"We Will Never Go Back" (UNICEF 1993) tells the story of nutrition and, more generally, community-based program development in the Iringa region of Tanzania during the 1980s; it tells how this effective programmatic approach expanded to other areas of the country, as the Child Survival and Development Programme (CSDP). Despite the achievements of the program and the buoyancy suggested by the tide, the monograph proved to be overly optimistic. During the 1990s in Tanzania, the CSDP and nutrition programs more generally were battered by economic decline, government and health sector reform, decentralization of authority to ill-equipped and poorly financed district authorities, and a high proportion of distressed communities that were no longer able to support village workers. Not surprisingly, the result has been a serious decline in the quantity and quality of nutrition-related services, stagnation or reversal of the earlier decrease in malnutrition, and the virtual disappearance of nutrition from the country's policy agenda.
This case study examines the derailing of nutrition during the 1990s. It briefly reviews the history of nutrition in Tanzania, nutritional trends, and the role of the World Bank and UNICEF in this history. It then presents the following three policy narratives: health sector reform and sector-wide approaches, the peripheralization and marginalization of the Tanzania Food and Nutrition Centre, and new beginnings. The idea is both to explore the precipitous decline of nutrition and to find signs of hope for the future.
* Carmel Dolan and James F. Levinson are the authors of this section.
The major actors in the history of nutrition in Tanzania are the Tanzania Food and Nutrition Centre (TFNC), the Swedish International Development Authority (SIDA), and UNICEF. The story roughly parallels developments and understandings of nutrition that were under way internationally. During the 1960s and early 1970s, malnutrition was associated primarily with the food cycle, tracing shortfalls in production through to its consumption consequences. By the 1980s, this conceptualization was largely swept aside as the country experienced a massive expansion of nutrition programming supported by a new framework for thinking about nutrition.
SIDA, the TFNC, and UNICEF formed an important partnership that pioneered what became UNICEF's conceptual framework and its Triple A approach to community-based problem solving. These understandings led in turn to the Joint Nutrition Support Programme in the Iringa region, a landmark project placing emphasis on social mobilization, local problem assessments and action plans, and tailor-made combinations of nutrition and food security at the community level. The dramatic success of the Iringa program in reducing the prevalence of severe malnutrition led to rapid expansion through the 1980s and early 90s to other areas of the country.
The CSDP and the nutrition and community consciousness that it engendered were surely partially responsible for the decline in childhood malnutrition. The prevalence of underweight declined from an estimated 50 percent in the 1970s and early 1980s (based, unfortunately, on a paucity of representative data) to roughly 30 percent by the early 1990s. In the 1990s, however, these levels reached a plateau, while infant and child mortality appeared to be increasing (along with declining use of maternal and child health services). Vitamin A, iron, and iodine deficiencies remain high despite considerable efforts.
SIDA and UNICEF were the primary donors supporting nutrition-related activity in the country during the 1980s and 1990s.
UNICEF support for the CSDP as well as for micronutrient activities went through a relative lull during the mid-1990s; however, UNICEF has now reemerged as the major supporter of nutrition and community-based services in the country.
The World Bank's initial intention was to support the expansion of the CSDP as part of a new health and nutrition project initiated in 1990. This intention was subsumed under a broader effort to support district health plans in consonance with the health sector reforms at the time. Responsibility for nutrition in these plans and for technical assistance to the districts was delegated to the TFNC, which received financing under the Bank project. Nutrition activities constituted 3 percent of the total project budget. Most nutrition activities were directed toward micronutrient control activities. A new health sector development program (discussed in narrative 1) included little mention of nutrition, as does the Bank-assisted Tanzania Social Action Fund.
Narrative 1: The Health Sector Development Program
The World Bank and partner organizations promoted health sector reform in many countries during the 1990s. In general, these reforms encouraged more rational (often decentralized) planning modes, implementation capacity , and facilities-based health service delivery. In Tanzania, health sector reform was formally initiated in 1997, but it had been an increasingly important phenomenon since the beginning of the decade, given that analysis revealed serious inefficiencies in the country's health service delivery. Although the national budget allocation to health is high compared with other countries at similar levels of economic development (World Bank 1999), its impact on fife expectancy, infant mortality, and total fertility have consistendy been lower than that of neighboring countries. Accordingly, health sector reform has been aimed toward improving resource management, upgrading service quality through capacity development, and shifting the planning and operations emphasis from inputs to outputs and impacts. While the problems addressed by health sector reform were indeed significant, they were not the only matters of concern. However, the reform process dominated the health discourse at the national and district levels so completely, that other issues, including nutrition and community-based services, were virtually ignored. By the late 1990s, they had largely disappeared from both health sector and development agendas.
Although briefly mentioned in health sector reform documents at the time, virtually no reference is made to nutrition or community-based services among performance indicators or activities. Health plans under development at the district level are similarly silent on these issues. Finally, while the Bank's health sector development program, which totaled US$619.5 million under the first three-year adaptable program loan, mentions nutrition and community services, it failed to include a nutrition indicator as one of its end-of-program outcome measures.
Can malnutrition be addressed in Tanzania solely through more or more effective district planning and facility-based delivery and without explicit attention to community-based services? International as well as Tanzania's own national experience suggests that reliable and efficient facility-based services are indeed necessary to sustain reductions in child and maternal malnutrition; however, other than in fairly well-off countries (for example, Chile), facility-based services alone are insufficient for reducing malnutrition. Sector reform that seeks to improve nutrition must be sufficiently broad-based to include community-based social mobilization and interventions.
Many voices could have been, but were not, raised in support of community-based services and nutrition in the health sector—the National Planning Commission (central to decisionmaking on the CSDP but stripped of its responsibility during the anti-central-planning reformist era), the TFNC (a pale, anachronistic shadow of its former self by the mid-1990s, see narrative 2), and the World Bank and its Danish bilateral health sector reform partners.
Because of senior personnel transfers in the early 1990s, UNICEF could not maintain its strong nutrition advocacy role during the critical transition period. At the time the case study was con-
ducted, UNICEF attempted to reinstate nutrition and community-based services. The resuscitation initiative, however, may have been hampered by an apparent "disconnect" between these efforts and those of the central actors in health sector reform (that is, the Bank, the bilateral Danish programs, and the ministry of health). Their focus was on the health system—and UNICEF and its priorities were on the outside.
In addition to disappearing from the national agenda, nutrition efforts in the country could be further harmed by cost sharing and user fees coming out of the health sector reform (primary education, water use charges, and health costs were estimated to represent around 35 percent of monthly total expenditures in low-income rural households). Information collected by the case study team suggested that these expenditures (generally made in poorly supplied facilities) were limiting the use of antenatal care, iron-folate tablet use, and facility-based deliveries with implications for maternal mortality. Revealingly, recent mortality data indicate that 80 percent of total death occurred at home; 60 percent of those who died made no effort to use the government health system at all (Ministry of Health, Tanzania 1997).
Community- and institution-based health services are complementary. Taking the long view of nutrition services in health sector reform, it makes little sense to marginalize the former while the latter is becoming increasingly expensive.
Narrative 2: The TFNC
During the 1970s and through the mid-1980s, the TFNC was a dominant presence. By the end of the 1990s, it was an anachronism, barely recognizable as an institution. At best, it played a minor role in reform debates; its operating budget covered only a small fraction of its needs, and the top-heavy staff spent nearly all of their time in the capital city.
Looking back at critical decision points in the mid- and late 1980s, senior staff lament their inability to continue at the core
(much less the cutting edge) of the country's nutritional and national development. In hindsight, the lost opportunities were significant. The national nutrition policy documents in review at the time potentially offered a blueprint for the kinds of essential services that the center might have provided. There was a rich array of program-driven training, operations research, and monitoring and evaluation needs. Much could have been contributed to the CSDP.
It is not clear that the center would, in fact, have chosen to carry out these support functions at the time. Could a top-heavy, research-oriented institution reorient itself to perform these functions effectively? It is clear that the choice was theirs only to a limited degree. With operating budgets financed entirely by donors, their programmatic direction was driven largely by the nutrition agendas of the donors.
In the mid-1980s and increasingly in the 1990s, the donors' nutrition agendas were dominated by a disproportionate emphasis on micronutrient nutrition. Accordingly, the bulk of assistance to the center during this period was related to micronutrients. By the early 1990s, the major operating departments were heavily involved in vitamin A, iodine, and iron deficiency activities.
While the micronutrient accomplishments should not be minimized, there were major costs to this reorientation. The most important may have been the perception that the center was a specialized organization whose narrow mandate was peripheral to the primary concerns of development.
Given the broad array of accompanying problems and the diminished relevance of top-down nutrition activity, it is uncertain whether a more holistic, program-driven orientation would have entirely prevented the institutional problems that the center now faces. However, had its activities been at the core of nutrition and development—as they were in the 1970s and early 1980s—its chances for survival would most certainly have been improved. As it happens, the TFNC may have yet one more chance to assume such a role. That opportunity is described in narrative 3.
Narrative 3: The Way Forward
With the problems described above still unresolved, how does Tanzania move ahead on nutrition? Rather than seek to resuscitate the CSDP as originally designed, UNICEF and its partners have given a fresh start to community-based nutrition activity. Entitled Early Childhood Care for Survival Growth and Development, the new program seeks to combine child survival and development approaches and a basic extended program of immunization, growth monitoring, health, nutrition counseling and HIV/AIDS attention with new approaches. The latter include activities addressing low birthweight prevention, psychosocial development, deworming and hygiene promotion, multi-micronutrient supplementation, and safe motherhood initiatives.
While challenges to this second-generation program are considerable—in fact, possibly insurmountable without a radical shift in the country's development dialogue—UNICEF to its credit has embraced two critically important underlying principles: reliability of information and capacity building. In an effort to avoid monitoring and management problems that have adversely affected child survival and development activities in recent years, the new program makes particular efforts to ensure information reliability through the intensified training of workers and supervisors and employment of independent quality checks on use of data. Similarly, in an environment in which capacity building has come to mean little more than cycles of workshops with per diem support, the new program will instead focus on workable systems for responsible, accountable service delivery. They will create necessary skills to make such systems function, as well as district-level capacity to employ "management by exception" processes in using and acting upon data from community activities.
The Bank-assisted Tanzania Social Action Fund, a vehicle to fund priorities identified by communities themselves, may offer the opportunity for the Bank to support the new UNICEF initiative by involving itself directly in grassroots initiatives. While nutrition is only peripherally mentioned in the documentation, it could become an important vehicle for financing the extended CSDP. A slightly reoriented Tanzania Social Action Fund indeed presents an ideal opportunity for the Bank and UNICEF to work together in addressing the needs of vulnerable and poor households during this important period of national transition.
The success of the new endeavor will depend on an array of factors, many beyond the capacity of UNICEF and its partners. A World Bank team genuinely attuned to the value of these initiatives and the consequences of abandoning community services would greatly strengthen these efforts. Nonetheless, as evidenced by the enthusiasms of the 1980s, success is contagious. Perhaps the best hope is that sustained, systematic, and well-managed efforts—in a discrete number of high-priority activities—will lead to services and impacts and, at the same time, provide a new model and impetus for the future.
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