Setting for Action
Scope of Options
A major factor in determining nutrition in poor households is the use of available resources, especially for provisioning food, and maintaining of health in the face of unsanitary conditions. This applies with particular force to children and mothers. Another way to say this is that, given certain levels of household food security, health environment and access to services, much depends on how the individuals in the household, especially the women, cope with their situation. Many of the underlying factors (e.g. women's education, skills, and time) and immediate linkages with nutrition (e.g. maternal health, breastfeeding) can be addressed by public policies, and must be to successfully alleviate malnutrition. Others lie in the realm of social organization, role patterns, and the division of labour in the individual household. This series of issues has been grouped under the heading of "caring capacity". The definition suggested is as follows.
"Care" in general refers to the provision in the household and the community, of time, attention and support to meet the physical, mental and social needs of the growing child and other family members. It leads to the optimal use of human, economic and organizational resources. At an extreme, lack of "care" is neglect. In the context of nutrition, most importantly it facilitates:
- optimal use of household food resources for child feeding;More generally it includes nurturing the full psychological and emotional well-being, which are goals in themselves, and which in turn may benefit nutrition and health.
- optimal use of parental (or other) resources to protect from infection, and care for the sick child, or other vulnerable members of society (e.g. the disabled, elderly).
The underlying theme of "care" has above all to do with women's role and resources - although "parental" care including that of the father and other relatives should be included. The major underlying issues affecting "care" are for women, knowledge, time, and control over economic resources, including income. At the same time, caring capacity at the level of family and community needs to be stressed; the priorities suggested here can apply at different levels.
Issues specific to maternal and child nutrition include breastfeeding and infant care, complementary feeding practices including energy density of foods, food quality, feeding frequency, etc.; as well as direct interventions to improve women's health and nutrition.
A good example of the levels of care and support that may be required are those needed for optimal breastfeeding. Breastfeeding women need: i) emotional support and appropriate information from family, community and/or health workers if any problem with breastfeeding occurs, ii) appropriate support and information any time they have contact with the health care sector: prenatally, at the time of delivery, during the early weeks of lactation, and even during the second year of life and beyond, iii) maternity benefits appropriate to their working situation, in many cases including paid leave for at least four months and a creche near the place of work.
Caring capacity mediates the effects of household food security and the health environment on the nutritional status of women and children. Again, all the relevant factors in this context are objectives in their own right. In this case setting priorities depends completely on the current situation: if, for example, women's literacy is low, it needs to be improved for many reasons including nutrition. So does access to family planning, for example. It is not the aim here to suggest priorities between such factors - where there is a need, it should be met for reasons including nutrition, although methods will depend on local circumstances. This contrasts with, for instance, options in the household food security field, where, say, targeted food subsidies may be an alternative to public works employment.
Constraints to adequate care can be viewed in general terms as lack of knowledge, lack of time, and lack of control over resources. Some specific options are suggested later in this section. Their relation to nutrition, and certain indicators, is introduced here.
Lack of knowledge is attributable to inadequate access to formal and informal education (including nutrition, health and family planning), and vocational training. The overall policy is clear: ensure access to all channels of knowledge and improve diffusion of new knowledge and awareness of new innovations. This is addressed in item (i) below. Several indicators could be used, including school enrolments, levels of adult literacy and vocational training, visits by extension agents and health workers, knowledge of family planning, child feeding practices.
Lack of time - or excessive work burdens - is another major problem which has worsened over time in some countries as population densities have grown and available resources such as fuel wood and water have decreased. For child nutrition, lack of time is a principal constraint to breastfeeding and effective child rearing practices (e.g. feeding frequency). Several policies could help ease pressures on women's time. These include those relating to appropriate labour-saving technologies for domestic work (e.g. fuel and water collection, food preparation and cooking) as well as policies on family planning and child spacing, child care arrangements for working women, maternity leave, etc. These are mentioned in items (ii), (iii) and (vii) below. Time allocation studies at the household level are a principal means for measuring the work efforts of women. Other indicators such as proportion of households with access to services and infrastructure (e.g. piped water) could be used.
Lack of assets and control of resources both within the family and outside. Evidence suggests that control of household incomes by women tends to have a favourable impact on child health, education and clothing. Female access to resources usually leads to overall improvements in family welfare. Around the world there are successful experiments (e.g. the Grameen Bank in Bangladesh) that widen women's income-earning opportunities. Policies and legislation should aim at improving access to land and livestock ownership. Social security including pensions, maternal benefits to landless, etc. can also be valuable, although these are more difficult to establish in poor societies. Items (iv) through (vii) below refer to this aspect. Assessments should use social and economic data, disaggregated by gender, from surveys (e.g. household budget) and administrative sources.
The relative importance for new policy decisions in these areas will depend both on the current situation and existing policy priorities and budget allocations. In some countries, for example, literacy may be high but women's economic and social security have not yet been addressed.
The following brief list groups possible interventions that should be considered under different circumstances to alleviate constraints on family - notably women's - coping and to improve the nutrition of all household members.
i) Education and literacy Women's education and literacy affects almost all aspects of their coping or caring capacity. In this context, it determines much of their ability to benefit from all the other policies listed here. While adult education/literacy classes should be a priority, carefully tailored education on child feeding/child care can begin to close the gap created by lack of formal education. Teachers and trainers themselves need access to up-to-date information; better training in nutrition, and investment in the relevant institutions is required. Educational efforts, if designed with the mothers intended to benefit, can improve the understanding and practices of non-literate or low literacy mothers (in areas such as breastfeeding and complementary feeding) to the levels of better-educated mothers.
Although other factors - such as an enabling environment, appropriate legislation, and social security -influence breastfeeding and complementary feeding, perhaps the latter are most importantly affected by women's education and best seen under this heading. Thus, communicating the importance of exclusive breastfeeding in the early months of life (four to six months), increasing the energy-density of complementary foods (e.g. through use of germinated flour), decreasing contamination (e.g. through fermented foods), maintaining frequent feeding, and similar factors, all depend on education, access to information, and public awareness. In the long run, improved education will contribute to lowered fertility, and better employment opportunities; and these in turn will enhance household food security, health, and caring capacity.
Investments in education particularly of the girl child would have large long-term returns because of her pivotal role (both reproductive and productive) in the future of her own family. Putting back the emphasis on the science of home economics and improving the quality of nutrition education taught at the secondary and tertiary school levels will generally improve the state of knowledge and future caring capacity of the girl child.
ii) Access to health and related services Women's own health and nutrition requires adequate access to publicly-provided services, notably:
- pre-natal and obstetric servicesFamily planning services need to be seen as having multiple benefit for individuals' health and nutrition. Adequate birth intervals benefit both the youngest child and the unborn baby: too close spacing may result in low birth weight, and in inadequate capacity for care of the new born and other young children. Equally, the previous child, for example abruptly weaned, is at greater risk. The mother herself may be both biologically depleted from too-frequent births, and burnt-out by too many tasks, including excessive demands for child care. Education on the value of family planning needs to be targeted also towards men, who often wish for more children than their spouses. The benefits of breastfeeding in contributing to longer birth intervals can be stressed in this context.
- family planning services
- health services in general.
iii) Technology and infrastructure Demands on women's time are a major constraint. Some of these may be relieved by investment in improved infrastructure and technology. Domestic chores need to be seen as productive work, to be made more efficient. In fact, most feasible labour-saving technologies for unremunerated work will be beneficial. Important examples - depending on local circumstances -include the following:
- supplies of fuel and water: enormous amounts of women's time could be spared by reducing the burden of collecting water (by improving water supplies) and of gathering fuel (by provision of more efficient stoves, fuel for cooking, etc.);iv) Women's property and income rights Legislation to ensure equitable access to property and productive resources is lacking in many societies. Without this, women are not able to care adequately for themselves and their families. Particular issues concern female-headed households (increasing in many communities) and families with migrant bread-winners. Ensuring access to potentially available household resources often requires legislation.
- access to health services is usually extremely time consuming: better service outreach, more mobile clinics - as well as improved transport - must be considered; somewhat similar considerations apply to access to markets;
- technical solutions exist for some hygienic problems - e.g. supplies of cleaning materials; piped water and sanitation; and technologies for food storage (including refrigerators where appropriate), etc. - these all free time and improve the household health environment.
v) Access to credit Growing experience confirms that providing credit facilities to women, even without traditional collateral, is feasible and effective as a means of improving the situation of women and their households. Micro-enterprises which are in the hands of women have been shown to have good credit repayment records in a number of credit schemes in Asia and Latin America. Knowing that women's resources preferentially benefit their children means that this is an important way of enhancing their caring capacity. Expansion of women's access to production-oriented credit, and development of the required institutions, must be pursued in this context.
vi) Employment, home productivity and control of resources It has been quite widely established that the income controlled by women has greater benefit for the family's nutrition than general, or male-controlled, income. Women's control over the household income needs to be enhanced through fostering opportunities for women's employment, and for remuneration of production from household assets. Policies here range from wage employment opportunities, enforcement of minimum wage legislation, to home industries, cropping policies in agriculture, and again education. Such policies should, however, also take into consideration the balance of work outside the home which can conflict with the capacity to provide adequate care for the family.
vii) Social security for women Some aspects have been considered under point ii). It is worth noting that programmes specifically aimed at enhancing food availability and access to health services have been shown to be cost-effective in developed countries (e.g. WIC in the United States). Targeting social security benefits specifically to women is accepted in many developed countries - e.g. supplementary benefits in United Kingdom. Rights to maternity leave are an important policy issue with potentially far-reaching benefits for the health and nutrition of women, and by extension their children. An enlightened evolution of social security policies in countries that can afford them may well usefully consider such specific targeting to women.