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III. INCORPORATING NUTRITION INTO THE PALAWAN INTEGRATED AREA DEVELOPMENT PROJECT IN THE PHILIPPINES
Background
Traditionally, combating malnutrition has implied programmes designed explicitly to improve nutritional wellbeing: child-feeding, nutrition education, and food enrichment or fortification. Indeed, these types of programmes have occupied the major attention of the international nutrition community for the past few decades. There is, however, general recognition today that the effect on nutritional status and food consumption levels of these direct nutrition interventions is far less significant than that of broader development programmes, particularly those related to food, agriculture, and rural development.
The problems facing the nutrition community in this regard are basically twofold: (a) We not only lack knowledge of the specific nutrition/consumption effects of these programmes but often do not even know whether these effects are positive or negative. (b) We generally have been incapable of affecting broader development policy and programmes on nutritional grounds.
In both cases the problem emanates from the traditional orientation of development planning. The formal, neoclassical development theory of Harrod-Domar, Fei-Ranis, and others, taught in American and European universities in the 1950s and 1960s, stressed investment-oriented planning and conservative monetary and fiscal policy. The emphasis was on growth of "capital stock" capable of generating high rates of return. In this context, social programmes were regarded as unnecessary, wasteful diversions, because, according to the planners, social gain ultimately would accrue from these physical investments.
The orientation of these neo-classical economists placed high premiums on industrial growth and gave little attention to the agricultural sector. During the 1960s, with new concern for food availability, this primary emphasis was shifted to the agricultural sector. However, the basic investment/production orientation was also transferred, nearly intact, from industry to agriculture.
Although agricultural production and rural development programmes often are justified by governments and international agencies as means of alleviating hunger and malnutrition, these programmes, once funded, usually are pursued in the traditional manner, with premiums on productivity, yield, and higher incomes for the producers. It may not be ultimately important to the planners of these programmes (a) that the producers themselves are not the hungry, (b) that the choice of production technology may not employ the hungry, or (c) that the crops produced may not be those consumed by the hungry.
During the 1970s the emphasis on basic human needs as a development orientation appeared, for a time, to be capable of shifting these premiums. In fact, the net effect of the basic-human-needs thrust appears to have been a slight increase in programmes explicitly addressing these needs: health, nutrition, potable water, sanitation. Meanwhile, the mainstream development programmes, capable of significantly addressing these needs, have continued largely unaffected-if anything, strengthened-by the recent dominance of the "Chicago School" of economic thought and the International Monetary Fund. Agricultural development planning, as taught to planners and policy-makers from low-income as well as industrialized countries, continues to place its highest premiums on rates of return, cost-benefit analysis, and foreign exchange earnings. Problems of poverty and malnutrition are recognized undoubtedly much more than before, but their solution is said to lie not in the reorientation or softening of the basic development thrust but in special programmes-costing at most a few per cent of the national budget, and emphasizing in each case technology rather than the transfer of resources.
The Project
It is against this backdrop that the design process of the Palawan Integrated Area Development (IAD) Project in the Philippines becomes significant. Everything about the project-its components, the foreign consultants involved in its design, and the funding sources - suggested a traditionally designed orientation, like that of previous IAD projects in the Philippines and elsewhere. Yet a combination of perceived national priorities, specific individuals, and timely financing permitted, perhaps for the first time in a non-socialist developing country, the large-scale influence of nutrition considerations in a major rural development programme-in this case, one with a budget of US$84 million.
The Palawan IAD Project is one of seven such multisectoral projects planned or being undertaken in the Philippines. Project planning, carried out over the course of several years, was completed in 1981. Implementation is now scheduled to begin in 1982. Palawan, physically the largest province in the country, comprises 1,768 islands and a population exceeding 300,000. Roughly 80 per cent of workers are engaged in rice, corn, coconut, or fish production. Seventy-five per cent of households have incomes below the nationally computed poverty line.
The ten-year project (in two phases of five years each) seeks to take advantage of the supposed synergistic relationships among development sectors by simultaneously addressing lowland and upland agriculture, irrigation, livestock and fisheries development, forestry, roads, cottage industry, port development, village water supply, and malaria eradication.
The Nutrition Factor
In retrospect, the inclusion of nutrition considerations in the project design and the agreement to use nutritional improvement as a primary evaluation criterion resulted from a combination of three factors:
a. the considerable lip-service paid to nutrition by the Philippine Government and the perception by the Asian Development Bank that improved nutrition was a central development priority of the Government;
b. the leadership role of Marito Garcia, a committed project leader, well versed both in economics and nutrition, in the National Nutrition Council (NNC), coupled with the receptivity of key individuals responsible for the Palawan IAD Project; and
c. key inputs from the Food Policy and Nutrition Division of FAO.
According to Palawan project staff members, the project design process was initiated using traditional production potential as the primary criterion, basing decisions purely on technical and economic considerations. The decision to introduce nutritional factors into this process was triggered by the Asian Development Bank, an institution not itself actively involved in nutrition issues in the past but anxious to reflect in its loans the development orientation of the recipient nation. The ADB, in turn, was influenced in this regard by staff members of the NNC involved in food and nutrition planning and potential participants in a six-country FAO-sponsored study on the introduction of nutrition objectives into agricultural and rural development. The NNC staff were successful in utilizing official government rhetoric to convince the ADB that incorporation of nutrition considerations in the Palawan project design was consistent with the Government's development policy.
The Palawan IAD Project staff admit that without this intervention there would have been virtually no chance for inclusion of nutrition criteria. The foreign consulting firm involved in project design refused to accept either the legitimacy of nutrition criteria or the methodology proposed by the NNC and, indeed, continued to ignore nutrition for the remainder of their consultancy. They were, however, ultimately overruled, with intense lobbying by the NNC project leadership on the assumption that the ADB and the Government wanted nutrition included.
Incorporating Nutrition Considerations
The plan pursued by the NNC consisted of the following:
a. an initial assessment of the food and nutrition problems in Palawan, relying mainly on secondary data and a short field reconnaissance survey that lasted for two weeks;
b. an in-depth nutrition study of 1,000 families in the project area, with data collected on nutritional status, food consumption, and socio-economic and demo graphic variables, in mid-1980; these data were analysed separately by area and occupation group, the latter broken down by categories of farmers, fishermen, and other labourers;
c. incorporation of the nutrition findings into the overall project planning; and
d. incorporation of nutrition criteria into overall project monitoring and evaluation; this is to include ongoing monitoring, a mid-project assessment, and a post-project evaluation.
On the basis of the survey data, the NNC staff was in a position to become fully integrated into the final process of project design. Their influence on the design was considerable. Among the more important contributions were the following:
1. The targeting of areas and population groups in the upland and lowland agricultural components of the project was adjusted to address those areas and groups most vulnerable in terms of nutrition and food consumption. Particular emphasis was placed on the slash-and-burn farmers in upland areas, who were found to be nutritionally at risk.
2. Provision was made to give increased attention to food crop production in upland areas where a nutritionally vulnerable population traditionally has been employed in the production of cash crops. This included provision for intercropping and for holding aside specific areas for the production of cassava and other root crops.
3. Attention was directed to the extremely low food consumption levels and nutritional status of subsistence fishing families. The project design was modified to give greater attention to this group.
4. Decisions on the placement of roads and potable water programmes were based, in part, on nutritional considerations.
5. Attention was directed to the risk of exacerbating malaria in endemic areas through increased irrigation that would provide additional habitat for mosquitoes.
6. A decision was made to include a nutrition programme component in the Palawan project, mainly an expansion of existing Philippine Nutrition Programme activities {nutrition extension workers, child weighing, supplements, and nutritional rehabilitation) being implemented under the NNC.
Throughout the final planning process there was a careful weighing of these nutritional criteria with other economic and technical criteria. Sometimes these appeared to be in direct conflict. It was argued that malnourished workers, suffering from anaemia, for example, and in need of project inputs to improve their overall well-being might be less productive and thus compromise project efficiency criteria. Nonetheless, discussions with the concerned individuals suggest that the nutrition advocates were equal partners in these deliberations, and roughly 50 per cent of their recommendations were ultimately accepted.
Long-Term Effectiveness
The long-term value of this planning, of course, can only be determined once actual programme operations are under way. Even when equity and welfare considerations are built into planning, there are many ways in which project inputs can be diverted to the local elite once implementation begins. The history of development bears considerable testament in this regard.
In the case of the Palawan project, the role of nutrition advocates in the planning process appears to have been highly positive. Efforts are continuing to use nutrition and food consumption levels as primary evaluation criteria. If monitoring is done on an ongoing basis, as currently planned, it will be possible to determine fairly quickly whether the desired benefits are accruing to the target groups.
The concern at present is that, if nutrition-based evaluations are carried out mechanically, they may indicate only whether or not target groups have received nutritional benefit, providing little insight into why or why not, and there would be only a tenuous connection between these data and project operations per se. This would be the case if the evaluative studies, like the earlier in-depth nutrition study, were limited to the collection of data on nutrition, food consumption, and socio-economic status. The in-depth nutrition study, though creatively analysed and used, was in reality a fairly traditional nutrition survey-one that might have been used for any purpose-and had little specific relationship to the project at hand.
In order to avoid this problem of disconnectedness, it is necessary to think beyond the collection of nutrition/ consumption data, in both the planning and the evaluation processes. (Curiously, the FAO guidelines for these projects explicitly discouraged the collection of data on food consumption. Granted that it is difficult to collect fully reliable data, it is nevertheless strange to approach the task of improving food consumption through development projects without collecting data on it. To their credit, the NNC decided otherwise and collected and used these data, which proved to be critical for inputs into the design of the project.) Using the phasing of the Palawan nutrition integration as an example, it might have been appropriate to use the initial assessment stage as an opportunity for a series of open-ended discussions with families characterized by inadequate food intake or malnutrition. The purpose of these discussions would be to determine, from these families themselves, their own perceptions of the constraints inhibiting improved nutritional well-being, and the difficulties faced in seeking to overcome these constraints. Another (or an additional) way of conceptualizing this is to determine, through such conversations and additional data collection, the causality of malnutrition, i.e., how much of the malnutrition found is a function of inadequate local food availability, low income, high prices, systemic or enteric infection, or deleterious belief patterns, and which of these lend themselves to intervention. While project documents discussed causality, no explicit causality analysis was undertaken.
With this information it would be possible to develop specific hypotheses that could then be tested empirically in the data collection processes during project planning and evaluation. The data, in turn, together with data on nutrition and food consumption variables, would provide the basis both for focusing project inputs and for understanding better the "why" or "why not" of project results.
Examples of hypotheses that might be developed and tested in IAD-type projects are the following (selected arbitrarily and not necessarily specific to the Philippines):
- Poor subsistence cultivators are unable to obtain credit for agricultural inputs because they lack formal title to the land.
- Among otherwise landless families, home garden production is limited by the absence of seeds and agricultural extension, reserved, in practice, for those who produce a marketable surplus.
- Cash-crop producers are periodically faced with low returns, but, even in good years, fail to benefit from the country's foreign exchange earnings.
- Families are reluctant to provide solid supplementary food to young children even when it is available, for fear of diarrhoea, which they do not know how to prevent or treat effectively.
While it may be argued that the collection of information on such hypotheses should be part of the overall project planning and evaluation process, the truth is that data collection on agricultural and rural development projects rarely goes beyond information on goods and services delivered, physical returns, and productivity (e.g., the number of roads built or canals dug, the number of seed multiplication nurseries established and on-farm demonstrations held, and the effect of these on water supply, soils, and yields). To understand the basis for nutritional improvement or the lack of it, these physical data are necessary but not sufficient. Between such physical data and those on nutritional status lies a considerable knowledge gap that must be closed if these nutrition components are to be successful.
The practice followed in the Palawan nutrition survey and others organized by NNC is to hire enumerators (college students or recent graduates from the area) specifically for this purpose. These enumerators are not involved in analysis or interpretation. Thus, there may be little direct contact between staff responsible for use of the data and the malnourished target families themselves.
It will be important to watch the Palawan IAD Project carefully in the coming years. The project, as now designed, offers considerable potential for nutritional benefit and will provide important data on which future efforts of this sort might be based.
IV. THE LUMBUNG DESA SYSTEM IN NUSA TENGGARA TIMUR, INDONESIA
Background
The province of Nusa Tenggara Timur (NTT), comprising Timor, Flores, Sumba, and some one hundred other islands in south-eastern Indonesia, has a population of 2.8 million. Much of NTT is characterized by semi-arid, hilly terrain. it is regarded by the Indonesian Government as its poorest province as well as a traditionally food-deficient area.
The province's most important developmental advantage is that, like most of the rest of Indonesia outside of Java, there is essentially no rural landlessness. (There are, however, complex patterns of kinship ownership and land-use right and of active seasonal migration.) Landholdings average roughly two hectares, though often producing only one harvest of a given crop per year.
In this situation, concern with levels of food consumption is not a matter of access to productive resources as is the case on Java. Rather, it is a matter of food security, of protection against natural disaster (the high incidence of drought, excessive rain, or destructive winds), and the traditional musim paceklik, the famine season, which usually occurs during the last few months of the year. Farm families, particularly those with smaller holdings, are highly vulnerable in this situation. When yields are inadequate and food runs out before the January-February harvest, these families are faced with market prices for corn that have tripled or even quadrupled relative to harvest prices.
Food and Nutrition Policy
Although the NTT provincial government does not speak explicitly in terms of food and nutrition plans or strategies, it has worked out, with considerable care, a multifaceted policy designed to take advantage of provincial resources and meet food needs. The policy is based on a map of surplus and deficit areas of the province, painstakingly developed over a period of several years. (Data availability and reliability in Indonesia historically have been problematic. The data situation for the less-studied outer islands is much worse than for Java.) The map distinguishes by colour between kecamatans (districts) that have a surplus, those that are borderline, and those that have deficits.
The first prong of the policy involves purchase and movement of surplus corn from the areas with a surplus to areas with a deficit. Because of high transport costs (an estimated four to five times the average transport costs on Java), little of this surplus is moved by private traders. The provincial government has also been setting up regional storage facilities to help this process.
The second prong involves differentiated development strategies for different areas of the province. In the areas with a surplus the government is pursuing a crash programme to increase agricultural production. For the less arable borderline and deficit areas, where there may be difficulty in increasing crop production substantially, programmes have been developed to raise rural income through fodder production, fisheries, and forestry. The government stresses the importance of income generation in these areas to assure adequate effective demand to purchase the corn increasingly provided from the surplus area.
The Lumbung Desa System
The third prong of the policy involves protection against food insecurity, primarily in the deficit areas, through the system of lumbung desa, or storage at the village level. This is a recent revival of a storage system that operated in some areas under the Dutch colonial regime. The system operates in three forms in NTT:
1. Under the Dinas Pertanian (Agriculture Department), since 1979, credit packages of corn seed and fertilizer have been given to farmers located in the food-deficit kecamatans and owning less than one hectare of land. The credit package depends on the amount of land owned. Farmers pay back the loan in the form of an equivalent value of corn, which is stored in a lumbung desa and managed by the village government. Then, during the musim paceklik, this corn is available on credit to families in need, with repayment at the time of harvest. At present this system operates on a small scale in eight kabupatens (counties: Kupang, TTS, Flores Timur, Sikka, Ende, Ngada, Sumba Timur, and Sumba Barat) and is scheduled for rapid expansion.
2. Under the Provincial Development Programme (PDP), and with assistance from USAID, there is provision for food credit (kredit bahan makanan) as well as monetary credit (kredit yang). This programme has been operating since 1978 in six kecamatans located in three kabupatens (Belu, TTU, and Alor). In this case, programme funds are used to purchase corn, rice, and mung beans that are available on credit to families certified as needy by the village motivator, who plays a key role in the establishment of PDP activities as a whole in the village. Borrowers have six months to repay the food, which is borrowed at an interest rate of 1.5 per cent month. The loan is guaranteed by the village group as a whole.
3. The largest number of lumbung desas, however, have been developed by gotong royong (self-help) village groups with relatively little government input beyond encouragement. Here, the capital is provided by the villagers themselves, who decide on the basis of group meetings how much food each household will contribute (the input of each family is the same regardless of household size or assets), who may borrow, and how much.
In one village of 330 households in TTU kabupaten, 75 ikat of corn were collected during 1980 (one ikat = 60 ears), and were distributed to 33 households during the musim paceklik. In 1978, a particularly bad year, the village collected and distributed a much larger quantity. Occasionally, the group will decide to sell a portion of the corn it has collected for some common good (e.g., a new building). In this village, borrowers were expected to pay back double the amount of corn borrowed. In other areas the repayment rate is one and a half times. Some farmers we talked to admitted that the terms were stiff but not unfair, considering the relative prices at musim paceklik, and all agreed that vulnerable farmers are the ultimate beneficiaries.
The stock of food in the lumbung desa can be supplemented by the government in one of two ways:
a. Beyond the major grain movement referred to above, the provincial government frequently purchases surplus peeled corn (which is easier to transport) and provides it to the lumbung desa for sale to members. The group then repays the government in cash, setting in motion a revolving fund.
b. In 1980, because of earthquake disasters, the central Government provided to the province 50 tons of rice per kabupaten. The provincial government sold this rice on the open market, and, with the proceeds, purchased corn from surplus areas and distributed it to existing lumbung desas in deficit areas for dispersal in the traditional, group-determined manner. This is a case of triple targeting:
(i) a lower status food
(ii) sent to deficit areas
(iii) for distribution to the most needy families.
The lumbung desas are simple, thatched structures atop four wooden poles and protected against rodents by tin wrapping around the poles and/or shelves farther up the pole. The community structure is similar to those used by individual families. Occasionally fires are lit on the ground below to smoke out insects, but during the dry season this is seldom necessary. While this technique works well for traditional corn varieties, it is not effective for storage of the new high-yielding varieties, on which the husk is less protective. Separate provision and storage techniques are used for peeled corn and for rice when these need to be stored.
We were told that each of 112 villages in kabupaten TTU has a lumbung desa but that not all of these are actively functioning. In our random interviews with small farmers in the area, we learned that:
- farmers are anxious to participate in such a system (all those with whom we spoke were from villages with lumbung desas);
- farmers themselves are the clear beneficiaries of the system; and
- where the system is functioning actively, no one goes hungry; the only exceptions identified were recently widowed women.
Our questions about seasonal food consumption revealed that, where lumbung desas exist, consumption of the basic staples does not decrease at the time of paceklik. We also found that in some areas, a second type of "paceklik insurance" operates in the form of cassava kept in the earth until needed.
Complementarity with Health and Nutrition Services
There is little question that the lumbung desa system, in providing food security, has increased food intake and prevented serious deterioration of nutritional status among vulnerable groups during the annual famine season as well as during natural disasters. Thus, it clearly represents a nutrition intervention, although such language may be unlikely and unnecessary in that context.
Beyond its own capacity to improve nutritional wellbeing, however, the lumbung desa system would seem to have the potential for increasing the effectiveness of more traditional community services in health and nutrition.
It is relatively clear that, in the presence of serious food insecurity or calorie shortage, health, nutrition, and family planning services always are at a distinct disadvantage. Neither the medical black bag nor nutrition education materials can provide food per se, which, in its absence, can dwarf all other basic needs. Maternal-child health services are at a comparative advantage in dealing with children whose major problem is hunger, particularly when, as in Indonesia, the food budgets of health/nutrition programmes are small or non-existent. Also, family planning programmes never operate at their best when the survival of existing children is in question, or, more generally, when a family's outlook for the future is bleak.
Where means exist to reduce or eliminate this primary concern, complementarily with the provision of services would seem direct and substantial. If so, there would be major advantages in locating new health/nutrition services, and/or new lumbung desas, in a manner to take advantage of this complementarily.
Where such food security and health/nutrition services exist side by side, several attractive opportunities present themselves to take advantage of the complementarity:
1. A nutrition surveillance system could be established with some assurance that, once problem areas are identified, food assistance could be provided immediately. (Normally, the issue of timely response represents the major stumbling block in efforts to establish workable surveillance systems.) This would require agreement that, in such cases, food stored in lumbung desas could be used immediately for relief purposes, with subsequent reimbursement from central or provincial stocks. Such provision already exists in the PDP Programme, under which food stored in lumbung desas can also be used to meet crises in neighbouring areas, but there seems to be no such provision under the Pertanian or gotong royong systems.
2. Special arrangements could be made for the provision of food from the lumbung desas for children identified in child-weighing programmes as being seriously at risk. Similarly, where nutrition rehabilitation activities are undertaken for these children, food might be provided from the lumbung desas. In agreeing to such an arrangement, the community is essentially consenting to use its common pool of food not only to protect its families against food shortage but also to protect its young children against malnutrition. One of the problems that has plagued the community nutrition programmes in Java from the outset has been its inadequacy in dealing with children whose malnutrition is poverty determined and who, by definition, will not improve with inputs of nutrition education, oral rehydration fluid, or referral to the puskesmas (health centre) (see the following section on the UPGK Programme in Indonesia).
It should be emphasized, however, that, even in the absence of these special arrangements, the location of health/nutrition services in proximity to lumbung degas should improve their effectiveness, simply because the first limiting factor-food insecurity-will have been removed.
Overall, the lumbung desa system appears to represent a sensible and rational food security component of the province's food and agricultural policies. Unquestionably, much of its value results from its response to felt needs at the local level. The system, as indicated, operates extensively in TTU kabupaten. It apparently operates less extensively in some other Parts of the province and in some other provinces, particularly on Limbok. Before any government efforts are initiated to extend this system, it would be important to understand the basis on which existing lumbung desas have been established, and whether there are culture-specific considerations that may make establishment more appropriate in some areas than others,
V THE INDONESIAN FAMILY NUTRITION IMPROVEMENT (UPGK) PROGRAMME
Background
Many governments of low-income countries, even those purporting to be committed to the alleviation of rural malnutrition, have in actuality been unwilling to develop, or incapable of developing, services at the village level. Instead, health services are developed in a hierarchical fashion with the bulk of resources used for urban hospitals and capital-intensive medical care and research and smaller amounts provided for rural health centres with a highly curative orientation. Sometimes provision is made for workers in the centre to perform outreach services in surrounding villages.
At the same time, important studies in India (Project Poshak) and elsewhere (e.g., the report of CARE's preschool child-feeding programme [11]) indicate clearly that, unless health and nutrition services are provided at the village level and with substantial village initiative and participation, they are unlikely to be successful. In general, even integrated health and nutrition services at the primary health centre (serving perhaps 15 villages) are incapable of reaching:
- the poorest families, particularly those of landless agricultural labourers;
- the youngest children, those below the age of two or three years; and
- those living farthest from the centre.
Furthermore, even those who do come to the centre do so for curative purposes, rarely permitting continuous preventive health initiatives or the ongoing identification of children nutritionally at risk.
Finally, most child-feeding efforts carried out through such health centres fail to provide the desired nutritional effects because they are inadequately integrated with nutrition education and the management of diarrhoeal infection. The CARE report found that in parts of India and Pakistan, where the norm is delayed introduction of solid food, take-home food from the centre was rarely given to young children. No effort was made in the process of food distribution to disseminate information on the importance of early solid food supplementation while continuing breast-feeding. Also, no effort was made to address the fear behind the reluctance to introduce solids, namely diarrhoeal infection, often the number-one killer of young children. Yet through the use of simple oral rehydration it is now possible to safeguard against dehydration and death from diarrhoea, and thus allay parents' natural fears about food supplementation.
The Project
The Indonesian Family Nutrition Improvement Programme, or UPGK, must be appreciated against this backdrop, for it probably represents the first large-scale effort to present nutrition services to the community in a manner that addresses each of the above concerns.
The UPGK, developed between 1974 and 1977, was a unique outgrowth of at least four sets of initiatives that proved to be highly complementary:
a. nutritional concern and activity in the country (governmental and academic) going back at least 15 years, but focused on the Applied Nutrition Programme (ANP) model that was generally found to be deficient;
b. a change in senior government personnel responsible for community health and nutrition activity-the new leadership was not tied to previous programmes and was willing to take a fresh look at programme needs;
c. pilot-project activity emanating from efforts of medical students and faculty at Gajah Mada University in Yogyakarta;
d. timely inputs and support from UNICEF.
The basic philosophy underlying the UPGK Programme is that the critical agent of change is neither the health centre nor the community health worker, but the mother. The ultimate task of the health centre (the puskesmas, located at the kecamatan, or county, level) and the community worker is to support the mother in this task: assisting her to see when her child is nutritionally at risk, and providing her with the means of improving her child's well-being. In doing this, the programme, in theory, can become viable and self-perpetuating without continuous external, assistance .
At the village level the community-based activities are initiated by trained village nutrition volunteers, termed cadres. The major activities undertaken are the following:
1. Ongoing identification of children nutritionally at risk through monthly community weighing of children under the age of five. This community weighing represents the focal point of all UPGK activities and also increasingly those of community health and of integrated family planning/ nutrition activities. Child-weighing, originally done with imported scales, then local market scales, and finally locally produced, inexpensive balance scales, is recorded on a carefully developed, colourful growth chart that has already been used as a model for weight surveillance programmes in several other countries. (There has also been discussion of a special weight card given to children whose weight has increased three times in succession, and the holding of village weight gain competitions.)
2. Mothers of children who fail to gain weight are, in theory, given guidance on means of improvement. Among the most important guidance is the need for solid food supplementation if it has not yet been introduced, and the use of oral rehydration fluid, either packaged or home-made, if the problem is diarrhoea. Other nutritional first aid, mainly vitamin and mineral supplements, is also dispensed at weighing sessions. There is also theoretical provision for referral to the puskesmas.
3. Children who fail to gain weight over three successive weighing periods, or whose weight falls below the red danger line, are in some areas now eligible for nutrition rehabilitation. This problem of ongoing growth failure and severe malnutrition has probably, in fact, represented the most difficult problem to address in the UPGK Programme, as is the case with many community health and nutrition initiatives. The original plan was for supplementary feeding at the village level for all young children. Some government funds and village resources were used for this purpose, but there was also heavy reliance on internationally donated food. Inevitably, this flow of food was irregular, and its interruption or cessation often had a serious negative effect on programme operations as a whole.
The plan now is for supplementary food to be provided only for malnourished children at nutrition rehabilitation centres established at the kecamatan-level puskesmas. A small number were scheduled to begin operation in 1981 on a trial basis. It may therefore be several years before the effectiveness of this approach in Indonesia can be determined.
4. Once a month there are supposed to be educational demonstrations for all mothers and children on the subjects of infant feeding and weaning, sanitation, immunization, diarrhoeal control, family planning, and food preparation. A small budgetary allocation is made for the purchase of foods for these demonstration purposes
5. Home and village gardening is supported by the village cadre with technical assistance from agricultural extension workers. In low-income areas, seed for this purpose is also distributed.
At present the UPGK Programme includes (a) a basic package of services, including child-weighing, education, nutritional first aid, and health-care referral, and (b) a complete package of these plus nutrition rehabilitation and intensive home food production. The complete package is designed specifically for poorer kecamatans,
At the central Government level, the UPGK is supported by several departments and agencies, most importantly the Health, Agriculture, and Religious Affairs departments and the Family Planning Agency. At the local level, efforts have been made to generate the support of village heads and community leaders. There has also been a unique effort to win the support of religious leaders through orientations and the publication of materials endorsed by the official national Islamic organization, which reproduce passages from the Koran that set forth principles of food sharing and community co-operation like those being followed in the UPGK Programme.
Rather than establish a precedent for ongoing continuous government inputs in each village, the Government has decided to limit these inputs to two years per village, a time period considered adequate for villages to organize themselves for these purposes, set up the activities, and train needed personnel. Beyond the two-year period, villages will receive only growth charts for new-born children and nutritional first-aid commodities.
On this basis, roughly half the villages in Indonesia are scheduled to be reached by the end of Repelita 3 (the third five-year plan) in 1983. Of these, 34,000 villages are to be covered by the basic package by the family-planning organization, and 10,000 are to receive the complete package under the Health and Agriculture ministries.
Assessment
There has been no formal assessment thus far on the actual benefits of the UPGK Programme in terms of deaths avoided or improved nutritional status. It is also too early to tell how many villages will continue these activities once the two-year government support ends. Some suggest that such assessment, at present, would in any case only be misleading. They argue that the role of the cadre is that of connector or catalyst, a partially social function that, by definition, can only be expected to modify behavioural patterns slowly over time, and that the expectation of quick, empirically supportable benefit is unrealistic. Nonetheless, the recently introduced data forms (requiring monthly data on the number and percentage of children gaining weight) should provide at least some indication over time of trends in programme effectiveness. Some effort is now being made to have these simple data displayed publicly in villages and used as a measure of village development.
The one existing micro-study of programme effectiveness was undertaken in East Java in a small number of villages included in a World Bank-assisted Nutrition Intervention Pilot Project. After three years of project operation, the study found a reduction in severe malnutrition (third degree, using Indonesian standards) from 14 to 3 per cent of young children, while mild and moderate malnutrition (first and second degree) dropped from 35 to 20 per cent. These results are comparable to some of the best international results taken from pilot and research projects. The study further indicated that, after three years, an average of 60 per cent of children were gaining weight each month as opposed to 50 per cent at the outset.
Of course, these study results, though impressive, need to be interpreted cautiously, not only because of the small sample and the unusual effort and attention focused on the village, but also because the prevalence of severe malnutrition found at the beginning was so unusually high (more than three times the national average) and quite possibly was a function of harvest or employment level rather than of behavioural patterns per se.
In the absence of more empirical data on programme effectiveness, reactions to the UPGK Programme are only impressions. There is general recognition that programme operations are improving with experience, better materials, and better-trained personnel. At the same time, there are important concerns about the organization of community health, nutrition, and family-planning activities in general and their rate of multiplication.
The problem is almost inherent in top-down bureaucratic systems-and virtually everything related to public policy in Indonesia is top-down. From the top (ministries or agencies in Jakarta), discrete vertical programmes in nutrition, immunization, water, etc., are developed almost always on the basis of initiative and funding from one of the many international assistance agencies working in this field. With this financial support, upper-level bureaucracy for each of these discrete programmes fills up rapidly. This bureaucracy inevitably is pressured to produce results that can be used to satisfy agency home offices in Geneva, Washington, or New York. All too often the results on which the highest premiums are placed are programme expansion and financial expenditure.
While positions fill up at the top, however, the number and quality of workers at the local level increase much more slowly. The ultimate village worker, the cadre, is not a paid government worker at all, but a volunteer. Yet most of these discrete vertical programmes rely on the same set of local staff for actual field implementation.
The results of such a pattern of vertical programmes, international pressures, and bureaucracies that are top-heavy but bottom-weary are inevitable:
- Programme expansion takes place much too quickly and is based on countables-e.g., number of villages served, number of health workers, number of scales distributed, number of children weighed-with little attention paid to substance and quality control. Although originally designed as an education-sensitization programme, actual activity sometimes amounts only to mechanical weighing, with no educational element whatever.
- In some areas there are as many as seven separate, vertical village-health-worker programmes operating, each relying on the health centre and many of the same village workers.
- Little effort is given to follow-up and support systems once the volunteers are trained and the physical inputs delivered. One striking finding is that, of one set of health cadres originally trained, only 6 per cent are still functioning. Overall, an estimated 30 per cent of cadres drop out after the first year. At present there is no provision for retraining. The common occurrence is that activities last for three to six months and then die of inertia, in a top-down system another inevitability when "no one tells us what to do," or when "we have already met the stipulations of the manual."
Most of the other specific difficulties identified in operational evaluations trace back, in some fashion, to the above structural problem:
- Many of the cadres have been unable to explain clearly to villagers either the advantages of weighing or the appropriate follow-up.
- In some areas, as a result, mothers were found to follow the programme because they had to, or obtained an input without any purpose.
- Referral to the puskesmas is rare, and, when it does occur, the puskesmas often is at a loss to know what to do. More generally, the puskesmas has constituted something of a weak link in the system. There is seldom adequate understanding of, and usually little support for, these village programmes among puskesmas staff, who themselves have had no training in community nutrition.
- Villagers themselves are often ignorant of programme purposes, and almost always confused by the overlap of competing activities.
- In one case, an external agency involved in nutrition education disseminated materials with messages directly in conflict with those of government materials.
- There has been inadequate synchronization in the delivery of materials, equipment, and funds. In one case in Central Java:
(i) training funds were delivered in August 1979;
(ii) funds for village food demonstrations were delivered in June 1980;
(iii) cooking utensils for these demonstrations were delivered in September 1980;
(iv) the guidebook was provided in June 1980;
(v) the forms were delivered in November 1980.
While these problems are in part the result of the top-down, discrete vertical-programme pattern of government services, a top-down system that works well has some capacity to deal with these problems. In Indonesia, operations of the government machinery have been improving to the point where problems such as those noted above are in time recognized at the central level and new top-down remedies are set in motion to deal with them. In the case of community services in Indonesia, the combination of central government officials and international agency collaborators represents a more effective base for such remedial action than that existing in most hierarchical government systems.
Overall, it is likely that a formal evaluation of the UPGK Programme at present would find a continuum of programme effectiveness and benefit. More than likely, benefits have been most impressive in villages where the programme has responded to felt local needs. (Some villages not included in the government's initial activities succeeded in initiating them themselves.) These villages will also be those most likely to continue UPGK activities once government support has been concluded.