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31. Ríos IME. Nutrition intervention: an anthropometric evaluation of changas in nutritional status, with reference to the National Nutrition Programme in Babia. Brazil. Doctoral thesis, London School of Hygiene and Tropical Medicine, 1981.
32. INAN. Subsidio para o encontro de avaliaçao da execuçao do projeto de abastecimento de alimentos básicos em áreas de baixa renda-PROAB. Brasilia: INAN, 1984.
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Fernando M. Dall'Acqua
The prolonged economic crisis of the 1980s led the Brazilian government to look for alternative measures to cut public spending as part of their strategy to reduce inflation and re-establish external balances. Because they receive substantial government funds, policies and programmes oriented toward production and consumption of agricultural products have been the foci of efforts to reduce the public deficit.
Inadequate nutrition has been viewed as one of the critical problems facing Brazilian society. Although the data are imprecise and incomplete, agreement is nearly unanimous that a substantial portion of the population is at risk of malnutrition.
The generally accepted argument is that adjustment and sustained growth are vital to the elimination of the problem. In other words, unless economic growth is accompanied by at least a moderate increase in per capita income, the extent of malnutrition endured by the poor majority will remain unchanged. This position was clearly expressed by the World Bank:
There is now a wide measure of agreement on several broad propositions.... Malnutrition is largely a reflection of poverty: people do not have income for food. Given the slow income growth that is likely for the poorest people in the foreseeable future, large numbers will remain malnourished for decades to come.... The most efficient long-term policies are those that raise the income of the poor. [1, p. 59]
The argument obviously presupposes a high income elasticity of nutrient consumption. In such a case, a large increase in poorer households' income could promote a sharp increase in nutrient consumption and, consequently, a pronounced improvement in the general nutrition status of the country as a whole. For example, a unitary elasticity implies that a 10% increase in income results in a 10% increase in nutrient consumption. This would justify emphasis on sustained economic growth as a means of attenuating the prevalence of malnutrition in lower-income countries [2]. If, on the other hand, the elasticity of nutrient consumption is low, eliminating poverty will not necessarily solve the problem of malnutrition. This would suggest the promotion of specific policies and programmes that could act as fundamental instruments for improving the nutrition status of the poorer segments of society.
The question of whether this elasticity is actually high or low, however, is an empirical issue that is not yet fully resolved in the literature. One group of studies suggests a strong relationship between income and nutrient consumption, justifying exclusive emphasis on economic growth [3-5]. A second group claims that the relationship between the two is weak and suggests that specific nutrition policies may fill an important role in alleviating malnutrition prevalent in lower-income countries [6-8].
It is in the context of this controversy over the effectiveness of nutrition policies and programmes that the principal questions addressed in this paper are introduced. First, an attempt is made to evaluate to what extent an emphasis on policies and programmes oriented directly toward alleviating the malnutrition prevalent among poorer Brazilians is justified. To do so, the income elasticity of calorie and protein consumption is calculated for low-income classes.
Analysis of a nutrition policy, beginning with the income elasticity of nutrient consumption, cannot be separated from the issue of structural adjustment. Although a low income elasticity reinforces the importance of nutrition programmes, it would be unrealistic not to consider the restrictions imposed by the current Brazilian crisis. In this sense, it is sufficiently clear that the crisis has among its principal determinants a large imbalance in the public sector.
Economic stabilization requires, therefore, substantial fiscal readjustment in order to re-establish a balance between public revenues and expenditures. It is quite probable that government authorities will be forced to be more selective in determining social programmes and policies. In this context, it is appropriate to turn to a more systematic evaluation of the performance of existing nutrition programmes so as to minimize the impact of fiscal adjustment on lower-income classes. This leads to the second critical aspect: the impact of the school-lunch programme on the nutrition status of low-income families.
The school-lunch programme in Brazil is designed to benefit schoolchildren from the preschool level up to 14 years of age. It is the country's principal nutrition programme, absorbing nearly 60% of funds destined for schemes of this sort. In 1986 about 25 million students, or 80% of all schoolchildren, were covered, and received at least one daily meal at school for 180 days of the year.
In order to study the income elasticity of nutrient consumption and the impact of the programme on the nutrition of low-income families, field research involving 253 families residing in the city of Campinas, São Paulo, was undertaken from April to July 1987. (The term "nutrient" here refers specifically to calories and protein. A justification for this limited definition is that, in general, malnutrition is attributed to the amount of calories and protein consumed.)
Campinas has about 35 public primary schools with approximately 19,000 students, and 21 public preschools with about 5,000 children. The preschools cater largely to children of women working outside the home. During March and April 1987 a sample of 2,000 children enrolled in primary and preschools was screened. The objective was to obtain basic information concerning the population that would permit the selection of a final sample of families stratified according to income, school-lunch receipts, and age of the child.
This procedure aimed principally to overcome some fundamental difficulties associated with the control group. In Campinas, nearly all of the public schools benefit from the school-lunch programme. For this reason, a simple random sample ran the risk of not including a control group (i.e., children who do not receive school lunches), which would compromise the proposed objective of evaluating the programme's effect on calorie and protein consumption. The initial stage of sampling (i.e., screening stage) helped to ensure the inclusion of a group of school-age children in the final sample who did not receive benefits from the programme and who would consequently function as controls. Through the selection of families that (1) had at least one child receiving benefits from the programme, and (2) were not receiving benefits from another nutrition programme, this procedure also reduced the risk of unintentionally capturing the interaction of unspecified variables.
TABLE 1. Distribution of sample of households by in come level and number of meals received by child en rolled in school
| Meals received | Monthly income | Total | ||
| 0-2.5 MW | 2.6-5 MW | +5.1 MW | ||
| None | 24 | 18 | 29 | 71 |
| 1 | 24 | 40 | 39 | 103 |
| 2 | 24 | 38 | 17 | 79 |
| Total | 72 | 96 | 85 | 253 |
MW = units of minimum wage.
The final sample was selected according to the above criteria and totalled 253 families, of which 70% to 80% were low-income. This included 182 families with children who attended school for either a complete period (from 8 a.m. until 5 p.m.), receiving two basic meals, or a partial period, receiving at least one meal (table 1). The remaining 71 families had children of school age, either attending school for a partial period or not enrolled at all, who did not receive benefits from the school-lunch programme. These made up the control group.
The size and the selection criteria of the final sample present some problems. Among these are limitations in generalizing the results to larger population groups. An advantage, however, is that the results are more precise and can provide a clearer impression of the phenomena under study. In this way, the methods permit not only a more sensitive interpretation of the results, but also the formulation of relevant hypotheses to be tested with more extensive research. Finally, the higher cost involved in statewide or national school-lunch programme survey gives some justification for smaller sample studies that can serve as a base for more extensive studies with other apparent advantages.
A pilot study was executed prior to the actual field research in order to test and finalize the questionnaire, as well as to allow for some enumerator training. The final questionnaire included various broadly defined social, economic, demographic, and cultural characteristics of the selected families, as well as more detailed information on food consumption over the interview period. Acquisition of food was used to calculate the availability of calories and protein that, in turn, acted as a proxy for nutrient consumption. (This procedure may bias the estimates of nutrient consumption by omitting losses in preparation, spoilage, and variation in the quantity and composition of stocks. )
The enumerators began in May 1987 and had planned to finish in two months. This time period turned out to be problematic. A series of difficulties arose that could not have been anticipated during the design stage. The study was planned during the Plano Cruzado in 1986, when the stability of prices resulting from price controls created an ideal climate in which to ask questions directly associated with nutrient consumption.
When the price controls were removed, beginning in 1987, the economic circumstances altered considerably. In May 1987, when the interviews were initiated, monthly inflation surpassed the 20% mark, and markets exhibited a destabilizing force on relative prices. This situation became even more complicated from 12 June 1987, when the government launched the Plano Bresser, which included the refreezing of prices and salaries. As a result of this plan, the rate of inflation dropped from 26% in June to 3% in July. This reduction was accompanied by divergent signals concerning the level of demand and supply in different sectors of the economy. During the execution of field research, an attempt was made to minimize the difficulties associated with these macroeconomic events through a replicated and more rigorous review of completed questionnaires. Similarly, given the strong destabilizing economic forces occurring during field research, the possibility that data related to nutrient consumption were unreliable cannot be ruled out.
Finally, it should be emphasized that the state of São Paulo does not participate in the national school-lunch programme, but implements its own, which is decentralized at the municipal level. This implies that the conclusions, having been based on field research undertaken in a municipality in the state of São Paulo, cannot easily be generalized to the country as a whole.