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References

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22. The relevance of rapid assessment procedures for overcoming hunger in the 1990s

Ending hunger in the 1990s: the Bellagio declaration of 1989
Eliminate famine deaths
Ending hunger in one-half of the poorest households
Cutting malnutrition among women and children by half
Eliminate iodine and vitamin a deficiencies as public health problems
Discussion
References

By Ellen Messer

Ellen Messer is affiliated with the World Hunger Programme at Brown University, Providence, RI 02912, USA.

This is the only paper in the applications section that is not based on field experience. Ellen Messer describes the various ways in which RAP could contribute to the conquest of hunger through their use for needs assessment, policy and programme implementation, and evaluation and monitoring. She also sees RAP presenting opportunities for communities to take responsibility for data collection, analysis, and action. The paper is included because it does describe a wide range of food and nutrition related issues for which the RAP approach could be useful. - Eds.

SINCE THE CLOSING years of the last decade, food and health policy makers have been trying to develop strategies for overcoming hunger in the 1990s (see, e.g., Kasperson and Kates 1990). United Nations activities, such as the Convention on the Rights of the Child and the Plan of Action for Implementing the World Declaration on the Survival, Protection, and Development of Children in the 1990s, present a series of legal and practical policy approaches to the task of ensuring children's health and survival by the year 2000. They emphasize first the need to focus on achievable (and measurable) goals, to be followed by an implementation plan that can assure such goals are achieved.

Such plans emphasize furthermore the need to mobilize all sectors of society toward giving high priority to the needs of children, even in circumstances of limited resources (UNICEF 1991). Plans and activities need to be coordinated to involve households, communities, and local groups; provincial, regional, and national government planning sectors; non-government organizations of all types and scales; and also intergovernmental agencies. In addition, academic, communication, and media specialists must be motivated to contribute to the campaign for superior health and nutrition for children (e.g., Plan of Action, Articles 34 and 35 in UNICEF 1991: 69-72).

Such plans and social mobilization efforts also entail new combinations of technologies and institutions - if not new technologies and institutions themselves - to make fewer deaths from hunger a reality. Rapid Assessment Procedures (RAP) that involve focused ethnographic interviews with community leaders, household heads, and programme personnel - in relation to child survival - have been discussed principally as a way to get more and better information about health needs and programme implementation from the local and household perspectives. RAP also has been discussed in relation to issues of rural development more generally as a way to improve the participation of proposed beneficiaries in the design, implementation, and evaluation of programmes to improve community health, nutrition, education and economic conditions. In either case, RAP constitutes a method to involve the poor in planning, implementing, and monitoring ways to ameliorate their living conditions.

This paper will consider how rapid assessment methods have been, or might be further employed to coordinate efforts in a four point plan for overcoming hunger in the 1990s (Bellagio Declaration 1989). For each of the points, we will consider how RAP at the community level might contribute to better programme design; and how RAP at the administrator level might improve planning, coordination and evaluation. Although the implementation planning for the Bellagio initiative has not yet endorsed RAP formally, we count on incorporating rapid assessment methods to implement, evaluate and also to plan the steps for overcoming hunger in the 1990s.

Ending hunger in the 1990s: the Bellagio declaration of 1989

In 1988, the World Hunger Programme of Brown University began a review of possible strategies for ending half the world's hunger in the 1990s (Brown University Faculty 1990). We worked with a three part topology that classified hunger as food shortage, food poverty or food deprivation and then matched possible food policy interventions against each. At a regional or national level, a food shortage may be due to political, climatic or socioeconomic forces. Food short famine conditions may be distinguished from food poverty at the household level, in which people go hungry because they lack the resources to acquire food even when the regional food supply is sufficient. Ultimately, however, even if households have sufficient resources to command and access food, individuals go hungry if distribution rules militate against their getting an adequate share, if cultural rules of consumption prejudice them from assuring an adequate mix of nutrients or if individuals are ill and unable to ingest, metabolize and benefit from the nutrients potentially available. This third context, termed food deprivation, includes situations of malnutrition among the so-called vulnerable groups: infants and young children, pregnant and lactating women, and others who are deprived of food in situations of social powerlessness or illness (Messer 1990).

A meeting in November, 1989, in Bellagio, Italy, with participants from 14 countries developed a four point plan for overcoming at least half the world's hunger by the year 2000. Taking into account the available technologies, institutions and costs, four areas were identified for immediate intervention: (1) eliminating famine deaths; (2) ending hunger in one half of the world's poorest households; (3) cutting malnutrition among women and children in half; and (4) eliminating iodine and vitamin A deficiencies as public health problems. An unenumerated goal is also the general one to prevent additional hunger by eliminating those policies which interfere with people obtaining adequate food and nutrition.

Since the Declaration, there have followed a series of meetings to coordinate an action plan for implementing the four goals, to identify: (1) what types of interventions should be undertaken; (2) who should (best) do them, and how such efforts might be coordinated and paid for; and finally, (3) what types of evaluation might ascertain how far interventions are achieving their desired goals or might otherwise be improved (World Hunger Programme and InterAction 1991). These points of the action plan correspond roughly to the conventional food policy dimensions of (1) needs assessment, (2) implementation, and (3) evaluation and monitoring. They are more ambitious than conventional food policy in that they attempt to bring together and coordinate within a single plan of action the "grassroots", the "summit" and all active groups in between.

Eliminate famine deaths

Famine Early Warning System(s) and Geographic Information Early Warning System(s) are two of the mechanisms that already exist for collecting timely information on harvest losses, people's coping mechanisms, numbers of people at risk, the levels of assistance required, and relief organizations' capacity to move food.

Famine monitoring already incorporates "rapid assessment" but the quality and timeliness of the information may be limited by the roles or identities of those collecting the information and the types of information collected. Moreover, the participation of those who are suffering through a bad season, year, or longer may be limited by the top-down orientation of data collection and response programmes. Relief agency, researcher and journalists' accounts report on changes in food availabilities and prices, sales of goods, especially livestock and ultimately, movements of people in response to localized food shortages. They also report failures of relief mechanisms due to disrupted markets and warfare. But they limit the extent of participation by possible beneficiaries in the surveillance process.

Through participation beneficiaries hold the key to letting possible sources of relief know how bad off they are, which groups, households, or individuals are worst off and which are least able to cope with such difficulties through indigenous mechanisms or from various types of relief (see, e.g., Harrell-Bond 1986; Torrey 1988). Such voices, elicited through systematic RAP focus group and key informant interviews, might enable more efficient response on the part of relief agencies. Such responses also could better build on local initiatives, and expand the knowledge base of the social indicators of hardship for future reference. RAP might also help develop infrastructure to keep reporting systematically on conditions, to anticipate and preclude future emergencies.

RAP can also enhance the data base on likely movements of peoples out of famine hardship zones, their most pressing needs (often water) and the most effective ways to help them. It can also suggest the most appropriate rations. Finally, RAP carried out in the form of focus-group interviews among relief personnel could also improve coordination of information and response. Especially in efforts to move food into zones of armed conflict, RAP might play a role in bringing together local community leaders, government, intergovernmental and NGO actors to discuss how to overcome key obstacles and to coordinate efforts to move food to the hungry (see, e.g., Minear 1991).

Ending hunger in one-half of the poorest households

The second Bellagio goal is to augment purchasing power and access to food through production, processing and utilization of post-harvest materials; or through other non-agricultural income-generating activities. One strategy has been to suggest a re-allocation of non-emergency food aid. In this way funds designated for food aid would be allocated on a competitive basis to government, NGO, or other community groups. Instead of government programmes commanding all food aid monetary funds, community or NGO projects that preserve land, biological, and water resources, that improve economic opportunities for women, that generate higher incomes on small farms, or that contribute to education in rural or urban areas might qualify. The competition would be based on the project design, but also on potential "hunger impact" (Reutlinger and Hyden 1991).

Focused (RAP) interviews with community leaders might help those judging applications to such a "food fund" to discern which project might be most beneficial in alleviating poverty, and also for subsequent monitoring and evaluation on how to make existing programmes work better. In rural areas, focus group interviewing on how to target improvements will prove essential in choosing programmes and their methods of administration. Rapid Rural Assessment (Chambers 1992) demonstrates that it is entirely possible for local groups to take into their own hands the triple aspects of needs assessment, programme planning and implementation, and evaluation and monitoring.

For urban areas, RAP provides an opportunity for food programmes designed to benefit the poor to achieve superior targeting, to eliminate waste and to improve efficiency through focused interviews with consumers and providers (e.g., small shop owners). For these programmes, RAP is probably not a new idea, but a RAP group could provide an umbrella to systematically overview what types of programmes work in the particular area, and how programmes to generate income might be adapted to meet local conditions. Additionally, local people might be systematically included in efforts to find ways to distribute food at lower cost, with increased participation.

Cutting malnutrition among women and children by half

Child survival programmes are those which have demonstrated most ably the value of RAP. RAP can indicate what local recipients of health programmes perceive as their major health problems, and also what they perceive as key problems with health care delivery - some of which might be easily and rapidly corrected mid-course. Additionally, RAP focus group interviews - with local parents and also with programme administrators - can indicate what kinds of information (measurements) stimulate action on the part of parents and are deemed relevant by decision makers.

The successes of growth monitoring in Iringa, Tanzania and in Yogyakarta, Indonesia are two cases in point. Both used growth monitoring and variations on RAP as tools to empower local people (especially mothers) and to involve them in the child health process, as well as to measure progress in child survival. In Iringa, information was channeled up from household and village level to regional administrators, who were able to identify problem locations and respond rapidly - in systematic consultation with local leaders and mothers.

Eliminate iodine and vitamin a deficiencies as public health problems

RAP should support micronutrient programme needs at two levels. The first is the need for increased awareness on the part of community members that iodine and/or vitamin A deficiencies are nutritional problems in their community and that there are multiple options for overcoming such deficiencies. The second is the need for more precise information on local dietary, health and human (social, political, economic, cultural) resources that might be involved in the solutions.

Awareness entails community participation in diagnosing problems and arriving at appropriate solutions. Focused interviews with local people can help pinpoint how they identify iodine or vitamin A problems, information which complements that collected by health personnel for purposes of planning, implementation, and monitoring of programmes. For iodine, interviews additionally can consider in what contexts iodized salt is appropriate, and where (and for what reasons?) an alternative must be sought. In such instances, where it is determined by community members in consultation with public health personnel, selected iodization of water sources might be seen as best to reach those at greatest risk for iodine deficiency. In some Thai villages, iodization of well water used by schoolchildren has been a trial intervention. In remote Andean communities massive parenteral or oral doses of iodinated oil has been the most feasible approach. There are numerous options; it is important that communities be made aware of them, and participate in selecting the most feasible so that they actively participate in creating the fit between supply and demand.

For vitamin A, focused interviews with community people can pinpoint how they identify vitamin A problems (e.g., local recognition of night blindness), and solutions (e.g., vitamin-A-rich foods and the contexts in which they might be consumed) that might be available locally. RAP can provide the context for constructing appropriate checklists for rapid dietary screening, and for having local people discuss with medical and non-medical personnel the range of options for reducing vitamin A deficiency. Capsules versus food system (gardening, food fortification) approaches need not be an either-or proposition; the relevance and contexts in which either or both are appropriate merit active community discussion and decision-making (Underwood 1991). Then they can choose among the options most appropriate for their community. Local interviews can also focus on how capsule delivery programmes, might be improved, be more sustainable and community-based.

The key to establishing effective programmes, is not only the availability of infrastructure that can deliver appropriate messages and materials, but also local communities who demand from their government and agencies (such as UNICEF) a vitamin A or iodine component.

RAP with health care personnel can also be used to determine how delivery of medical dosages of vitamin A or iodine might be simplified, or made more effective; and also where piggy-backing medical delivery of vitamin A capsules or iodine might interfere with other programme functions. It has been proposed, for example, that vitamin A be attached to immunization programmes, where modifications for age-appropriate dosing and delivery might be made. Alternatively, it might become part of the message and materials presented along with growth monitoring, oral rehydration, breast-feeding, and other components of child survival, food, economic, and literacy programmes. But it must be determined how to take advantage of existing infrastructure without interfering with performance of other functions, such as care and delivery of vaccines, nutrition education, growth monitoring, etc. Ideally, putting the disparate components of health care together should be reinforcing rather than disintegrating. But the former can only be achieved by RAP with the health care providers as well as community consumers.

Discussion

Rapid assessment procedures provide opportunities for improving the implementation of the "plans" for child survival (UNICEF 1991) and overcoming hunger at multiple social levels (Bellagio Declaration 1989). So far, RAP has been used mainly to elicit information for government, NGO, or other "top-down" administrators, who use RAP to collect "process" information to improve deficiencies in health, sanitation, or other programmes. But in addition, RAP suggests opportunities to involve the proposed beneficiaries in diagnosing and ameliorating their own problems. The opportunity also exists to interview multiple levels of administrators in order to rapidly assess what different classes of actors in any food or health policy "Action Plan" are proposing, to facilitate coordination, and ultimately, efficient use of resources and end benefits from such plans.

RAP potentially can provide reliable information on most of the hungermonitoring concerns of the Bellagio Declaration. RAP can be useful in identifying indicators of households at risk for food poverty and illness. In addition, RAP can provide the basis for constructing effective dietary, health, and economic surveys to ferret out those at risk of micronutrient or other nutritional deficiencies. NGOs are very interested in RAP as a tool to know where and how to intervene quickly, monitor progress, and if necessary, correct the course of programmes, rapidly, midstream. UNICEF proposes to use RAP as a way to get standard, quick, short field reports on what is going on.

National programmes are using RAP as a way to channel information on needs and progress rapidly from village, to central authority, and to administrative layers in between - to improve performance and health. There are many organizations that are trying to carry out rapid nutrition surveillance and dietary indicators of malnutrition, but there is no coordination or agreement on the strengths and weaknesses of various indicators for different populations. Special networks and discussions might focus on particular micronutrient deficiencies. Taking the politics of these programmes out of the ministries or specialized health programmes currently handling them, and into a more neutral "methods" context might improve information exchange and performance all around. But such efforts raise additional questions of standardization of methods, scale-up, cultural diversity and management, and community empowerment.

RAP involves some standardization in overall research design, that is then tailored to the particular community interests and concerns. Such specifications take away from the overall projects the commonality on which comparability is built, but may also result in more successful local utilization of methods. Growth monitoring projects are a good example where measuring tools tailored to local ideas of human physical, social, and psychological development have proved to work very well. The mix is delicate between RAP with a top-down orientation and RAP with a bottom-up orientation to create a unified programme which nevertheless expresses, and benefits from, the diversity of perspectives in its origins. In sum, RAP is flexible, but the permissible parameters of flexibility need to be spelled out.

Questions remain of how to generalize or scale up from successful local information, surveys, and community programmes and processes, and how to adapt information and projects across wider geographical areas that tend to be culturally diverse and socially complex.

Finally, viewed from the villagers' perspective, RAP should lead to empowerment: it presents opportunities for communities to take away from non-community based organizations responsibility for, and ownership of, data collection, analysis and action. This raises serious questions of how far government and donor/provider organizations will welcome or allow possible usurpation of their authority.

References

1. Bellagio Declaration. World Hunger Program, Brown University, Box 1831 Brown University, Providence, RI 02912 USA, 1989. (available in multiple languages)

2. Brown University Faculty. Overcoming Hunger: Promising Programs and Policies. Food Policy 1990; 15(4): 286-298.

3. Chambers R. Rapid but Relaxed and Participatory Rural Appraisal: Towards Applications in health and Nutrition. In: Scrimshaw NS, Gleason GR, eds. Rapid Assessment Procedures: Qualitative Methodologies for Planning and Evaluation of Health Related Programmes. Boston, MA: International Nutrition Foundation for Developing Countries (INFDC), 1992: 295-306.

4. Harrell-Bond B. Imposing Aid: Emergency Assistance to Refugees. Oxford: Oxford University Press, 1986.

5. Kasperson JX, Kates RW. Introduction: Halving Hunger. Food Policy 1990; 15 (4): 274-276

6. Messer E. Hunger Vulnerability from an Anthropologist's Food Systems Perspective. Development Anthropology Network 1990; 8(2): 8-15.

7. Minear L. Humanitarianism Under Siege. A critical review of Operation Lifeline Sudan. Trenton, NJ: The Red Sea Press, 1991.

8. Reutlinger S. Hyden G. Reaching the Rural and Urban Poor: Suggestions for Implementing the Bellagio Declaration. Background Paper Fourth Annual Hunger Research Briefing and Exchange. Providence, RI: Brown University World Hunger Program, 1991.

9. Torrey W I. FEWS: The Need for an Anthropological Dimension. Human Org 1988; 47(3): 273-281

10. Underwood B. Achieving the Achievable in Reducing Vitamin A Deficiency by the Year 2000. Background Paper Fourth Annual Hunger Research Briefing and Exchange. Providence, RI: Brown University World Hunger Program, 1991.

11. UNICEF. Plan of Action for Implementing the World Declaration on the Survival, Protection, and Development of Children in the 1990s. In: The State of the World's Children. New York: UNICEF, 1991: 60-74.

12. World Hunger Program, Brown University and InterAction. Fourth Annual Hunger Research Briefing and Exchange. Providence, RI: Brown University, World Hunger Program, 1991.

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