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Possible actions by governments to improve
human nutrition
Recommendations submitted to the
World Food Council by the ACC
Six priority areas are listed below, the first five relating to developing countries and the sixth to countries in a position to co-operate with them. They should be considered as supplementary to improved food production and conservation.
A. Appraisal of current information about the state of nutrition; of the impact of current policies and programmes; and of the opportunities for action. This would include the following elements.
1. A simple review can be made of current information about the state of nutrition among the lower income groups, and especially that of young children, infants, and pregnant and nursing mothers. This may suggest: (a) a need for strengthening the current system of surveillance of nutritional problems and/or (b) areas where actions to improve nutrition are required.
2. A review of the impact of current policies could cover the main factors influencing nutrition-either directly or indirectly-ranging from those affecting the reduction of poverty to services directed more specifically to the prevention or treatment of malnutrition. In particular, it should review the distribution of government assistance and privileges among different socio-economic groups of urban and rural populations.
3. A review of the possibilities for action deserves even more attention than the review suggested in 1 above. It must be made in the light of political, budgetary, organizational, and personnel constraints and opportunities. Frequently it will happen that the possibilities for action are limited, but they still need review within the framework of the complex set of factors determining the nutrition status of the population. Many opportunities are currently overlooked, e.g., building nutrition components into development projects, or incorporating concepts of nutrition into various training programmes and services that influence nutrition indirectly.
National institutes or departments dealing with development planning and administration, as well as nutrition and health, can be drawn on to prepare material for a policy review of these possibilities. Food and nutrition should be a part of all sector and overall planning. Help is also available from the UN system of agencies and organizations at country, regional, and Headquarters levels.
B. Supplementary action in the area of food production, storage, and marketing. Considerations of nutrition are important in agricultural planning. Attention needs to be given to the composition of the food basket, for example by the encouragement of production of food legumes; to the support of food production and marketing by small cultivators; to more direct producer-consumer links; to the reorientation of extension services to family and community food production and storage; to the extent that women are important family-food producers and involved in the processing and marketing of foods; to the control of food quality and safety; and to the consideration that agricultural extension services should also deal with women's needs and problems. In addition, action at the farm and rural community level to reduce post-harvest food losses due to rodents, insects, moulds, and spoilage is needed in all developing countries.
C. Support for ideals of nutrition by all relevant sectors. In addition to general actions for the reduction of poverty -e.g., agrarian reform and rural development programmes; increase of income-earning opportunities in rural areas and the peri-urban sector-it is advisable to review policies and services in all sectors with a potential for influencing the state of nutrition. Actions more specifically directed to the improvement of nutrition could include: access to safe water for household use; nutrition education and the promotion of good infant and child feeding practices through schools at appropriate levels, health centres, and available information media; access to maternal- and child-health and family-planning services; surveillance of the nutrition of young children through the health services, e.g., by regular weighing; fortification of staple foods or other vehicles; and legislation concerning the provision for the nutritional needs of workers and their families.
D. Nutrition interventions targeted to groups at risk The steps listed under A and B will reduce malnutrition, but will leave groups that can only be dealt with by specifically targeted programmes. These programmes may be considered in the order of their recurring costs in relation to benefits. They will require the training of personnel at management and other levels.
Certain deficiency diseases can be effectively controlled through specific interventions, e.g., iodization of salt for the prevention of endemic goiter, distribution of iron/folate tablets to pregnant women to prevent anemia, or limited vitamin-A distribution to children at risk of eye damage from avitaminosis A and who are within reach of existing services, are financially feasible in almost any country where they are needed, and should be provided. Nutrient supplementation or fortification of foods can often be used to reduce the occurrence of deficiency disease.
The next step could be to build on existing services for nutrition activities, e.g., the local network of health and extension services and existing organizations such as cooperatives, and women's organizations; and to mobilize community resources, e.g., by the use of local foods supplied by the community for supplementary feeding of poorly nourished children. In using existing services, the main recurring cost will be for short in-service training of existing staff and for some additional personnel.
A following step is to extend such services to underserved or unserved populations and areas since in most developing countries a considerable proportion of the population is not reached by existing services. Communities are usually ready to participate in the extension of services, but there must also be provision for increased government support.
A fourth type of intervention would be addressed to groups of landless and to people working in the informal peri-urban sector whose nutritional needs cannot be met by extension of the above services, and where more costly national support is required. This applies to programmes such as selective food distribution, low-price food shops, or price subsidies. How far a country can go with such measures depends on its social policy, the level of its resources, and the amount of external co-operation provided on a long-term basis.
E. Involvement of the family and community in the improvement of nutrition. This is particularly recommended because nutrition at the point of end-use of food is first an individual and family affair and then a community concern. The organization of primary health care', as recommended by WHO and UNICEF, offers examples of promoting and organizing community participation. Similar approaches can be made through agricultural extension agents and home economists to promote family food production and use, and to create awareness of the nutritional needs of family members, with special concern for young children.
F. External co-operation and assistance. The UN system of agencies draws the attention of the world community to the fact that least-developed countries, and probably most of those with a per capita income below $300 (at 1975 prices) cannot by themselves finance targeted nutrition interventions on a sufficient scale.2 The implementation of the New International Economic Order (NIEO) could improve the situation of the low-income countries in a major way. Further, external co-operation in paying part of the recurring costs in such countries is desirable on an assured long-term basis, during which the country's own financial base can be expected to grow. The need for long-term arrangements applies to financial support and to food aid, and is analogous to government support of poorer regions within a country.
Practical Application
The above five steps (B-F) open to developing countries have necessarily been described in general, abstract terms. Description of the possibilities in more practical terms can only be illustrative, and not fully applicable to any country. The UN agencies believe that a typical set of policies and actions resulting from the above steps would be as follows.
a. The increase in food production would be adapted to nutritional needs, in order to derive full nutritional benefits from the overriding priority accorded to increasing food production. Attention needs to be given to producing appropriate food as close as possible to the consumers, not only in terms of regions, but extending down to community and family food production and storage, especially by small farmers. Processing and distribution of food must parallel food production increases and take into account the nutritional needs of populations at risk of malnutrition. In this context, a government may wish to examine the possibilities of re-deploying its agricultural extension staff to devote more of their services to small farm units, and/or to serve as a delivery system for nutrition education to encourage on-farm production, conservation, and consumption of nutritious foods. It may be possible to make garden lots available to the rural landless and to urban dwellers for supplementing family food production.
b. Food production would be supported by other aspects of rural development, e g., by strengthening the infrastructure such as dikes, drainage, irrigation, and other works; by providing safe water for household use; by income-generating activities such as rural handicrafts and industry; and by other anti-poverty policies. "Food for Work" may be used for creating some of these assets.
c. Specific deficiency diseases such as goitre, vitamin-A deficiency, and anemia would be fought through fortification of food or distribution of supplements, and by means of encouraging production and consumption of foods rich in the needed nutrients.
d. All available means would be used for nutrition and health education, e.g., the schools, health services, cooperatives, women's organizations, and the social use of the information media, including traditional media. This would begin with a few simple messages directed at specific problems relating, for example, to the consumption of low-cost traditional foods of good nutritional value, the importance of breast-feeding, the need for introduction of supplementary foods between four and six months of age, and the proper feeding and care of young children. There is also a need for education and training programmes aimed at producing teachers of nutrition at the many different levels required.
e. The health services would be used to deal with individual cases where prevention or treatment of malnutrition is required. This will usually require:
(i) community health workers supported by some reorientation of the health services, in order, for example, to introduce regular child weighing and to demonstrate use of local foods for supplementary feeding of infants and young children over four to six months of age; and
(ii) priority for the progressive extension of primary-health care and preventive medical services into unserved and underserved areas. Health services may also be used to provide access to family planning services.
f. Local governments, communities, and women's organizations would be involved. Many experiences show how this can be done. The contribution of these groups to local services will permit wider extension of services within budgetary constraints. Local day-care centres for young children can meet an urgent need of working mothers, improve child feeding, and provide parents with information about nutrition.
g. Selective food distribution or low-price shops where supplies either from national or external sources can be assured for long periods would be set up. This approach may have particular application in poor urban areas. The fair-price shops in India, Mexico, and Pakistan and the programmes in Brazil and Colombia illustrate possibilities.
h. Required policy studies would be initiated through government and university research organizations on the implications for nutrition of cropping patterns, agricultural subsidies, food-export policies, economic development plans, etc.
Many of the foregoing steps can be initiated on a limited basis, e.g., for a specific geographic area or age group, in order to test operational feasibility and to obtain cost-effectiveness data in order to facilitate government judgements with respect to expanding or dropping the proposed service.
The above suggests a pragmatic approach to improving nutrition, which has substantial advantages. The danger of such an approach becoming ad hoc and lacking in continuing support can be reduced by a firm political commitment to the objective and by flexible strategies and tactics to use available opportunities.