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Myanmar's experience with nutrition programming - Thyra Po and Michael Gurney

The objectives of the Joint WHO/UNICEF Nutrition Support Programme (JNSP), begun in 1983 with support from the government of Italy, were to reduce infant and young child mortality, improve child growth, and reduce malnutrition in mothers. Since 1984 the programme has been in operation in 17 countries, with widely varying results. In most countries a strong interdisciplinary approach was adopted, with an emphasis on the convergence of a range of services for children and mothers. The programme usually took place in a province or in a number of districts, with an additional element of central coordination. Myanmar (formerly Burma) was an exception.

A consultation on current views on nutrition strategies to avert the "crisis of dying children" [1], held in 1983, listed three major constraints: lack of appropriate technology and infrastructure, high costs of implementation, and low coverage of targeted groups. It emphasized two important approaches to reduce child mortality-primary health care and poverty reduction-and recommended effective and large-scale implementation of a focused, low-cost, childsaving mix of measures as an answer to the crisis. The JNSP in Myanmar concentrated on the first approachprimary health care-and did not assume responsibility for poverty reduction.

Levinson [2], in a review of what works in combating malnutrition, concluded that any number of approaches might work as long as there is a threshold level of commitment, imagination, and financial and political support. He considered that support and commitment to the principle of meeting basic human needs are more critical than the technical choice of intervention or its design. He found that programmes that depended on imported food resulted in more harm than good, and concluded that it is unrealistic to expect to eliminate poverty-related protein-energy malnutrition inexpensively. In five of the six programmes reviewed, the provision of food was an important element. The sixth, the Indonesian Family Nutrition Improvement Programme, was designed to give food only to malnourished children at nutrition rehabilitation centres. The Indonesian programme is discussed in some detail by Rohde and Hendrata [3], who concluded that the feeding elements overwhelmed both the mothers and programme personnel. They defined six critical elements for success:

• clear, simple, achievable, and objectively measurable programme objectives,
• emphasis entirely on behavioural change leading to monthly weight gain,
• village staff chosen from among and by the participating village women,
• a high degree of community participation and self-reliance,
• highly standardized procedures,
• the monitoring and reporting system designed primarily as a stimulating and motivating tool.

The JNSP in Myanmar emphasized these points. It avoided getting involved in the provision of food on the grounds that this was neither sustainable nor replicable.

The programme

From its beginning in 1984 the JNSP in Myanmar was seen as a nationwide programme, although its expansion took place in three phases. It concentrated almost entirely on limited and focused activities, which were administered through the Ministry of Health. The JNSP completely redesigned training in nutrition for village workers, their supervisors, and district health personnel. It strengthened nutrition units at the central and regional levels and allowed for increased staff at the district and local levels; the staff members have been absorbed into the Health Ministry's regular establishment. The technical activities fell into two categories, nutrition monitoring and counselling. The JNSP also supported the Expanded Programme on Immunization (EPI) and provided equipment and pharmaceuticals. A food and nutrition surveillance system was set up and operated as part of the programme.

The decision to concentrate activities and implement them nationally from the beginning was based on a detailed situation analysis of nutrition conditions and nutrition programmes in primary health care which had been carried out before the JNSP began. Such a situation analysis before starting activities was unique to Myanmar among JNSP countries.

The government already had a defined plan for primary health care, the People's Health Plan, which had taken the situation analysis into account. The JNSP provided the means to implement this in its nutrition and nutrition-related aspects and had the added effect of making possible a rapid decentralization of responsibilities within the context of the plan. It also allowed for some flexibility in response to experience and operational research findings within the context of the plan.

Results

The programme in Myanmar was evaluated in 1989; this paper is based on the report of that evaluation.

During the JNSP period, mortality in children under three years old decreased and they grew faster. Protein-energy malnutrition declined. Young-child feeding practices and mothers' health-seeking behaviour improved during the review period. This was along the lines advocated in the counselling component of the programme. Health-staff performance also improved with the training implemented through the JNSP.

The evaluation concluded that the JNSP had a direct beneficial effect on the health and nutrition of the target group of children, under three years old, made possible through the limited though extensive activities undertaken by the programme.

Costs

The external costs of the programme were US$5.63 million. The input from government sources was assessed at US$5.43 million and that from the communities valued at US$9.29 million. Thirty per cent of the total population of Myanmar was covered by the programme. It is estimated that around 1.63 million children and 550,000 pregnant women have benefited. The per capita annual costs are estimated at US$1.67 for each child and the same amount for each mother covered (the identical figures are fortuitous). US$0.46 came directly from the communities (the work of assistant nurse midwives, who are community volunteers). This is a remarkably small figure, which indicates that the programme is sustainable and replicable. However, further expansion of coverage depends on the expansion of the health delivery system, as the JNSP in Myanmar is a constituent part of the primary health care system operating in the country.

Discussion

Selective versus broad approach

Field [4] reviewed nutrition programming from the standpoint of implementation. While acknowledging that the problem of protein-energy malnutrition is embedded in a total ecology of deprivation, he concluded that programmes that involve conceptual and operational complexities are bound to fail. He described "comprehensive planning" as an albatross that inhibits action, however appealing it is intellectually. To these negative factors he added the long time frames, which inevitably lengthen as the programme continues, and unreasonable reliance on beneficiary support and participation. He concluded that far more attention needs to be given in nutrition programmer to "how to do it" rather than just "what to do"-in other words, to implementation.

The JNSP in Myanmar resisted pressure to plan comprehensively. It concentrated on a simple approach mainly within the competence of the Ministry of Health and emphasized implementation rather than planning. This was made possible by the knowledge gained from the situation analysis carried out in advance.

In a later paper, Field [5] concluded that the multisectoral approach to nutrition planning is a mistake. He identified twelve lessons for intersectoral initiatives against malnutrition:

• 1) Downgrade the importance attached to planning. The promise of successful intervention lies not so much in planning nutrition programmes as in managing the new strategies that exist and in making them work in live situations. Good management is the operational link between the desirable and the feasible and between the economically rational and the politically possible.
• 2) Do not divorce planning, even within a single sector, from operational responsibility. Not only do senior administrators function as an important realitycheck, their understanding and support are essential to effective action.
• 3) Do not leave nutrition isolated in policy space, much less assume that other interests can easily be subsumed under the banner of combating malnutrition. The former invites powerlessness, the latter sabotage.
• 4) Make every effort to integrate nutrition with mainstream activities in agriculture and health. Nutrition initiatives that are added to established policies and programmes but neither reconciled nor coordinated with them are vulnerable. A major task of nutrition management is to make nutrition compatible with and, to the extent possible, a logical component of the larger pantheon of a ministry's concerns, objectives, priorities and programmes.
• 5) Keep things as simple as possible. Simplicity in design and operational requirements is a blessing, complexity a curse. By extension, do not overload those who design nutrition interventions with specification tasks. If good planning is the key to identifying targets of opportunity, adaptability in implementation is the key to eventual success.
• 6) Subordinate data acquisition and analysis to action. Data generation should be focused, instrumental, manageable and-above all- phased over time so as to permit learning in the course of doing, as against being a prerequisite to decision making.
• 7) Eschew machine theory. Implementors are not gears to be moved; they are people to be motivated whose effectiveness often requires considerable discretionary latitude. Field- and clinic-level personnel, in particular, must receive sensitive treatment in terms of job coherence and load, incentives, supports and related factors vital to morale and performance. Reporting requirements should be modest and oriented more to problem solving than to mere accounting and compliance.
• 8) Avoid the temptation to treat the beneficiaries as passive receptacles or as objects of manipulation. Agents of nutrition preoccupied with the flow of services and neglectful of the need to cultivate clients are unlikely to stimulate the understanding, trust and support essential to sustained participation. Target groups must be engaged, encouraged and satisfied. Strategies of engagement and mobilization are critically important to programme success in most instances.
• 9) Try to operationalize the concept of "backward mapping." In contrast to top-down planning, backward mapping begins at the periphery, where administrative actions intersect private choices, and works back so as to enhance the likelihood that government will function in a manner supportive of client mobilization. Backward mapping emphasizes proximity, discretion, adaptability, coalition building at the base and reciprocity in place of standardized solutions, formal duties, hierarchy and control. It is appropriate to nutrition interventions for which strategies of engagement with beneficiaries are important to success, especially those requiring sustained popular participation and behavioural change.
• 10) Recognize that however promising new technologies may be, their capacity to produce results is highly dependent on the organizations that use them. Success is not simply a function of technology alone, nor even of intervention design. Strong management and organization are what convert inputs into desired outcomes.
• 11) Be wary of blueprints and formula approaches developed elsewhere or derived from pilot experience. Whatever their formula merit, they communicate potential more than guaranteed impact. Sponsorship scale, setting and scope of effort all powerfully condition performance.
• 12) Finally, always be sensitive to political and other contextual parameters. Not only is there a politics inherently imbedded in any environment in which one functions, there is a politics of action as well. Those who manage nutrition initiative must harness political capital, steer nutrition through the inevitable maze of government institutions, maintain momentum as programmer are activated in society and cultivate positive responsiveness among beneficiaries. Politically astute management enables economic and other technical expertise to survive and prosper in the real world. When confronting protein-energy malnutrition, good management is the key to success more often than not. Its absence is a principal cause of failure.

The JNSP in Myanmar was planned and implemented by the health sector with these same considerations.

Berg [6], in a rejoinder to Field's criticism of multisectoral nutrition planning, emphasized that multisectoral analysis was different from multisectoral implementation, and considered that there was no prima facie case for ruling out multisectoral operational efforts. He did, however, acknowledge mistakes in nutrition planning in the past, in particular the presumption that policy people would be concerned with nutrition, a lack of managerial expertise to anchor policies in established interest groups or ministries, and a lack of attention to the ultimate clients. He made a plea for a balance between bottom-up and top-down planning and between intersectoral and intrasectoral planning.

The global management of the JNSP suggested a broad approach in participating countries to achieve the programme objectives of reducing infant and young child mortality and morbidity, improving child growth and development, and improving maternal nutrition. The initial emphasis of the two agencies managing the JNSP was on support for what can be done directly by the health sector, but it also included what the health sector can do indirectly through cooperation with other sectors. They suggested including actions directed at incomes and food prices, food supply, knowledge and attitudes leading to changed family behaviour, the status of women, and health care services. This was a much broader and more multisectoral approach than that chosen by the JNSP programme in Myanmar.

Seventeen countries participated in the JNSP. All except Myanmar and the Caribbean countries chose to concentrate their programme in only a part of the country and, to a greater or lesser extent, to have activities in various sectors. Myanmar, on the other hand, chose a programme virtually confined to the health sector and covering all regions of the country.

Comparison with Tanzania

A useful comparison can be made between the JNSP in Myanmar and that in Tanzania [7]. The Tanzanian programme was confined to the Iringa region, which has about 2.1 million inhabitants. The Myanmar programme covered a population of about 11.7 million. The total external budget in Tanzania (US$5.7 million) was similar to that in Myanmar (US$5.6 million), but the per capita costs were much higher in Tanzania than in Myanmar. In Tanzania, approximately US$8 was spent per child per year from external sources, with a further US$2 from national sources plus US$9 for start-up and expansion. In Myanmar, the total yearly costs per child were much less, about US$1.67. of which US$0.57 per child was from external JNSP inputs. The Tanzanian programme, besides being more expensive, was more comprehensive than that in Myanmar, covering water and environmental sanitation, household food security, and income-generating activities. This befits the emphasis on a comprehensive, though simple, conceptual framework explaining the causes of young child deaths in the project communities, which formed the basis for the selection of activities in Tanzania. None of these areas were tackled by the JNSP in Myanmar.

Another difference between the Myanmar and Tanzanian JNSP programmer was in the area of community participation. Tanzania developed a "triple-A cycle," linking data collection with decisions and actions so as to motivate and maintain community participation; the three A's are assessment, leading to analysis, leading to action, as a continuous cycle of events. The JNSP villages there assessed the nutrition status of children through growth monitoring, analysed the reasons for the patterns found, and took or sought appropriate action [7, 8]. This can be contrasted with Myanmar, which concentrated on the training of volunteer villagelevel workers (the assistant nurse midwives) and their supportive supervision.

Both programmer placed heavy emphasis on growth monitoring. Each had a successful outcome. Although the impact, as indicated by child growth performance, was considerably greater in Tanzania, its replicability will probably be easier and more affordable in Myanmar.

Are the differences in the results of the two programmes due mainly to the differences in programme strategy, to the different per capita costs, or to the sociopolitical-geographic differences between Tanzania and Myanmar? The Tanzanian approach is much more expensive (although replication costs can perhaps be reduced). It also tries to get to the underlying causes of malnutrition. The Myanmar approach concentrates on ensuring the best possible use of services. It lays great emphasis on ensuring that training, motivation, and supervision are as good as possible.

Probably the most useful conclusion is that both approaches are needed. The experiences of the Myanmar JNSP can be applied universally. They can be replicated at little cost in all countries that implement primary health care, and the probability of benefit is high. The main limiting factor to its replicability elsewhere may be the tradition of volunteer work in Myanmar. The assistant nurse midwives are volunteers. This is a basic issue for primary health care in general rather than just for nutrition. It concerns how to ensure adequate and affordable coverage of all the population.

The Tanzanian approach addresses the underlying causes of malnutrition, but its replicability elsewhere depends to a large extent on the political and social context. There is a tradition of a considerable amount of community decision-making in Tanzania. The approach of the Tanzania JNSP is not all that different from the "basic minimum needs" approach adopted by Thailand. The Myanmar JNSP approach bears some relationship to the Indonesian National Family Nutrition Improvement Programme.

Conclusion

The JNSP in Myanmar demonstrated that, despite poverty, improvement in child health and nutrition can be made in a large population over a short period of time and at low per capita cost. This can be achieved in the following circumstances:

• A primary health care system with concentration on outreach is in place. In Myanmar, the tradition of voluntary work was a great help in achieving broad coverage of primary health services for children and their mothers.
• A situation analysis is undertaken before the activities are started so that the programme is planned on the basis of adequate knowledge of the problems and resources.
• Concentration is maintained on a few priority activities carried out well with sufficiently detailed planning.
• A "cascading" model of detailed training of health workers, including regular refresher courses at all levels, is implemented, with carefully developed complementary educational content and messages.
• Support and supervision are provided regularly at all levels, with frequent, planned evaluation and feedback.
• Nutrition surveillance, including growth monitoring at the local level, is implemented routinely but interpreted creatively so as to maintain both knowledge and enthusiasm and to draw attention to changes needed.
• Flexible implementation is facilitated, using the programme monitoring and surveillance results to aid decisions.

One last comment is due. All implementers of and commentators on nutrition programmes accept that malnutrition is caused by a combination of factors, some of them running very deep in the structure of a society and its economy. Most will agree with Begin et al. [8] that a solution of the nutrition problems requires action in a variety of sectors as well as international cooperation. Myanmar decided to use the JNSP to do a few things very well at as low a cost as possible. This resulted in a real advance in familylevel practices and local services and a reasonable improvement in nutrition status. This was in spite of the economic decline. The programme was at a low cost and was thus almost certainly sustainable.

Acknowledgement

Support for the work reported on in this paper came from the government of Italy through the Joint WHO/UNICEF Nutrition Support Programme.

References

1. UNICEF. Current views on nutrition strategies. New York: UNICEF, 1983.

2. Levinson FJ. Toward success in combating malnutrition: an assessment of what works. Food Nutr Bull 1982; 4(3):23-44.

3. Rhode JE, Hendrata L. Development from below transformation from village-based nutrition projects to a national family nutrition programme in Indonesia. In: Morley D, Rohde JE, Williams G. ads. Practicing health for all. Oxford: Oxford University Press, 1983:252-71.

4. Field JO. Implementing nutrition programs: lessons from an unheeded literature. Ann Rev Nutr 1985;5:14372.

5. Field JO. Multisectoral nutrition planning: a postmortem. Food Policy 1987;12:15-29.

6. Berg A. Nutrition planning is alive and well, thank you. Food Policy 1987;12:365-75.

7. WHO, UNICEF, Government of Tanzania. The joint WHO/UNICEF Nutrition Support Programme in Iringa, Tanzania (1983-1988): evaluation report. Dar-es-Salaam: WHO, UNICEF, 1988.

8. Moneli F. Lee V. Mobilization for nutrition results from Iringa. Mothers and Children 1989;8(2):1-3.

9. Beghin I, Cap M, Dujardin B. A guide to nutritional assessment. Geneva: WHO, 1988.

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