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Abraham Horwitz
Department of Health, Education and Welfare, National Library of Medicine, Public Health Service, National Institutes of Health, Bethesda, Maryland, USA
Do national and international agencies really lack the capacity for policy formulation and the resultant programme preparation in nutrition? One school of thought contends that what is essential is the political decision ascribing priority to nutrition in national development plans, introducing nutrition objectives into agricultural production, and integrating nutrition interventions in the health care system. This will be the result of an effective sensitization of governments, one that will be reflected in adequate policies and programmes, appropriate funding for short-term and long-range objectives-in sum, concrete goals reflecting sustained political will. Should the capacity of countries be insufficient, the international agencies- multilateral or bilateral-could supplement it while at the same time assisting in a building-up process.
A second school of thought argues that countries actually lack the experience to formulate a nutrition policy and to prepare and implement the programmes. What is needed is adequate institution building. The political decision is taken for granted. Should the country have well-trained professionals, even in small numbers, they will certainly contribute effectively to induce the response of government for specific activities, the beginning of a process. The role of the UN system and other agencies engaged in reducing malnutrition is delineated by the weaknesses in the national resources for specific goals and target populations. It may well be that both situations exist in the world, and may coexist in some countries, according to the nature of the problems and the availability of resources.
With reference to the formulation and implementation of
programmes with significant coverage to reduce nutritional
deficiencies, nations of the Third World would be classified as
follows.
a. Those where the problem seems to be under control, as
witnessed by the rates of infant mortality, life expectancy, and
literacy. Taiwan, Singapore, Cuba, and the People's Republic of
China may be in this category.
b. Countries in which programmes are under way and where there
has already been a significant decline in the indicators
reflecting morbidity and mortality. The political decision is
sustained and projects are sound; however, resources are still
limited for universal coverage. Sri Lanka, Chile, Costa Rica,
Colombia, Tanzania, Malaysia, and Kerala State in India are some
examples.
c. Countries where the government has clearly expressed the
intent to deal with the problem, but is doing so on a limited
scale in relation to the dimension of malnutrition: Brazil,
India, Bangladesh, the Central American nations, Indonesia, Peru,
and Mexico, among others.
d. Countries that remain in a poor nutritional status quo: Haiti
and several in the African region are examples.
This classification of countries applied to the whole world will certainly show where efforts of the international community should be concentrated. Under the assumption that the last two groups of nations do lack the capacity to deal with the problem, the question is: Which should be the areas of their concern? In other words, what do they have the capacity to do? A common denominator to all of them is prevailing poverty and deprivation, and a great distortion in resource allocation with its attendant nutritional deficiencies in vulnerable groups. This reflects, at best, maldistribution of essential nutrients, and at worst, lack of food availability and/or purchasing power for a balanced diet in each household. It is for governments to decide on the nature and extent of programmes. The international agencies can, indeed, assist in the process of identifying priority problems and recommending adequate approaches to deal with them.
Despite great shortcomings in data availability, there is a clear profile of malnutrition and the main nutritional deficiencies in less-developed societies. Furthermore, lines of action to be taken by governments to improve human nutrition as distinct from those concerned with food production and conservation have been defined.' It is claimed that the problem remains, or is even growing,
In the poverty-stricken countries of the world because programmes are not addressed to the vulnerable groups in the rural areas and shanty towns, or, if they are, they are fragmented and reach too few people, Measures proposed often do not fit local conditions, dietary practices, financial possibilities, and cultural traits. Nutrition objectives are either absent or have no priority in the health system, and no well-tested methodology is available to introduce them in the primary health care. The role of the natural leaders in communities has not been clearly defined, and this is paramount for enlisting the latter's participation from the planning to the implementation and evaluation phases of each programme. As a general rule, nutrition considerations are not usually included in development policies, and agricultural production is not consistently guided toward the improvement of the people's nutrition status.
Clearly, the causes and consequences of hunger and malnutrition are better understood despite their complexities. There is consensus regarding measures to be taken for progressively reducing their incidence. The question is: What are the main constraints on the application of available knowledge and technology? The following appear to be of the greatest significance.
1. The absence of a systematic decision-making process, reflecting lack of political will on the part of governments, is the most important constraint. Those countries where the status quo prevails do not show the strength to overcome vested interests or to deal rationally with them even though they increase deprivation and malnutrition. A sound sensitization process is urgently needed, a fact that is apparent in a large number of countries. Although in the final analysis, programmes to reduce malnutrition should be national in origin and cultural characteristics, the international agencies have a definite promotional role to play. No matter how general they may be considered, the Resolutions of the World Food Conference are a mandate from the governments to the multilateral and bilateral organizations for co-operation in order to identify the main nutritional deficiencies, formulate adequate policies and programmes, implement operational activities, and evaluate outcomes.
Governments want the agencies to exercise an active role on the bases of their collective decisions made during the meetings of the governing bodies. Suggestions, recommendations, and co-operation for short-term or long-range activities, if properly offered, are usually not considered interference. Greater is the risk of passivity, a waiting for requests from the countries to visit them, for it may be interpreted as equivalent to lack of initiative and leadership.
2. The lack of an organizational structure for policy formation, programme implementation and evaluation, and nutrition surveillance may be the main constraint in countries whose governments have made the decision to address food and nutrition problems. Whether the approach to nutritional deficiencies is comprehensive or specific, the need for an institution-building process in each country is essential. It should include structures at the national, regional, and community levels. Some believe that an Institute of Nutrition for adaptive research and for extension to the household is an essential instrument of the whole system. if it is related to international centres for basic research, the prospects are even better. The experience stemming from the agricultural systems in many countries complemented by results from the chain of international agriculture institutes throughout the world-a success story-could be useful for developing an organizational structure in nutrition.
3. The need for better data collection and collation, more rational problem analysis, and effective programme and project preparation for most countries, if not all of them, are common constraints. This is reflected in the selection of priorities and target groups, the inadequacy of resources in relation to objectives, the lack of methods for the evaluation of outcomes, the absence of cost benefit studies, the deficiency of timetables for the different phases of the process, and insufficient financing.
4. The underestimation of the need for adaptive and mission oriented research by decision-makers, as reflected in budget allocations, is another common constraint. The usual question is still: Why research, when the problem is simply to produce more food? We feel that the agricultural system has been relatively more successful in reaching the target farmer with an effective technology than the nutrition system has been in reaching the poor urban and rural household. In general, explicit linkages between investigation and experimentation for adapting techniques to local nutrition needs are not always apparent. For most countries, studies of the nutritional implications of present economic, agricultural, and health policies could stimulate changes of budget allocations with significant benefit to vulnerable groups and others.
5. It is obvious that in many countries the national investment for nutrition programmes is way below what is urgently needed. One indicator of an effective sensitization process should be the redeployment of funds in accordance with strategies and projects decided by governments. Still, for the least developed countries, there may be great difficulties in financing long term, recurring costs. This situation could be approached either by adjusting available resources to objectives or by innovative external assistance. It is not sufficiently recognized that at present there are not enough sound projects.
All of these constraints disclose an acute need for trained professional and auxiliary personnel in the field of nutrition and allied disciplines. As an example, no country in Latin America has a sufficient number of nutritionists/ dietitians to carry out an effective nutrition programme.
Although there are nutrition units in Ministries of Health in most countries, their outreach is severely limited. There is a pressing need for the creation or strengthening of inter-ministerial structures dealing with different facets of the nutrition problem. The need for agricultural planners to incorporate nutrition objectives in food production and for nutrition planners for specific interventions is also apparent. Education and training programmes aimed at producing teachers in food science and nutrition as well as management personnel for food and nutrition programmes should be organized or expanded in developing countries as soon as possible.
It may be safely assumed that in all nations where the problem of hunger and malnutrition is still prevalent, there is a need to prepare the human resources that are indispensable to deal with it in a systematic way. This will depend on fundamental decisions made by governments. They may choose to adjust development policies toward nutrition objectives; to change trends in agricultural production for increasing food consumption; to introduce concrete nutrition goals in the health care system, particularly at the primary level; to enlarge programmes for reducing nutritional deficiencies that are prevalent among target groups or in specific geographic locations, or any combinations of these.
The extent and nature of the decision-making process will determine the quantity and quality of nutrition manpower needed in each country It will also induce the mobilization of existing human resources and promote the education of additional manpower, which is indispensable. Clear career opportunities must be established and other incentives offered, such as postgraduate studies at home or abroad, recognition for outstanding performance, and advancement to positions of greater responsibilities and income.
Suitable institutions-universities or institutes of nutrition
-are urgently needed in many countries of the world for preparing
specialists in food and nutrition sciences. Although external
technical and financial co-operation may be important for many of
them, increasing domestic resources should reflect the
government's recognition of the significance of nutrition
policies and practices. Several areas require newer, more
multidisciplinary and applied approaches to education and
training, such as:
a. nutrition objectives in economic and social development;
b. nutrition-oriented agricultural planning;
c. nutrition planning for direct and indirect interventions in
health and other sectors;
d. rural development planning, including subsistence agriculture
and food consumption;
e. nutrition objectives in primary health care to be implemented
by indigenous health workers and community leaders.
It is to be expected that professionals thus trained in appropriate postgraduate courses will be able to formulate policies and strategies and prepare programmes and projects. Research on appropriate models for diverse ecologic settings is clearly needed.
It is impossible to over-emphasize the urgency of reintroducing nutrition as a distinct discipline in the curriculum of medical and other schools of health sciences as well as in the education of agricultural scientists. For many this has been a major factor contributing to the low priority that nutritional deficiencies have in the decision-making process of most governments of the world.
THE ROLE OF THE AGENCIES OF THE UN SYSTEM AND OTHERS DEALING WITH CO-OPERATION AND/OR FINANCING OF NUTRITION PROGRAMMES
Do the UN agencies and the "bilateral" lack capacity to co-operate with governments in nutrition-policy formulation and programme preparation? They do not lack the mandate to respond to government's requests, but generally do not have trained staff However, they can obtain access to the world's pool of knowledge and experience through specialists acting as short term Consultants and expert committees. Do governments bear the whole responsibility for the persistence of the problem? For some, the agencies have suffered from the same "malaise" as governments have, namely, a limited priority ascribed to nutrition. As a result they have not brought to the attention of the highest authorities in each country the magnitude and consequences of the problem. Thus, there has been no effective promotion of nutrition.
Another factor is that the process of delivery of technical, material, or financial co-operation is often so slow that it goes beyond the average "ministerial life expectancy" in the country.
A general criticism of all the UN agencies is that their policies and programmes have not been directed to the actual sufferers from malnutrition in the world: the actual poor in the rural villages and in the urban slums and shanty towns. In the words of World Bank president Robert S. McNamara: "It is time for all of us to confront this issue head-on." And he adds: "In short, national managerial and intellectual resources must be redirected to serve the many instead of the few, the deprived instead of the privileged."2
Wherever this is the case, the international agencies should be prepared to respond promptly and co-operate with governments in:
a. determining adequate levels of policies and effective
actions;
b. developing nutrition surveys to identify groups at risk and a
surveillance system based on simple, least costly, and useful
indicators;
c. formulating programmes and projects on the basis of existing
rather than imported resources, and with a technology,
appropriate to culture and environment, that is simple and
inexpensive;
d. training professional and non-professional personnel either in
the country or abroad;
e. obtaining complementary external financial and material
resources; and
f. organizing adaptive research to determine the most
cost-effective "mix" of operations to reach targets and
objectives.
There is need for an active promotion by the agencies instead of the prevailing attitude of "wait for a request to come." True, governments have the responsibility and the power to decide on what to do and how to invest national resources. However, many will welcome rational co-operation for a top-priority problem such as malnutrition.
In addition to their present functions, what additional ones could the SCN and other UN agencies assume? In support of the recommendations for governmental action to improve human nutrition, supplementary to food production and conservation,' the SCN and its participating agencies should: a. Participate actively in the agreed-upon procedures for sensitization of governments and their different relevant agencies as well as voluntary organizations.
b. Take the necessary steps to prepare models for: (i) the introduction of nutrition considerations and objectives in the strategies for economic development; (ii) the revision of agricultural production in order to make it consistently responsive to the aim of improvement of the nutrition status of the people; (iii) the promotion of rural development, including food production and consumption, primary health care, education, sanitation, and other significant sectors; and (iv) helping to organise patterns at the central, regional, and local levels in accordance with the nature and extension of programmes. The International Food Policy Research Institute and some universities could be assigned this responsibility.
c. Create a nutrition centre for project formulation and matching financing to serve all agencies, both national and international, private and public. It would be instrumental in designing viable projects in which quantifiable objectives are commensurate with effective resources and that include the elements for evaluation and monitoring. Thus, it could contribute to speeding up the implementation of nutrition programmes with or without external technical and financial co-operation.
References
1. "Co-operation with Governments for the Improvement of Nutrition; Appendix IV," draft report to the World Food Council of the Fifth Session of the ACC Sub-Committee on Nutrition and its Advisory Group on Nutrition, Geneva, 26 February-2 March 1979.
2. R.S. McNamara, "Address to the Board of Governors of the International Bank for Reconstruction and Development," Nairobi, Kenya, September 1973, pp. 14 and 18.