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Community-level nutrition interventions in Sri Lanka: a case study

H.C. Karunanayake
Deputy Director, Sri Lanka Field Office, US Save the Children Fund

INTRODUCTION-NATIONAL BACKGROUND

Community-level nutrition interventions in Sri Lanka are handled almost entirely by private non-governmental organizations (NGOs), although many of these programmes depend to a great extent on government-originated or government-sponsored nutrition supplies for their sustenance. There are about a dozen NGOs currently engaged in community-level nutrition interventions. This study confines itself to a representative selection of three programmes-those of the Lanka Jathika Sarvodaya Sangamaya; Redd Barna, the Norwegian Save the Children programme; and the US Save the Children Fund-chosen for the extent of their coverage of beneficiaries as well as for their varied styles and methods of approaching the problem.* The study will focus to a great extent on the Sarvodaya programme, since it is by far the most extensive and is supplemented with considerable data.

A brief reference to the national background and the overall situation regarding nutrition is appropriate here as a preface to the case description, since this gives a better perspective of nutritional needs at the community level.

Sri Lanka is an island in the Indian Ocean having a land area of 25,000 square miles and a population of 14 million. The south-western and central parts of the island compose the wet zone hill country. The rest of the island, which is the larger area, is in the dry zone, and most of the people live here. The country is inhabited principally by the Sinhalese (71.9 per cent), Tamils (20 per cent), and Moors (8 per cent). There are 24,000 villages in the rural sector, containing 76 per cent of the population.

The island's economy, long dependent on three principal export crops-tea, rubber, and coconut-has shown trends towards diversification in the past decade, gems and ready-made garments being two industries that are expanding rapidly. A major problem in the rural areas is unemployment. The present national rate of unemployment is estimated to be 15 per cent. Income distribution shows that the income share for the lowest 40 per cent of the population is 12.3 per cent compared to the highest socio-economic group, who receive 39 per cent of the income, the Gini concentration ratio now being 0.49. The country has a free educational system from primary up to university level, and this has contributed largely to its high literacy rate, which now stands at 78 per cent.

Housing is better in urban areas than in rural areas where most houses are semi-permanent and have neither pipe borne water nor hygienic sewage disposal systems.

Health facilities are also concentrated in the urban areas. The Colombo District alone has 125 of the island's 435 hospitals and 26,000 of a total of 35,000 hospital beds. The country's medical and health facilities are available free of charge to the population, and this perhaps accounts for the low infant mortality rate of 37.5, an overall mortality rate of 6.5, a life expectancy at birth of 64.2 years for males and 67 for females, and a maternal mortality rate of 0.9 per 1,000 live births.

A nutrition survey carried out during 1975-1976 by the Ministry of Health (with technical assistance from the Center for Disease Control, Atlanta, Georgia, and financial assistance from CAR E) covering the age groups between 8 months and 71 months, showed a weighted average percentage of chronically undernourished children of 34.7 per cent and of acutely undernourished children, 6.6 per cent. A main problem, especially among rural mothers, was prolonged breast-feeding without alternative sources of nutrition and the sudden termination of breast-feeding without recourse to suitable weaning foods.

At the national level, the major intervention programmes are the food stamp scheme, the thriposha programme, and the school biscuit project. The food stamp scheme is an income-support plan directed towards the low-income groups, who are provided with food stamps for the
purchase of rice, sugar, bread, dairy products, and kerosene. The stamps are available to all households receiving a monthly income of less than Rs 300 regardless of the nutritional status of the occupants. The food stamp scheme is administered directly by the Government through its Food Department, although supplies in exchange for stamps can be obtained from private traders registered with the Government.

The thriposha fortified food project was developed in 1972 in collaboration with CARE at the request of the Ministry of Health. The food consists of corn and soy milk powder combined with maize and soy and is distributed to beneficiaries, mainly of pre-school age, found to be in second- and third-degree stages of protein-calorie malnutrition. Thriposha is distributed through health clinics of the Department of Health, estate clinics, and voluntary organizations.

The school biscuit project, a nutrition feeding programme, was begun in 1973 and is conducted jointly by the Ministry of Education and CARE Sri Lanka. The target beneficiaries here are children of school age and distribution is through the island's educational system consisting of 9,000 schools. At present, however, coverage is limited to 7,500 schools with 1,250,000 children, leaving 1,500 schools and 750,000 children to be reached.

The outreach of the thriposha programme has also fallen far short of its goal, reaching only 46 per cent of the target group. The use of public sector distributional systems and the bureaucratic rigidity resulting from the administration of nation-wide programmes have fed not only to supplies going to waste, but to their being distributed to those outside the target groups. The resort to community-level interventions through organizations with smaller and more flexible administrative structures therefore seems appealing under the circumstances, and the Government has encouraged the mobilization of NGO resources towards nutrition interventions. It is hoped that the ensuing case studies will provide a basis for evaluating the efficacy of community-level interventions.

THE SARVODAYA NUTRITION PROGRAMME

The Sarvodaya Shramadana Sangamaya is a private, nonprofit organization that began its activities in 1958, devoted to mobilizing voluntary labour for village reconstruction. It has since acquired a national character and is now engaged in a series of development projects, including village development in over 2,000 villages. One of its main objectives is to mobilize community resources for development, and in order to induce such participation the movement uses its organizational framework as a base from which its programmes operate. The movement also aims at self-reliance within communities and stresses this aspect in its work programmes. While the major inputs for its activities come from the human and material resources available at village level, it has also become necessary to have a strong administrative back-up to induce village-level participation. Such an effort requires not only professional, technical, and managerial skills but also such elements as finances, equipment, materials, etc. The movement's success as a purely indigenous organization attracted international donors who now make contributions to various aspects of the movement's programmes in cash and equipment, in expertise and training, and in other ways. Much of the movement's present financial and equipment resources have come from foreign donors.

The Organizational Framework

The organization is incorporated under the name Lanka Jathika Sarvodaya Sangamaya. Its members include children (ages 7 to 15), Youth (16 and over), mothers, farmers, and general elders. The 35-member Sarvodaya Executive Council is elected at the annual general meeting of the Sangamaya. The Sangamaya meets monthly to review performance and decide on the general policy of the movement. The annual general meeting also elects the officebearers and the Elder's Council, which are part of the Executive Council. The officebearers and Executive Committee, in turn, appoint an Implementation Committee consisting of 12 full-time workers who coordinate the 12 different departments of the organization, viz.: communications (including newspapers, research publications, lithography, and development education); Shramadana camps; children's services, including education, health, and nutrition; development education; Gramodaya centres; Tanamalwila complex; Gramodaya revolving fund; Bhikku services; research centre; production services; finance; and administration.

The regional centres are linked with the villages through 80 extension centres that serve a cluster of villages, usually within a 10-mile radius, with between 2 and 35 villages. Through the extension centre, the headquarters and the regional centres provide services, advice, and material assistance, such as the provision of powdered milk and thriposha for the community kitchens. Most of the Gramodaya extension centres are located at temples or in a church or community building and are administered by two or three Sarvodaya workers who have been trained in community leadership and community development methods. These voluntary workers are paid an allowance ranging from Rs 100 to Rs 150 per month by headquarters. The worker at the extension centre keeps in close touch with village development in the village under his or her charge, having herself been chosen by her village Sarvodaya group for training at the centre.

Implementation

The organizational structure of the movement is the springboard from which Sarvodaya activities in villages take off. At the village level it is a Sarvodaya worker or a person connected with the movement who brings a village in touch with the central organization, which then acts as a catalyst, using its massive infrastructure to set in motion the changes planned in the village. Often Sarvodaya activities commence in a village with a voluntary self-help project (Shramadana) relating to a common village need.

A normal step following the formation of a society in a village is for Sarvodaya workers to conduct a socioeconomic survey of the village and work out a development plan. Ideally, the Sarvodaya organization in a village includes a youth group (16 to 25 years), mothers' group, farmers' group, children's group (7 to 10 years), and a pre-school group connected with the mothers' group. The ideal model is completed by the inclusion of an elders' group and the Samudan group, which consists of respected and talented persons of the village not already in any of the other groups.

In practice, however, there are very few villages in which all of these groups exist. In many only one group functions. The village development programme consists of three stages: In the pre-formation stage, a village is identified and a base survey is conducted. The second stage is the Sharamadana stage, when a group of village volunteers are mobilized in a self-help project relating to a common need. This stage evokes a high degree of participation. The third stage is the Gramodaya stage-the "awakening" of the village. At this stage the villagers are expected to understand fully the philosophy of Sarvodaya and to make their own plans for their village.

The Gramodaya Mandalaya is the key organization of the village and consists of representatives from all the Sarvodaya groups in the village. Not all villages having Sarvodaya reach the Gramodaya stage. Recent surveys indicate one-third at the first stage, another third at the second stage, and the balance at the third stage of development. Much of the viability of the village development programme depends on the commitment and skills of the voluntary workers who form the backbone of the movement. Their quality, in turn, depends on their education and training, and a great deal of emphasis is placed on these factors in the Sarvodaya movement. The major training and educational activities carried out at headquarters and regional centres are: (a) community leadership training, (b) training for pre-school instruction, (c) training in crafts and skills, (d) agricultural training, and (e) leadership training for Buddhist monks.

Nutritional Programmes-The Outreach

In 1972 the Sarvodaya Sangamaya began a pre-school project to meet the educational needs of children in the rural areas. The children's service now integrates three services: pre-school, nutrition, and community health care. The beneficiary groups are pregnant women and children of pre-school age, who are divided into two groups -0 to 2 ¹/₂ years old and 2 ¹/₂ to 5 years old.

The needs of the under-2 ^1/2 -year age group are met through day-care centres, while the needs of the pre-schoolers are met through preschools and community kitchens.

Day - Care Centres

There are an estimated 86 day-care centres, mostly in villages, run with assistance from the Department of Probation and Child Care Services, the Social Services Department, and local government bodies. The assistance given by Sarvodaya is in the training of staff and management of the centre through volunteers who are on a monthly stipend paid by the relevant government departments. The different departments contribute to the running of the centres by meeting the staff costs or by providing a per capita payment based on the average number of children in attendance. These day-care centres, which are open from 8.00 a.m. to 5.00 p.m. on weekdays, were, at the inception of the scheme, confined mainly to the plantation areas where both husband and wife are usually at work away from home, and infant care tends to interrupt the education of older siblings. The day-care concept has since been extended to urban and rural areas, but the rate of expansion of this service has been slow, constrained undoubtedly by the low increase in demand for such services from low-income groups.

The main service available in a day-care centre, apart from the physical care of infants, is the provision of nutritious foods. The morning meal usually consists of a preparation based on thriposha or a rice canjee prepared with greens. A forenoon fruit juice is also usually given, followed two hours later by lunch consisting of boiled rice and vegetables and a cup of tea, and a thriposha in the evening. The outreach of the day-care centres is currently estimated to be around 1,500 to 2,000 children.

Training for Instructors in Pre-schools

The base of the nutrition intervention is the pre-school programme, which, in turn, rests heavily on the commitment and interest shown by the voluntary workers in charge of each pre-school. The pre-school centre, the community kitchen, and the mothers' group jointly cater to the needs of children below the age of five and, to some extent, the needs of mothers.

The worker in charge of each centre is a young woman from the village who is given preparatory training by Sarvodaya. Usually the selected candidate is given two weeks of training at one of the district centres and thereafter three months of training at headquarters. Trainees are selected by the village Sarvodaya organization, often in conjunction with the headquarters staff, on the basis of the person's suitability and aptitude for community development.

Trainees generally have completed about nine years of schooling. The courses cover subject areas related to child development, principles of nutrition, organization of community kitchens, basic health care for children and mothers, preventive measures, and the principles and goals of the Sarvodaya organization. Some of the more promising trainees are selected from the three-month training course and appointed as community workers and given a further three months of training. Community health workers oversee a cluster of villages.

The Pre-school Centres

BY far the largest outreach is effected by the pre-school nutrition programmes administered through the Sarvodaya movement's pre-school centres that began with 17 in 1972 and today number about 2,200. Each centre caters to groups ranging from 15 to 100 children below the age of five years. Each centre is under the charge of a trained worker from the village.

The objectives of the nutrition programme conducted through the pre-school centres are:

- to meet the nutritional needs of children by providing at least four servings of food during the day,
- to assist pregnant women in maintaining a healthy, well cared-for pregnancy.
- to induce pregnant women to make full use of the services provided by government,
- to use village-level supplementary food for very young babies,
-to use village-level food as weaning foods, and
- to help the community kitchen by supplying food available in the village.

The children are requested and encouraged to bring whatever raw foods are available in their homes for processing in the community kitchen, which is part of the pre-school centre. Rice, vegetables, and other foods are brought in quantities affordable by individual parents. Breakfast from the community kitchen usually consists of a cooked canjee made of rice or green vegetables, or a thriposha preparation. A forenoon thirst-quenching fruit juice or glass of milk is provided a few hours later. Milk is donated by NOVIB. Pre-school centres are open from 8.00 to 11.30 a.m., and most are open on weekdays only.

The pre-school centres now cover 2,237 villages, as estimated from the number of thriposha distributions made at each centre. The Sarvodaya movement receives a monthly quota of 59,330 packets of thriposha that is distributed among 29,665 children of pre-school age at the rate of two packets per person per month. The packets are not distributed directly, but given in the form of a preparation from the community kitchen, and generally two packets are required by a child. The outreach of the nutrition programme therefore covers about 30,000 persons.

Although the Sarvodaya nutrition programme aims at mobilizing village resources for supplementary feeding, the soaring costs of food have created a heavy dependency on the supply of thriposha. It would therefore be useful to take a brief look at the design of the thriposha programme itself and examine the Sarvodaya method in relation to national perspectives.

In the national thriposha fortified food project, there are five beneficiary categories: pregnant women, lactating mothers, infants (0 to 12 months), pre-school children, and hospital ward patients. Medical selection is a prerequisite for the receipt of thriposha, which is distributed through health clinics, estate clinics, and voluntary agencies like Sarvodaya. Infants 6 to 12 months old are eligible to receive thriposha, as are pre-school children aged 13 to 72 months who are in the second or third degree stage of protein-calorie malnutrition, determined by weight-for-age measurement. The medical criteria for selection of pregnant women are a talequist reading of 50 per cent or below, and for lactating mothers, clinical signs of anaemia. The number of beneficiaries approved in 1979 was 500,000, and in 1980 it was 550,000, but the actual numbers reached were 269,992 and 253,243, respectively, or 54 and 46 per cent of the targeted national figures.

The Sarvodaya programme reaches an estimated 30,000, which is less than 6 per cent of the national target. A significant difference, however, is that some of the Sarvodaya beneficiaries may not be in need of nutrition intervention, as no medical selection of beneficiaries is required. On the other hand, the Sarvodaya outreach is typically community-based, so the use of thriposha as a nutrition supplement could be a temporary measure for the purpose of creating community awareness and increasing the level of nutrition consciousness among disadvantaged communities. Growth charts are expected to be maintained in all pre-schools, but this is not done systematically because weighing scales are available only at the Gramodaya centres and at a few of the village preschools. The voluntary workers in most pre-schools do not seem to attach sufficient emphasis to the need for periodic monitoring of progress. The nutrition evaluation element is therefore not stressed sufficiently

Resources and Costs

As described in the sections dealing with organizational structure and mode of Policy implementation, the Sarvodaya movement depends heavily on a central, almost monolithic, structure that continuously acts as a resource base upon which the entire village development programmes stand. Such a system not only calls for manpower resources with their attendant costs, but also has other requirements such as transport, buildings and accomodations, equipment, etc. The nutrition programme has its direct costs, i.e., the cost of the food and the stipends paid to the voluntary workers. Additionally, there are the overheads for each activity. The total budget for the Year 1977/78 was Rs 34,042,000 (Rs 18 = US$1).

Major items of expenditure are maintenance of buildings, equipment, and vehicles and the different training activities. The total maintenance budget for 1977/78 was Rs 12 million, and the amount allotted to all forms of organized training was Rs 3 million.

There are 4,481 volunteer workers currently engaged in the pre-school centres. Of these, 2,385 receive a monthly allowance of Rs 100. The direct operational costs are therefore around Rs 240,000 per month for staffing needs. The cost of thriposha at an estimated Rs 3 per packet would be Rs 180,000 per month, or Rs 2.16 million per annum. Total direct costs would be in the region of Rs 5 million per annum. If 25 per cent is added for overhead costs, the pre-school programme would cost in the range of Rs 6 to 7 million.

How does this compare with the direct costs of production and distribution of thriposha by the Government? For the period 1 July 1980 to 30 June 1981 a sum of Rs 21 million was approved as payment to CARE and the US Government for the supply of 1.2 million packets of thriposha per month for that year. Additionally, a considerable sum is spent on distribution. The amount expended on thriposha distribution is not known, but school biscuit distribution cost Rs 43 million in 1980.

The Sarvodaya programme costs about Rs 230 per beneficiary per annum. This programme, however, includes the cost of allowances paid to trainees and the invisible benefits of propagating nutrition awareness among rural communities. The pre-school centres offer a very valuable and rare opportunity for rural mothers to get systematic exposure to nutrition education. Such an outreach is usually not possible through conventional governmental approaches, hence the failure of the national thriposha programme to reach adequate numbers of beneficiaries through the Health Department clinics. A strict cost comparison is not possible because of the divergent elements involved. A salient conclusion is that a nutrition
programme coupled with community participation will lead to more intensive involvement of target beneficiaries.

Evaluations

The International Council of Educational Development from the United States, which was invited to review the Sarvodaya movement together with Sarvodaya's own researchers, made the following comments on the nutrition intervention programme:

(a) The combination of the pre-school centre community kitchen and mothers' group-the hallmark of the Sarvodaya programmes-not only opens up a unique opportunity for educating the mothers and the community at large about the social and physical development of children and basic health care for the entire family, but at the same time makes important educational, nutritional, and health services available to both mothers and children.

(b} The pre-school community kitchen is the most widespread community service in Sarvodaya villages, and caters to the health, nutrition, and social development needs of thousands of children. To a lesser degree this complex also provides health education and some health care to mothers prenatally and post-partum. This programme has served in liaison with the Government Health Service in bringing immunization and basic health care within reach of children and mothers in many Sarvodaya vi l loges.

(c) In a nutrition programme, it is essential to do regular monitoring and evaluation of beneficiaries' progress. This aspect is not given due priority, and there is no systematic record of progress either of individual growth or of morbidity and mortality within the community. This is a serious drawback and undoubtedly a weak feature in a non-selective nutrion intervention, and could well result in the waste of resources. Another aspect that calls for comment is the quality of training for volunteer workers. Most training staff are not professionals and have not been exposed to systematic programmes of health and nutrition education. Hence, the training imparted tends to be of low quality, as has been evident in some of the nutrition workshops conducted by Sarvodaya.

Conclusions on the Sarvodaya Programme

The outreach of the Sarovaya nutrition intervention is comparatively extensive and has the capacity of reaching almost 10 per cent of the rural villages of Sri Lanka. Some of these villages are in very remote areas and are not accessible through the conventional network of governmental health and nutrition programmes. Its methodology has induced the voluntary participation of rural people in
nutrition programmes, and this is undoubtedly a commendable achievement in view of the fact that the main goal of most national nutrition programmes is to bring nutrition awareness to rural people. The programme has also been able to draw in people with a sense of commitment and dedication, and this has enhanced the quality of service.

A main criticism of the Sarvodaya programme is its heavy administrative infrastructure, which is costly and tends to detract from the voluntary nature of the entire movement. Another aspect that limits the possibility of replicating this project on a larger scale is its heavy dependence on foreign donations-a feature that cannot be considered as a generally available long-term resource.

It must be stated in conclusion, however, that despite the shortcomings, the Sarvodaya movement, through its health and nutrition programmes, has created a substantial rural oriented infrastructure through which a continuous process of nutrition awareness is imparted from the centre. With more experience, its staff could improve the quality of its programmes, and there is good reason, therefore, to expect an improved system in the future.

THE REDO BARNA NUTRITION PROGRAMME

History

The Norwegian Save the Children (Read Barna) programme in Sri Lanka was established in 1974 with the opening of a curative health centre on Karainagar island in the District of Jaffoa. Thereafter, the organization gave further financial assistance to community development programmes in the district and decided to extend its programme into four new community development projects. In order to formalize its assistance, a general agreement of co-operation between the Government of Sri Lanka, through the Ministry of Plan Implementation, and Redd Barna was signed early in 1979. Under this agreement, Redd Barna, in consultation and co-operation with the Government of Sri Lanka, through the Sri Lanka IYC Sercretariat in the Ministry of Plan Implementation, either directly or in co-operation with local non-profit organizations, implements a programme of projects relating to urban and rural development, health, education, and other fields beneficial to the welfare of children in Sri Lanka.

The projects commenced in 1979 are of two types: la) settlement projects, where the landless, unemployed, or under-employed population from the surrounding areas are given assistance to settle and make their living in agricultural production; and (b) integrated community development projects aiming to improve the general standard of living,
with particular attention to child welfare in an already existing community.

Elements common to both programmes are: incomegenerating activities, preventive health and child care, community awareness-building, water supply and infrastructure, housing, and disaster relief. The importance of each component is related to the expressed need in a particular project area. There are 12 projects administered by Redd Barna, and of these 7 have health and nutrition components.

The aims of the preventive health and child care component are to: help the community understand that they are responsible for the children's health; teach the community to utilize public health facilities offered by the Government and understand their importance; make the community aware of the importance of hygiene in connection with health; increase the community's knowledge and understanding of the importance of immunization and child care so that more children are immunized; and finally, help the community to understand the importance of nutrition so that they are able to give their children a better start in life.

Administrative Structure

The Redd Barna administrative structure consists of a central secretariat in Colombo that coordinates the administration of each project under the charge of a project administrator. The resident representative in Sri Lanka is in charge of the secretariat as well as responsible for the different project offices that have their own staff. The central secretariat houses the administrative staff required for co-ordination, as well as supplies, transport, and stores. Additionally, there are expert project consultants from the secretariat who are required to advise on sectoral programmes such as health, agriculture, and engineering work. Project staff are mostly core administrative staff, as the Redd Barna methodology is to work through existing networks, preferably government departments, strengthening supplies or services as each case demands.

Health Programme

The Redd Barna health programme aims to carry out its activities in co-operation with the local health authorities. It is a programme of education and motivation through community health workers trained by Redd Barna in co-operation with local health authorities. Where projects are located in remote areas and difficult to reach and services are poor, steps are taken to improve existing preventive health facilities. This takes the form of building clinics, payment of travel allowances to government medical health officers, supplying equipment, etc.

One of the main components of the health programme is the training of community health workers. Selection is done jointly by the Rural Development Society of the area in consultation with a staff member of Redd Barna. The Society ensures the selection of a person they feel is suitable for village work, and the Redd Barna staff member ensures that the candidate has the correct aptitude for health work. The programme candidates were all female at the beginning of the programme, but a few males have since been recruited as well.

Training of community health workers is conducted for three weeks in the project area. The programme is planned by the Redd Barna health staff and involves government officers working in relevant fields, e.g., the Public Health Inspector and the Public Health Midwife. Each trainee's progress on the job is followed up for a planned period of two years, with ten workshops and refresher courses interspersed during this period.

Each health worker is assigned a group of houses, usually between 20 to 50 homes, which become her responsibility in terms of immunization of children, nutrition education, motivation for family planning, identifying suitable cases for supplementary feeding, "at risk" children and families, personal hygiene, and environmental sanitation. Each worker is paid an allowance of Rs 40 per month and has an average educational level of Grade 8. There are 180 community health workers in service.

Supplementary Feeding Programme

The Redd Barna nutrition programmes are directed mainly towards nutrition education and applied nutrition programmes through home gardens, poultry-keeping, cattle-rearing, etc. Project areas often expose cases of severely malnourished children requiring urgent rehabilitation. The possibility of obtaining thriposha was considered, but since it could only be obtained through a lengthy procedure, other methods of supplementary feeding were investigated.

It was then decided to make an indigenous preparation for supplementary feeding so that the organization could deal directly with the recipients and provide close follow-up. Several alternative mixtures with rice, soybeans, cowpeas, skimmed milk, sugar, ground-nuts, and green gram were experimented with by the Ceylon Institute of Scientific and Industrial Research. A weaning food was also developed at the Central Agricultural Research Institute, Sri Lanka, and further adaptations were made through the Soya Bean Research Station, Gannoruwa, Sri Lanka, to work out a village-level technology. Two mixtures were developed, one containing rice, soy, and flour and another rice, soy, green gram, and sugar. Both mixtures were fortified with vitamins and minerals.

Progress of the Supplementary Feeding Programme

The Redd Barna supplementary feeding programme is designed as a short-term project because the organization believes that supplementary feeding works against self reliance, and so it uses its experimental weaning food only as an urgent rehabilitative measure. In the meantime, its health and nutrition programmes will concentrate on educating mothers in the use of cereal-pulse mixtures in various forms as weaning foods, with frequent use of soybean preparations, and the identification and rehabilitation of malnourished children at home.

Costs

Two batches of 1,000 packets each weighing 500 grams were produced in March 1980 at a cost of Rs 4/50 per packet. These were distributed free to malnourished children under age 12, and to pregnant and lactating mothers identified by observation. The average monthly distribution of the weaning food has been less than 100 packets.

THE US SAVE THE CHILDREN NUTRITION INTERVENTION

History

The US Save the Children Fund (SCF), a private, non-profit voluntary organization incorporated in the United States, set up its Sri Lanka field office in July 1979 and began its first project in urban community development in a slum and squatter settlement in Kirillapone within the City of Colombo. This community, which consists of 439 families, represents the lowest income group in Colombo. Their substandard housing lacks even basic amenities and is the most squalid of the urban slum agglomerations in Colombo. While substandard housing is the central problem facing the community, all the associated ill effects spinning off from a combination of low incomes, poor housing, and official apathy seem to work insidiously to retain this community at the bottom of the socio-economic ladder. Grossly inadequate primary health care, low nutritional standards, non-participation in the formal educational system, lack of basic sanitation facilities, and social barriers preventing access to public services form part of the familiar syndrome of this disadvantaged community

The integrated urban community development project that began in JUlY 1979, while focusing on housing as its main development base, incorporates several other social and economic development elements, such as programmes for employment and income generation, health and sanitation, environmental sanitation, women's development, child care, and programmes to improve the physical infrastructure of the area. This integrated programme, planned through a sustained dialogue and interaction with the community, is implemented by the SCF staff acting in close collaboration with a community committee elected by the residents of Kirillapone.

Save the Children Organizational Structure

While the aim of the project is to motivate and mobilize community resources for development, such a plan of action requires patient, continuous work in co-operation with community residents. SCF uses a team of professionally qualified, experienced staff to co-ordinate these activities. The field office in Sri Lanka is administered by a director, assisted by a deputy director and a full-time staff of 15 persons.

These programmes are implemented by a co-ordinator for each main sector, there being a field co-ordinator broadly responsible for general community development, a woman co-ordinator for most activities relating to women's development, and a social development coordinator, who oversees the various work teams engaged in the production of roof sheeting and bricks and the workforce engaged in carpentry and masonry. Additionally, a small administrative and service staff completes the personnel of this organization.

The Health and Nutrition Programme

Long-range objectives are (a) to improve the social, economic, physical, and environmental conditions of low-income families through the active participation of members of the selected communities in development programmer; (b) to ensure that family health training and organization in the selected areas are consonant with national priorities in preventive health, reducing the burden of curative health needs; and (c) to eliminate malnutrition within the community

Immediate objectives are la) to strengthen access to existing health services for community residents; (b) to develop mechanisms for improving the standards of preventive health care and train selected community leaders to maintain and operate these mechanisms; (c) to improve the nutritional condition of the most vulnerable groups in the community measurably; and (d) to create an awareness of nutrition as a priority in the lives of children and demonstrate the means by which adequate nutrition can be ensured within the families' economic means.

The Health and Nutrition Setting within the Community

A baseline survey conducted by a research institute in 1979 identified the following health and nutrition conditions: Although the Government of Sri Lanka provides free
medical care, shanty-town residents, for a variety of reasons related to their socio-economic position within society, are unable to utilize existing medical facilities. Although most of the residents are aware of the problems of illness and disease, they are not adequately motivated to alleviate the underlying causes. An anthropometric survey of the children conducted by the Medical Research Institute revealed that, of a total of 32 pre-school children in the sample, 40.6 per cent suffered from chronic malnutrition and 12.5 per cent from acute malnutrition. The study also revealed that the level of disease prevention was low because of unsatisfactory hygienic and sanitary conditions. Of the persons ill within the 16 months preceding the study, children constituted 34 per cent and mothers 21 per cent. In spite of the fact that 76 per cent of the women surveyed responded affirmatively to the question relating to knowledge of health and nutrition, the actual conditions in which the women lived indicated that this knowledge was not applied.

Implementation of the Programme

The implementation of the health and nutrition intervention programme is through a band of trained health auxiliaries selected from within the community. They are all females with about an eighthgrade educational level and have received training in preventive health, child care, and family planning at the Colombo South Hospital, the Lady Ridgeway Children's Hospital, and the Population Information Centre of the Ministry of Family Health. Their work includes a population survey of all families and the identification of three target categories: family planning activities and education, the operation of a referral system to hospitals and clinics for women requiring sterilization or contraceptive assistance, and identification of children requiring urgent medical treatment. They also have to keep periodic records of the heights and weights of children under 12, and administer thriposha daily to all children in this age group.

Additionally, the health auxiliaries are required to monitor a regular deworming programme for children; render assistance in the fortnightly paediatric clinic held in the community; attend to the weekly dressing of wounds of children living there; make house visits daily to maintain records relating to immunization, family planning, and nutrition; and identify pregnant women and malnourished children.

The Process

All the above activities are carried out through a process divided into the following areas:

1. Paediatric clinic. A fortnightly paediatric clinic for diagnosis, treatment, and dispensing of drugs and medicines is conducted with the assistance of a corps of volunteer doctors and pharmacists. The health auxiliaries assist the doctors in dressing wounds and in the maintenance of clinic records. The clinic itself is being systematically linked with the Municipal Council Clinic, through which the community will, in the long-term, be served.

2. Home visits register. Health auxiliaries operate a referral system for children in urgent need of medical attention and men and women in need of family planning services with the existing health and medical care facilities in Colombo. The auxiliaries, having been assigned to on-the-job training at these institutions, are familiar with the level and types of services available in them and are effective in channelling community members into these services.

3. Nutritional status survey. A nutritional status survey was conducted by the health auxiliaries and will be repeated periodically for children under 12 years old, using the weight-for-height criterion. Data from the first survey are shown in table 1.

4. Supplementary feeding programme. On the basis of the survey, a supplementary feeding programme was begun in October 1979 and is still in operation, serving all children under 12 years of age and pregnant and lactating women.

A community kitchen was set up in the shanty town, and the health auxiliaries prepare different foods from thriposha that is obtained free from CARE. The thriposha clinic is open on weekdays, and different preparations are made on different days of the week, mixing the cereal with wheat, flour, coconut, sugar, salt, and green leaves. Each child and eligible mother is given 70 grams of thriposha a day for five days a week in premixed form, either as a soup, porridge, or as a steamed or boiled solid food. Of the 600 eligible children, almost 98 per cent attend this clinic on weekdays. It is open from 10.00 a.m. to noon, and from 1.30 to 3.00 p.m.

The clinic is run by the health auxiliaries under the supervision of the health co-ordinator, and the cost of obtaining thriposha supplies from CARE, transporting it to the community, cooking, preparing, and distributing it is borne by the Save the Children Fund.

TABLE 1. Findings of a Nutritional Status Survey

5. Nutrition education. The health auxiliaries are vested with the responsibility of counselling families on nutrition needs and are assisted by voluntary women's groups organized for mobilizing women towards development.

6. Day-care centre. A day-care centre is planned within the community setting. This centre will have a creches, and each mother is expected to serve the centre one day of the week. The opportunity for nutrition education will be provided to all mothers.

Costs of the Programme

The direct costs of the nutrition programme are the monthly stipends of ten health auxiliaries at Rs 250 per month. Sixty packets of thriposha are used daily in the community kitchen. Other direct costs, such as supplementary material for food preparation, are Rs 80 per day. On this basis, the direct costs of the feeding programme would be:

The approximate direct costs of the programme would be Rs 7,700 per month, for an average of Rs 13 per month, or Rs 156 per annum, per beneficiary.

Resources

The financial resources of the Save the Children project in Sri Lanka depend entirely on the funding arrangements between the parent body in the United States and the field office in Sri Lanka. Within a planned programme budget sectoral allocations are made each year, and these amounts are made available for different programmes. There is, however, an underlying assumption that this NGO bases its development programmes within a community on a needs assessment made before commencement of the project Such a plan of implementation usually takes into account the financial and material requirements of the project that would arise from time to time. It would not be unreasonable, therefore, to assume that the Save the Children Fund's community-based development programmes operate within manageable limits and do not face the resource constraints that other programmes of this type usually encounter.

SOME OBSERVATIONS ON THE CHARACTERISTICS OF THE THREE PROJECTS

Of the three community-based nutrition interventions reviewed in this article, there are significant differences in the methods of operation, the type of target beneficiary groups, the outreach, and cost efficiency. The Sarvodaya movement works in more than 2,000 of the 24,000 villages in Sri Lanka, and its outreach is far beyond the coverage of the smaller projects of Redd Barna and Save the Children. On the other hand, sustaining the Sarodaya programmes involves a gigantic administrative infrastructure almost similar to a large government department. The question that naturally arises is whether such a programme could not be almost identically implemented by a government department. It is useful to remember here that the governmental outreach to rural communities through medical clinics, rural development departments, and the conventional administrative machinery has failed to deliver the intended services because of defects and imbalances in its own implementation processes, as well as waste, bureaucratic ineptitude, etc.

A voluntary organization, on the other hand, is able to draw in people with a sense of commitment and has the advantage of flexibility in terms of selection of projects, areas, and personnel and even in the modification of plans in the light of experience. The Sarvodaya programme has benefitted from these advantages and has additionally created a sense of nutrition awareness in far-flung rural communities that have been bypassed hitherto in official development endeavours. The mobilization of rural communities in nutrition-oriented programmes is an achievement in itself, without which the outreach to these communities would have been greatly delayed. The use of the monolithic administrative infrastructure of Sarvodaya, however, tends to support the hypothesis that successful planning at the village level initially requires external mot iv at ion .

Another feature of the Sarvodaya nutrition intervention is that the programme is aimed at specific age groups in villages and not selected needy groups within such age groups. The scarce national resources it uses in its programme may therefore reach people outside those determined as national target groups for nutrition intervention. A point that emerges at this stage is whether a widespread movement such as Sarvodaya cannot better serve national nutritional programming by effectively using its organizational structure and outreach for an intervention with greater emphasis on nutrition education and a feeding programme based on village nutrition resources.

Redd Barna is making a conscious effort to serve nutritional needs by a long-term programme of nutrition awareness and education and meets current urgent rehabilitative needs through supplementary feeding based on locally available food materials. The Redd Barna approach is distinctly different from Sarvodaya in that its dependence on its own cadres for community health work is minimized, and it seeks to strengthen public services where delivery of such services is inadequate, complementing this effort by creating nutrition awareness within the communities in which it works.

Save the Children makes a more intensive effort by having an almost case-work approach to nutrition and community health in its project. It has the advantage of a relatively small project area within which all its programmes can be integrated, and such an effort is bound to show early results. The replication of such an approach on a larger scale may not be cost-efficient, but since this project has a demonstrable impact, the useful elements in its methodology could be identified for replication on a larger scale elsewhere.

The unique features of the small-scale NGO programmes such as Redd Barna and the US Save the Children lend themselves to testing and evaluation more easily than large-scale projects do. The SCF programme, for instance, covers almost 100 per cent of its target groups, and this is made possible by the intensive nature of its health auxiliary system. The administrative system that makes this possible -the maintenance of health records for each household- could be a useful method for dealing with disadvantaged urban communities.

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