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Importance of the planning phase
In discussing the interaction between an intervention and the socio-economic and cultural environment, Pinstrup-Andersen states that "a great deal must be known about the target group before an intervention is designed" [1]. This point is not clearly recognized in many developing countries, which move directly to action programmes without adequate pre-investigation.
PROAB is a good example. Its design was inspired by features of an integrated health and nutrition pilot project (PINS) financed by the World Bank and carried out in Recife. PINS comprised four different alternative modes of food delivery which were to be evaluated. On the basis of this evaluation a new programme (which ended up being PROAB) would be formulated, but the new programme was formulated and implemented before the evaluation results were available. Many of the shortcomings of PROAB pointed out in Sampaio's report [7] might have been avoided had the evaluation results been available and used [10].
Issues in targeting
Sampaio [7] reported that PROAB lacked an effective targeting mechanism, at least in the area that he surveyed; he indicated that the "low-income area selected for. . . intervention had a low percentage of households with malnourished children." This lack of a good targeting mechanism was responsible for the ineffectiveness of the programme in terms of its lack of impact on the nutrition status of pre-school children and its negative impact on food expenditures.
The other programme in which the targeting mechanism was responsible for leakages and the eventual exclusion of poor families as beneficiaries was the PDS in India. Attendance at public health centres, the targeting mechanism used by the FMP and CFP, was pointed out as one of the reasons for the efficiency and effectiveness of the programmes.
These findings lead to the conclusion that targeting by income seems to be less efficient than targeting by outlet. It is not possible to draw conclusions relative to targeting by geographic location from the PROAB experience, since its low impact seems to stem from the fact that there was an inappropriate selection of the area; that is, the failure was in the application of the criteria and not in the criteria themselves. (Pinstrup-Andersen reports that "geographic targeting has been successfully used in several countries" and "offers great promise in cases where the poor tend to be concentrated in certain localities" [1].)
Two reasons can explain the success of targeting by attendance at health centres: integration with health actions and a self-selection mechanism. The integration of the food-donation programme with health actions is the key to the positive nutritional impact of the CFP and FMP; the lack of such integration explains the lack of success of PROAB on nutritional grounds. The self-selection mechanism is associated with the fact that in Latin American countries only the poor population uses the services provided through public health facilities. The integration of food donation with public health services guarantees that only the poor will benefit from the donated food (the importance of integrating nutrition programmes with health-care activities is discussed in more detail later).
The conclusion, therefore, is that to guarantee a greater degree of efficiency and effectiveness, food and nutrition programmes should be integrated with health actions, such as growth monitoring and the follow-up with pregnant mothers. Hence. attendance at public health facilities is one of the most appropriate targeting mechanisms.
An important conclusion relative to targeting by income is found in the report by Bapna on the PDS in India. He concludes that targeting by income can either exclude potential beneficiaries or include beneficiaries who should not have been included [8]. The conclusion drawn in the case of India, which can be applied to many developing countries, is that in the rural areas it would be more efficient to target by entitlement, that is, to enrol as beneficiaries the population that has no resources or has marginal resources and skills, for example the landless and marginal farmers. In rural as well as in urban areas, occupation can also be used as a criterion for identification of beneficiaries.
The ineffectiveness of targeting by income [8] has a significance that extends beyond the area of food and nutrition into the formulation of guidelines for social policy. For example, the multilateral banks have been pressing the underdeveloped countries to adopt user fees as a way of recovering part of the costs of health services. Bapna's findings [8] point to the extreme difficulty in implementing measures of this sort, since it is very difficult to assess family income in situations in which a significant proportion of the population is underemployed and performs odd jobs and therefore cannot report income with reasonable accuracy. In addition, the user of health services is often the woman, who may not have information on the income of the male members of the family.
Role of income
In the context of the programmes evaluated, it was presumed that the distribution of donated foods or the price subsidies on some food items would increase household income; this increase in income would be translated into an increase in food consumption, given a positive income elasticity of food consumption. (4)
Regarding the impact of the programmes on total income, the evaluation of the CFP found that, for the lowest quintile of the income distribution, the food distributed by the programme corresponded to between 9.2% and 13.2% of the income of the families of undernourished children (depending upon their age). These values are compatible with those found in the evaluation of the FMP in Brazil, where the value of foods donated through the FMP and SFP corresponded to 31.5% of the value of household food supplies, or around 15% of income, since poor families expend at least half of their incomes on food [6]. However, this result is not general. Working with expenditures rather than income, Sampaio found in the evaluation of PROAB that the impact of the programme is negligible; the benefits of participation in PROAB (given by quantities consumed times price differentials) corresponded to 0.81% of total expenditures for the poorest population and were smaller (0.62%) for the other expenditure groups [7].
The other relevant question relates to the income elasticity of calorie and protein consumption. In the evaluation of the PNAE, Dall'Acqua found very low elasticities (0.08 for calories, 0.05 for protein) [5]. In the evaluation of PROAB, Sampaio [7] obtained a similar value for the income elasticity of calorie acquisition (0.09). These results are very similar to the ones found in the studies conducted in India and reported by Behrman and Deolalikar [11]. The fact that the income elasticity of calorie consumption is near zero led these authors to conclude that increases in income are not a relevant policy measure if one is interested in improving calorie and protein consumption.
This conclusion can lead to mistakes in policy formulation. What the evaluations of PROAB and the CFP really indicate is that neither food distribution alone nor increases in income alone produce an improvement in nutrition status; a series of other inputs is required, such as water and sanitation, access to prenatal care, and access to the health infrastructure. As was very well put by Schiff and Valdés [12; 13], if one thinks in terms of a production function of nutrition status, nutrients are just one of the inputs, the others being non-nutrient food attributes, other privately provided inputs such as clean water and refrigeration, publicly provided inputs such as sewage disposal, potable water and electricity, nutrition information, health status, gender, age, and urban or rural location.
In addition to considering the factors that result in improvement in nutrition status in the context of a production function, one should consider that the elasticity values should be linked with average calorie consumption levels. The reason for the low income elasticity could be that households, on average, are meeting their perceived energy requirements. In this case, additional incomes would not be expected to result in additional energy consumption. This could be the reason why Muchnik and Vial did not find an impact of the CFP on calorie consumption, but rather on diet diversification [4].
Finally, it should be pointed out that the results presented above may be biased downwards, owing to our inability to assess income adequately. (5) Sampaio has stressed, in the evaluation of PROAB, that when one works with low-income populations there is usually underreporting of income, and expenditure is a more reliable variable to work with [7]. In the case of PROAB he reports that he obtained an expenditure elasticity for calorie acquisition of 0.28.
Importance of integration with health actions
After examining the situation in several countries in Africa, in Guatemala, and in the Philippines, several IFPRI reports have concluded that interventions aimed at increasing the income derived from cash cropping had little or no nutritional impact. Pinstrup-Andersen added to that the evidence that "a number of primary health care projects show no nutrition effects in the absence of nutrition interventions" and concluded that "alleviating one constraint while ignoring others may do little for nutrition" [1]. The advantage of combining food-related programmes with primary health care is that it addresses several interacting constraints simultaneously [1].
The importance of integrating nutrition interventions with health actions appears very clearly in the results of the evaluations of PROAB and the CFP and in the discriminant analysis conducted for the FMP. Health and nutrition status depends upon a package of intervening variables, food distribution being one of them, but not the most important one. The evaluations also indicated that besides guaranteeing an adequate access to food, a successful nutrition programme requires access to better sanitation (PROAB, FMP), access to prenatal care (PROAB, FMP), and the existence of an adequate health infrastructure (PROAB, CFP).
Conclusions and recommendations
The papers that presented an overview of the food and nutrition programmes in Brazil and Chile clearly indicate that political commitment at the highest level and decentralization of administration were key factors in the success observed in Chile and the limited impacts of the programmes in Brazil. It was also clear that the main problem faced by the food and nutrition programmes in both countries and in India was not lack of resources but an inadequate use of the resources available due to lack of managerial skills, lack of community participation, excess of centralization, and lack of control at the periphery.
The ineffectiveness of some programmes is associated with poor planning. Programmes were formulated without incorporating the lessons that could have been learned from previous ones, and PROAB was cited as an example. Adequate planning would have supplied information about the education level, the level and composition of income, food habits, food expenditure, and location of the target population, and would have ensured the formulation of a programme more suited to population needs. Moreover, in order to have access to this type of information, planners would have to get in touch with the beneficiary population, which would help them jointly to devise arrangements for community participation. This would also create conditions for the specification of a control group, which would make evaluations possible and would guarantee their use as a managerial tool.
Better planning would ensure better targeting. The main conclusion of the evaluations was that targeting by income proved to be inefficient. Other targeting mechanisms, such as targeting by outlet in urban areas or targeting by land entitlement or occupation of the head of the household in rural areas, are more effective.
The evaluations also made it clear that, to be successful, food and nutrition programmes should be integrated with health actions, such as growth-monitoring and prenatal care. Where this integration occurred, as in the CFP, the programme succeeded on nutritional grounds, and where it did not occur the programme failed, as in the case of PROAB. The reason for this outcome seems to be the one expressed by Pinstrup-Andersen [1], that programme integration guarantees the simultaneous removal of several constraints faced by low-income populations.
There is a need for the formulation of comprehensive programmes. The objective of the programmes reviewed was to provide adequate access to food. None of the programmes aimed at the removal of other constraints to good nutrition, such as infectious diseases, lack of knowledge about nutrition, and short birth intervals. None of the programmes reviewed aimed at increasing the practice of breastfeeding and it could be argued that the CFP could be inducing mothers to reduce breast-feeding when it includes the distribution of powdered milk to children in the 0-6month age bracket.
On the positive side, the programmes seemed to be an important source of calorie and protein intake or availability, and in one case the programme represented an important part of the monetary value of the total food availability at the household level (FMP). In the only case for which it was possible to obtain data on food expenditures from a control group and a target group (PROAB), however, participation seemed to be associated with a reduction in food expenditures.
Owing to the difficulty of establishing a control group, it was not possible to verify the impact of the programmes on the nutrition status of the beneficiary population. It was possible to establish that the proportion of undernourished children decreased after one year of participation in only one programme, the FMP.
The impact on income is not clear: in one case a very positive impact was found (CFP); in the other case for which data were available (PROAB) it was negligible.
Not all of the evaluations were able to tackle the same issues, owing to practical difficulties in the field. But what could not be included in the evaluations is as important as the conclusions drawn above. They indicate the following:
We are grateful to the W. K. Kellogg Foundation for initiating and providing financial support for the Kellogg International Fellowship Program in Food Systems (KIFP/FS), and to the institute of International Agriculture at Michigan State University (MSU) for its administrative support.
We extend special thanks to Gary King, programme director at the Kellogg Foundation, and to Professors Harold Riley and Darrell Fienup, the directors of the KIFP/FS at MSU, for the thoughtful way they devised and organized the three regional seminars in Latin America, Africa, and Asia, for the insights they contributed to discussions of our individual projects. and for their continued support throughout the four-year programme. We would also like to thank MSU professors James Shaffer and Michael Weber for their technical contributions during the regional seminars.
A warm word of thanks is due to Ardell Ward (MSU) for efficient administrative support, to Bets Caldwell, project secretary, and to graduate student assistants Joan Parker, William Guyton, and Julie Howard, who provided us with the latest bibliographies and publications available in the United States.
A special word of thanks is due to Dr. Per Pinstrup-Andersen for the guidance he gave us in formulating, revising, and completing our individual projects and for organizing the research-methods seminar held at Cornell University early in our fellowship programme.
The word-processing services of Eleanor Noonan and the editing assistance of Teresa Howe, Laura Geis, and Emily Evershed are gratefully acknowledged, as is the additional editing at the UNU Cambridge programme office by Nevin Scrimshaw, Sarah Jeffries, and Edwina Murray.
Finally, I wish to thank Professor Harold Riley for his careful reading of all the manuscripts, his comments and suggestions, and his guidance in making this publication possible.
Notes
1. Unpublished data compiled by Lucia Pontes de Miranda Baptista, of the Applied Economics Research Institute of the Ministry of Economy, Finance, and Planning of Brazil.
2. The beneficiaries of the complementary feeding programme (CFP) in Chile were children under 5 years of age and pregnant and lactating women who attended the health centres and were covered by the social security system. All were entitled to what was called the "basic" programme, but those who were identified as being "at risk" were entitled to a "reinforced" programme. The at-risk group was defined by two criteria: (1) biomedical risk measured by the evolution of weight between medical visits, and (2) socio-economic risk, determined by family characteristics such as the employment status of family members and housing conditions.
The beneficiaries of the fluid-milk programme (FMP) in Brazil were children from 6 months to 5 years old who either were malnourished or lost weight in three successive weighings and whose family income was less than two minimum wages. The beneficiaries of the PNAE (school feeding programme) were children who attended public schools in either urban or rural areas.
The public distribution system (PDS) in India and PROAB in Brazil. both providing subsidized foods at retail stores, were aimed at low-income families, either urban (PROAB) or urban and rural (PDS).
3. When beliefs about the underlying causes of malnutrition are identified in the text, this does not necessarily mean that they are identified as such in an official document: it merely means that these are possible causes that are consistent with the programme's objectives. For example. Bapna [8], referring to the PDS in India, says that "the main purpose. . . is to improve household-level food security by insulating the poor and undernourished from increases in prices and by increasing their purchasing power." This is consistent with the identification of lack of income and price rises and not, for example, the mother's educational status as the main cause of malnutrition.
4. The same reasoning can be followed for increases in calorie or protein consumption if one computes income elasticities relative to calorie or protein consumption rather than to food consumption. Moreover. it should he borne in mind that increases in calorie or protein consumption at the family level could be compatible with no increases in such consumption by preschoolers, depending on the pattern of intra-household food distribution.
5. In less developed countries the low-income population very often perform odd jobs in the informal market. Therefore they lack a steady flow of income that can be reported as an average monthly income, Moreover, the source of information for household surveys is usually the housewife, who may not have adequate information on her husband's income but who surely knows how much she spends on bread. milk, and other food items. For this reason, information on expenditures seems to be more reliable than information on income. Indeed. I can report that, in the family-budget survey conducted for the city of São Paulo in 1981/82 by the Institute of Economic Research of the University of São Paulo, one family reported expenditures that were eight times its income!
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7. Sampaio Y. PROAB-a food-price subsidy programme in low-income urban areas of Recife, Brazil: its impact on food consumption, nutrition status, and low birth weight. Food Nutr Bull 1991;13(3):220-29.
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9. World Bank. Feeding Latin America's children. Internal Discussion Paper no. 49. Washington, DC: World Bank, 1989.
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