This paper reviews nutrition trends and relevant actions in Tanzania that have been formulated and implemented during the 1980s. The aim is to draw conclusions as to which programmes are effective in preventing malnutrition, why, and how they are best managed. A national level perspective is adopted with descriptions of relevant policies as well as individual programmes, including considerations for their design, implementation and impact. The scope, however, goes beyond “nutrition” programmes per se and includes various macroeconomic adjustments and indicators relevant to nutrition. The national political and socioeconomic context during the last decade is considered paying particular attention to trends.
Interest is focused on understanding community level processes for addressing nutrition problems paying particular attention to the communities ability and capacity to assess, analyze and act on their nutrition problems with necessary support from other administrative levels. The effect on local institutional capacity to plan and implement nutrition interventions and future prospects and lessons for policy for nutrition improvement is also considered.
The review draws mainly on secondary data from published and unpublished reports from various relevant institutions in Tanzania and where appropriate primary data was collected. The experience of the authors in participating or influencing the formulation of nutrition policies and programmes and in managing and researching on them for more than a decade has been invaluable in carrying out the review.
The review starts with a discussion on the framework used for the analysis and briefly discusses the basic political and macro-economic and institutional determinants of the nutrition situation during the 1980s. The nutrition trends, policies and programmes during this period are critically presented. In each section possible lessons for the future are derived.
The review reveals that over the last decade the major nutrition problems in Tanzania have manifested as high rates of malnutrition and mortality among children under-five years and women particularly those pregnant. Like for other countries in sub-Saharan Africa the major nutrition problems are protein energy deficiency (PED), and the micronutrient deficiencies of iron leading to iron deficiency anaemia (IDA); iodine leading to iodine deficiency disorders (IDD); and vitamin A leading to vitamin A deficiency (VAD) and xerophthalmia. Other nutrition problems affecting smaller and more defined sections of the community are fluorosis, overweight and obesity and diet related cardiovascular disease in the elite and business sections of urban communities emulating harmful food habits and life styles.
The immediate causes and problems are related to low frequency of feeding; low energy density of consumed food staples; and diseases particularly malaria, diarrhoea, measles, intestinal worms and respiratory infections. AIDS is becoming an increasingly important cause of infant and adult malnutrition and deaths.
The major underlying problems and causes are related to inadequate household food security; inadequate caring capacity of the vulnerable groups; and inadequacies in the quality and quantity of the provision of basic services like health, education, housing and water and sanitation.
The poor economic situation combined with climatic (floods, drought); environmental problems like deforestation and low production technology are serious basic causes of poor nutrition. Unfavourable terms of external trade and the debt burden are added basic problems. These problems have been made worse by a high population growth outpacing the growth of essential services and the rate at which potential and actual resources are exploited.
Also the review reveals a significant improvement in both general and micronutrient nutritional status during the 1980s despite a severe economic crisis during the first half of the decade. Apart from reductions in the rates of malnutrition, notable reductions in child mortality, women’s workload, gender disparities, and increases in marital accord and cooperation and increases in the allocation of resources for the alleviation of malnutrition have been recorded. Life expectancy increased from about 40 years in the 1960s to about 55 years in the 1980s. The infant mortality rate decreased from about 190 per 1,000 live births in the 1960s to 115/1,000 in the 1980s. There has also been a substantial decrease in the rates of under-five child mortality from a very high 300/1,000 live births in the 1960s to 191/1,000 live births in the 1980s. Substantial decreases in the rates of maternal mortality from more than 450/100,000 births during the 1960s to about 200/100,000 births in the 1980s have also been achieved. The present levels of mortality are still very high by world standards and there is a major concern about an increasing trend in maternal mortality during the first two years of 1990s an indication of the deterioration of the quality of health services. Initially these improvements in the manifestations of the problem of malnutrition were mainly related to improvements of health care rather than improvements in the nutritional status.
However, the last decade has seen substantial improvements in the nutrition status of children under-five years of age especially in areas implementing integrated nutrition programmes like the Joint Nutrition Support Programme (JNSP) and the Child Survival and Development (CSD) programmes. In eight regions implementing these programmes total malnutrition as measured by weight-for-age below 80 percent (minus 2 SD) of the Harvard reference values decreased from an average of about 50 percent during the mid-eighties to about 30 percent during the early 1990s. Severe malnutrition decreased from an average of about 6 percent to about 2 percent during the same period. The rates of reduction of underweight in these eight regions in an average period of 4 years was about 59 percent for severe underweight, 29 percent for moderate underweight and 32 percent for total underweight. At the national level the 1991/92 Household and Demographic surveys have also indicated that just about a quarter of the under-five children were underweight as compared to survey averages of 40-60 percent in the early 1980s.
At the national level, there also seems to be an improvement in the prevalence of low birth weight, which is an indication of an improvement in the nutritional status of women. While estimates for the prevalence of low birth weight in the early 1980s was 14 percent, the prevalence for 1990-91 was about 9 percent.
There have also been improvements in the micronutrient situation. For IDD, in some places severe IDD as manifested by visible goitre rates has decreased by nearly 60 percent while total goitre rates have decreased by about 30 percent through oral iodinated oil distribution. Vitamin A deficiency in the form of xerophthalmia has decreased by about 25 percent through integrated dietary, supplementation and public health measures. In one region, Shinyanga, it was possible to reduce severe vitamin A deficiency measured by the prevalence of serum retinol levels of below 10 mg/dl from about 20 to below 2 percent in a period of two years in two divisions through universal periodic distribution of capsules.
These improvements are particularly significant because the nutrition situation even during the good economic times of the 1960s and early 1970s was described as constant over time and geographical location. The improvements in the nutritional situation is a reflection of a series of positive nutrition related policies and programmes carried out during the mid- and late 1980s. It is of interest to note that the initial improvements in the indicators of the nutrition situation occurred at the same time as the economic indicators were improving.
The economic reforms and structural adjustment programmes which followed the economic crisis during the 1980s have begun to generate economic growth currently at a Gross Domestic Product (GDP) of above 4 percent compared to a population growth rate of 2.8 percent. The reforms which were highlighted by the liberalization of trade, introduction of flexible management of foreign exchange transactions and cutting down on government spending, have also been accompanied by institutional and political reforms to increase accountability and greater participation in the mobilization of people for grassroots development and official participation of the private sector in the country’s economy. This kind of economic growth is essential to enable the government to effectively finance “social security” for those adversely affected by the short-term effects of the economic reforms and further develop human resources for sustained development. The political reforms are meant to strengthen people’s participation in the growth of the economy.
The basic reason for success in both the improvement of nutrition and the economic and political reforms lies in Tanzania’s political stability and ideological commitment to social action. This politically favourable climate backed up by an unprecedented grassroots social mobilization structure from the national to the village level has resulted in the mobilization of some kind of a nutrition movement in Tanzania and to a very large extent the inclusion of nutrition considerations in sub-national and national development plans.
The formation of the Tanzania Food and Nutrition Centre (TFNC) by an act of parliament as early as in 1973 to catalyse and harmonize nutrition related policies and programmes is seen as one of the important forces behind the improvements in the nutrition situation. Nutrition advocacy for decision makers, assessment, analysis, operational research, training and conceptualization done during the late 1970s and early 1980s by TFNC laid down the ground work for the major nutrition programmes in the form of the WHO/UNICEF supported Iringa JNSP and the UNICEF supported CSD programmes in the mid- and late 1980s. It was also during this period that the micronutrient malnutrition control programmes initiated by TFNC, under the various component financial support of SIDA, the Netherlands Government, UNICEF, WHO, FAO and a soft loan from the World Bank were started. It is pertinent to mention that a number of NGOs have also increased their nutrition activities on the basis of the TFNC/UNICEF conceptual model during the last decade.
Thus although Government financial resource allocation to the nutrition related sectors declined during the 1980s due to the severe economic crisis and an apparent shift in emphasis, a closer examination will reveal that if donor and NGO support was included in the equation, financial, human and organizational resources to support nutrition during the last decade were more than in previous decades. It seems that donor financial support was able to mobilize apparently idle human and organizational resources and created widespread community concern about malnutrition and child and maternal mortality.
An analysis of the successful programmes shows a number of characteristics which should act as lessons for the 1990s.
Firstly they are community-based with strong community participation and management through the Government and Party administrative structures. National, regional and district technical supportive mechanisms were strengthened or in some cases established. The major stimulus for undertaking the programme came from broad developmental thrusts of the government and the programmes were distinctly inter-sectoral in nature with a wide variety of health, agriculture, education, planning, community development and other productive activities linked to nutrition. The lead role was played by planning or community development with health playing an important role. Community members actively participated in the programmes with specific and relatively concrete tasks such as helping in the quarterly weighing of children, running feeding stations and participating in the selection of village staff like Village Health Workers. Secondly there was a strong component of social mobilization through animation, advocacy, information and communication which led to the creation of community concern with regard to the problem of child deaths and malnutrition. Results of nutrition monitoring using weight-for age were effectively reviewed and used for making various decisions at all levels beginning right in the community through the “triple A cycle” of assessment, analysis and action. Both a top-down and bottom-up approach was used in social mobilization. The top-down approach focused on the improvement of local conditions by trying to meet their practical needs. The empowering bottom-up approach recognized the people as able to act on their own behalf to acquire new skills and knowledge in order to increase their power and control over resources for the improvement of nutrition. The environment created by the process of social mobilization permitted the use of both approaches without necessarily creating a conflict.
Thirdly active participation was sustained through improved management; the result of the systematic strengthening of the process of continuous assessment, analysis and action. The management systems emphasized improved information through quarterly child growth monitoring using children’s growth cards and the understanding by both men and women of the child’s growth. Programme design was flexible and decision making was sufficiently responsive to feed-back and feed-up so that it was possible to make any necessary adjustments throughout. Starting relatively small and then expanding after careful review of results was also an important programme management design.
Also management was strengthened through training at all levels and discussing results from the information systems in the health and nutrition committees. Training was mainly in-service and was augmented with frequent supervision. Some people have described the Child Survival, Protection and Development (CSPD) programmes as an Open Rural University stressing the educational component implemented at all levels. To a very large extent this improved the implementation and decision making process. This indicates that with some training field staff with limited basic education can perform adequately. As a result nutrition improvement was included as a goal to be achieved; and to some extent the contradiction between men and women with regard to nutrition related information and resource allocation improved. More household and community resources are now been allocated towards the improvement of nutrition. Management was also strengthened through the provision of essential management tools like supervisory transport and other expendables. The management systems created helped also in monitoring programme impact.
The fourth characteristic was the integrated multi-sectoral and multidisciplinary approach used. Actions on the improvement of household food security, caring capacity, health services, education and water were carried out at the same time. In many cases extension staff from the relevant sectors including NGOs continued to do the same things they used to do. But with an understanding of the consequences of their actions on the nutrition situation, they did them better. The explicit conceptual approach used facilitated dialogue and analysis of the causes and problems of malnutrition. The emphasis on the triple A approach prevented the intrusion of external magic packages of solutions. As a result emphasis was initially placed on the development of the process for the reduction of child and maternal mortality and malnutrition. Coupled with extensive internal and external technical contacts, this resulted in the creation of confidence and capacity in community and national institutions.
But success is usually accompanied by problems and contradictions. As local people become more empowered to act on their own behalf, they are more likely to challenge authoritarian leadership styles common in village and district leaders. Women would be less likely to accept gender discrimination as enforced by tradition. Many extension staff are somewhat naive about the existence of social differentiation at the local level. The delineation between mobilization from above and animation inherent in the social mobilization process provides space for people to raise questions concerning the behaviour of state officials and local leaders. Though this is useful for furthering grassroots democratization it has a potential to lead to increased conflict and tensions. Practitioners must learn how to cope up with this issue. There is also the issue of the contradictory role of external funding and external control even if it is unintended. External donors, national and sub-national levels and the beneficiaries may need to pay special attention to this at the local level as it affects sustainability. The “Mtwara Initiative” is an example of what can be done.
The coverage of actions in relation to nutrition needs need to be expanded. Out of the 20 regions in Mainland Tanzania only nine regions had been covered and only in selected districts between 1983 and 1991. There are plans to cover the rest of the regions during 1992-96. The whole of Zanzibar is covered by the JNSP which started in 1989. As the 29th largest country in the world, the geographical vastness of Tanzania and the general low population density of about 27 per kilometre makes it difficult to evenly spread out the nutrition programmes without compromising impact. The villagization programmes of the 1970s partly resolved this problem. In the face of limited continuing limitation of resources, targeting was done to those in greatest need. Thus activities initially were targeted to those areas with highest levels of infant and child mortality and malnutrition. In these areas the programmes targeted children and women in general and children and women in “poor” households and villages in particular.
While mechanisms for targeting women and children were set in place, no mechanisms were developed to help identify and target the poor. Indicators for the assessment of the manifestations, immediate and underlying causes of malnutrition as articulated by the ‘conceptual framework’ are available, but no social indicators exist to assess and monitor the basic causes. There is need to work out conceptual tools of assessment and analysis of the basic causes at local as well as district, national and even at the international level. There is clearly a need to pay more attention to social indicators. The lack of a clear formulation about social and economic relations in the conceptual framework is indicative of the inherent difficulty there is in concretizing better what is meant by these relationships.
Observations from the programme areas clearly show that there are two opposing conceptions by focusing on women alone. The first is the “women focus” where the analysis of the problems, causes and solutions tend to be focused on women, thus reinforcing the gender division of labour, with the woman pushed more and more into the home. The “gender” view includes men in the analysis and assumes that gender relations themselves need to be changed and not just individual women and men. Since it is the women focus view which dominates over the gender view there is need to further articulate the gender view in the social mobilization and animation process.
There are indications that the achievements which have been made can be sustained provided that further mobilization of financial, human and organizational resources continue and that the economic and political reforms currently under way continue to be peaceful and create adequate safety nets for social security of the vulnerable groups. There should be increased national and local resource mobilization for nutrition and if possible fix the proportion of financial resources allocated to the social sector by law. Ways should be found to further increase the cost-effectiveness of the programmes and create a conducive mechanism for the convergence of resources. The 1993 National Plan of Action (NPA) for the implementation of the 1990 Child Summit, the 1991 National Food and Nutrition Policy and the 1992 International Conference of Nutrition (ICN) goals are steps in the right direction to achieve convergence of resources for nutrition.
Political advocacy will be needed to maintain the political support and awareness on nutrition of the 1980s since there seems to be a danger that the current economic and institutional reform programmes and the democratic climate of multi-partysm are shifting the “people centred development” paradigm of the 1960s and 1970s to “a material centred development” paradigm. There is a need to make health and nutrition improvement good politics for all parties so that any party should be embarrassed if it does not put these as priority issues on their agenda. Democratization of donor institutions is also called for, so that they become increasingly more responsible to the people they serve rather than only the bureaucracies they represent. This can take place only if there is more global justice and national accountability. In the 1990s, global and national resource allocation to nutrition should move from the plane of political commitment to that of being a political choice. As a political choice it will not be possible for a country not to have enough resources to allocate to nutrition improvement.
This means that the flexibility of the conceptual framework would need to be called into play and even modified to improve the designing of nutrition related actions for the 1990s. Much more advocacy at all levels is needed to seek consensus to share the ethical and scientific position reflected in the conceptual framework. The community-based approach which has been used in the JNSP and CSD programmes and especially the triple A cycle approach has already created a good basis for the redesign of programmes as it cycles. It has several advantages. Its ability to deal with successive rapid approximation of the situation avoids delays in taking action and focuses better assessment, analysis and action as it cycles. The process recognizes the existence of direct and indirect misinformation and thus the need to advocate for behavioral change. In this process planning is with the people and deals with all resources including financial, organizational and human resources. It also recognizes the existence of the triple A process at all levels and is therefore not an imposition. In this process, there is an urgent need to learn from the only two major generalizable experiences gained so far.
The first is that the ‘only magic bullet’ for a successful nutrition programme is a “process approach” of a cyclic assessment, analysis and action done within an explicit conceptual framework where you learn and adapt as the programme progresses. Several key factors in this approach need to be born in mind (Jonsson, 1992). The first is that the people should be regarded as key actors in the process. Secondly, provided that they have access to adequate information and resources, the people are in a better position to judge what will work or not work in their local situation. Thirdly, their mere existence in a continuously changing and sometimes hostile environment, indicates that their survival and coping strategies are adaptive processes, which need to be recognized and facilitated. Thus instead of preparing detailed multi-year nutrition plans, a mechanism should be established to facilitate what Jonson calls “adaptive programming”. The fourth factor is empowerment of the people in terms of among other things, resources, reduction of social and gender disparities and improved knowledge and health. Community participation is the fifth factor and is a means and outcome of empowerment. Often participation is sought at the stage of implementation only. This is not participation, but involvement. Participation should cover all stages of the project including planning, assessment, analysis and action. The sixth factor is community ownership which is an outcome of participation and empowerment. Local ownership is important for sustainability. People will feel inclined to contribute or take some risk in an issue they feel it is theirs. The best programme would be that which after it is successfully over, people would say “we did it ourselves”. That would be the best way to implement the various global plans of action on nutrition of the 1990s. This approach requires social mobilization and animation which will create enthusiasm and commitment. Again, there is no one magic formula which will lead to successful mobilization/animation for nutrition or other goals except using the process approach.
The second major lesson is the shift in emphasis in the analysis of the malnutrition problem at all levels from a biological perspective to a social perspective. Conceptualization and methodology were valued at all stages. This was facilitated by the integrated conceptual framework. Thus the major arguments for action started to be based not on economic developmental issues but on what Jonsson (1992) calls “normative, moral or ethical arguments.” The successful programmes incorporated moral and ethical issues pertaining to equity, accountability, dignity and justice with a high degree of commitment, solidarity and cooperation among the various actors who included scholars and social activists. This provided space to carry out deep analysis of issues for innovative actions and correction of mistakes. The lesson is that social factors need to be emphasized more in nutrition programmes if they are to be successful. This was exemplified by the growth monitoring systems which provided a quantitative goal within a long time frame, which were not primarily designed for impact monitoring, but for mobilizing social action. In many villages the concept of the growth monitoring card with green (normal), grey (moderately underweight) and red (severely underweight) was given a new social meaning and scope: - the green household, the green school and the green village. The implication is that you cannot maintain a “green child” in a “grey or red” household in which access to resources is not adequate to sustain the “green revolution.” In the final analysis, households, schools and villages need to be “weighed” just as the child to determine its position on the colour band and take appropriate action. This village social concept could be extended to a “green district, a green region, a green nation and even to a green globe.” The challenge is to determine a minimum set of social indicators needed to nutritionally weigh the household, the village, the district, the region, the nation and the globe.
