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B. "Nutrition-Based Development Planning" Methodology
The methodology advanced by Leonard Joy and Philip Payne, in a report prepared under the sponsorship of the Food and Agriculture Organization, is probably the most fully elaborated nutrition-planning approach developed to date.5 The authors say that their approach is "fundamentally new,"6 requiring revised methods for setting food-intake targets as well as for identifying, designing, and appraising policies and programmes. The methodology, according to the authors, involves fully integrating nutrition concerns and objectives into development planning.
The methodology is a reaction to the food-supply planning approach to the improvement of nutrition, which is based on the assumption that if rates of growth in food production can be made to increase faster than population growth rates, the nutrition problem will be solved. Joy and Payne argue that malnutrition is not simply a problem of food availability, but is rather a function of poverty, of deprivation. Thus, while food supplies may need to be increased, the central thrust of food and nutrition planning must be the reduction of the causes of deprivation that lead to malnutrition; and nutrition planning becomes central to overall development planning "in the sense that a prime objective of planning needs to be the sustained reduction of malnutrition."7 Although planning should not be taken over by nutritionists, their role should be integrated into the overall development process.
As in the case of the "systems analysis" approaches to nutrition planning, the starting point of the Joy/Payne methodology is the definition and diagnosis of the nutrition problem. The diagnostic analysis should include, not just an identification of proximal causes and clinical symptoms of nutritional deprivation, but also a delineation of deeper, underlying levels of causality. The prescribed means for developing such a diagnosis is the preparation of a "functional classification," which includes "typical profile" case studies. Such a classification relates nutrient-deficiency patterns to spatial, ecological, socio-economic, and demographic characteristics of the nutritionally deficient population groups.
The functional classification is to be quantified through correlation of the various population characteristics. The presentation of the methodology contains considerable discussion of indicators of nutritional deprivation, exploring the relationships of conventional indices of nutritional status to non-nutrition indicators (even suggesting the construction of "iso-deprivation curves".
Next comes the search for means to solve the problems that have been diagnosed. The authors discuss in detail the establishment of goals, objectives, and targets. Here again, the emphasis is on explicit, disaggregated statements incorporating analysis of differing levels and kinds of deprivation (intensity of need) among the various population classes. They propose that measurements of effectiveness be capable of distinguishing and predicting changes in the pattern of "distribution of deprivation" (i.e., satisfaction of needs).
The methodology contends that "area level" planning is a better strategy than the sector-by-sector approach usually employed. The authors suggest that such a reorientation in planning procedures and organization will facilitate the kind of coordinated, integrated "overview" planning required to reduce deprivation and malnutrition. The authors note, however, that ". . . unhappily, experience with area level planning has not been encouraging."8 They also acknowledge that this reorientation requires ". . . some redistribution of political and administrative power from the centre to the periphery and from ministries to area planning bodies, which may not be readily accepted."9 Finally, the methodology prescribes aggregating the area and sector plans into national plans.
The methodological presentation then turns to the task of explaining techniques for identifying, designing, and selecting interventions. The recommendation is that a checklist of questions be asked of each potential intervention. Problems inherent in trying to employ the technique of social cost-benefit analysis are also discussed as a means of developing interventions.
Joy and Payne, too, discuss systems analysis. They argue that ". . . a systems approach is inevitable,")10 that quantification and testing of the interrelationships would be desirable, but that generating a formal quantifiable system ". . . would require a considerable effort of analysis.''11The authors assert that it would be necessary to model many interacting variables before the dynamics and trends in malnutrition could be simulated or predicted. They maintain, however, that if the system could be validly simplified, and if the opportunity costs of the scarce resources required were kept low (through, for example, foreign-donated assistance), modelling could contribute significantly to our understanding of problems of nutrition, if not their solutions. (Attempts to use formal mathematical models for nutrition-planning purposes will be described shortly.)
Finally, the presentation recommends that a "nutrition planning unit" be established in the central government. The role of the unit, the kinds of skills required in its personnel, and aspects of its operation are discussed. The authors suggest that it be located in, or directly under, the office of the government's chief executive. They propose that it focus its initial efforts on diagnosing the nutrition problem.
Without question, the Joy/Payne methodology has contributed substantially to the advancement of theoretical knowledge in nutrition planning. The methodology clearly puts a premium on conceptual elegance and completeness. It explicity addresses several questions left open by other methodologies. For example, it provides a conceptual basis for setting goals, and for integrating nutrition planning into overall development planning. Most methodological presentations simply assert that, once the problems have been described, nutrition objectives should be set. Although criteria are proffered for judging the degree to which a goal or objective is well stated (i.e., the extent to which it is specific and time-sequenced and costs are described), and parables are presented to illustrate the fact that the setting of goals is also a political process, little or nothing is usually said about how the planner gets from the definition of the problem to the statement of the goal.
The Joy/Payne methodology points out that the objectives and goals do not spring self-evidently from most descriptions of the problem. Instead, analysis of the priority of the needs and potential improvements, as well as the availability of suitable solutions, must be conducted. Similarly, many nutrition planners talk about integrating nutrition concerns into the overall development-planning process. In a sense, the sum total of their writings represents an attempt to explain the need for such integration, and, to some extent at least, the means of achieving it, for example, by setting up an inter-ministerial committee or by placing nutritionists in the central planning agency. The Joy/Payne methodology goes further and suggests a specific procedural approach - area planning-for integrating consideration of nutrition into overall planning. In many ways, the Joy/Payne methodology essentially follows the key propositions of the "systems analysis" approach to their logical extremes, thereby producing a more conceptually complex, though fundamentally similar, methodology.
However, the Joy/Payne methodology leaves some major questions unanswered. One group of such questions has to do with implementation, programme management, and policy control. The flow chart depicting the food and nutrition system (Fig. 2) contains a block labelled "implementation," but the text does not elaborate on it except to say that "plan implementation is weak for reasons additional to that of poor design," that "monitoring procedures, by which a process of adaptive control of projects is guided, are of critical importance," but that "it does not seem appropriate to elaborate here on so detailed and pragmatic a subject and one which has received reasonable attention in the planning literature.'' Nor does the presentation devote much attention to the problem of aggregating area plans into a national plan.
C. Policy Formulation
The Interagency Regional Programme for the Promotion of National Food and Nutrition Policies (PIA/PNAN) has been working in nutrition planning in Latin America and the Caribbean since 1971.13 The agencies associated with the project are FAO, PAHO/WHO, UNESCO, CEPAL, and UNICEF, with the latter providing most of the funding. An Interdisciplinary Technical Team, headed by Dr. Javier Toro, was constituted and gradually staffed. The region's governments were encouraged to form National Technical Groups to carry out the project at the country level.
FIG. 2. Schematic Flow Chart of Food and Nutrition-Planning Process
The goal of the project is to promote formulation of national food and nutrition policies for inclusion in development plans and translation into specific programmes and projects. Operationally, the project aims at: stimulating awareness of the existing food and nutrition problems and of the need to plan for their alleviation; advising on problem diagnosis, policy definition, and programme area determination; and consulting on the incorporation of nutrition objectives, policies, and programmes into national and sectoral plans. It also offers assistance on the establishment of an institutional system to manage the resulting food and nutrition policies; on the elaboration of specific projects, their follow-up, appraisal, and subsequent reformulation; the financing, on a reimbursable basis, of nutrition policy and plan activities; and the provision of training.
Like the other methodologies already discussed, the conceptual framework of the PIA/PNAN approach emphasizes a logical sequence of steps for solving nutrition problems and speaks of a "systems analysis" approach. An analysis of real and nutritionally desirable demand for food and the supply of it (in its production and marketing aspects), as well as the biological uses of nutrients, leads to an identification of priority areas of concern and the key linkages requiring further examination. The factors to be investigated are: income level and distribution; population profiles and trends; cultural characteristics; the specific structure of diets in terms of major nutrients; agricultural production; marketing; prevention and control of communicable diseases; environmental sanitation and hygiene; and education in nutrition. After the awareness of nutrition concerns is raised to the required level and the problems are diagnosed, the process of developing policies, programmes, and projects for inclusion in the plans is begun.
A methodological guide has been published and is currently being revised. The new version of the guide appears to take a less doctrinaire, more eclectic, stance on the issue of the best methods for planning improvements in nutritional status. While continuing to advocate the application of systematic planning concepts to the solution of nutrition problems, it talks of explaining the advantages of various approaches and the cases and circumstances in which they are appropriate. The guide also proposes to foster an understanding of the limitation and implication of planning in the field of nutrition. It is intended to include an examination of theories, methodologies, and experience in Latin America using a critical analytical approach. In regard to diagnosis, for example, the guide will include a discussion of alternative limits, including political ones, on the ability of the planner to carry out a rigorous analysis of the problems and their various kinds of diagnoses.
The project appears to have taken a flexible approach in practice to the organization of efforts to develop food and nutrition policies. For example, the role of nutrition policies and programmes has varied. In some cases, they are officially included in the food and nutrition components of national development plans (as in Paraguay, Bolivia, and Colombia); in others, they constitute a social development strategy within the overall development model. Presumably, the revised guide will clarify the means by which the planner decides which approach to adopt in a particular situation, as well as the expected implications of the decision.
Of all the nutrition-planning approaches available, the PIA/PNAN methodology has been most often applied in actual practice. A distinguishing feature of this methodology is the stress it has placed on promoting awareness of nutrition planning among decision-makers. It has also concentrated on policy analysis and formulation to a much greater degree than have most other methodologies. In this aspect, it bears greater resemblance to the Joy/Payne z approach than to that of the "systems analysis" school.
D. Community Nutrition Methodology
The methodologies discussed so far are, in essence, schemes to be used by government planners in planning nutrition improvement for the population. They represent "top down" planning and programming. The implicit assumption is that a community's nutritional needs, and the best means of satisfying them, can be determined better by an outsider than by the members of the community. Thus the planner in the central, regional, or local government makes an objective assessment of the population's nutrition problems and their potential solutions without the beneficiaries' participation being required. A few nutrition-planning conceptualizers and practitioners have, however, begun to emphasize the need for community participation in the planning and implementation of nutrition programmes.'4
It is not clear whether this "bottom-up" approach represents a truly distinct methodology or simply a difference in focus. In practice, it involves the application of a systematic approach to nutrition planning at the community level. Mothers are encouraged to keep weight charts for their children. Cooperative groups are formed to discuss the community's nutrition problems and community efforts at solving them. Community members themselves become the village or neighbourhood extension workers. The community residents, relying heavily on their own resources, are expected to set up their own child-care centres, produce their own weaning foods, and even redistribute their own resources (as is reportedly being done in one area of Indonesia).
In most cases, the community plans that emerge from this local self-help approach are seen as part of a national planning programme, with the national plan purportedly being built up from the local and regional plans. Thus, the community nutrition-planning approach could be interpreted as a complement to nutrition planning at higher levels of administration. Almost certainly, any national plan that contained projects designed to reach local communities would have to rely on at least the acquiescence of the community in the implementation of the project.
II. COUNTRY APPLICATIONS
In the following section, a brief review is offered of some of the ways in which the methodologies described have been applied in selected countries. The intent is to highlight the practical implications of the methodologies - how they operate and differ in practice. No attempt is made to evaluate the performance of the methodologies, because no first-hand information from discussions or field observation is available.
A. "Systems Analysis" Methodology in Practice
Perhaps the earliest attempted application of the "systems analysis" methodology was in the southern state of Tamil Nadu in India. That experience is described in the Nutrition Factor and further reviewed by Burkhalter.15 The main lesson emerging from the Tamil Nadu experience was that nutrition - planning attempts in the context of developing countries should not be overly ambitious. Hundreds of person-hours of contractor, AID personnel, and Indian Government servant time, plus several years, went into the initial step of diagnosing the problems in Tamil Nadu. By the time that task was completed, the project had apparently run out of momentum, and little further progress was made toward solving the problem.
Another country where the "systems analysis" approach is being tried is Brazil. The World Bank is helping to finance a multi-year project designed to develop a comprehensive food and nutrition policy and programme. The project consists of: (1 ) the development of a nutrition-planning information base generated by a national nutrition survey, a surveillance system, and sustained research and agricultural policy analysis; (2) testing of the effectiveness of alternative agricultural delivery systems to improve the status of the target groups; (3) the development and commercialization of nutritious foods for the target group; (4) training; and (5) support for the National Food and Nutrition Institute.
Particularly noteworthy is the fact that diagnosis does not play such an upstaging role in the project, at least in its design, and that experimentation with intervention projects, in the form of alternative delivery-system tests, is emphasized. Although presumably the front-end research and analysis is intended to be comprehensive, the action oriented activities are focused on specific interventions and the problems of the nutritionally vulnerable groups. Rather than operating on the assumption that a thoroughgoing analysis of nutrition problems and their causes must be completed before work on the selection of interventions can begin, the project proceeds concurrently with the testing of a pre-established set of priority intervention possibilities.
The project is implemented by a special set of institutional arrangements. it calls for a strengthening of the National Food and Nutrition Institute in Brazil and the establishment within it of a Planning Unit. It also specifies that contracts between the Institute and other agencies officially involved in nutrition are to be executed. Moreover, the technical assistance component of the project encompasses a full-time project management adviser and six years of short-term consultancy manpower.
In a few countries several agencies work more or less concurrently, although not necessarily collaboratively, in the field of nutrition. One such country is Brazil, where the PIA/PNAN group has been active. Another example is Colombia. An experiment in applying a community oriented approach to nutrition planning and programming was mounted in Call, Colombia, and the application of the PIA/PNAN methodology was undertaken by the national government. More wilt be said about these experiences shortly. For the past several years, AID and other donor agencies have been working with the government to foster a concerted, systematic approach to the analysis and solution of nutrition problems and to the development of multi-sectoral nutrition interventions. The most recent development is the promulgation of a national nutrition plan, with the assistance of a World Bank loan to help further develop and implement it. This four-year project, to be launched in 22 departamentos and Bogota, envisages, at the community level:
1. the incorporation of nutrition delivery interventions into the health system;
2. the installation of potable water supply facilities;
3. the increased production and consumption of home grown nutritious foods through a family garden programme. At the national level, the project includes:
1. applied food technology and quality control;
2. intensive testing of the regional nutrition delivery system and nutritional surveillance;
3. programme co-ordination and administration.
The project is to be implemented within the existing, relatively elaborate, government organizational structure. Various agencies, including the National Food and Nutrition Plan group of the Department of National Planning, the Health Ministry, the National Institute of Health, the Colombian Institute of Family Welfare, and the Institute of Technological Research, are to be involved. The project calls for the co-ordination of its activities with efforts supported by other donor agencies, including AID and three UN agencies, as well as the government of the Netherlands. (It is interesting to note, however, that there appears to be no formal link between the World Bank project and PIA/PNAN activities.) The project contains a technical assistance component, which provides for four person-years of foreign consultant services and ten person-years of training fellowships.
As in the case of the Brazil project, the design of the Colombian effort puts a premium on action-oriented activities. Less attention is paid to diagnostic work, and the interventions seem to have been pre-selected for the project. Although much of the experimentation with programmes and projects contains an operationally oriented research element, the emphasis is on developing practical solutions rather than continuing to study the problems and their causes in all their nuances. The scope of the project has been limited, and the emphasis placed on a selected set of interventions. A similar World Bank project is now being launched in Indonesia.
The Philippines is another country where several approaches to planning nutritional betterment are being applied. In 1971 a National Food and Agricultural Council was created, by executive order, to oversee food production, supplementary feeding, nutrition education, nutrition training, and the Malward programme. The Council elaborated a four-year Philippine Food and Nutrition Programme, which called for the formation of provincial, municipal, and barrio nutrition committees. Real impetus was given to the nutrition effort in the Philippines when the President issued a decree establishing the National Nutrition Council (NNC), charged with the development of an integrated national nutrition programme. At the same time, the First Lady created the Nutrition Centre of the Philippines as the private counterpart of the NNC.
One of the first undertakings of the NNC was the establishment of an institutional infra-structure for carrying out nutrition planning and programming activities at various levels of administration. After the task of setting up the committees at the various levels all the way down to the barangays was completed, the NNC initiated a series of training programmes for the committee members.
The third major thrust of the NNC was to locate the malnourished at the community level through a massive child-weighing campaign known as "Operation Timbang." This operation may be viewed as the first step in an essentially pragmatic approach toward diagnosing the nutrition problem. After the results of the weighing were further analyzed in order to identify regional and other potentially causal correlations, a package of nutrition interventions was designed. The resulting Philippine Nutrition Programme consists of food assistance, nutrition information and education, food production, health protection, and family planning. The interventions are implemented through the municipalities and the barangay networks, which link the agencies providing nutrition services with individual families having low weight-for-age children, who are the programmers targets, and with school teachers serving as co-ordinators of the purok (zone) leaders.
This part of the Philippines nutrition improvement effort clearly concentrates on action and operationally oriented activity, rather than on fundamental research for detailed problem specification. It also focuses on the problems of malnutrition among the most seriously affected population groups, instead of dealing with the whole gamut of nutritional deprivation problems. Although foreign agencies, such as Al D and FAO, and the government of the Netherlands have been involved, the undertaking has been primarily an indigenous effort. Like most of the nutrition planning attempts to date, however, it is probably too early to assess the lasting effectiveness of this effort.
B. Nutrition-Based Development-Planning Methodology in Practice
The Philippines has also begun to apply a nutrition-planning approach similar to that represented by the Joy/Payne methodology. That attempt is discussed in some detail in a paper, "Case Studies in Nutrition Planning Support," prepared for the meeting of the Ad Hoc Committee on Food and Nutrition Policies (FAO) held 6-10 March 1978 in Rome. Only a few key points will be discussed here. With FAO assistance, the National Nutrition Council of the Philippines undertook a macro-economic analysis of the nutrition situation in order to integrate nutrition into development programmes. The macroeconomic analysis began by studying the extent to which projected income growth would lead to improved food consumption for the undernourished segment of the population. The findings were that the bottom third of the income groups would not achieve a substantial improvement in food intake over the next five years as a result of income growth alone.
For purposes of developing specific nutrition objectives and measures for integration into the overall development programme, a diagnosis like that envisaged in the Joy/Payne methodology was undertaken on a pilot basis, and a functional classification was started for one area of the country. A causality analysis was also begun. The paper reports that ". . . unfortunately, the sample sizes were too small for regular use, but data from one province gave helpful indications." It would appear that, if the aim of instituting nutrition-based development planning is to be achieved, the data base will have to be improved substantially.
An attempt to apply the Joy/Payne methodology is under way in Sri Lanka with support from FAO. A nutrition planning unit has been established at the national government level, with the assistance of UNICEF. The main assignment of the unit is to develop a diagnosis of the country's nutrition problems and their causes, using available data in "functional classification" form. A second activity is the review of the draft development plan to determine the extent to which its proposed policies and programmes are likely to benefit the target groups classified functionally. Only after this work and the task of formulating nutrition objectives, identification and selection of relevant measures, and analysis of probable trends have been completed, is the unit expected to begin identifying, designing, and appraising potential interventions. The Government has reportedly determined that the unit is not to engage in any implementation, even the testing of promising interventions. Although no resident adviser is called for, the technical-assistance component is to include training support and consultancy services, for it is felt that the unit's skills in analysis and, particularly, programme development and operation, need to be strengthened before they begin attempting action-oriented work.
C. Policy Formulation Methodology in Practice
The PIA/PNAN methodology has been applied, to varying degrees, in several Latin American and Caribbean nations. The "Report of the Group on the External Evaluation of the Inter-Agency Project for the Promotion of National Food and Nutrition Policies," an internal United Nations document, describes the experiences in nine countries. In Bolivia, a diagnosis of the food and nutrition problem has been undertaken, and a first formulation of policies begun. The set of policies was revised in 1976 as part of the preparation for the general development plan. A national technical group has been formed and is working on the formulation of specific programmes and projects. (It is interesting to note, incidentally, that US/AID has been at work simultaneously in Bolivia applying a systematic nutrition-planning approach primarily to sector activities.)
The project in Ecuador helped bring about a "very complete diagnosis" and an outline of policies for a national food and nutrition programme. The work of diagnosing the nutrition problem is still going on in Haiti. For this purpose, a series of sample surveys and studies are being conducted on a zonal basis.
In Paraguay, PIA/PNAN has assisted in the preparation of a National Food and Nutrition Plan that diagnoses the situation comprehensively, defines policies, and "points out" activities for short- and long-term implementation. The creation of a Food Ministry in 1974 was one result of collaboration by PIA/PNAN in Peru, with a more recent development being an initial survey of the needs and prospects for food production in the Department of Puno. A national technical unit was created in the Dominican Republic's National Planning Council in 1976. The unit, with the assistance of PIA/PNAN, is now nearing completion of a diagnostic study of the food and nutrition situation in the country, a revision of the table of recommended dietary allowances applicable to local conditions, and the development of "nutrition guidelines" for agricultural development. As already mentioned, PIA/PNAN has also collaborated in similar fashion with the governments of Brazil and Colombia.
As these country applications clearly indicate, the emphasis of the PIA/PNAN methodology is on overall nutrition strategy and policy analysis. An interim outcome of the effort is a national nutrition plan. Although the development, implementation, and evaluation of specific intervention projects are theoretically integral parts of the process embodied in the PIA/PNAN methodology, the experience to date suggests that work on these activities is secondary, in the sense of both time sequence and priority, to the business of plan and policy formulation. Reportedly, however, PIA/PNAN has recently begun to give increased attention to "application projects."
D. Community Nutrition Methodology in Practice
Perhaps the best example of the application of the community development approach to nutrition planning and programming is represented by the Philippine effort. Each municipality or city was required to prepare a one-year and a five-year nutrition-action plan by the end of 1977. The plans were to be formulated by the municipal or city nutrition committees. The community planning process involves scheduling the local nutrition-improvement programmes, assigning personnel to them in the barangays, and assessing the other resources required for their implementation. The process of aggregating the local plans is intended to concentrate field personnel and other resources in the barangays having the most malnutrition.
Although documentation of the experiences is scarce, a community nutrition-planning approach has been tried in a few other countries. The Candelaria project in Colombia represents one such effort. A new national health plan, based on the Colombia experience, was initiated in 1976. It centred upon the design of a regionalized health care system that would operate at three levels. Within the community, the key person is the health worker (promotora), selected locally by her community. The second level consists of community health posts staffed by two auxiliary nurses (auxiliares), who supervise a team of four to six health workers. The hospitals constitute the third tier. A Division of Community Participation has been established at the Ministry of Health to develop policy and methodology for enrolling the community in the diagnosis and solution of their own health problems. The regionalized health care system is to serve as the outlet for services such as food stamps, safe water supply installations, and nutrition education. The community health workers will also be used to monitor and evaluate the programme.
III . COMPARATIVE ANALYSIS OF SIMILARITIES AND DIFFERENCES
This review of the concepts and practices of various nutrition-planning approaches indicates that there are a number of similarities among the available methodologies. They all fall within the "rationalist" school of planning, to use Burkhalter's terminology.)16 They are all based on the assumption that nutrition should be dealt with as a development problem, rather than as a disease or a problem of food shortage. They recommend that careful analysis go into determining the dynamics of the problem in order to increase the probability that the set of solutions chosen will be effective and efficient. There is a shared recognition of the fact that the causes of malnutrition, and thus its solutions, do not all lie in one sector of activity; and there is consensus on the point that the talent and other resources of a combination of disciplines must be brought to bear on efforts to alleviate nutrition problems.
The comparative analysis also leads to the conclusion, however, that there are several ways in which the methodologies differ, at least in emphasis or degree. Some of the disagreements among the approaches are theoretical, but the major differences are those that emerge in practice-in the application of the methodologies.
Several of the differences have been pointed out in the description of the methodologies or the review of their applications. These differences will now be discussed, along with a few additional important ones.
One major way in which the methodologies differ is in the degree of emphasis they place on the various parts of the planning process. As we have seen, the theoretical framework of the "systems analysis" methodology focuses on the first steps in the process, whereas the application of that methodology tends to pay at least equal attention to implementation activities such as intervention testing. While in theory the Joy/Payne and PIA/PNAN methodologies advocate a comprehensive problem-solving approach, in practice they have focused on problem definition and analysis. The primary stress of the community nutrition methodology has, almost by definition, been on applied problem-solving.
A related difference is the extent to which the several methodologies attach importance to logical and conceptual elegance and completeness versus pragmatism. The Joy/Payne approach is by far the most detailed and complex of the group. The PIA/PNAN methodology, in the form proposed for its new methodological guide, aims for another kinds of completeness. It proposes to offer the practitioner of nutrition planning a range of methods to choose among. The "systems" methodologies, particularly in the more recent applied versions, tend to focus on the practicalities of the process, and that is what the community nutrition methodology is primarily concerned with.
Another difference relates to the methodology's definition of target groups. The review has shown that the "systems" methodology focuses on the nutritionally vulnerable groups of the population, particularly in practice. The community nutrition methodology has a similar focus. The other two methodologies tend to take a broader approach, although they ultimately deal with problems of vulnerable groups in their projects. (The issue of "top-down" versus "bottom up" planning has already been discussed.)
Several important issues emerge from this comparison. The first concerns the extent to which developing country governments are willing to wait for the results of nutrition planning. Some methodologies, as this comparative review has highlighted, entail devoting considerable time and effort to research and analysis before any even preliminary work on the development of interventions, of either a policy or project nature, is initiated. This author's experience in nutrition planning in Pakistan indicates that not all countries will be willing to wait for a comprehensive diagnosis to be completed before beginning to treat the malady. There was a sharp difference of opinion within the Government of Pakistan and among donor-agency representatives over the question of how much front-end research versus action was appropriate for nutrition planning. Some quarters became increasingly impatient with the disproportionate (in their view) amount of time being devoted to such diagnostic activities as the national nutrition survey and the problem analysis work that went into the preparation of the Development Plan's nutrition chapters.
A second, related concern has to do with the degree of sophistication and complexity a developing country is willing and able to have in its nutrition-planning process. All of the approaches require considerable extra effort, with the Joy/Payne methodology being the most demanding of the lot. The data, time, talent, and other resources required to implement anything like a complete version of it are probably outside the range of what most developing countries can now afford, as the Philippines experience is apparently showing.
In their defence, the proponents of the various schools of thought on nutrition planning, and particularly Joy and Payne, are careful to point out in several places that they are presenting an idealized approach that can be scaled down to suit local conditions. However, none of the methodologies prescribes how this scaling-down is to be done. Nor do any of the authors describe the anticipated tradeoffs between completeness and effectiveness. The nutrition planner trying to apply a particular methodology is given little guidance on what diminution in results to expect from a scaled-down version. If, for example, only half of the methodology can be applied in a given set of circumstances, would the effectiveness be reduced by 50 per cent? Or is the relationship other than linear? Which half of the methodology should be adopted? Would not the Parts of the methodology chosen make a major, nonlinear difference in the magnitude of the results to be expected in practice?
It may also be argued that, where governments of developing countries are starting to adopt a "basic needs" approach to development planning, a complicated nutrition-planning methodology such as that advocated by Joy and Payne may be more feasible. The argument contends that, " . . . in these conditions, the resources needed to apply it (data, time, talent, etc.) are no longer out of scope because they are an integral part of inputs required anyway for satisfying other basic needs.''17 If this author's experience in Pakistan is any indication, however, it will be years before many developing countries are in a position to undertake anything like regionalized, basic-needs planning. The Pakistan Planning Commission, which, to its credit, has been trying to do consumption and nutrition planning since the early 1970s, does very little formal (in the technical sense) planning of any kind and does not have a computer of its own. No household income and expenditure survey (which is the only direct national source on the size distribution of income) has been conducted since 1972, and the Government has only quite recently begun to establish local community organizations.
A final question relates to the level of political, institution al, popular, and other commitment required to implement a particular methodology. The PIA/PNAN approach, with its emphasis on policy formulation, brings in the decision-makers and politicians at an early, perhaps premature, stage. In a related way, the Joy/Payne methodology, to the extent that it advocates nutrition-based development planning, could represent an unacceptable threat to other kinds of planners. The question is whether the initiation of a high-level debate over such controversial, politically sensitive issues as the direction and equity implications of the country's food, nutrition, and welfare policies is the most prudent and potentially fruitful first step in the institutionalization of nutrition planning. Might a lower profile, more incremental approach to the formulation of nutrition plans be less likely to foster opposition capable of nipping the nutrition-planning effort in the bud?
It appears that a number of nutrition planners are beginning to think so. Disenchantment with holistic approaches to nutrition planning seems to be increasing.18 Some writers are now arguing that nutrition planning has promised much more than it could ever deliver, and that what is needed, instead, is a less all-encompassing, more instrumentalist approach." 19 The first step in such a new approach would not be the formulation of a national nutrition plan or set of policies, but rather the review of existing or proposed policies and programmes to determine their probable consequences on nutrition, and ways in which they might be altered to have more nutritionally beneficial impacts. In this approach, the nutrition planner would become an advocate for nutrition, a sort of consumption and nutrition ombudsman.
One might ask why the advocates of holistic nutrition - planning approaches tend to push for policy formulation as the first step in the process. Or to put the question in a slightly different way: How important is the initial policy consensus to the all-encompassing nutrition-planning methodologies? In finding the answer, we might look at the logic underlying the development of such methodologies: A systematic approach is to be taken to nutrition planning. This implies that co-ordination among various sectoral agencies is required. In fact, the whole development planning effort is to be based heavily, if not primarily, on nutrition concerns. If nutrition planners are to have the as kind of clout required to carry out such an effort, a firm, public, top-level commitment is essential from the outset.
Critics of the holistic approaches would raise several objections to this reasoning. First, they would argue that no planning process is ever as systematic as desired, even in the industrialized countries. Second, the policy pronouncement may turn out to be merely a smokescreen or palliative: the government might content itself with rhetoric rather than action.
Again, this writer's experience in Pakistan may be relevant and instructive. We in the Planning Commission's Nutrition Cell tried to do a systematic assessment of the country's nutrition problems, but our approach to developing interventions, either of a policy or programme nature, was basically opportunistic. At the same time that we were trying to marshal support for our highest plan priorities, we were also seizing any intervention opportunities that arose, so long as they were not counter to our objectives. To have done otherwise would almost certainly have meant that the office would have been abolished or prevented from doing anything. On the issue of policy pronouncements as palliatives, we found that it was usually much easier to announce a policy than to implement an effective intervention.
The nutrition-planning community seems to be moving toward the consensus that the initial methodological preaches generally promised more than they could realistically hope to deliver. Perhaps the time has come for much nutrition planners to retrench and adopt a less all-encompassing, more pragmatic strategy. Many nutrition programmes have been introduced where no overt nutrition planning was being done, and that could continue to be the case. If the basic-needs approach to development begins to succeed, nutrition planners may well be asked to play a major role in the development process. Meanwhile, nutrition planners can be quietly reviewing the nutrition implications of plans and activities in other sectors, and diplomatically advocating incremental, nutritionally beneficial modifications in them. They can also develop worthwhile interventions that fit into the overall development framework, thereby equipping themselves with the experience, knowledge, and techniques to use when more explicitly equity-based plans are to be developed and, most importantly, implemented.
1. Alan Berg, The Nutrition Factor, The Brookings Institution, Washington, D.C. 1973. This is "must" reading on any list of works on nutrition planning.
2. See "Planning National Nutrition Programs: A Suggested Approach," Office of Nutrition, Bureau of Technical Assistance, Agency for International Development, Jan. 1973.
4. In Nutrition, National Development and Planning, edited by Alan Berg, Nevin Scrimshaw, and David T. Call, MIT Press, Cambridge. Mass., USA, 1973.
5. "Food and Nutrition Planning," FAO, Nutrition Consultants Reports Series No. 35, Rome, 1975 (ESN: CRS/75/351.
6. Ibid., p. 2.
7. Ibid., P. 4.
8. Ibid., p. 37.
9. Ibid., p. 43.
10. Ibid., p. 65.
11. Ibid., p. 65
12. Ibid., p. 41.
13. A summary of the PIA/PNAN approach and experience with it to date may be found in "Project Extension Proposed for the Americas Region Interagency Project for the Promotion of National Food and Nutrition Policies," 9 Feb. 1978, one of the United Nations Working Papers, United Nations, N.Y.
14. The literature on the "community nutrition" methodology is sparse. For one statement, see Dean Wilson, "Notes on Community Approaches to Food and Nutrition Policy Analysis," Community Systems Foundation, Ann Arbor, Mich. ,USA (mimeograph)
15. Berg, op. cit.; and Barton R. Burkhalter, "A Critical Review of Nutrition Planning Models and Experience," Community Systems Foundation, Ann Arbor, Mich., USA, Dec. 1974.
16. Burkhalter, op.cit.
17. Personal communication to the author from Dr. P. Lunven of FAO, Rome, in a letter dated 16 June 1978.
18. See Donald S. McLaren, "Nutrition Planning: The Poverty of Holism," Nature, Vol. 267, No. 5614, 30 June 1977.
19 See James M. Pines, "Review and Advocacy: First Steps in Nutrition Planning," Document 1.1 7/13, 22nd PAG Meeting, Rome, 24-27 June 1974; "The Impact of Nutrition Goals on Agriculture," by the same author, in Food and Nutrition, Vol. 2, No. 1, 1976; and John Osgood Field, "The Soft Underbelly of Applied Knowledge: Conceptual and Operational Problems in Nutrition Planning," Food Policy, Aug.1977.
PARTIAL LIST OF DOCUMENTS REVIEWED
Nutrition, National Development and Planning, edited by Alan Berg, Nevin S. Scrimshaw, and David T. Call. MIT Press, Cambridge, Mass. USA, 1973 "Food and Nutrition Planning," FAO, Nutrition Consultants Reports Series No. 35, Rome, 1975 (ESN: CRS/75/35).
Alan Berg. The Nutrition Factor, The Brookings Institution, Washington, D.C., 1973.
Dov Chernichovsky. "Household Economics and Impact Measurement of Nutrition and Health Related Programs." Paper prepared for the Conference on the Measurement of the Impact of Nutrition and Related Health Programs in Laten America, 1-4 Aug 1977, Panama City, Panama. Population and Human Resources Division, Development Economics Department, World Bank.
"Interagency Workshop on Intersectoral Food and Nutrition Planning." FAO Headquarters, Rome, 13-15 Oct. 1975 (Preliminary document!.
"Report of Interagency Workshop on Intersectoral Food and Nutrition Planning." Rome, 13-15 Oct. 1975.
Lance Taylor. "Research Directions in Income Distribution, Nutrition and the Economics of Food." Food Research Institute Studies, SVI, 2,1977.
"Planner's Manual, Municipal and City Nutrition Action Plans, 1-Year and 5-Year " NNC and FAO
"Municipal and City Nutrition Action Plans: 1-Year and 5-Year Formats." NNC and FAO.
Ashok Mitra. "Making Hard Choices between Cost-Benefit Streams of Health and Nutrition Programmes." (PAG 1.17/15.)
"Review of Indicators of General and Agricultural Development." Food Policy and Nutrition Division, FAO (PAG 1.17/15).
Leonard Joy. "Range of Means and Programmes Available." (PAG. 1.17/18.)
Jose Maria Lopes and Julain M. Chacel. "Nature and Amount of Data Required for a Definition of Strategies and Programs on Food and Nutrition." ( PAG 1.17/16.)
G.H. Beaton. "Definition of the Food and Nutrition Situation." Joint FAD/WHO Committee of Experts on Nutrition, Ninth Session, Rome, 11-20 Dec. 1974.
"Report of the First Session of the Ad Hoc Committee on Food and Nutrition Policies - Nutrition: Towards a New Strategy for improving Nutrition." Rome, 9-20 June 1975.
Robert Cook and Yuel-Heng Yang. "National Food and Nutrition Policy in the Commonwealth Caribbean." (PAHO Bulletin VIII, 2, 1974.)
"Conclusions and Recommendations - Senior Level Nutrition Planners Workshop." Asilomar, Pacific Grove, Calif., USA, 2-5 Apr.1977.
"Consultative Group on Food Production and Investment in Developing Countries - Report on the Fourth Meeting," 7-9 Sept. 1977, W.D.C. CGFPI Third Meeting, 22-24 Sept. 1976, Manila; CGFPI Fourth Meeting, 7-9 Sept. 1977; Document D, National Investment Strategy for Increasing Food Production - Honduras; Document B. National Investment Strategy for Increasing Food Production - Senegal.
Official statements of guidelines for "A National Nutrition Policy" ( April 1974), Nutrition Today, Mar.- Apr. 1974.
"National Food and Nutrition Plan." Republic of Colombia, Nutritional Planning Office (DNP - 1.260 - J), Bogota, 5 Mar.1975.
"Colombia: Appraisal of an Integrated Nutrition Improvement Project," Agricultural and Rural Development Department, Nutrition Division, World Bank, 29 Aug.1977.
"Methodologies for the Formulation of National Food and Nutrition Policies and Their Intersectoral Implementation." PAHO, CD23/PT/1, 14 Aug. 1975.
"Methodologies for the Formulation of National Food and Nutria tion Policies and Their Intersectoral Implementation - Guidelines for Discussion by the Working Groups." PAHO CD23/DT/2, 29 Sept. 1975,
"Food and Nutrition Strategies in National Development." Ninth Report of the Joint FAO/WHO Expert Committee on Nutrition (WHO Tech. Rep. Series No. 584).
"Report of the First Session of the Ad Hoc Committee on Food and Nutrition Policies - Nutrition: Towards a New Strategy for Improve ing Nutrition." FAO, CL66/7 Rev. 1, June 1975.
"Intersectoral Food and Nutrition Planning." Ad Hoc Committee on Food and Nutrition Policies, FAO, ESN/FNP/7515, Apr. 1975.
"Report of Interagency Workshop on Intersectoral Food and Nutrition Planning." FAO, ESN: MISC/76/3, March, 1976.
Donald S. McLaren. "Nutrition Planning: The Poverty of Holism." Nature, Vol. 267, No. 5614, 30 June 1977.
"Appraisal Report of a Proposed Nutrition Research and Development Project in Brazil." Agriculture and Rural Development Project Department, World Bank, 7 June 1976.
Food and Nutrition Bulletin, Vol. 1, No. 2, February 1979, page 32.
The local hosts of the workshop on the State of the Art of Bioconversion of Organic Residues for Rural Communities, held 13 - 15 November 1978 in Guatemala, were the Institute of Nutrition of Central America and Panama, and the Central American Research Institute for Industry - not the Tropical Agricultural Research and Training Centre, which is located in Costa Rica.
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