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Giorgio Solimano and Maximo Jeria
Introduction
Human needs and the objectives of development
Development models
Case studies
Intervention programmes
Surveillance and evaluation
References
Discussion
The decades of the 1960s and 1970s have shown the incapacity of the process of economic development to fulfill the elementary needs of life in Third World countries. This economic underdevelopment is characterized by the transference, perpetuation, and, in some cases, worsening of the already deplorable conditions of unemployment, poor health, lack of education, decent housing, and undernourishment in wide sectors of the population.
There is evidence that even in countries whose economic growth rates have risen considerably, poverty has not only not been eradicated but has grown worse, leading the international community to dedicate more time, effort, and resources to the generation of ideas and policy measures for overcoming these problems.
However, these efforts have not always been directed toward what we believe is the root of the problem. In the 1960s, great emphasis was placed on diagnosis and the elaboration of measures for solving unemployment, recognizing implicitly that poverty would tend to be eliminated if access to work, and therefore purchasing power, improved.
As unemployment and under-employment continue to be high priority problems, and because the outlook for improvement within the next few years is not optimistic, the attention and justified concern of the international community must turn toward the most painful consequences of the type of development prevailing in most underdeveloped countries.
It is at this point that a vacuum appears in most of the studies on this topic. Although the conflict between style of development and its real capacity for solving minimum welfare problems is recognized, barriers that oppose the introduction of changes into the prevailing mode of growth direct attention to the search for solutions focused on the consequences of the problems rather than on the causes. Limitations are there and we do not pretend to underestimate them. It is not possible to expect substantial improvements without a considerable degree of political, social, and economic change.
The growing emphasis on measuring the dimensions of malnutrition and its consequences, and the inadequacy of existing social services in many countries, point toward the need to redesign and relocate the fundamental objectives of development.
Fulfillment of basic human needs-an implicit objective in any development strategy -should be turned into an explicit objective. This redefinition of objectives is well described in the words of Mahbub ul Haq:
We were taught to take care of our GNP, because this would take care of poverty.
Let us reverse this and take care of poverty, because this will take care of the GNP. Let us worry about the content of GNP even more than its rate of increase. (1 )
This focus necessarily implies a change in the way problems are approached, in the resources to be used, and in the kind, quality, and quantity of information that needs to be sought. Policy measures implied by one or another type of development may differ greatly and will surely affect the view one has of the real interrelations of income, nutrition, and health.
Although the direction of the change in real income and its effect on the health and nutritional status of a population may be obvious, the political economic interactions by which the results are produced and the means by which different social groups are affected, are not. Malnutrition is associated with poverty and poverty with low income, which, in turn, reflects a given place, or lack of place, in the labour force. Therefore, the problem can be likened to a pair of scissors, where one blade is represented by income and buying capacity, and the other by the availability of food.
The major economic studies in this area have approached the problem from the angle of food availability, problems related to marketing and storage, characteristics of the agricultural supply, and the role of prices for the producer. Estimates have been made of the nutritional gap and the cost of coping with it. Taking into account the limitations of the available data, Reutlinger and Selowsky estimated that in the mid1960s, " .... 56 per cent of the population in developing countries (some 840 million people) had calorie-deficient diets in excess of 250 calories a day. Another 19 per cent (some 250 million people) had deficits of less than 250 calories a day." (2) These authors conclude that malnutrition is basically the result of unequal distribution of the food consumed within and among countries, and that, therefore, it is not a problem of world food scarcity or agricultural potential. The relevance and magnitude of the distributional differences are partially documented by Almeida et al. (3), who point out that comparative studies of children in families with low incomes and those in high-income families in such diverse places as Hyderabad (Pakistan) and Lagos (Nigeria) show that poor children consume 50 per cent fewer calories and proteins than they need. Hakim and Solimano (4) have arrived at similar conclusions in studying the conditions prevailing in Chile over the past 40 years.
With reference to demand, the use of family budget surveys has allowed the calculation of income elasticities and estimations of the Engelian curves in order to explain consumer behaviour, and later, to construct models of redistributed consumption. However, specific mechanisms for redistributing consumption have not been explored in detail, nor have the relationships through which different measures of political economy affect the nutritional status by way of modifications in real income.
Figure 1 shows a simplified model of the acquisition-power-availability circuit whose point of encounter determines consumption and, to a great extent, the nutritional status of a population. A macroeconomic model including all variables that explain the different relationships would give more precise results as to the causes and magnitude of the circuit; however, this is beyond the limits of this paper.
The demand sector represents the income and price and policies to the consumer that determine his buying power in the market. The supply sector illustrates production policies, producer policies, and public expenditure that determine the availability either in the market or through direct channels. The latter, in turn, influences- through changes in relative prices or direct supplementation-the real income level.
As to demand, traditional policies, whose character depends on the inclinations of the politicians and technicians in charge, stress the equilibrium of the macro-economic aggregates. Strengthening the balance of payments, reducing the fiscal deficit, and controlling the rate of inflation are the common objectives. In general, emphasis rests on visualization of the effects that policies of different kinds have upon different segments of the population, but the final consequences of these policies on nutrition and health become only the subject of historical studies of the result of the policies.
In the case of stabilization programmes based on the maintenance of real income levels, or redistribution of consumption, there appears to be a spectrum of new problems that runs through the acquisition-power-availability circuit: monitorization of agriculture prices, subsidized price policies, supply restructure, following the marketing process at the wholesale and retail levels, etc. Thus, it is relatively more important in these attempts to identify probable lack of supplies and the physical quantification of food balance as a way to avoid the creation of parallel markets that almost immediately impose additional pressures on imports and, consequently, on the balance of payments. This also implies a redefinition of the remaining sectoral and global policies, especially those that refer to the restructure of the food supply in response to growth and/or changes in the structure of the effective demand produced by the redistributive attempt.
With regard to food availability, two main areas are proposed along with the factors that determine them: production policies and agricultural prices on one hand, and public expenditure policies in nutrition and health and their respective distribution channels on the other. In the former, there is more emphasis on production aspects than on the distributive effects that change the relative price of agricultural products. The problem acquires more relevance in regions and countries with a high proportion of rural population where the level of real income depends essentially on the agricultural price policy.
Using consumption data for types of income in India, Mellor (5) shows that changes in food grain prices cause an average greater change in the real income of low-income sectors, but a more important absolute change in the real income of high-income groups. Consequently, it is practically impossible to protect, through market mechanisms, the poorest sectors from loss of acquisition power produced by reductions in the agricultural supply. Partial equilibrium analysis of the distributive effects of changes in these policies gives incomplete answers to a limited number of options.
The introduction of general equilibrium models, particularly the one developed by McCarthy and Taylor (6), shows the possibility of advancing the design of policy packages. In the particular case of Pakistan, an increase in fiscal expenditure on the order of thousands of millions of rupees would produce changes in calorie ingestion that, if maintained for some years, would cause significant changes in the nutritional status of the population. This model furnishes examples of changes in the buying power by evaluating the effects of integrated policies as well as the traditional ones on income, distribution, balance of payments, and subsidy levels.
However, at least two levels that exert direct and indirect influence on nutritional status are superimposed on this purely economic circuit. One is the development strategy determining the objectives, and therefore the character, of policies, already referred to above; the second is related to a group of big-demographic and socio-cultural elements that condition the character of food consumption and that therefore assume an essential role in determining nutrition and health.
Consideration of these aspects generates new areas for attention, one of which is the enormous statistical effort needed to determine, not only the magnitude of the affected population, but also its characteristics-a fundamental element in the design of policies. These characteristics range from urban-rural differentiation, regional location, and position in the labour force, to cultural values, consumption habits, and health.
Emphasis must be placed on the features of that part of the population that, due to conditions of marginality and exclusion from the market, are not reported through the usual data-gathering systems, and that no doubt constitute a significant portion of the total population.
On the other hand, interrelations between nutrition and health point to the necessity to determinine the extension, location, and need for health services, and improvement of infrastructure (drinking water, sewerage system, etc.)-elements that greatly influence the effective improvement of nutritional status.
In addition, the diversity and complexity of the variables require effective interdisciplinary work in order to define those most relevant, as well as the most appropriate means to measure them. This implies the necessity of elaborating sensitive indicators for evaluating the effectiveness of different programmes.
Finally, lack of knowledge about the size, demographic characteristics, birth and death rates of the target population partially explains the surprising inability to characterize the causal relationships between income and nutritional status. Once gathered, the data must be disaggregated to permit the design of policies and programmes that can assure an acceptable degree of coverage and effectiveness.
The previous analysis has led to the conclusion that economic strategies are not neutral, and that their possible effects on food consumption and nutritional status differ according to the nature of each strategy. Due to the macroeconomic character of the variables they consider, it has been extremely difficult to relate them to the individual, the family, and the community.
The perspective of specialists in nutrition, on the other hand, has been the opposite. It has centred on the study of biological and behavioural effects of different nutritional deficiencies. Most of the research intended to measure the magnitude of the problem and determine its causes has taken the individual and the family as the work unit. Food consumption has been related to family structure and size, crowding indexes and basic sanitation, literacy levels, dietary habits, and cultural patterns, and, in some cases, employment and income. Nutritional as well as health programmes have also been directed toward modification of the conditions of the micro-environment, emphasizing the extension of medical care, nutrition education, and the delivery of food as a supplement to the traditional diet. Because these functions belong to the nutrition and health sectors, there is no room for questioning their nature.
Studies of the "ecology" of malnutrition in Latin America and on other continents have permitted recognition of the different factors present in the groups at greatest risk. Several models have been developed. However, this type of model does not reveal the cause-effect relationships of greatest significance, nor the economic factors that determine access to adequate food consumption.
Experts in nutrition have been able to characterize the problem adequately, recognizing the multiple variables at the micro-environmental level, and defining one or more "vicious circles" that tend to perpetuate it. But they have done very little to identify those points most sensitive for intervention, the possible impact of specific interventions, or their relevance to the economic and social development strategy in which the vicious circle exists. For this reason, a model focused primarily on the determinants is presented in figure 2.
In summary, the nutritionist has looked at it through the microscope. While both perspectives are valid and complementary, the need is to look for mechanisms and instruments that will permit a joint harmonious analysis of these two perspectives as a part of a whole development strategy.
Some studies relating changes in food availability and consumption, nutritional status, and death rates in specific groups to characterize economic development in different countries have recently been published. However, this type of analysis is based on secondary sources and is generally retrospective.
Hakim and Solimano concluded that the economic and social development strategy adopted in Chile during 1930 1970 discriminated against the lowest income group, including peasants and unskilled labourers. At least a third of the Chilean population could not consume sufficient calories and suffered high rates of malnutrition. The possibilities of survival for children under one year of age were also less for those belonging to the low socioeconomic strata. From the methodological point of view, considering the limitations posed by the kind of information available, this analysis has allowed the construction of a body of information of acceptable consistency that combines factors from the economic sector with nutritional and health studies, including biological and psychosocial variables at a community level (4).
Gwatkin analyzed the Kerala {India) and Sri Lanka experiences with regard to nutrition planning and the physical wealth of the population and reached the following conclusions:
Sri Lanka's egalitarian food consumption pattern cannot be legitimately attributed to any one measure alone, but rather is associated with the distribution of income in that country. Social and cultural factors such as the roles of the women who care for children, are also likely to be partially responsible .... Food and nutrition policies in Kerala and Sri Lanka are not discrete entities functioning effectively in an otherwise neutral political, social and economic setting. They are rather important manifestations of a more general government determination to help the poor, a determination that also gave rise to the other people-oriented development efforts with which food and nutrition programs have interacted so effectively. (7).
Equally interesting is a study of the situation in Jamaica. Marchione researched. the effects of policies oriented toward improving self-sufficiency in food production on child nutrition, combining economic analysis with the observation of changes in domestic economy and the nutritional status of the community as a whole. The increased food prices and reduction in international aid, starting in 1974, led to the need to adopt a policy of self-sufficiency. The index of consumer prices increased 90 per cent in a 12-month period, from mid-1973 to mid-1974, as compared with 70 per cent during the previous five years, 1967 - 1973.
On the other hand, in the St. James community, the semi-subsistence agriculture increased significantly-from 37 per cent to 56 per cent-for all homes during the same period, with a simultaneous significant improvement in the nutritional status of children in the rural areas. The severe forms of malnutrition (Gomez grades II and III) diminished by 50 per cent -from 9.5 to 4.5 per cent; but the most significant improvement was observed in families developing a semi-subsistence agriculture- from 14.4 to 24.3 per cent, or 66 per cent. At the urban level, the incidence of severe malnutrition remained at about 4 per cent without major modifications. It is important to mention that in St. James, a Community Health Aide Programme was implemented concomitantly, utilizing health assistants who, after training, returned to their villages. The activities of this staff included encouragement of breast-feeding, redistribution of food toward children, and better use and diversification of food within the home. Marchione concludes:
. . . the benefits of self-reliance policies which tend to relocalize food energy sources and generally strengthen local environmental control, can lead to positive nutritional benefits for young children of subsistence farmers .....
This analysis also suggests that study of macro-level political and economic events can be directly linked with community-based micro-level research on health, nutrition and other topics that show the concrete results of governmental policies and planning. (8)
Changes observed in nutrition and health status in Cuba during the last 20 years also contribute much to the study of relationships between economic policies and biosocial-cultural factors. A paper by Cordova and Amador, presented at the International Congress of Pediatrics in India, reported that the incidence of malnutrition in 0- to 15year-old children in Cuba is estimated, at the national level, to be about 1 to 2 per cent; overweight and obesity occur in 6 to 10 per cent of the same group; the infant death rate decreased from 46.7 per thousand live-born in 1969 to 22.8 in 1976 (9). The world average infant death rate has recently been estimated to be 107 deaths per thousand live-born, with 100 per thousand in Latin America (10). The actual daily availability of food in Cuba was 2,650 calories and 64 grams of protein, 29 of which were of animal origin. The authors explain these changes as follows:
Starting in 1959, the human feeding and nutrition problem has been seen in our country as a governmental priority, with a multisectoral approach which is not limited to the narrow framework of the hospital, but acquires the great dimension of the socio-economic advances generated in the country. (9)
In summary, it has been only a few years since the causes of malnutrition were examined and explained in individual terms, or within the domestic surroundings of the undernourished, without any reference to the social order to which they belong. Only recently have nutrition specialists, together with planners, economists, and other social scientists, begun to study seriously the social and economic dimensions of malnutrition in developing countries, to try to prove the relationship between nutrition and national development.
However, in spite of the theoretical and practical contributions, present knowledge has serious limitations with regard to the analysis of the problem and the proposed actions arising from it. The study of the variables that determine a given nutritional status and affect efforts oriented toward solving the malnutrition problem is also disappointing.
Quite consciously, and to a certain extent because of fear of the possible effects of profound changes in the structure of society, most of those reponsible for making policies directed toward improving the food and nutrition situation have preferred to implement direct intervention programmes as part of the public expenditure. These programmes, which do not generate antagonisms, can be added to the whole panoply of services provided by a government without requiring structural reorientations, and can therefore be easily expanded or eliminated. However, the impact of direct programmes for solving nutritional problems is an open question. Some aspects requiring further research are: the level of achievement of specific objectives; definition of the target groups and the extent to which they are covered; the possibility of overcoming existing institutional and political barriers; and the significance of such programmes in relation to different models of economic development.
The impact of certain direct nutrition intervention programmes in relation to the delivery of health services at the community level and to basic public health sanitation is another area requiring evaluation. Even when such programmes exist, in many countries a significant reorientation will be required to make them effectively accessible to low-income groups, and to adapt the services to the actual needs of these sectors. The conclusion reached after carefully analyzing the distribution of milk in Chile, a programme established in 1925, is illustrative in this sense:
The development of an extensive program of milk distribution in Chile was made possible by the country's social and political evolution. That evolution, however, also resulted in a highly stratified society with sharp disparities of income and wealth among social classes, with a large segment of the population living at or near subsistence levels, and with high incidences of malnutrition among low income groups. The milk program may have contributed to some improvement of nutritional standards in Chile and certainly led to heightened attention to nutrition in the practice of health care. Malnutrition, however, has remained a feature of patterns of distribution, consumption, and production-patterns which have been reinforced, with few exceptions, by the country's strategies of economic development. The eradication of malnutrition in Chile, as elsewhere, will require sharp changes in those patterns, and is unlikely to be accomplished by autonomous measures grafted on to them. (11 )
Nevertheless, it is possible to recognize advances in the definition of objectives and in the implementation of these types of programmes in recent years. Our purpose is to discuss briefly two related aspects: the choice of target groups, and the identification of indicators for programme evaluation.
The contributions of social scientists and economists and an increased awareness of biological variables have allowed a broadening of the concept and definition of target groups with regard to their nutritional risk. However, for programme objectives, these definitions are still too general, as they are based on widely varying estimates, especially of factors related to income and food consumption. For instance, the Food Supplementation Program in Panama, with data based on the national nutrition survey carried out in 1967, estimated mean calorie and protein deficits to be 25 per cent; however, a more detailed analysis showed a variation in deficits of 10 to 50 per cent in the families surveyed. Obviously, a favourable impact of the programme will depend on the adequate satisfaction of actual deficits (12).
A more accurate and specific definition of the target groups also depends on the possibility of obtaining the required data. Data collection services are limited in developing countries, and this limitation is accentuated for the poorest groups, who have least access to these services. For example, it is a fact that the low birth weight of a baby born under inadequate socio-economic and health conditions increases the risk of malnutrition and death in the child, but the data available for these groups are derived from less than 20 per cent of births in many rural sectors. The same is true concerning the level of income, actual availability of food, and family organization and structure.
Most programmes for increasing food supply have individuals at risk as their objective. However, it has been recognized that families do not distribute food according to need but according to habits and family or community organization. In 1972, in Chile, 58 per cent of the families surveyed answered that milk was shared by all members of the family. On the other hand, participation in the programme was higher in the lowest income groups and in families with four or more beneficiaries (11). Based on this and other experiences, the need to broaden the definition of objectives to the family unit and, in certain cases, to the community, has been recognized, particularly in rural areas or in middle-sized urban conglomerates. In the case of nutrition education and enrichment of traditional foods, this practice is the only alternative. In the Panama programme families were chosen using an index that included: death rates among children one to four years of age, quality of basic sanitation, and housing conditions. In those communities where 60 per cent or more of the families showed a high risk, all members of such communities were included in the programme (12).
According to Rosa, this approach has a double value:
The preventive action of risk may offer an opportunity for preventive action and also, even if this action is not practicable, health workers in the program are enabled to allocate some priority to care for these families and perhaps even to undertake specific action on their behalf. (13).
Another well-researched aspect that has shown conclusive results concerns the intrafamilial psycho-social variables in terms of composition, structure, and quality. The mother-child relationship, the birth order of the undernourished child or children in the family, the presence of medical-social pathology such as alcoholism, drug addiction, abandonment, food consumption habits, and health practices constitute very important variables, among others. Scrimshaw and Pelto have developed a useful model for conceptualizing the impact of health and nutrition programmes on family composition and structure (14).
The structure, composition, and size of the target group is influenced by economic, political, and social factors and will vary because of them. Therefore, it is necessary to obtain timely and periodic information in order to be able to adapt programmes to changes in the target groups. In 1975, a Poverty Map was published in Chile, utilizing data from the Population Census of 1970-obsolete statistics if one takes into account the transformation that occurred in the country during that period.
Adequate information and selection of indicators has a direct effect on the evaluation of any programme or policy. Extensive research is being carried out in this area, recognizing the limitations of the traditional indicators of social and economic growth, in order to evaluate the effects of different economic and social development styles. Similar problems are associated with assessment of food consumption patterns and nutritional status as well as the effects of different programmes for its betterment. According to Bengoa, it is necessary to distinguish between surveillance and evaluation:
One evaluates the success or failure of an activity and one watches over a situation, without taking into account if there is or is not an intervening or corrective action for that situation.
On the other hand:
Preventive nutritional surveillance stresses not only the indicators that point out the past history or the present situation, but also the gathering of data and analysis of those indicators capable of predicting a possible deterioration of the populations' nutritional state. (15).
He also systematizes the nutrition indicators most commonly used according to coverage, periodicity, ease of obtainment, cost, objectivity, specificity, and sensitivity. The definition of such characteristics represents significant progress, and the efforts to increase its reliability must be continued (15).
The construction of adequate indicators for the measurement of "development benefits," or of satisfactory levels of meeting "basic human needs" is even more complex.
As part of its investigation of the measurement of the effectiveness with which different development strategies distribute basic benefits to all the members of a society, the Overseas Development Council has created a compound index called "Physical Quality of Life Index" (POLI). Their conclusion is that three indicators, life expectancy, infant mortality, and literacy level, allow measurement of the results of a wide range of policies (16).
Adelman and Morris (17) have been more interested in discovering the "leading empirical regularities" than in determining linear relations. They have shown that the six most important variables that affect income distribution are: rate of improvement of human resources (high school and professional education); direct governmental activity; socio-economic dualism; economic development potential; GNP per capita, and strength of the labour movement. Nevertheless, when they related economic and political variables to fertility levels, the indicators that emerged were somewhat different: the most powerful were the social and community structure associated with urbanization and industrialization, together with political participation.
1. Mahbub ul Haq, "Employment in the 1970s: A New Perspective", Education and Develop ment Reconsidered, The Bellagio Conference Papers Ford Foundation/Rockefeller Foundation, Praeger Publishers, New York, 1974.
2. S. Reutlinger and M. Selowskv, "Malnutrition and Poverty-Magnitude and Policy Options." World Bank Staff Occasional Papers, No. 23. The Johns Hopkins University Press, Baltimore, Maryland and London, 1976.
3. S. Almeida, D. Baytelman, J. Chonchol, J. Collins, S. George, L. Aragon Vieira, and J.M. von der Weid, "Assessment of the World Food Situation-Present and Future." Internatl. J. Health Services, 5: 95 - 120,1975.
4. P. Hakim and G. Solimano, Development, Reform and Malnutrition in Chile. MIT Press, Cambridge, Massachusetts and London, U.K., 1978.
5. J.W. Mellor, "Agricultural Price Policy and Income Distribution in Low Income Nations." World Bank Staff Working Paper, No. 214, Washington, O.C., 1975.
6. D. McCarthy and L. Taylor, "Macro Food Policy: A General Equilibrium Model for Pakistan." Rev. Econ. Statist., in press, 1980.
7. D. Gwatkin, "Nutrition Planning and Physical Wellbeing in Kerala and Sri Lanka." Presented at Inter science, AAAS Symposium on Nutrition and Agriculture: Strategies for Latin America, Washington, D.C., February, 1978.
8. J.T. Marchione, "Food and Nutrition in Self-Reliant National Development: The Impact on Children of Jamaican Policy." Medical Anthrop., 1: 57 - 79,1977.
9. L. Cordova Vargas and M. Amador, "Prevención V Eradicación de la Mala Nutrición en Cuba." Presented at the International Congress of Pediatrics, New Delhi, India, 1977.
10. R. Riveron, "Mortalidad infantil en Cuba: Análisis del Programa pare su Reducción (1970- 1976)." Presented at the National Paediatric Meeting, Havana, Cuba, December, 1977.
11. P. Hakim and G. Solimano, "Supplemental Feeding as a Nutritional Intervention: The Chilean Experience in the Distribution of Milk." Environmental Child Health Monograph, No. 6, 22: 185 - 202,1976.
12. G. Solimano and J. Sandoval, "The Role of Supplementary Feeding and Food Production as Nutrition Interventions in Rural Panama." Unpublished report, 1978.
13. F.W, Rosa, "The Family Unit in Health Programmes" In: Nutrition in Preventive Medicine. G.H. Beaton and J.M. Bengoa (eds.), World Health Organization, Geneva, 1976.
14. N.S. Scrimshaw and G. Pelto "Family Composition and Structure in Relation to Nutrition and Health Programs." In: Eva/uating the Impact of Nutrition and Health Programs. R.E. Klein, M.S. Read, H.W. Riecken, J.A. Brown, Jr., A. Pradilla, and C. Daza (eds.), Plenum Press, New York and London, 1977.
1 5. J.M. Bengoa, "Vigilancia Nutricional Preventiva." Archiv. Latinoamer. Nutr., 27: 1 - 8, Suppl. 1,1977.
16. Overseas Development Council, The United States and World Development, Agenda 1977. J. Sewall (ed.), Praeger Publishers, New York, 1977.
17. I. Adelman, and C. Morris, Economic Growth and Social/ Equity in Developing Countries. Stanford University Press, Stanford, California, 1973, pp.14 - 106.
FIG. 1. Acquisition-Power-Availability Circuit
FlG .2. Determinants of Malnutrition
