Nutrition and Development Policies
This summary is intended to be useful for international agencies concerned with certain major nutritional problems in poor societies, and through them for governments making decisions on policies to alleviate these problems. It aims to provide a view of the state of current knowledge, based on recent experience, emanating from a meeting convened by the ACC/SCN in November 1990, and reviewed by the UN and bilateral agency representatives at the ACC/SCN 18th Session in February 1991.
Nutrition itself is seen as an outcome, a result of access to food, dietary intake, care of the individual, and health. Access to adequate food and to health are among the universally adopted human rights1. It is therefore the responsibility of those whose actions affect the nutrition of the deprived to assign priority to protecting this central aspect of their rights. Adequate nutrition is also a pre-requisite for most other human aspirations. From conception through old age, adequate nutrition is essential for individual development, activity, good health, and self-fulfilment. For societies and nations, adequate nutrition is required for their function and success. The concerns range from day-to-day meeting of basic needs, including survival especially in infants and children, through lagged effects on performance of individuals and societies, even to inter-generational influences notably through women's nutrition.
The aims of socio-economic development include preventing inadequate nutrition. But this objective will not be reached unless actions different or additional to those presently undertaken are pursued. One aim of this paper is to outline the scope of possible actions that now, at the beginning of the 1990s, should be considered as feasible options under different circumstances.
Inadequate nutrition encompasses a set of issues with biological and social dimensions. In the child, it concerns survival, growth, health or sickness, activity and cognitive development. In adults, it particularly concerns health, biological function, and productive activity. Nutritional status might be assessed by a number of these outcomes; most often in practice it is estimated using growth in children and thinness in both children and adults (for protein-energy; other measures are used for micronutrient deficiencies). Poor nutritional status of the individual results usually from a combination of inadequate dietary intake and infectious disease.
Malnutrition is extensive in the world. There is (by definition) no single measure. Some widely quoted indicators of the present status do however give a usable picture, for example: some 150 million children are underweight2; around 500 million women anaemic due to iron deficiency3; over 20 million low birth weight infants born each year4; some 40 million children are estimated to be vitamin A deficient, and over 1,000 million people either suffering or at risk of iodine deficiency5. In this context the trends are particularly relevant. During the 1980s, although in all regions except Sub-Saharan Africa the average proportion of the population malnourished may have declined or at least remained static, the numbers affected - whether assessed by growth in children or as underfed in the whole population - continued to increase. Moreover, where the average proportion has declined, the rate is nowhere near rapid enough that maintaining current policies offers the prospect of an acceptable nutrition situation in the foreseeable future. A judgement based on the continuation of present trends would be that numbers malnourished may substantially increase in the 1990s. Goals proposed for the Fourth Development Decade by the UN6, by WHO/UNICEF7, at the World Summit for Children8 and in a number of international contexts recently9 include such aims as: virtually to eradicate severe malnutrition, and to reduce mild/moderate malnutrition by half. Such goals will only begin to be met with a great deal of deliberate action. Again, one purpose of this paper is to suggest a possible scope for this action.
Although global and regional trends of malnutrition, and their implications for the future, are cause for concern, success in improving nutrition has been seen within a number of countries from all regions. In some cases nutrition has improved more than might be expected from the economic situation, or has been protected during recession10. It is on this basis that specific actions can be proposed. The causes of improvement are often multiple. They range from favourable macro-economic policies through improved service delivery to direct nutrition interventions. Although nutrition may not be the primary motivation for all such policies, the fact that success is possible encourages the preparation of this statement.
Since the Second World War the view of nutrition has evolved, and it is hoped that the present view of problems and their possible solutions is appropriate to the time. While there have been different schools of thought over the years, a consensus is now emerging. It may be worth looking briefly at the history to set the context.
In the 1940s and 1950s, freedom from hunger and prevention of famine were seen as global priorities -e.g. the constitution of FAO11. At the same time malnutrition itself (at least in children, and for micro-nutrients) was regarded as largely a medical problem. (Starting even earlier, attempts were made to conquer such vitamin deficiency diseases as beri-beri, pellagra, scurvy, and xerophthalmia.) Kwashiorkor - more visible in children than thinness - was widely reported, as was its cure by high-protein foods; as well, protein requirements were over-estimated. Consequently, protein deficiency came to be seen as the most extensive nutrition problem. This perception led on the one hand to attempting prevention and treatment by providing protein to individuals (by technical means); and on the other hand to a global supply concern for the "protein gap".
The reappraisal of protein requirements in the early 1970s and better understanding of protein-energy interactions, combined with the temporary food supply crisis at the time of the World Food Conference of 1974, swung the pendulum the other way: overall food energy supply became the issue. Analysis soon revealed (e.g. FAO's Fourth World Food Survey12) that distribution of food, or access to food for the poor, was crucial. Poverty was then established as a major cause of malnutrition. The inference drawn however was that addressing poverty as a whole was the only way to prevent malnutrition, which was over-ambitious, and often set nutritional concerns in potential competition - or anyway interfering - with virtually all other aspects of socio-economic development. It also tended to lead to unworkable schemes for integrated policy-making and programmes. In turn, this led to a sector-wise view of nutrition - in agriculture and in health especially -with emphasis on introducing nutritional considerations into sectoral planning. An issue here was that these sectors essentially retained their own priorities, and considered what they were doing as that which was necessary anyway to improve nutrition, so that specific nutrition considerations were often regarded as rather superfluous.
A number of national governments however confronted this problem more directly. Measures such as food price stabilization, social security, and special health services for women and children, gradually took root. One result is that today, whatever the theory, there is experience to build on.
An opportunity is also provided by the convergence between policies advocated internationally for poverty alleviation13, and those for nutrition. Emergence of household food security (as opposed to national) as a concern, with the emphasis that 60-80% of the expenditure of the poor is for food, sets household food issues centrally in concerns for poverty14, and within social security as short-term measures for support. Prevention of the malnutrition-infection complex15 - still the most prevalent public health problem in the world - is a major objective of primary health care. The crucial role of women in all aspects of nutrition (here especially in caring for their families) is increasingly recognized16.
Strategies for addressing malnutrition can be based on these considerations. UNICEF's nutrition strategy focuses on the three underlying issues of food, health, and care17. FAO/WHO, in preparing for the forthcoming International Conference on Nutrition, use a similar structure18. This framework has guided the structuring of the strategies and policies discussed here.
At the same time, two other issues of emerging importance should be noted, although they are not treated in detail here. First, the priority of tackling specific micronutrient deficiencies is now being reemphasized, particularly since the technical feasibility of preventing them through focused and relatively inexpensive programmes is now clear19. This applies particularly to iodine and vitamin A deficiencies. Control programmes for iron deficiency - the most prevalent - while effective technically are more dependent on service delivery infrastructure and may take longer to develop. A short section on control of micronutrient deficiencies is included here, as section E. *
* While it is recognized that micronutrients relate to the qualitative aspects of household food security (as defined), this section is separate for ease of presentation and added emphasis.Second, the contribution of incorrect nutrition to chronic disease is being more firmly established as research progresses. Aspects of nutrition policy, initially in industrialized countries, are addressing this issue. The concern extends to developing countries -nutrition contributes to chronic disease among poor in many societies - and actions to head off or reverse trends in diet are needed. These issues are not gone into here, which in no way reflects their priority but results from the need to limit the scope.
The principles for development policies in the 1990s are widely put forward - most recently by World Bank and UNDP20 - as including three tracks. First, economic growth that deliberately involves participation of the poor is the long-term solution to poverty. Second, social security is required to maintain a basic level of living ("safety net") for the poor; sustained access to adequate food ("food security") is a central feature of this. Third, development of human resources is an essential underpinning of the first two.
The options put forward here in the technical areas related to nutrition are entirely consistent with these principles and are aimed at achieving nutritional goals for the 1990s.
A number of points influencing their application to nutrition should be made concerning these principles. First, allocation of resources to poverty-oriented growth may or may not involve trade-offs with total economic growth: under many national circumstances deliberate decisions are needed as to how far investments are made that benefit the income of the poor specifically. Second, the financing of effective social security for the poor depends on adequate economic growth: the first two principles are linked. Third, the effects of growth policies that fail to involve the poor cannot sustainably be rectified through social security.
A related issue is that policies must address both underlying trends, and short-term fluctuations or "shocks". There is some distinction between shocks that affect whole societies, and those affecting individuals. For example, in drought-prone areas a safety net mechanism may be appropriate for preventing effects of occasional drought on the population; somewhat similar considerations apply to seasonal effects. Buffer stocks or price stabilization are examples of appropriate policies. On the other hand, individuals require social security against sudden illness, or unemployment. This may be developed in communities, but generally needs resources from more central levels.
A specific concern at the present time is for the effects of structural adjustment policies on nutrition, particularly in the short-run. This concern is likely to continue in the 1990s, and is discussed below under "household food security".
Malnutrition, especially in women and children, is the problem to be solved. The immediate causes at an individual level are inadequate dietary intake and infectious disease (viral, bacterial, parasitic). Certain actions can address these directly, as will be discussed later, while measures addressing underlying household-level causes are often more practical. Nutrition issues are grouped here into three clusters: household food security, nutrition and infectious disease control, and caring capacity, with their detailed definitions being given in respective sections later. Briefly, their interaction is as follows.
Household food security is clearly a pre-requisite for adequate dietary intake of all household members, which in turn is one (of the two) requirements for preventing malnutrition/infection, disease prevention being the other. However, dietary intake is influenced by many within-household factors, especially to do with women's roles; this applies particularly to infant and child feeding. At the same time, exposure to infection in the household environment is greatly affected by care of the individual which includes provision of adequate hygiene, clothing, care when sick and recovering, etc. Thus the cluster of problems concerned with "care", affecting both dietary intake and infection, has been included as central to policies to address malnutrition.
The problem clustering has, it should be emphasized, been defined pragmatically for operational purposes of grouping policies, rather than on a rigorous analytical basis. This applies particularly to women's issues, which are important in all three policy areas.
The policy options and experience described in the next sections are not prescriptive. It is not implied that, even under given circumstances, one particular set of actions is always recommended. They are intended as "building blocks" when policy options are considered for alleviating malnutrition. They provide examples of actions that have been considered effective sufficiently widely that their serious consideration is advocated. Further, it should be stressed that this paper does not address the process of deciding on actions - or policy-making - but rather the potential content and results of such decisions.
Usually a judicious mix of policies - within the cluster of problems/options such as household food security -is appropriate. Reliance on one option has been seen to be less effective: only public works employment, or only food subsidies (even if targeted), for instance.
The relative priority assigned to each of the three clusters of problems/options is likely to vary country-by-country. In some countries household food security is relatively assured, but malnutrition persists for reasons encapsulated in the other clusters; in others, this factor may be of overriding importance. But it is stressed that adequacy in each of the areas is required: each is necessary but not of itself sufficient.
Inter-sectoral policies or interventions are nevertheless not considered essential to address nutrition problems *. Experience has shown that complicated plans involving many different possible actions have been difficult to implement. Often a better approach is to decide on currently feasible sectoral actions. Because nutrition problems have multiple causes does not mean that all causes have to be addressed at the same time. Equally, as for many other development interventions, flexibility in nutrition policy and interventions is desirable. Lessons may be learned from an evolutionary process of planning as opposed to the less flexible "blueprint" planning. There is thus no absolute need for governments to develop all-embracing statements which constitute a "nutrition policy". Such a document may promote the notion that a centralized inter-sectoral planning approach is required (although developing such a policy can in some cases give focus to commitments to nutritional goals, and a framework for deciding between options). Decisions and actions however are more important than statements.
*A distinction has been drawn between "inter-sectoral", meaning "measures of different sectors integrated with each other for a coordinated effort", and "multi-sectoral", meaning "several sectors taking part".Characteristics of nutrition problems, their causes and options for solutions, vary by country. In theory, suggestions could be made for relative priorities of options based on typology of problems and situations; attempting this could be a future step, but was not undertaken for this review. Such a typology might link problems and options with (a) characteristics of countries, e.g. by income level, government expenditures especially on health, education, and social security, population factors (density, growth rate, urbanization); (b) specific factors relative to household food security, such as dietary energy availability, dietary patterns, proportion of income spent on food; (c) nutrition and infectious disease, including infant and child mortality rates, access to health services, sanitation, disease patterns; and (d) assessment of caring capacity, perhaps using such data as female literacy rates and other measures of women's status.
Prioritization of policies and interventions cannot be done in a general manner. Just as the preconditions for successful actions differ between countries, so do the chances that any particular intervention will be appropriate and feasible. Furthermore, the success of interventions depends on the existence of other policies e.g. infrastructure, access to markets. Policy priorities are thus, to a large extent, country-specific and cannot be decided without full consideration of the social and economic context in which they would be implemented. Again, the process of deciding options could be considered as a future step, but was not part of the present review.