italy, the influential Iringa project in Tanzania in the early 1980s. Through the United Nations, the ACC/SCN brought together experiences in managing successful nutrition programs at the International Union of Nutrition Sciences (TUNS) congress in 1989. This was followed up in 1993 with a synthesis of national policies and programs, contributing to the prevailing paradigm on how nutrition improves.

UNICEF's important formulation in the early 1990s of a coherent nutrition strategy of carefully judged scope was widely promoted and accepted. This provided a common language and focus in which players from different disciplines could see their own place. The U.N. World Summit for Children, organized by UNICEF in 1990, was a milestone in setting nutritional goals, aiming for ambitious reductions in malnutrition using the UNICEF strategy. An international meeting, Ending Hidden Hunger, in 1991 strengthened the micronutrient programming dimension. Then, the ICN convened by the FAO and WHO in 1992, explicitly incorporated Food, Health, and Care; and both agencies endorsed the World Summit goals for malnutrition reduction. For the first time in such a context, priority was focused on micronutrient deficiency control programs. While mentioned, these themes were less evident at the FAO World Food Summit in 1996.

Together with UNICEF country programs, the 1992 ICN provided impetus for many countries to develop nutrition action plans during the mid- to late 1990s. These are the programs that we still see today. Another development can be mentioned: the idea that nutrition in society, at the population level, should be seen as a topic in its own right, in which many disciplines contribute and which is the responsibility of society as a whole and of the state. Thus public nutrition (having analogies with public health) as a concept was moved ahead in the late 1990s, through an IUNS workshop in 1997. At the same time during the 1990s, micronutrient control programs achieved a certain success: iodized salt was being used in more than 60 percent of developing country households by the end of the decade. About 30 percent of the children were receiving vitamin A capsules twice a year. For lack of data, the impact of these programs is not yet known, so this is an achievement yet to be fully appreciated.

Analysis

The general understanding of how nutrition improves, as laid out in the concept material that launched this assessment, is that equitable economic policy, proactive governmental investment in health, education, and welfare, allied with a judicious mix of direct nutrition-relevant programs at the community level, provide the optimal mix for nutritional improvement. The background paper (Mason 2002), which this summary draws upon, examined experiences in several countries with this in mind. It considers when, where, and why nutrition has significantly improved; it then explains these observations, including the role of international agencies. Particular attention is paid to community-based programs. This section summarizes the observations and suggested explanations that are elaborated in greater depth in the background paper (Mason 2002).

Thailand, Indonesia, Costa Rica, and Tanzania are examples of countries where malnutrition was reduced faster than would be explained by the effects of economic development alone. These countries all relied on community-based programs of wide coverage —national, in some cases—with little targeting beyond the effects of progressive geographic spread. These programs all emphasized child growth monitoring and high ratios of village workers per family. They built on indigenous structures; the momentum they achieved was largely from the inside.

Large-scale nutrition programs are essentially similar in operation to the community-based programs discussed above, though with greater influence by external agencies. Examples are the Integrated Child Development Services in India, the World Bank-supported TINP, the Bangladesh Integrated Nutrition program, the Nutrition Improvement Pilot Project in Indonesia, and the Iringa program in Tanzania. These tend to have a core set of activities— viewed as a "menu" in Thailand—that includes antenatal care, safe delivery, support for breastfeeding, growth monitoring, complementary feeding, micronutrient supplementation, immunization, and referral. Some include home gardens, water and sanitation, and income-generating activities. Though their scope is generally well defined, these programs are often part of broader community activities. The overall programs are multifaceted; nutrition represents a part and an objective but is not usually the sole driving force.

In other cases, often postconfiict situations, nutrition has been energetically addressed through mass mobilizations. Grassroots organizations are typically already providing health care, so they turn readily to community-based activities of the type described above. The energy and connectedness of societies are crucial con textual factors at certain points in time—especially after revolutionary upheavals, but also when more mundane factors come together: education, communication, improved governance.

Analysis of these experiences suggests a number of policy issues. The program context must be carefully considered. Some contexts can be made more favorable, such as improving the status of women, but these take time. Others cannot be changed at all, such as location or natural resource potential. If contextual factors can be improved, then priorities naturally suggest themselves. If not, program design and targeting may need to work around fixed constraints. Programs should be targeted to those who can respond, not just to those in need. By definition, sustainability happens over time. Malnutrition will be solved over decades, not years. This reality must be planned for, especially through investment in capacity building.

Programs can be assessed by their coverage, targeting, intensity (resources per head), and content. In many cases, countries strive for national coverage, but when resources are scarce, project quality suffers, because the intensity (resources invested per child) is too low for impact. As noted, the content of nutrition program is becoming clearer and well-established in a core of broadly accepted activities. It is the means of supporting these activities that represents the cutting edge of today's knowledge.

The pattern for improvement is generally consistent: rapid initial improvement, especially visible in the reduction of severe malnutrition, is followed by a slower but sustained reduction in prevalence of one to two percentage points per year in mild-moderate malnutrition (see Mason 2002). In projects, the temptation to set ambitious but unrealistic planning goals (for example, to reduce malnutrition by half in a few years), coupled with infrequent evaluations that compare objectives to achievement) ironically undervalues less dramatic but solid success of some projects (e.g. ICDS in some states in India).

External agencies have met with mixed success in supporting these efforts. In general, their influence has been positive when the programs were sustained for long enough to learn effective methods.

Investing in institutions and professional development, at the right time and appropriate levels, also paid off. Continuing to support ineffective programs, whether for political or other reasons, is not helpful. More rigorous evaluations will provide crucial information for decisionmaking on continued support for programs.

Lessons

The key to improving nutrition is involvement of those concerned, especially parents and children at risk. "Thinking up" from the individual is important for planning. In sustainable programs, a consistent pattern of change is seen; steady reduction in malnutrition continues after a rapid initial decline. This implies that the initial response, which liberates people's energies, needs consistent long-term support, including from outside sources.

Where programs have not spread nationally (for example, TINP), political rather than technical causes may be the explanation. Similarly, changes in government structures exert overarching influence—for example, the devolution of authority from central to municipal governments in the Philippines. Contextual factors such as these can be either synergistic or detrimental; but one way or another, they must be taken into account.

Community-based programs are usually not initiated for nutrition activities alone; communities normally have a broader range of priorities. This means that nutrition programs must be multifaceted and embedded in other health and community development activities. In many programs, community child weighing provides a practical focus. While the program design parameters—coverage, targeting, intensity, and content—are not adequately specified, this review suggests that in situations where malnutrition levels are high, aiming for national coverage, later becoming more targeted, is usually the preferred option. Intensity of investment should be roughly US$5 per child per year. For personnel, the ratios should be approximately 1 village volunteer for 20 families, or up to 100 families per fall-time worker, and 1 supervisor to 20 workers. With these ratios, reductions of one or two percentage points per year in the prevalence of underweight in preschool children can be expected (Mason 2002)

Given the technical complexity of such matters, a broader lesson is that nutritionists need to decide and agree upon certain factors. What conceptual framework do we follow? What level of finance is required, and what is available? What are the appropriate approaches to programming and policy dialogue? And how should these guidelines be adapted based on experience?

More of the same will not eliminate malnutrition. But more of some of the same will help: better implementation and sustained support for effective actions, solid and systematic evaluation, revamping ineffective programs, and above all for the external agencies, continuous support and building of local capacity.

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