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Malnutrition in the 1980s: roles for the international agencies
Robert J. Muscat
INTRODUCTION
This is a summary of a study commissioned in 1982 by the Sub-committee on Nutrition (SCN) of the United Nations Administrative Committee on Co-ordination.* The SCN is a co-ordinating body composed of most UN organizations active in the field of nutrition, and associated with several bilateral aid agencies. The terms of reference were as follows:
The consultant will study the changing nutritional conditions of the 1980s and the implications for the UN and other international agencies. The study will cover: the scope and nature of the problem and the future outlook; government efforts, approaches, constraints, priorities, and preferences; the priorities, programmes, and services of the international nutrition system and the future perspective; particular attention will be paid to operational issues of implementation and co-ordination at the field level.
Although the study attempts to sketch the economic environment, and draws conclusions on steps to deal with some of the implications, it stays close to nutrition per se and the nutrition/health/consumption nexus. Thus it does not go into the need for measures to increase aggregate growth prospects, incomes of the poor, food production, etc., despite their great importance for the nutritional status of large numbers of people. The focus is on practical steps that could be taken by the SCN and its member agencies and by other agencies of the UN system that are not yet active in nutrition.
A GLOBAL LOOK
What are the prospects for improvement in nutritional status in developing countries in the 1980s? What will be the context in which governments and international agencies will be working and setting priorities for what the external agencies most usefully can do?
Peace and civil order (and individual biological variation} aside, the determinants of nutritional status are economic and social, environmental, and behavioural. For any group of malnourished, nutritional prospects will depend on its income and changes in employment and access to productive assets, economic forces shaping food prices and availability, health factors, and behavioural norms (especially associated with child-feeding and care and with maternal nutrition} and on the course of government actions affecting these factors.
It is hard to be optimistic about overall growth of the developing countries in the 1980s. In contrast to the expansionism of the 1950s and 1960s, the restrictive world outlook for the 1980s has unfavourable implications for the developing countries and the very poor. Protectionism could grow stronger if the recovery is weak, dimming the outlook for manufactured exports of the developing countries and for employment and income growth of the urban labour fource. At the same time, competition for jobs and pressure on wage rates will grow as the rising child survival rates of the 1960s and 1970s translate into high labour-force growth The outlook for resource transfers is not encouraging either Traditional donors and capital-exporting oil producers are not likely to expand concessional aid much, while commercial lending to developing countries is undergoing adjustment and consolidation rather than significant growth.
In these conditions, government financing of social programmes will be under pressure. Structural adjustment, a process begun in many countries to cope with the economic shocks and changes of the 1970s, will dominate economic policy. The process typically reduces consumer subsidies, restrains government expenditures, and reduces domestic demand for imports. It focuses policy attention on short-term equilibrium. Surveying the poverty alleviation outlook for the 1980s, a recent IBRD study observed:
These circumstances heighten pressures on developing country governments, aid donors and multilateral institutions to turn away from balanced development programmes where growth and poverty alleviation are pursued together. Resource constraints create a crisis atmosphere where budgetary choices tend to stress the reduction of current-account and public-sector deficits at the cost of longer-term investments in, say agriculture and education. In these circumstances, the real choice may be one of short-term balance as against both poverty alleviation and growth, with poor people in the poorest countries suffering lasting damage. Increased flows of external assistance can help cushion the worst effects of a painful short-term trade-off, but prospects for substantial additional resources in the near term are not encouraging. [ 1 ]
Examples of the impact of these fiscal pressures on SCN concerns are discussed below.
In sum, we cannot look to general economic advance for significant alleviation of malnutrition in the 1980s (although obviously there will be country exceptions). Three conclusions can be drawn:
The prospects for domestic income redistribution, which could raise the consumption levels of the poor in a period of economic difficulty, also are not enouraging. However, where aggregate national food supply is not the problem, there are strategies that can go a long way towards closing the consumption gap without need for major redistribution of income or assets. In other countries, the poverty of substantial groups appears difficult to relieve without major structural change, including land reform and large-scale expansion of educational opportunities. Even in these cases, there is some scope for partial programmes.
Regional Prospects
There is wide variation in regional outlook. That for sub-Saharan Africa is the most difficult. in the face of rapid increases in population, per capita food production has been declining. With typically over 70 per cent of the population dependent on agriculture for both income and direct consumption, this trend translates directly into pressure on food intake. It would be unrealistic to expect any early agricultural break-through that would raise rural incomes and also benefit poor urban consumers by substituting domestically produced food for higher-priced imported food. Looking at prospects for Africa in the 1980s, the IBRD 1981 World Development Report concluded that per capita income would remain flat under the most optimistic assumptions (2). Meanwhile, the at-risk infant and child populations will grow very much larger by 1990. Also, compared with other regions, Africa has the weakest health infrastructure in place.
A number of rapidly growing countries in South-East Asia and East Asia are farther along than most African countries in the accumulation of physical and human capital and are likely to continue per capita progress in income and food availability, although more slowly than in the past. The demographics will not translate automatically into increases in at risk population, but will mean a substantially greater number to be served by extended health/ nutrition delivery systems.
In South Asia, the extreme poverty of some large areas and populations poses problems more severe than those of Africa in terms of resource requirements and the need for fundamental economic and social solutions. Even if these were on hand today, they would be unlikely to effect much change in the 1980s. Although in India, Bangladesh, and Pakistan the population under 10 years old is projected to rise only 11 per cent in this decade, this will amount to nearly 35 million more children, since the number of children in these three countries is much greater than the number for the same age group in all of Africa south of the Sahara.
It is important to stress that in many Asian and Latin American countries, sheer size of food production and total national supply is not the main source of the consumption problem, as it is in much of Africa. Under-consumption arises instead from unequal distribution of income and effective demand for acquiring food. While in some countries income distribution appears to be improving moderately, there are alarming trends in other countries, especially those experiencing rapid increases in the landless and near-landless (i.e., owners and tenants working tiny holdings). The biggest population groups at risk of malnutrition in the 1980s are in Asia.
While South Asia's lack of health facilities (Sri Lanka and parts of India excepted) is similar to the situation in Africa, it has more favourable ratios of population to health personnel, although rural areas are under-served. The ratios are more favourable still in South-East Asia and the Pacific. In fact, one finds problems of under-utilization of public health facilities. The Latin American and Caribbean regions are relatively advanced in terms of life expectancy, infant mortality, and nutritional status, but there are a few countries or areas and population groups within countries where malnutrition is still severe. The more advanced have well-developed health infrastructures, though less in rural areas. In the face of general economic conditions and the effects of adjustment to heavy debt service burdens, it is hard to be optimistic about the broad context of Latin American poverty or the likelihood that substantial income redistribution offers an alternative early cure.
The Middle East/North African region is very heterogenous. It includes several countries with no severe financial constraints against improving the consumption levels of their populations or the coverage of their health systems, although these systems suffer from management weaknesses and acute shortage of female personnel. Food production has been relatively stagnant, but import capacity has not been, and is not likely to be, the constraint it is in sub-Saharan Africa. The effects of turmoil in some areas aside, the extent of malnutrition should continue to diminish.
Urban and rural malnutrition differ greatly in cause. Urban populations generally have higher incomes, greater access to education and health facilities, and smaller fractions of people malnourished. Still, there remains a core of low-income, unskilled urban dwellers who comprise an important segment of the malnourished, especially in large urban centres of Latin America and Asia, and in the Caribbean, where they typically reside in female-headed households. Recent migrants have special problems of dietary change, unsanitary food and waste-disposal systems, decline of breast-feeding, and absence of proper child care and feeding. Slow growth of the modern sector may tend to narrow the gap between urban and rural incomes and produce open unemployment that would make visible to potential migrants a slackening of opportunities in the cities. Fiscal effects of structural adjustment on urban subsidies should improve rural/urban terms of trade. Even a temporary slowdown in urban migration would give more breathing space to efforts to develop an urban analogue to primary health care (which until now appears largely rural-oriented).
OUTLOOK FOR GOVERNMENT EFFORTS
The extent to which governments act to reduce malnutrition will depend on four factors: (a) availability of technical answers, i.e., confidence that the nutrition community knows what to do, (b) availability of funds, (c) technical and managerial resources, and (d) political will to give priority to the problem.
Technical Answers
The SCN has given much attention to "what works"- what can be recommended to governments with confidence. On the broadest level, confidence and important lessons can be drawn from the small set of countries that have reduced infant and child mortality and malnutrition substantially, especially those where the accomplishment was managed despite low per capita income. Feasibility of large-scale successes for this age group is not merely a theoretical possibility, although there is still uncertainty over the relative contribution of different factors and programmes. Health systems, widespread supplementary feeding or food subsidies, female education, and sanitation facilities are among the factors involved.
For some sharply defined problems, especially the micro" nutrient deficiencies, major reduction in prevalence can be achieved with current knowledge. Confidence in supplementary feeding by itself does not have much solid evaluative backing. The decline in government requests to WFP for allocating food aid to feeding projects for nutritional purposes may be an indicator of low confidence (3). Targeted consumption studies in various forms have been shown to raise food consumption of the needy under proper circumstances and design. Some things have not worked as expected, e.g. traditional nutrition education as an isolated programme, and have receded in importance. Some mass media experience has been very promising, based on tested, cost-effective techniques. Cost-effectiveness comparisons have begun to be employed to provide planning guidance, and nutrition planning has had impact in a few countries extending the nutrition perspective into the health and agriculture sectors, food price policy, and marketing. These approaches add concreteness to the planning of poverty alleviation and give planners specific criteria for measuring need and impact.
The SCN agencies have pushed integration of nutrition considerations into agriculture policy, programmes, and project planning, from which significant benefits for nutritional status might emerge in some countries in the 1980s, provided the political will is present. Fifty countries are now undertaking food strategy reviews. Integrated health and nutrition delivery services have been shown {mainly in pilot projects) to be effective and potentially low cost, depending on their design (4). A virtual consensus has developed that primary health care (PHC) can substantially alleviate health problems in developing countries. Much of the nutrition community appears to view PHC as the vehicle that can carry nutrition interventions (of the face-to-face type) to the community level on a mass scale.
The emergence of PHC is a major opportunity that builds on the policy environment that had been developing in earlier years regarding nutrition. That environment began to turn favourable in the late 1960s when it became evident that in many countries economic growth was not bringing about rapid or even discernible reduction in poverty. Developments in nutrition and food science, and a myriad of pilot projects in delivery services, contributed to the readiness of the nutrition community to take advantage of these perceptions. The emergence of multisectoral understanding of the determinants of nutritional status opened the door to the introduction of nutritional impact as a factor in policy and project areas beyond the confines of nutrition per se. It also reached beyond the areas of direct responsibility of those institutional units formally charged with nutrition and comprising the ACC Subcommittee and its bilateral associates.
In sum, the record of policy development and of confidence in knowledge gained from experience and the advance in scientific knowledge is remarkable, especially when compared with earlier years when nutrition policy and intervention were limited to goitre, the "applied nutrition programme," and rehabilitation, supplemented by minor feeding programmes.
However, some caveats are in order regarding how much confidence should be placed in multisectoral planning as a reliable indicator of future nutrition policy. Some observers feel that multisectoral planning has done a disservice by diverting attention from practical, micro-level programmes. Nutrition planning appears to have delivered less than was expected. Professional disagreement remains over how PHC should be defined, with differences over the proper mix between functional ("vertical") and "horizontal" systems of health delivery. A similar tension exists between broad and sharply defined interventions in nutrition. After health, integration of nutritional considerations into the planning of agricultural development warrants highest priority. While there are encouraging examples, they are still infrequent. Despite the strength of views in some quarters that integration of nutrition in agriculture projects holds great potential, methodological and institutional obstacles have kept this approach from being tested widely.
Agriculture research is another important area where introduction of nutrition considerations could yield benefits. The SCN effort to promote nutrition in the work of the Consultative Group on International Agricultural Research (CGIAR) is an important initiative. Even more important is the need to have these considerations introduced into national research institutions that appear to be behind the international centres in these distributional impact considerations. To the extent that technical assistance activities are not now raising these dimensions with country counterparts, it would be appropriate for the SCN to help link the international and local institutions in this respect, and ensure that agencies helping country agriculture research units also recommend and offer the requisite nutritional and social science aspects.
There is a need for greater conviction and clarity on recommendations. To a non-technical observer of international nutrition, the continuing uncertainties and often intense professional disagreement over basic questions of definition and measurement tend to focus attention on the half-empty rather than half-full portion of the glass. Increasing agricultural production is also a complex business. The fact that agriculture planners are able to put their proposals in a neat conceptual framework has played an important part in the willingness of financing institutions to place funds in that sector. Nutritionists need to convey a recognition that they are not significantly worse off than practitioners of other disciplines where there has been less hesitancy about "going with what you've got."
Domestic Resource Availability
It is ironic that, just as the nutrition/health community has produced a universally accepted approach to extended service delivery, the climate for new claims on public funds has grown worse than at any time in the last 30 years. In many countries, health budgets are "mortgaged" by the need to maintain urban-based hospital systems. Despite the dedication to devising methods to elicit community self-financing, the recurrent cost constraint in many countries is likely to be severely inhibiting to the rate of PHC system expansion. The problem deserves more attention than it has received from the SCN. In addition to the resource suggestions below, consideration should be given to local fund-raising possibilities among the middle and upper income classes, and opportunities in the private sector.
Technical Capacity
Technical capacity is a second key constraint on the expansion of delivery systems in the 1980s. One finds a range from countries with few trained personnel at all levels of skill and fledgling institutional framework to countries with established scientific institutions, substantial numbers of skilled personnel, and years of experience in research, programme design, and field operations. It might be tempting and safe to conclude piously that the aid agencies need to provide the full range of technical support in response to all needs of all countries as they emerge. To do so would mean abandoning all sense of priority.
Strategies for Technical Development and Technical Assistance
One finds many intelligent explanations for individual technical assistance projects in SCN agency budget documents and policy material. Most of this documentation, however, lacks a sense of timing of needs of different character and a sense of technical development strategy. Among countries of vastly different size, ecologies, aetiologies of malnutrition, levels of development, etc., the technical and institutional capabilities needed to attack malnutrition cannot be identical. But little differentiation is made in the technical development paths recommended (or implicit) in this material.
With the objective of attaining some "requisite" technical capability, which must be defined in light of country objectives within specific time frames, it would be useful to develop a technical assistance rationale in nutrition, from which guidelines could be drawn for different country situations and institutional development needs. The idea of self-reliance is central to UN-system thinking about the role of technical assistance. What does self-reliance mean in the field of nutrition? What is the efficient route for getting there?
Food and Nutrition Planning Agencies
One element in the institution-building activity and advocacy of the past is in need of rethinking. I refer to the "apex" food and nutrition institute or nutrition planning agency, charged with national-level analysis, monitoring, and policy and programme formulation. The forms and responsibilities of these agencies vary, but their character as a central focus of integrated thinking about malnutrition is common. Their record is mixed, but some have been successful. It would be useful to evaluate their experience to draw lessons on what might be done better in the future. Also worth exploring would be the extent to which problems of these agencies have stemmed from complexity of the subject and absence of simple methods of focusing on the key determinants of nutritional status, once a multisectoral framework has been set. Integration of agricultural and consumption economics with health, diet, and family food behaviour aspects that are more traditional to the nutrition community remains poor. With several years of nutrition planning efforts behind us, and of experience of "apex" agencies of different mandate, it would be helpful to attempt to clarify the field, to lay out what now appear to be the essential ingredients of nutrition planning and how the disparate pieces can be made to fit together (5).
Management
Management capability appears to be the most important constraint (besides money) that will hamper expansion of delivery systems in the 1980s. Recent reviews of integrated delivery projects (e.g., 4) stress that the success of a pilot project does not guarantee that the same model will work when scaled up to large programmes in thousands of communities. With expansion of nutrition services closely tied to the expansion of PHC-type systems, the problem of scaling-up management deserves special attention.
Pilot activities demonstrate intervention techniques and test cultural factors and monitoring techniques, etc. But the very qualities typical of pilots- close supervision under highly trained and motivated professionals, fast attention to financial and logistical problems, and frequently charismatic leadership- are just the things impossible to replicate on a large scale under ordinary bureaucracies. There is a striking contrast between the strength of the external system in supporting pilot-scale and research activities and the dearth (outside Latin America) of assistance in straight health management. (WHO work in health management was more active in the past.) Nutritionists in developing countries recognize this problem. Health management is too specific to be learned adequately in institutions of general management training. Technical assistance in PHC management now offered by the system does not include the building of local institutions for advanced training in health systems management. This weakness could be the one constraint above all that disappoints those hoping for rapid expansion of integrated delivery systems in the 1980s. With so much riding on this issue, it is recommended that the SCN take up the subject of management of scaled-up delivery systems as a high priority subject hitherto under-attended.
Political Will
Financial resource constraints can be eased if the political priority is high enough to transfer funds from other subjects. The record shows dramatic contrasts between cases where governments placed high priority on creating delivery systems and budgeted the required funds, where large-scale food consumption subsidies were introduced before technical and institutional self-reliance had been reached, and where institutional maturity was reached but the decision to allocate the funds required to alleviate malnutrition substantially had not been taken.
Agency views of priorities, especially where there is a common system view, can have considerable influence if communicated with tact and tailored to country situations. For the agencies to play an effective role in policy dialogue, however, they must recognize the importance of field-level co-ordination, especially as it relates to the role of country nutrition/health authorities and the audience they are able to obtain within their own governments. A serious criticism of the concerned agencies lies in their failure to organize themselves in the field in a way that would support the creation and strengthening of government nutrition co-ordination and advocacy processes. By their policy literature, the agencies have gained wide acceptance of the understanding of malnutrition as multisectoral in origin and in programme requirements. At best, the absence of the "demonstration effect" of a well co-ordinated grouping for nutrition-related assistance may mean missing an opportunity to contribute to the establishment of a country co-ordination and advocacy mechanism. At worst, absence of a co-ordinated grouping may be positively harmful to a country's nutrition authorities The SNC should give high priority to the development of field-co-ordinating arrangements among the family of external agencies working in this area.
THE INTERNATIONAL NUTRITION SYSTEM
UN System Priorities and Resources
Priorities
Among the specialized agencies, none has nutrition as a top priority. Primary health care is the central health strategy for WHO; nutrition is one component of PHC, presumably a critical one for infant, child, and maternal health. Yet nutrition, anomalously, has had low organizational status within WHO and very small staff at headquarters and regional levels. WHO is currently reviewing its organizational arrangements for nutrition. It will be unfortunate if the subject does not emerge strengthened and more visible.
Nutrition has divisional status in FAO and the largest headquarters nutrition staff of the UN system, although part of this staff is devoted to international food standards. The division has a large portfolio of field projects in nutrition planning, surveillance, research surveys, and other subjects. Still, nutrition remains a relatively minor subject in FAO, a large agency with staff mainly allocated to agricultural production rather than consumption. Concern over food consumption has been increasing in recent years, so the prospects for nutrition's being taken into account in production work appear better than in the past.
The International Labour Organisation (ILO) and Unesco have had small involvement in field programmes in nutrition. ILO's Rural Employment Policies Branch has participated in programming and evaluation missions of the International Fund for Agricultural Development ( I FAD), and the World Food Programme (WFP) has undertaken activities involving women's groups and is conducting several research projects on food pricing, food strategies, and aspects of rural income and employment that affect purchasing power and food consumption. While Unesco's country projects in nutrition financed under the United Nations Development Programme (UNDP) programmes have been few in number, Unesco is planning an expanded set of activities.
With immediate survival at stake in the case of refugees, nutrition is an important subject for the United Nations High Commissioner for Refugees. UNHCR maintains close relations with other organizations involved in refugee sustenance. Although there are co-ordination problems when large numbers of voluntary agencies are running projects in camps, the special situations under UNHCR responsibility are outside the scope of this study. The United Nations Environmental Programme {UNEP) has been helping finance several activities related to nutrition. Besides supporting the ACC workshops in food and nutrition planning, UNEP has worked with FAO and WHO on the post-harvest crop loss problem and on contamination of foods.
Among the funding agencies, IFAD's target group contains large numbers of the malnourished, opening up significant opportunities even though production rather than distribution is the fund's mandate. IFAD interest in nutrition has been growing, reflected in the active role IFAD has in the SCN work on methodology for taking nutrition into account in agriculture and rural development projects. in the World Bank (IBRD), nutrition shares formal division status with health and population and has been a loan subject itself for a few years. Nutrition projects have amounted to an order of one-half of one per cent of World Bank lending. Considerable effort has gone into integrating nutrition into country economic work and agriculture and rural development projects and including nutrition in World Bank research.
In the context of UNICEF's mandate in child welfare, and its operational role in PHC and maternal and child delivery services, nutrition should be a high priority subject, although budget allocations identifiable as direct child nutrition have been declining. The new UNICEF/WHO programme in nutrition will mean an infusion of new funds that could strengthen nutrition activities in a number of countries. Nutrition has high priority for the United Nations University, where the sub-programme on Food, Nutrition, and Poverty is one of the themes under which UNU activities are developed. For WFP, nutrition has been a declining subject as the proportion of resources in nutrition projects and the number of country requests have fallen. Staff interest remains high, and there has been much evaluation of feeding projects that could form the basis for a re-evaluation of priorities, including the suggestions made herein.
Nutrition is less dependent financially on UNDP than are other subjects not related to children or health. On the other hand, UNDP funding is important for activities of the FAO Food Policy and Nutrition Division and for nutrition education, planning, research, and operational activities of other specialized agencies. In contrast with UNICEF, which attained its revenue targets in recent years, UNDP has been experiencing shortfalls. As the Secretary-General's 1981 operational report noted, there are "disturbing signs of movement of some major donors away from their hitherto traditional support of multilateral aid channels towards increased reliance on bilateral flows" 16). Many UNDP country programmes contain no nutrition activities. Very few of the country programmes presented to the May 1982 session of the Governing Council for the Fifth UNDP Cycle (1982-1986) envisage full-scale nutrition projects.
Aside from the handful of countries receiving technical inputs under loans, the budget data we have collected would not support a conclusion that the level of multilateral technical assistance in nutrition has been growing. However, given the pressures in the system and the member governments, and the ambiguity as to what activities should be considered "nutritional" even if not so labelled, one must be cautious about interpreting what these numbers imply for nutrition's priority.
Increasing Nutrition Resources
Needless to say, nutrition could benefit from growth in overall development assistance. Where nutrition is integrated in a PHC system, the health-resources-group initiative of WHO may be able to raise the aid resources allocated to nutrition. The resources-group concept brings together the donor agencies working in a country for joint examination of overall PHC resource needs, after preparation of a health plan designed to focus on close estimates of resource requirements. Resources groups have been formed for a few countries in response to the problem that PHC objectives have been adopted without the detailed planning that health ministries need as a basis for mobilizing additional resources.
Increasing the Impact of Food Aid
Donated foods that are not foods normally consumed by the recipients are seen as counter-productive in programmes designed to create a supplementation system based on local production and a reliable supply of familiar foods. Since foods are often given because they are surplus, the commodities are not fungible; the donor lacks flexibility to offer the value equivalent in money or other commodities. If donors allowed the executing agency to sell the commodity in the recipient country (assuming a market exists) and to use the local currency proceeds to finance the feeding programme with appropriate domestic foods, a completely unusable resource would be turned into an entirely fungible one.
Once insistence on connecting the physical aid commodity with the mouths of the beneficiaries is put aside, the potentialities of food aid are greatly enhanced. Sale could yield the following advantages: feeding programmes would fit local tastes and availabilities; special logistic and bureaucratic systems to move the food from port to inland feeding points would be unnecessary, and commodity losses through leakages in handling and storage could be reduced or eliminated; in addition to buying food upcountry near the feeding points, the local currency could be used to help finance a PHC/nutrition programme. Some governments may find such arrangements attractive enough to propose a shift in food projects away from food-for-work and marginal feeding projects in favour, in effect, of recurrent cost-financing for PHC/nutrition field programmes. A recent study for USAID has made an intriguing suggestion for increasing the value of food aid to the recipients (7). It proposes substituting higher-valued commodities in place of food grains in supplementary programmes. Observing the tendency of beneficiaries to treat food supplements as extra income, not strictly as extra food, it suggests that one maximizes the value of the transfer to the recipient family by buying a commodity in the donor country (e.g. cooking oil) that has relatively high value in the recipient country (and in the recipient's budget) relative to its cost in the donor country.
These approaches or others would have to be adjusted to local conditions- prices, efficiency of local food markets, leakage problems, etc. But the opportunities for increasing impact appear too important not to be taken up by the SCN for examination and advocacy. Food aid is one of the few "big ticket" resources available. It is ironic that, despite WFP's relatively large resources and good headquarters liaison, project co-ordination and collaboration remain poor. Whatever the reasons for the reluctance of other agencies (the FAO Nutrition Division excepted) to seek out WFP for collaboration, the situation might be transformed if WFP could monetize its resources along the lines suggested.
Project Loans
To what extent can one look to financing agencies to increase allocations to health/nutrition projects? Nutrition project loans have been extended only by IBRD. Although the Inter-American Development Bank has a nutrition policy on the books, it has not filled a staff position that was envisaged as a focal point for developing IADB nutrition activities, nor has it developed the nutrition project as a form of lending. This was due partly to a desire to avoid the problems of inter-ministerial co-ordination that have been experienced by IBRD nutrition projects that have included several kinds of interventions. The Asian and African regional banks have not reached the point of putting forth a policy on the subject and have not attempted nutrition loans.
In 1980 IBRD's first stock-taking on nutrition projects, based on three innovative loans of unprecedented size for external nutrition funding, concluded that overly optimistic assumptions had been made about the management capacity of the organization responsible for implementation. The projects appear to have had satisfactory results: the number of beneficiaries was greater than expected; operational components improved over time; and consideration was being given to follow-on loans by some of the governments involved. Impressed by the implementation problems that had arisen from the multifaceted nature of the projects, the Bank concluded that future nutrition projects should contain fewer components. An important consequence of IBRD involvement has been the serious attention by ministries of planning and finance that IBRD interest and funding levels brought to the subject and to country nutrition authorities.
The history of IBRD nutrition lending is still short. The Bank has recently evaluated its nutrition experience and reached significant conclusions regarding nutrition loans and numerous innovations these loans helped finance. It would be useful to hold a workshop at which senior regional bank and IFAD officials review the lessons as a basis for considering their own future nutritional work. It would also be useful to round out SCN membership by getting the regional banks to join.
Other Funding Sources
Some funding has been available from the United Nations Family Planning Association (UNFPA) for projects supporting integrated delivery systems. Although UNFPA is not a potential funder of direct nutrition activities, its role in integrated delivery systems (especially in Africa) argues for membership on the SCN, complementing the co-ordination between UNFPA and other agencies at the field level. Of the smaller UN system funds, three finance activities in areas related to nutrition. The UN Capital Development Fund is devoted to small-scale projects benefiting the poor. About 25 per cent of its resources have been allocated to health. The Voluntary Fund for the UN Decade for Women is a small fund that supports economic and social development activities. The UN Centre for Human Settlements is concerned with housing and the environmental improvement of human settlements. It would be worth placing information on these funds in the hands of nutrition authorities so that the occasional opportunity to make a contact with one of these source does not pass by through unawareness of the potential.
There are also opportunities in other sectors. The low-income urban migrant family is typically a group at high risk of malnutrition because of low purchasing power, unsanitary environment, and inadequate breast-feeding and child supervision. This group should be well represented in low-income housing projects, especially slum up-grading. This is an area where more useful work could be done than is now the case, experimenting with methods for organizing privately operated or self-help operations in child-care and homemaking services.
Finally, resource mobilization and political will could be strengthened if the system had a more focused, formal nutrition institutional presence. Resource mobilization, campaigns, and targeting lend themselves to institutionalization in the UN system. A nutrition centre could serve as focal point for financing, goal-setting, progress evaluation, etc., along the lines of the CGIAR or tropical disease control efforts. It would have greater visibility than the SCN. An alternative that would not raise the problems of creating new institutional arrangements could be imagined in the form of a more active SCN and/or AGN.
The Bilaterals
Ten bilateral aid agencies are known by the SCN to be active in nutrition. Italy has become the eleventh with its recent contribution of US$85 million for the new WHO/UNICEF joint programme. The level of activity varies considerably. Between six and eight of the bilaterals attend SCN meetings. They play an important role in the international nutrition systems as sources of assistance to developing countries and as funders of the multilateral agencies. In each case different factors determine the size of nutrition budgets and allocation between direct and multilateral execution. Desire for donor identification, country allocation preferences, whether or not the donor has its own field network, and policy towards UN system funding are among the determinants. Apart from the recent grant from Italy, there appears little prospect of significant change in nutrition funding levels of the bilaterals.
If the bilaterals agree that an effort to raise nutrition priority is warranted, a joint effort might reinforce the steps that would have to be taken inside each bilateral agency. The SCN could be helpful, possibly working through the OECD Development Assistance Committee.