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A national strategy to alleviate malnutrition may usefully distinguish between policies and programmes aimed at maintaining or modifying the economic environments within which households with malnourished members operate, and those aimed specifically at alleviating nutrition problems in specific population groups. The former include price, income. credit, interest-rate, and employment policies, and policies influencing asset ownership and user rights. The latter include targeted nutrition programmes, which are the focus of this paper. However, since the former are likely to exercise very powerful influences over the nutrition status of the poor, correct choices and design of targeted programmes must be made within the context of existing policies and expected changes in them.
Ideally, the most appropriate government support will be identified through effective participation by communities and target households. However, with or without such participation, the basic initial steps are to identify the target groups, the constraints to good nutrition with which they are faced, and their food-acquisition and allocation and health-seeking behaviour; assess institutional and administrative capabilities for implementation; and identify sources of financing.
FIG. 1. Percentages of households with malnutrition, by functional group, Peru, 1984: 1. Executives (16.6%). 2. Commercial/clerical employees (19.6%).3. Professional/technical workers (21.4%).4. Retirees (21.7%). 5. Service employees (27.4%). 6. Transportation workers (30.1%). 7. Unskilled workers (38.4%). 8. Street vendors (38.X%). 9. Merchants (38.8%). 10. Skilled workers (39.4%). 11. Construction workers (47.8%). 12. Farm workers (53.0%). 13. Livestock growers (56.8%). 14. Commercial farmers (60.2%) 15. Cooperative members (60.5%). 16. Small commercial farmers (72.4%). 17. Subsistence farmers (74.3%).18. Day labourers (76.9%). (Source: Ref. 17)
Identifying target groups, their constraints, and behaviour
Growth monitoring may be useful for identifying individual children who require assistance, but targeting may be necessary to identify groups of households likely to be faced with high risk of malnutrition. Several indicators may be used, including household incomes, asset ownership, geographical location, employment status, and occupation. To be useful, these indicators should have a known relationship to malnutrition in a given country, as illustrated in figure 1 for Peru and in table 2 for the Philippines. Geographical targeting, which has been used successfully in several countries, including the Philippines and Colombia, offers great promise when the poor tend to be concentrated in certain localities. Approaches are discussed further elsewhere .
Several authors of subsequent papers identify ineffective targeting as a major constraint to achieving high cost-effectiveness. The Indian public food-distribution scheme seems to be particularly poorly targeted , and the problem is also serious in Brazil .
TABLE 2 Nutrition status of preschoolers by population group in three low-income regions of the Philippines, 1983 - 1984
|Weight for agea||Malnourished (%)b|
|Tenants (other crops)||-1.82||28|
|Corn farmers (rice)||-1.70||24|
|Tenant farmers (rice)||-1.70||22|
|Landless farm workers||-1.63||22|
|Farmers (other crops)||-1.48||17|
|Tenant farmers (corn)||-1.43||20|
Source: Ref. 13.
a. Mean Z scores.
b. Percentage of preschoolers below 75% of standard weight for age
Assessment of institutional and administrative capabilities for programme implementation
Some programme types require more institutional support than others. For example, food-stamp schemes and food-price subsidies may be based exclusively on private-sector distribution, whereas food supplementation usually requires separate distribution channels. If a solid primary health care system is in place, food distribution may be linked to such a system at relatively low cost, particularly if excess capacity exists.
Integrating food-related programmes with primary health care offers great promise because it addresses several interacting constraints simultaneously. The drawback is that integrated programmes are very demanding on administrative and institutional capabilities. For this reason, many that have been successful as small pilot schemes fail when extended nationally. This does not mean that no integration should be attempted, but rather that the administrative and institutional capabilities should be assessed prior to programme design and implementation. Distribution of food at health posts has been successful in a large number of cases and should be considered as one of several options. However, the logistical problems associated with public-sector food distribution should not be underestimated. These may be avoided by issuing food stamps that are redeemed at private-sector retailers. This was successful in Colombia and the Philippines.
Sources of funding
How realistic is it to recommend targeted nutrition programmes during a period of macroeconomic adjustments that include cuts in government spending? The answer depends on government priorities. Government spending on nutrition and health could be increased even though overall spending is reduced. Furthermore, reallocations could be made within overall nutrition and health spending to favour preventive over curative and recurrent over capital costs.
External funds are becoming available to compensate groups of low-income households expected to suffer short-run losses from macroeconomic adjustments, and to assist countries in making adjustments within specific sectors, including agriculture and health. These funds could be used to support new initiatives for improved nutrition.
Innovative uses of external food aid offer another opportunity while protecting farmers from adverse effects. Food aid may be used directly in food-supplementation schemes or it may be sold for cash by the government. If used directly, recipients might be asked to provide a small payment, which in turn may be used to cover the cost of primary health care or other nutrition-related activities. Such an approach was successful in financing certain costs of running primary health care clinics in a number of African countries. If the food aid is monetized, the local currency revenues may be used to support a variety of nutrition-related activities, including a targeted food-stamp or other transfer programme.
In addition to partial payment of food or food stamps, the target households may be charged user fees for health-care services. Selective user fees graduated by ability to pay are preferable if the administrative capability necessary for their implementation is available.
In an imperfect world where, at least in the foreseeable future, we will not eradicate poverty, make a complete array of primary health care services, information, and education available to all, or ensure the right to self-determination by individuals including women and children, which targeted nutrition programmes should be pursued by governments? The answer will vary among countries, among population groups, and over time. However, experience from past and continuing programmes provides guidelines that can be generalized, at least to a certain extent.
First, promotion of breast-feeding, wider child spacing, and improved weaning practices have resulted in improved infant and child nutrition, and well-designed programmes in these areas are likely to have a significant impact. Family planning resulting in more appropriate child spacing and programmes to support the nutrition needs of low-income women in the child-bearing age are likely to be effective in reducing mortality, morbidity, and malnutrition among women as well as reducing the prevalence of low birth weight in infants and associated nutrition risks during the first year of life.
Poverty, and the associated lack of access to sufficient food to meet nutritional requirements, is clearly an overwhelming reason for malnutrition. However, programmes with the sole goal of enhancing income have not been as effective in alleviating malnutrition as expected. The reasons vary among population groups. Severely malnourished infants and children usually live in an environment that fosters high health risks, including infectious diseases. Under such conditions, additional food may have little nutritional effect, partly because of lack of appetite and partly because of poor physiological use of ingested food. In the longer run, increasing income is likely to improve the environment, reduce health risks, and improve nutrition. In the meantime, a significant effect of enhanced access to food may occur only if primary health care programmes and programmes to modify health behaviour and improve sanitary conditions and drinking water are introduced as well.
Another reason that income increases may not be effective is that households may be unaware that a nutrition problem exists, or they may lack knowledge and information about how best to use new income to improve nutrition. Competing household priorities are another possible explanation. In such cases, growth monitoring and/or nutrition education may be required as well.
The nutrition effects of increased income may also be less than expected because women allocate more time to earning money and less to child care, cooking, and other nutrition-related activities. In such cases, programmes to increase the productivity of women's time within and/or outside the household are necessary.
The interaction between an intervention and the socio-economic and cultural environment within which it is introduced, as well as the interaction among types of interventions, is of paramount importance. This has led to the conclusion that interventions must be tailored to the particular environment, and integrated interventions are more likely to be successful than single ones. Two dilemmas result. First, a great deal must be known about the target group before an intervention is designed. The generation of such knowledge is expensive and time-consuming, and requires participation by communities and target groups. Second, integrated interventions require institutional and administrative capabilities and infrastructure that are frequently in short supply.
In countries where the necessary capabilities and infrastructure are available or can be developed, integrated health and nutrition programmes combined with favourable government policies offer a great deal of promise. Although overall primary health care may form the core, each programme should be tailored to the particular circumstances, but should include a combination of: growth monitoring; nutrition education emphasizing breast-feeding, child spacing, and weaning practices; financial and technical assistance in the production and distribution of weaning food; and food stamps to participating households. Active participation by the community and target groups in all aspects of programme design and implementation is essential for long-term sustainability, and separate but related efforts to assist the target group in strengthening their income-generating capacity are needed to reduce the need for future outside financial support.
When institutional and administrative capabilities and infrastructure are weak, less complex programmes should be pursued. In areas where health posts are in place and insufficient food intake is a constraint to good nutrition, the distribution of food stamps to low-income mothers who bring their preschool children to the posts should be considered. Such an approach was successful in urban and rural areas of Colombia, and in both remote and less remote rural areas of the Philippines. Using food stamps instead of the more traditional food supplementation relieves the health system of physical food distribution, a job for which it is not well equipped.
Where health posts are not in place, small-scale ad hoc programmes may still be the only viable alternative. They may be very cost-effective if designed by and for the community target groups with outside support.
Attempts to set up large-scale programmes that exceed the institutional and administrative capabilities have failed in the past and will fail again. Instead, emphasis should be on strengthening these capabilities, including training at all levels and the building of nationwide primary health care systems that may become the conduit for integrated nutrition and health programmes. At the same time, nutrition improvements should be pursued through policies and programmes requiring fewer administrative and institutional capabilities and less infrastructure, such as price, income, and employment policies, credit and technical assistance to low-income people, basic training, and education.
The evaluation of programmes in Brazil, Chile, and India reported in this journal provide important new information useful for the design and implementation of future interventions and policies [1, 3-6, 18, 19].
Comments on an earlier version of this paper by Susan Burger, Jean-Pierre Habicht, and David Pelletier are gratefully acknowledged.
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