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Supporting food and nutrition programmes through projects
World Bank project loans, as distinct from adjustment operations, disburse funds only against specific expenditures associated with the project. Therefore, they usually disburse at a much slower rate, at a pace determined by the progress of the project.
Several project loans in progress have an important nutrition component. Some have already been approved by the board of the Bank; others are under active preparation, and others are still at the planning stage. They all provide a wide cross-section of the different issues being faced by the countries.
Argentina
Although Argentina is relatively well off, a sharp and continuous decline in economic activity and per capita income is jeopardizing the nutrition status of the most vulnerable groups. The institutional set-up of the health service is weak, and any delivery system is contingent on the administrative capacity of the provinces.
To avoid deterioration of health and nutrition indicators, the Bank is designing a maternal and child health and nutrition project aimed at reaching preschoolers and pregnant and lactating mothers in the poorest urban neighbourhoods. This targeted population numbers 1.5 million.
The project's nutrition component would be divided into two subcomponents. One would support a transitory programme of limited food distribution to the targeted population designed to promote their regular monthly attendance at health check-ups. The programme would be phased out as the basic health services (supported through the health component) improve, thus generating sufficient incentives for regular attendance. The second subcomponent would support the introduction of a permanent programme for preventing malnutrition. The population identified as malnourished or at risk of malnourishment through the health check-ups is currently estimated to be 350,000. Determining the precise supplementary food to be distributed is presently identified as part of the preparatory work.
The need for micronutrient supplementation is being investigated during loan preparation. It would eventually be included in the health component. In addition, a study of the school feeding programme would be financed through the loan, and technical assistance would be provided for the rehabilitation of school feeding, depending on study results.
Chile
Chile has made important advances in targeted nutrition programmes and has among the best children's health and nutrition indicators in Latin America. Key priorities are to increase the quality of preschool and primary education and to reduce drop-out rates, particularly among lower-income children.
The primary-education improvement project currently in preparation focuses on improving the primary school curriculum and teachers' training. It also has an important component to increase the incentives for poor children to attend preschool education as well as to increase the quality of such education. The project will finance 80,000 daily food rations to new five-year-old low-income children attending preschools. It is expected that these programmes will sharply increase the enrolment in such schools.
Bolivia
The population of Bolivia has among the worst health indicators on the continent. Malnutrition is widespread, particularly in the rapidly growing suburbs of the larger cities and in the rural areas. One-fifth of all children below age five experience severe malnutrition, and almost 40% are at risk.
Since 1986 the government has increasingly focused on social issues, particularly those of an emergency and short-term nature. The Emergency Social Fund, created for this purpose, is estimated to have benefited some 229,000 persons through direct assistance projects designed to improve health and nutrition. The government is now seeking to reorient the emergency effort toward more investment-oriented targets through the creation of a Social Investment Fund, in which programmes will be designed to yield longer-term social and economic benefits. This fund stresses the funding of subprojects meeting the most urgent needs of poor communities-child care, child nutrition programmes, and basic and primary health care and education, among others. A central agency, or social fund, evaluates projects regardless of sector, liaises with non-government organizations (NGOs) and community organizations, and disburses funds.
The Integrated Health Development Project (fiscal year 1990) is also part of this effort. It will benefit about 790,000 children and women of reproductive age currently without access to basic health services in the low-income neighbourhoods of La Paz, El Alto, Cochabamba, and Santa Cruz, the four largest cities. It will reorient public health expenditure in favour of basic health care and improve the efficiency of resource use through better coordination between NGOs and donors. The project includes a service delivery component (US$29.6 million) financing the extension of pre- and postnatal care, reproductive health care and child development, nutrition and nutrition control, and the control of diarrhoea. It will also support outreach activities to be organized at the health district level, which will include food distribution.
Brazil
A major issue in the Brazilian health system has been the inequities resulting from overemphasis on the curative care system and a consequent neglect of preventive and basic health care services. The government is now redirecting resources to basic health programmes, and particularly those involving preventive care. Specific health interventions that are being given priority in north-east Brazil include the control of transmittable diseases (particularly immuno-compromising and endemic ones), improvement of basic sanitation services, expanded food and nutrition activities, and improved access of high-risk groups to ambulatory and hospital medical care. A recent report, "Addressing Nutritional Problems in Brazil," provides the basis for several of the new initiatives.
The Northeast Basic Health Services II loan will support the renovation of basic health facilities in rural areas of seven north-east states. It does not have a nutrition component per se; however, maternal and child health is a major component, and many interventions in this area should have an impact on nutrition. The project will include breast-feeding promotion and the use of oral rehydration therapy.
The second nutrition project is still in the initial stages of discussion. The most probable focus will be on improving targeting and strengthening those programmes run through the Ministry of Social Action, including the national milk programme and the complementary feeding programme. The former targets children under seven years of age, and the latter pregnant and lactating mothers.
The possibility of a food fortification and breastfeeding promotion component as part of the proposed Quality Assurance and Health Promotion Project is being explored. This would be located in the Ministry of Health, under the Institute for Food and Nutrition. The Institute has in the past run a very successful breast-feeding promotion programme and is currently interested in exploring the possibility of food fortification with iron and vitamin A.
Colombia
An estimated 25% of Colombia's population live below the poverty line. In the towns, the worst poverty is borne disproportionately by children, who are at risk from malnutrition, illness, neglect, isolation, and violence. To address these problems, the Colombian government and local NGOs developed a system of preschool child care that includes a feeding programme and health monitoring. The Bank's Community Child Care and Nutrition Project is financing components of the programme.
The target group-children two to six years old and their parents-is drawn mainly from the poorest 20% of the population. A group of parents selects a "community mother" to provide day care and other services for 15 children in her home. With help from the National Family Welfare Institute, she receives training, a small monthly stipend, and a credit to upgrade her home to minimum standards of hygiene and safety. The Institute also provides food, including a domestically produced nutrition supplement, to meet 80% of the daily requirements of each child. The service is much in demand. It started on a broad scale in 1987 and by late 1989 had served a half a million children. Its goal is to reach all children at risk-more than a million of them-by 1994.
Participating children receive improved nutrition and care as well as exposure to preschool learning activities. Community mothers are benefiting from additional income, and parents, often single female heads of household, gain an opportunity to seek remunerative employment outside the home. The cost of the programme, at about US$11 a month per child, compares well with US$33 a month for day care provided through the Institute's centres. In addition, the subsidies are better targeted to the poor; day-care centres largely serve a middle- and lower middle-income clientele.
The Dominican Republic
The nutrition component of the Primary Education Development Project, currently in preparation, is designed to expand school feeding programmes in the poorer areas of the country. At present, these programmes operate in the poor rural areas on the border with Haiti. Food is provided through USAID, logistical support by CARE, and transportation by the National Education Secretariat. The project will expand coverage by serving 100,000 children in peri-urban areas as well. Support of the World Health Programme and local NGOs will be sought in initiating the urban programme. Emphasis is given to strengthening parent participation in the programme to ensure that meals are provided early in the school day to stay hunger and to increase students' learning productivity. The programmes include a pilot effort to treat iron deficiency and parasitic infections, and are also to explore the potential for the use of pre-prepared foods not currently used.
Ecuador
A planned social development project is expected to include a basic health and nutrition component with three subcomponents: Information dissemination and informal education about general nutrition and breast-feeding activities will include the training of health-sector staff and mass media campaigns. Growth monitoring and evaluation of nutrition status will include expanded growth monitoring for children under the age of three, expanded pregnancy weight monitoring, and corrective measures for substandard cases. Food supplementation will be provided to low-income mothers and children attending the preventive health care programmes, and a micronutrient programme will emphasize iron and iodine deficiencies.
Guyana
Guyana experienced more than 12 years of continuous economic decline between 1977 and 1989, and its GDP fell at an average annual rate of over 2%. The decline has had severe consequences for the population and most especially for the poor. The number of severely malnourished children under five years of age almost quadrupled between 1982 and 1987, and in 1987 more than one-fourth of the children in that age group were moderately malnourished. The severity of the problem is aggravated by the accompanying deterioration of social services.
In 1989 the IDB initiated preparation of a pilot operation to support the government's Social Impact Amelioration Programme. The Health, Nutrition, and Water and Sanitation Project consists of an institutional-development component and a project component. The first will complement the IDB's efforts in strengthening the administration and management of the programme. The project component addresses the basic health, nutrition, and sanitation needs of the most vulnerable groups, in particular women and children.
The nutrition component has six main features. It targets high-risk groups: women of childbearing age-in particular, pregnant and lactating women- and children under the age of five. It is integrated with primary health care programmes delivered through government and non-government health centres and health posts. Food is distributed and consumed on site at health centres, health posts, and daycare centres and is also distributed on a take-home basis. It incorporates nutrition education, especially aimed at promoting breast-feeding and adequate use of food in the take-home scheme. Food supplementation subprojects will incorporate a proposal for upgrading health facilities responsible for food distribution to guarantee that storage areas are secure and clean and that equipment, drugs, and supplies are available to provide basic health services. The nutrition supplementation programme should be sustained for at least four years.
Haiti
Malnutrition is strongly associated with illness in Haiti and is a major determinant of the country's high child mortality. In a 1987 survey, 27% of the children were severely or moderately malnourished, and only one-fourth of those under six years of age were in the normal weight range.
Public and private aid agencies offer a variety of nutrition interventions, but there are continuing concerns about the complexity of administering these programmes and also about their sustainability. The Economic and Social Fund Project will facilitate the distribution of food and provide logistical support to existing programmes. It will finance two nutrition subprojects: day-care and preschool programmes, and programmes in health facilities having the capacity to distribute food supplements, including vitamin A and iron supplements.
Honduras
The Bank is supporting the targeting of social-sector services through two operations: the Social Investment Fund project and the Social Sector Adjustment Credit, each of which has important nutrition components.
The objective of the nutrition component of the Social Investment Fund is to ensure a minimum level of nutrition to mothers and children under five, who are especially vulnerable during a period of economic adjustment. It will be administered by the Family Assistance Programme, which will use existing institutions, including the facilities of the ministries of Health and Finance, the Central Bank, commercial banks, and participating stores. Beneficiaries will receive coupons for basic staple foods (maize, rice, oats, beans, fat, and milk) while attending health check-ups at health posts and centres in specified geographical areas. The coupons will provide a 30% supplement in calories and protein to participating mothers and children. The beneficiaries use the coupons to buy food at a local participating store, and the store redeems them against cash at a commercial bank, which is itself funded by the Central Bank.
The project will finance a pilot operation to test the logistics of the programme, its acceptability to beneficiaries and participating stores, and the availability of foods. The programme started in January 1991 and will be undertaken during an initial period of six months in two regions, one rural and one urban. The cost of the food for an estimated 24,000 beneficiaries will be paid by the government. Other costs- including consultants' studies, vehicles, materials, Family Assistance Programme overhead costs, the printing of coupons, and incremental costs such as partial salaries of auxiliary nurses distributing the coupons in the health posts-will be financed by USAID and other donors. The total cost of this pilot project is estimated at US$400,000 for six months. If it is successful, it is to be expanded to the national level and should benefit about 300,000 mothers and children.
To support and promote long-term reforms in the social sector, the Bank is preparing a Social Sector Adjustment Credit, which would support the expansion of the government's actions in nutrition and address major institutional issues in the sector such as planning and budgeting, resource allocation, staffing and training, institutional development, and decentralization. These institutional reforms are crucial to make sure that the delivery systems do not become a bottleneck when more resources are allocated to the social sectors.
Conclusions
Latin American countries can make a stabilization and structural adjustment programme compatible with the protection of health and nutrition among the most vulnerable groups, particularly poor young children and pregnant and lactating mothers. This requires strong reforms in public finances and in the role of the state. The state must stop subsidizing particular industries through subsidized credit, tax exemptions, weak tax collection, and procurement practices that unnecessarily burden public finances. Prestige projects must be eliminated. Using public enterprises and provincial governments as employment-creation agencies has been an enormous cost to public finances. Reforms in this area could release significant resources to be used in targeted social programmes. An important part of the Bank's activities is to assist countries in the process of restructuring the state and thus to help release these resources.
Channelling these resources to targeted social programmes requires a significant improvement in institutions and delivery systems. Sometimes it may call for stricter coordination of agencies and sometimes the elimination of others. It may call for increasing the technical capacity and the motivation of social-sector institutions. These institutions should be able to attract the best managerial talent in society. Their salaries should be as high as those paid by the central bank or the state petroleum companies.
All this requires strong commitments and initiatives from government leaders. The World Bank can support this process through technical assistance, economic studies, mobilizing cofinancing, and its own lending. Ultimately, however, progress depends on the willingness of governments to lead and sustain those initiatives.
Acknowledgements
I wish to thank my colleagues in the World Bank's Latin American Region Human Resources Division for their assistance.
References
1. World Bank. Feeding Latin America's children. Internal discussion paper. New York: World Bank, 1989.
2. Grosh M. Social spending in Latin America: the story of the 1980s. Discussion Paper no. 106. New York: World Bank, 1990.
3. Selowsky M. Stages in the recovery of Latin America's growth. Finance Dev 1990;27(2):28-31.
4. Comisión Presidencial pare los Derechos del Niño. Los niños: el compromiso de los noventa. Caracas, Venezuela, 1991.