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Nutrition-planning methodologies: A comparative
review of types and applications
Unexpected benefit from a dairy project
Consultative group on maternal and young child
nutrition
Nutrition-planning methodologies: A comparative review of types and applications
Lowell Lynch
Research Associate, Center for International Studies and International Nutrition Policy and Planning Program, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
Throughout the current decade, much has been written about nutrition planning. A review of the literature reveals consensus on several basic concepts. A common conceptual theme is that the causes of nutrition problems are multi-sectoral in nature and, consequently, the solutions must be developed by multi-disciplinary efforts. The various writers also generally agree that a systematic approach to nutrition planning is required. Another shared concept has it that malnutrition is an important socio-economic development concern, although disagreement has arisen over the issue of whether nutrition problems are fundamentally a consequence of poverty, or a combination of factors.
Despite the widespread agreement among nutrition planners on several theoretical principles, some differences appear to have emerged, both in opinion and especially in action. A certain body of writings focuses on the economics of nutrition at either the macro- or micro-level, while other writings concentrate on a particular sector (e.g., agriculture or health). A third approach stresses organizational (i.e., political, bureaucratic, institutional, or social) considerations. One group of nutrition planners deals primarily in econometric modelling; another group works largely with linear programming; a third employs systems analysis or other quantitative analytical methods, while a fourth uses few, if any, formal planning techniques. The administrative level at which various practitioners of nutrition planning operate also varies, with some serving in a national planning or co-ordinating agency, others working within a particular sector, and still others operating at the community level. Differing degrees of attention are given to the various steps in the planning and development process: one approach emphasizes policy analysis and formulation; another focuses on integrated programme planning and development; yet another concentrates on intervention project design and implementation, especially stressing operational and organizational factors.
Finally, the nutrition-planning approaches associated with various individuals or organizations often reflect their separate disciplinary orientations. Those with medical and related backgrounds tend to view malnutrition as a public health problem whose most serious consequences manifest themselves among special vulnerable groups in society, or as a disease with a complicated epidemiology requiring extraordinary administrative measures for control and prevention. Those from the field of economics often deal with malnutrition as a question of social incentives and welfare maximization, focusing on food production and consumption areas in which considerable research has already been done by economists with interests other than nutrition. Planners and administrators are more concerned with governmental and social processes, organizational considerations, and operationally oriented problem-solving.
The nutrition-planning literature contains little direct debate, or even dialogue, about apparent methodological differences which exist at least in emphasis if not in fundamental direction. Nor, given the relative newness of nutrition planning as a field, is there much experiential evidence on which to base a comparative analysis of similarities and differences, let alone actual performance, among the various approaches to nutrition planning. Only a handful of countries purport to have launched a full-fledged nutrition-planning effort, and to date precious few have attempted to evaluate those efforts. While some nutrition planners profess to adhere to a particular methodology, many others seem to be doing what the theorists would call nutrition planning without following any explicit theory. Still others say that they are attempting to apply certain concepts and practices in an experimental way, adapting the doctrine to the practical realities.
The remainder of this paper represents an attempt to answer the question of the extent to which the various pronouncements on nutrition planning constitute distinct methodological differences that have significant practical implications. First, a description of the types of approaches and major schools of thought on nutrition planning will be presented. The salient features of each methodology will be outlined, and the contrasts in approach will be highlighted. Next, the history of attempts to apply these various methods in selected countries will be reviewed, concentrating on the operational aspects of the attempted applications. Finally, a contrastive analysis will be offered, pointing out some of the issues emerging from the discussion of the methodologies and their attempted application.
1. DESCRIPTION OF METHODOLOGIES
An ad hoc working categorization is employed to sort out the various statements on methods for planning improvements in nutrition. The classification is not meant to be definitive or taxonomic. The categories are not always absolutely discrete, nor are the labels intended to have any significance beyond identifying a particular methodology or group of methodologies. A list of the methodologies, their major proponents, their main features, and some institutions and countries using them is given in the table below.
| Type of methodology | Major proponents | Main features | Institutions using the methodologies |
Countries employing methodologies |
| "Systems analysis" approach | Berg/Muscat, Pines, Call/Levinson | Systematic problem-solving
process. Analysis of nutrition problems and their causes
using readily available data. Formulation of specific time-phased, costed-out objectives (quantitative, if possible). Selection of interventions using cost-benefit analysis. Evaluation and reprogramming. Fairly pragmatic approaches. |
The World Bank AID | Colombia, Brazil, Philippines, Indonesia, et al. |
| "Nutrition-based development planning" approach |
Joy/Payne | Emphasis on malnutrition as aspect
of deprivation syndrome. Scientific diagnosis of nutrition problems. Development of "functional classifications" and "typical profiles." Establishment of goals, objectives, and targets. Choosing of interventions. Area-level planning. Emphasis on elegance and completeness. |
FAO | Philippines, Sri Lanka |
| Policy formulation approach |
Toro | Formulation of food and nutrition policies for inclusion in devel- opment plans. Stimulation of awareness of nutrition factor. Problem diagnosis, policy definition and programme area determination. Incorporation of nutrition objectives, policies and programmes in nation al and sectoral plans. |
PIA/PNAN | Nine Caribbean and Latin American countries |
| Community nutri- tion approach |
Wilson | "Bottom-up" as opposed
to "top-down" planning. Systematic approach at local level. Community involvement and action encouraged. Co-operatives formed. Self-help approach. Community members serve as extension workers. |
? | Colombia, Philippines, Chile (?) |
A. "Systems Analysis" Methodology
One of the earliest and most complete attempts to articulate a set of methods for planning nutrition programmes is contained in Appendix D of The Nutrition factor by Alan Berg with Robert Muscat.1 The proposed methodology clearly stems from the main thesis of the book, which contends that malnutrition is a serious developmental problem representing a major impediment to human capital formation, and deserving of priority and well-conceived and co-ordinated attention. It reflects the growing disenchantment with traditional food supply, public health, education, or similar compartmentalized approaches to improved nutrition, which are viewed as piecemeal efforts, often incapable of being replicated, and having little chance of making a significant, lasting impact on the problem. According to this thesis, what is needed, instead, is a systematic, co-ordinated, multi-disciplinary, and multi-sectoral nutrition improvement campaign capable of commanding resources sufficient to enable nutrition planning to play a leading role in the overall development process.
The methodology entails the application of a systematic approach to the analysis of nutrition problems and their potential solutions. It describes a sequence of steps to be followed in the process. The steps are:
1. identification of the nutrition problems to be addressed;
2. specification of objectives;
3. analysis of the causes of the problems identified;
4. comparison of alternative interventions, and selection of those to be implemented;
5. evaluation of the performance and achievements of the intervention programme.
The Berg/Muscat methodology lit the path of nutrition-planning theory that several other conceptualizers followed (as will be discussed later). The stepping-stones in the nutrition-planning sequence were illuminated. Light was shed on many of the key issues to be addressed and the general approaches to be employed in developing a comprehensive plan for nutrition.
Given the novelty and scope of the attempt, it is not surprising that some elements of the methodology remain in the shadows. In a few cases, for example, the specific analytic methods for making a systematic diagnosis of the problems and their causes are not spelled out. Similarly, little attention is paid to the implementation aspects of planning and programme development. For instance, nothing is said about the kinds of institutional arrangements, manpower, and other resources that might be required to carry out the planning process. Nor is there any discussion of the techniques that might be used to develop programmes. (As will be evident from this paper's review of the application of this methodology, however, intervention testing becomes an important part of World Bank-supported projects that attempt to put systematic nutrition planning into practice.)
A similar methodology was developed for the Agency for International Development by James Pines and a group of other consultants.2 Their methodology also speaks of a "systems" approach to the nutrition problem. Systematic planning, as advocated here, calls attention to nutrition problems and, particularly, to their network of causes; sets goals for alleviating the problems; and compares the costs and benefits of alternative programmes designed to do so.
The steps in the systematic planning sequence are:
1. describing the national nutrition system, "quantifying to the extent possible all factors that appear to influence the nutritional status of the population";3
2. selecting target groups, goals, and objectives;
3. identifying intervention points;
4. comparing the alternatives in terms of both the intervention points and the interventions themselves;
5. developing implementation plans.
The nutrition system is viewed as having three parts: (1) food supply; (2) distribution and processing; and (3) consumption. The nutrition system and its three subsystems, along with related systems, is portrayed in a diagrammatic form. The methodology suggests that, in describing the nutrition problems, the planner "map" malnutrition by dividing the country into subdivisions.
Some guidance is given on means of selecting goals and on the "art of intervention." There is also discussion of the organization of nutrition planning, including the costs and resources required. A flow chart on national nutrition planning is presented in Fig. 1.
A variation on the "systems" theme is contained in a paper by David T. Call and F. James Levinson entitled, "Systematic Approach to Nutrition Programs."4 After endorsing the Berg/Muscat methodology, Call and Levinson present a model of the determinants of a child's nutritional status. After explaining the model, the authors discuss in detail various interventions that might have the desired effect on each of five key determinants. In addition to the traditional criteria of nutritional effectiveness, cost, and feasibility, it is suggested that three other tests be applied to the assessment of potential interventions: (1) the time required for the desired results to be produced; (2) the degree of focus and probable impact on the target group; and (3) the presence or absence of economic or social multipliers affecting other development sectors. The Call/Levinson approach thus begins to fill in the picture of the systems analysis approach by focusing on actions (interventions) more than on basic research (diagnosis).
