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Food and Nutrition Bulletin
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The Food and Nutrition Bulletin incorporates and continues the PAG Bulletin of the former Protein-Calorie Advisory Group of the United Nations system and is published quarterly by the United Nations University Press in collaboration with the United Nations ACC Sub-committee on Nutrition. The views expressed are those of the authors and not necessarily those of the United Nations University or the ACC Sub-committee on Nutrition.

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The Food and Nutrition Bulletin is intended to make available policy analyses, state-of-the-art summaries, and original scientific articles relating to multidisciplinary efforts to alleviate the problems of hunger and malnutrition in the developing world. It is not intended for the publication of scientific articles of principal interest only to individuals in a single discipline or within a single country or region. Notices of relevant books and other publications will be published if they are received for review. The Bulletin is also a vehicle for notices of forthcoming international meetings that satisfy the above criteria and for summaries of such meetings.

The Food and Nutrition Bulletin also serves as the principal outlet for the publication of reports of working groups and other activities of the UN ACC Sub-committee on Nutrition (SCN) and its Advisory Group on Nutrition. The SCN itself is a focal point for co-ordinating activities of FAO, WHO, UNICEF, the UNU, Unesco, the World Bank, the World Food Programme, the World Food Council, the United Nations Environment Programme, and other bodies of the United Nations system which have an interest in food and nutrition.

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The United Nations University (UNU) is an organ of the United Nations established by the General Assembly in 1972 to be an international community of scholars engaged in research, advanced training, and the dissemination of knowledge related to the pressing global problems of human survival, development, and welfare. Its activities focus mainly on peace and conflict resolution, development in a changing world, and science and technology in relation to human welfare. The University operates through a worldwide network of research and postgraduate training centres, with its planning and coordinating headquarters in Tokyo, Japan.

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Food and Nutrition Bulletin

Editor: Dr. Nevin S. Scrimshaw
Assistant Editor: Ms. Edwina B. Murray
Editorial Consultant: Ms. Sarah Jeffries
Associate Editors:
Dr. Hernán Delgado, Director, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatamala
Dr. Cutberto Garza, Director and Professor, Division of Nutritional Sciences, Cornell University, Ithaca, N.Y., USA
Dr. Peter Pellet, Professor, Department of Food Science and Nutrition, University of Massachusetts, Amherst, Mass., USA
Dr. Aree Valyasevi, Professor and Institute Consultant, Mahidol University, Bangkok, Thailand

The Kellogg International Fellowship Program in Food Systems, administered at Michigan State University, East Lansing, Michigan, USA, provided financial support for the publication of this issue of the Food and Nutrition Bulletin.

Food and Nutrition Bulletin, vol. 13, no. 3

(c) The United Nations University, 1991

United Nations University Press
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WHFNB-51/UNUP-792
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Preface

The papers in this issue of the Food and Nutrition Bulletin were written by a group of professionals who participated in a four-year, non-degree fellowship programme financed by the W. K. Kellogg Foundation and administered by Michigan State University. The central purpose of the programme, known as the Kellogg International Fellowship Program in Food Systems, was to advance professional leadership in bringing about improvements in food systems, with special concern for the needs of low-income households in developing countries.

Thirty-two mid-career professionals, largely from Latin America, Asia, and Africa, were selected for the programme, which provided structured opportunities for travel study, home-based projects, and participation in annual seminars held in different regions of the world. An important goal of the programme was to enhance professional effectiveness by broadening and deepening the fellows' understanding of the possibilities for improving food-system performance through policy reforms, organizational and institutional innovations, and technological advancement. The fellows organized themselves into four interest groups: (1) comprehensive food and agricultural policy, (2) agricultural marketing, price policy, and trade; (3) programmes and policies to feed the poor; and (4) technology for food production and processing.

The interest group on programmes and policies to feed the poor included 11 fellows from seven countries:

Brazil
Antonio Campino, University of São Paulo
Fernando Dall'Acqua, Group Pão de Açúcar
Yony Sampaio, Federal University of Pernambuco

Chile
Eugenia Muchnik, Catholic University of Chile
Isabel Vial, University of Chile

Colombia
Tomas Uribe, Foundation for Higher Education and Development

India
Shanti Bapna, Indian Institute of Management

Indonesia
Hidayat Syarief, Bogor Agricultural University

Malawi
Katundu M. Mtawali, Ministry of Agriculture

Sri Lanka
Sathyapala Pinnaduwage, University of Peradeniya

A programme steering committee member, Dr. Per Pinstrup-Andersen, then director of the Food Consumption and Nutrition Policy Program in the International Food Policy Research Institute and now director of the Cornell University Food and Nutrition Policy Program, was the mentor for this group.

Each fellow carried out a country-level study and conducted seminars to disseminate study results and promote discussions of policy and programme recommendations within their countries.

This special issue of the Bulletin includes seven papers authored by the Kellogg fellows, including comprehensive reviews of the experience with nutrition intervention programmes in Chile and Brazil along with more focused evaluations of the impacts of specific nutrition interventions in Brazil, Chile, and India. The lead paper, by Per Pinstrup-Andersen, is an assessment of past experience with targeted nutrition interventions. Antonio Campino, co-editor of the papers, is the author of a concluding article, in which he attempts to summarize the lessons learned and the issues to be considered in evaluating nutrition interventions.

Harold Riley, Director
Kellogg International Fellowship
Program in Food Systems
Michigan State University
East Lansing, Michigan, USA

Targeted nutrition interventions

Per Pinstrup-Andersen

Introduction

A variety of nutrition programmes have been used to alleviate malnutrition in specific population groups. Their records are mixed. Some have been successful in achieving their goals at reasonable costs, others have been excessively costly, and many have failed to achieve any measurable effect on nutrition. In spite of many years of experience with targeted programmes and many attempts to determine what works, our understanding of how best to ensure success at reasonable cost is still very deficient. The papers in this issue make a significant contribution to such understanding.

The causes of malnutrition are complex and differ among households, among communities, and over time. Furthermore, attempts to alleviate nutrition problems are influenced by human behaviour and the socioeconomic, cultural, and political environments within which they are found-factors that also differ among communities and over time. Therefore, cost-effective and sustainable solutions must be tailored to a particular set of circumstances. As illustrated by the evaluations in papers here, we have no magic bullets that will provide the most cost-effective solutions globally. This is most obvious in the case of energy and protein deficiencies, but even in cases of micro-nutrient deficiency, where quick-fix technologies such as iodine fortification and vitamin A capsules are available, programmes will be implemented successfully only if they are correctly tailored to local environments and behavioural patterns. When this point is overlooked, they will fail.

The implications are that programmes must be based on a solid understanding of the environment within which they are to operate, and target households and communities should play a major role in problem identification and diagnosis as well as programme design and implementation.

Although a great deal of lip-service has been paid to community participation in primary health care and nutrition programmes, in the vast majority of these schemes this has not been achieved. The top-down approach still prevails, and failures are still more common than successes. Where successes have occurred, as in the Tamil Nadu Integrated Nutrition Project in India and the Iringa Project in Tanzania, programmes have been tailored to the local environment, community participation has been real, and the programmes have been flexible enough to respond to new knowledge derived locally.

Household and community participation does not reduce the need for government action; it merely changes its nature. Instead of offering pre-designed programmes, the role of the government becomes one of providing support to target groups and their communities to solve their own nutrition problems in the most appropriate and, therefore, the most cost-effective manner. The nature of the support will vary, but may include information, education, primary health care facilities, income, food, credit, technical assistance, and a variety of other resources and programmes, as discussed below. Target groups and communities also need support to become effective participants in efforts to diagnose their own problems and identify the most binding constraints and the most appropriate solutions.

In the absence of true community participation in decision-making, government agencies should make a special effort to ensure that interventions are appropriate for the target groups. They should be designed to alleviate the most binding constraints to good nutrition, taking into account the socioeconomic and cultural contexts as well as household behaviour and institutional and administrative capabilities. Experience gained from past and continuing programmes provides a point of departure but not a recipe.

Experience from past and continuing programmes

The most common constraints to good nutrition are (1) insufficient access to food, (2) infectious diseases, (3) lack of knowledge, and (4) short birth intervals. Programmes have attempted to alleviate one or more of these constraints.

Programmes to improve access to food

Food-supplementation schemes, food-stamp programmes, and food-price subsidies fall into this category. Income-generating and income-transfer programmes that do not aim at nutritional improvements per se, such as public works (including food for work, employment generation, social programmes, unemployment compensation, and support to small farmers), may also be effective in enhancing access to food among the poor and malnourished.

Supplementary feeding programmes, such as the one discussed by Muchnik and Vial [1], distribute food through public-sector or non-government agencies to pregnant and lactating women, infants, and preschool children. Three types of delivery systems are used: on-site feeding, take-home feeding, and nutrition rehabilitation centres. Experience shows that the degree of success depends on the amount, type, and quality of food, duration of feeding, timing of supplementation, nutrition status of entrants, and degree of targeting [2]. Access to primary health care and nutrition information, as well as household behaviour and the economic circumstances of the target households, is also of critical importance.

Some food-supplementation schemes have been associated with higher birth weight and improved growth, decreased morbidity, and improved cognitive development among infants and preschool children. The benefits are usually small, however, and many programmes show no effect at all. One reason for this is that the amounts of foods made available are so small that the effects cannot be measured. After leakage to other household members and reductions in food acquisition from other sources are taken into account, net additions to food consumption typically fill only 10% to 25% of the apparent energy gap of the target individuals.

Another major reason for the disappointing results is that lack of access to food might not be the most binding constraint. To be cost-effective, food-supplementation schemes must be designed on the basis of a solid understanding of the existing constraints and must be integrated with programmes that can deal effectively with such impediments, such as infectious diseases and lack of knowledge. This is clearly illustrated for Chile and Brazil in other papers in this issue [3; 4]. Furthermore, the size of the supplement must be large enough to make a difference to the target individuals after accounting for its being shared with other household members and being substituted for food from other sources.

Food-stamp programmes and food-price subsidies, including subsidized rations to target households, may be preferable to food supplementation because they usually require less administrative capacity. However, unless they are well targeted, they tend not to be cost-effective. Targeting of food stamps or ration cards combined with nutrition education and primary health care offers a very promising approach in countries with sufficient infrastructure and administrative capacity to manage such integrated programmes. One successful example was a Colombian programme that issued food stamps and provided nutrition education to mothers who brought their preschool children to primary health care posts.

The need to integrate food transfers and primary health care is emphasized by several of the authors of the papers to follow. Sampaio stresses the importance of improving sanitation and primary health care together with enhanced food consumption [5], and Campino argues that food stamps should be issued by health clinics instead of food per se [6].

One of the major deficiencies of food-supplementation and food-stamp programmes is that they treat the symptoms of malnutrition, not the causes. Therefore, they are sustainable only as long as they are funded. They do not lead to conditions in which they are no longer needed; programmes to enhance the capacity of households to generate income may. Therefore, the challenge is to design programmes that will increase access to food in the short run while creating the capacity within the household to obtain the food needed without the programmes in the long run. Opportunities for using income and food-transfer schemes to create self-sustained, income-generating capacity among the poor have not been fully exploited and should be pursued. Such opportunities include the formation of human capital through improved health, nutrition, and education. as well as the use of food, along with technical assistance and credit, to facilitate the development of small-scale enterprises and other self-help activities for the large portion of the poor who are self-employed. Public work schemes, which are focused not only on the generation of incomes during the period of the scheme but also on the development of infrastructure that will facilitate employment for the poor after the scheme is completed, offer great promise.

Table 1 summarizes some of the key characteristics of various types of programmes designed to enhance access to food among the poor.

TABLE 1. Typology of nutrition intervention

Programmes to alleviate infectious diseases

Access to primary health care services is of paramount importance in efforts to alleviate malnutrition. Their effect on the prevalence and severity of infectious diseases is of particular importance. However, health interventions such as oral rehydration services and immunizations can reduce child mortality while morbidity and malnutrition remain high. Health services are usually necessary but not sufficient to alleviate malnutrition. Their nutrition effect may be negligible in the absence of other interventions. Furthermore, the nature of appropriate services may vary across communities and should be tailored to needs and opportunities.

Malnutrition among infants and preschool children is usually a result of insufficient food intake, infectious diseases, or, most frequently, a combination of the two. Although this is well known, most past programmes have been limited to either food (e.g., food supplementation and nutrition education) or disease risks (e.g., narrowly defined primary health care, drinking water, and sanitation). The results of such approaches have been disappointing. Findings from recent studies of the nutrition effects of cash cropping in Kenya [8], Guatemala [9], Gambia [10], Rwanda [11], and the Philippines [12] show that although increased commercialization of small-scale agriculture resulted in higher incomes and increased food consumption by rural households with malnourished members, the nutrition status of preschool children in these households changed little if at all. Similarly, a number of primary health care projects show no nutrition effects in the absence of specific interventions. The lessons are clear: (1) to be effective, interventions must be designed to deal with existing constraints; and (2) alleviating one constraint while ignoring others may do little for nutrition.

Breast-feeding is one of the most effective means of reducing infant mortality and malnutrition, particularly in environments of poor sanitation. Thus, national or regional breast-feeding promotion programmes, which have proved successful in some countries, should be given high priority under most or all circumstances. Two sources of nutrition risks associated with breast-feeding, insufficient feeding during weaning and conflicts with the mother's employment and income-earning opportunities, should be addressed explicitly. Inappropriate weaning practices. including inappropriate feeding and poor sanitary conditions, are of critical importance in most cases of malnutrition among children under two years of age. Thus, national support to facilitate improved weaning practices is likely to be required generally. Education aimed at promoting better child feeding through appropriate weaning foods has been successful in enhancing child growth; however, the nature of national support may have to vary across communities. It is unlikely that a pre-packaged national programme will be effective across communities.

Programmes to provide knowledge

Inadequate knowledge undoubtedly has been and still is an important cause of malnutrition, but care should be taken to introduce education programmes only in those cases where this is the most limiting constraint or as a complement to other interventions. The need for such education is most pronounced where large changes have occurred in the environment and in the constraints within which household decisions are made. such as rural-to-urban migration, shifts from subsistence to cash cropping, and other changes that significantly alter the magnitude and source of household incomes and availability of food and non-food commodities. However, these programmes are often promoted in situations where households are unable to respond for other reasons. Households with severely malnourished members are frequently deprived of other basic necessities as well, and insufficient incomes are the most limiting factor. For them, education aimed at reallocating a given amount of real income or food is not likely to be effective. This is illustrated in a recent study in the Philippines where education was most effective in households that also received a food subsidy [13].

Nutrition education may be effective in households where a significant budget share is spent on nonessential goods, where the cost of the diet is high due to lack of emphasis on available low-cost foods, and where the allocation of food is biased against high-risk groups. Programmes focused on behavioural changes related to breast-feeding, feeding of weaning-aged children, diarrhoeal diseases, and sanitary practices have also proved to be effective in a large number of cases [14]. Although they are most likely to be successful when linked with other resource changes, as mentioned above, a recent project in Indonesia illustrates the fact that education may also work well by itself when the necessary resources are available [15]. This project, which was based on mass-media communication, contributed significantly to improved food intakes and growth of children at a relatively low cost.

High correlation between the needs and constraints of the target households and the design and implementation of the programme is undoubtedly the most critical feature of a successful nutrition education programme. Programmes based on a thorough understanding of the problems and the limitations within which they may be solved are more likely to be successful than those based on preconceived ideas about what households and individuals ought to do.

Growth monitoring deserves particular attention as a source of information for mothers. Its effectiveness depends on the quality and timeliness of the information as well as its usage, precisely because it is a source of information rather than a nutrition intervention per se. Unless the information is used to guide action, even the best growth-monitoring system will have no impact on nutrition. Furthermore, growth monitoring that provides faulty information is not only useless but may mislead action and result in waste of resources.

Although good evaluations are scarce, it appears that a large portion of past growth monitoring either was poorly implemented or lacked links with effective action. The integrated nutrition project in Tamil Nadu, India, successfully used growth monitoring to guide action to improve the nutrition status of pre-school children. This project is discussed further below. Other examples of apparent success are projects in Indonesia and Tanzania.

A positive nutrition effect of the formal education of women has been demonstrated in many countries, although the causal relationship is not fully understood. The magnitude of the effect will vary across households and communities, but the probability of a significant and positive effect is high in most cases. Furthermore, nutrition improvements brought about by enhanced formal education of women are more likely to be self-sustaining than most other interventions. Thus, we have one of many reasons to promote the formal education of low-income women.

Family-planning programmes

High birth rate and associated short birth intervals may increase infant mortality, lower birth weight. hinder child growth, shorten the length of breast-feeding, and, as a consequence, increase the risk of malnutrition in infants and preschool children. Large family size also affects the nutrition status of children through demands on income and time. Short birth intervals increase the risk of malnutrition among women of child-bearing age. Therefore, programmes that improve child spacing are likely to reduce significantly nutrition risks among infants, pre-school children, and women of child-bearing age.

Because of their demonstrated effect on health and nutrition, such programmes should be promoted regardless of whether reduced population growth is a goal.

Integrated programmes

Since existing constraints interact, removing one may contribute little to improved nutrition. In many cases, it is necessary to provide support that includes primary health care, access to more food, better information, and better child spacing.

Several integrated nutrition and health programmes have been at least partially successful. One of these, in Tamil Nadu, India, uses growth monitoring to identify children six months to three years old who are at risk of malnutrition. Food supplementation is provided to these children until they achieve normal growth. Nutrition education is provided together with a series of health services. The impact on nutrition status has been impressive.

The Iringa project in Tanzania is another example. Child weighing is used as a source of information for nutrition education and screening. Child feeding and a variety of health services are integral parts of the project, and malnutrition has been reduced considerably over a period of a few years.

A number of other health and nutrition projects were reviewed by Lamptey and Sai [16]. The authors concluded that whereas most of them have been successful, although to varying degrees, they generally were pilot projects, and it may be difficult to maintain success if they are scaled up. This is so for four reasons. First, the pilot projects have effective organization and administration. Service personnel are carefully selected and trained, are well supervised and supported, and are given carefully developed and realistic job assignments in a relatively small population. Second, they usually have motivated, dedicated, and at times charismatic leadership. The departure of leaders with these qualities may lead to the collapse of projects. Third, most of the projects are of limited duration. Finally, continuing evaluation and feedback help with realistic reordering of project activities, but they often do not take place once projects are scaled up.

Many of these characteristics may not be transferable to larger projects. Lamptey and Sai identified many difficulties with integrated programmes and projects, of which they argue that the following recur constantly: planning requires inputs from several individuals and agencies, which may prove difficult to harmonize; collaboration and coordination at all stages can be problematic; the traditional governmental organization of line agencies creates peripheral management problems in personnel. budgeting, and many other areas; the training of most health workers is too specific and technological to make them readily adaptable to the broader perspectives required within integrated activities-for example, working with the community as equal partners is too new a concept for health workers generally; peripheral managerial expertise is often lacking; and evaluation is more difficult in these programmes than in vertical ones.

According to the authors, successful programmes require high-level political commitment, administration that ensures decentralization, administrative control at the periphery that is handled by the periphery, and community participation. Participation in this case means helping the community to identify its own needs and develop its own plans for meeting them, recruiting the necessary personnel from within the community, and mobilizing resources for funding sub-activities.

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