Why the review
Framework and setting for the review
Western media headlines on Africa only occur when an area is affected by drought, starvation, war, civil commotion or severe economic crisis. Thus it is not surprising that too many people in the west view Africa as an undifferentiated social and economic disaster area; a continent of drought and starvation, wars and refugees, economic crisis, taboos and primitive habits. Fortunately this widespread perception is slowly been challenged as more stories of optimism and success including nutrition policies, programmes and institutions working for nutrition are documented and lessons are drawn. True, there are serious problems in Africa; but there is also hope. This hope is reflected in a number of optimistic conditions and recent reforms. This review is intended to add to that hope.
Most of Africa’s natural resources are as yet untapped indicating the continent’s potential. Although there exists communities where the environmental carrying capacity has been exceeded; in general terms Africa and Tanzania in particular does not have the geographical population pressure of other continents. If the current high population growth of Africa is arrested, and effective environmental rehabilitation and promotion policies are pursued the population carrying capacity will continue to be favourable to the next century.
In Africa and especially in Tanzania, there still exists good traditional practices relevant to nutrition like sustained breast-feeding, caring for the pregnant woman, community-based child care arrangements, mutual aid and safety nets, consultative methods of community-based participation and decision making and strong traditional and religious moral and ethical systems. The persistence of the extended family traditional system partly accounts for this. Within the extended family system, wealthier members typically help poor members meet their basic needs especially in health and education. This is exemplified by the African tradition of leaving a “I have a big problem” message when wanting an immediate response from a relative or friend. This “economics of affection” traditional approach to Africa’s economic crisis has prevented the collapse of many families and communities.
In recent years, there is also the changing political situation in Africa characterized by democratization, decentralization, the decline of apartheid and the trends towards the resolution of conflicts made possible by the ending of the cold war. This provides opportunities for development. In addition there seems to be emerging, albeit slowly, a new global development paradigm that sees health and nutrition improvement not only as the outcomes of economic development, but also as a prerequisite for economic development.
At the global level commitment and concern for nutrition, especially as it relates to the well-being of children and women is now world-wide. This concern is signified by four sets of actions. The first is the Convention on the Rights of the Child adopted unanimously in 1989. It stipulates legal standards for the protection of children against neglect, abuse and threats to survival, and enjoined all nations to take appropriate actions to guarantee proper growth and well-being of children. The second was the World Declaration on the Survival, Protection and Development of children adopted in New York by a World Summit of Heads of State and Government on September 30, September, 1990. The Declaration included a Plan of Action for implementing Global Goals which included Nutrition Goals for the 1990s. The third is the 1991 Montreal Conference on “Ending Hidden Hunger” which provided further political impetus for the elimination of micronutrient malnutrition. The fourth is the December 1992 International Conference on Nutrition (ICN) in Rome, where a World Declaration on Nutrition and a Global Plan of Action was adopted which put nutrition on the world developmental agenda for the rest of the twentieth century and beyond. Especially important for Africa is the recognition that priority needs to be given to Africa and the encouragement to continue to develop an African Nutrition Strategy which has already started under the Organization of African Unity (OAU).
Nationally within Tanzania, commitment and concern for the social well-being of the population with emphasis on children and women dates back to the early days of independence, but especially so after the Arusha Declaration (TANU, 1967) and the Tanganyika African National Union’s (TANU’s) directive of 1973 which gave priority to rural development, water, health and education free of user charges. An important and nutrition relevant move in 1973 was the legal creation of the Tanzania Food and Nutrition Centre (TFNC). More recently, several sets of actions have given practical effect to this commitment, namely: -(1) Ratification of the Convention of the Rights of the Child and the designation of June 16th as the Day of the African Child (2) President Mwinyi’s personal endorsement of the World Declaration on the Survival, Protection and Development of Children; (3) the holding of a National Summit for Children in 1991 which was chaired by the Prime Minister, and attended by Ministers and Members of Parliament and the adaptation and adoption of the Global Goals and a National Plan of Action (NPA) (4) inclusion in the extended Economic Recovery Programme (1989\92) of a Priority Social Action Programme (PSAP) to improve the essential social services which suffered under previous structural adjustment programmes and (4) the creation of a Ministry of Community Development, Women Affairs and Children in 1990 (6) the declaration of a Food and Nutrition Policy.
The nutrition field is not a particular sector. It is a complex field depending on a number of variables. Here we shall focus on four sets of variables which affect nutrition both directly and indirectly. These are (1) the status of the economy; (2) the country’s ideology and policies; (3) institutions and pattern of resource allocation; and (4) nutrition related interventions through the various sectors. These clusters of variables have not been static; they have changed during various phases of the country’s history, with varying effects on nutrition relevant actions. While in the analysis of these variables a national level perspective is adopted interest is also focused on understanding community level processes for sustained nutrition intervention 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.
This chapter introduces the reasons and basis for the analysis including the conceptual model frameworks within which the problem of malnutrition is analyzed. Chapter two analyzes the political economy and the institutional context. Chapter three discusses the nutrition situation and trends; chapter four introduces the analysis of the different problems and causes related to the nutrition situation and chapters five to seven discusses the major clusters of determinants of malnutrition (food security, health and care including women’s control over resources). Chapter eight critically examines the different nutrition related integrated and sectoral policies and programmes and chapter nine provides the overall conclusions and recommendations.
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.
This review has been carried out as part of the ACC/SCN’s efforts to review successful nutrition-relevant actions in some selected countries so that experiences from the eighties can be documented and lessons for the nineties be drawn (Gillespie and Mason, 1991; ACC/SCN 1991a&b). The review analyzes nutrition trends and relevant actions in Tanzania that have been formulated and implemented during the 1980s.
The review is primarily based on the terms of reference as given by ACC/SCN. The framework used is based on an explicit and flexible conceptual model for assessing, analysing and acting on the causes of malnutrition [Jonsson, 1988]. The framework has two components: a factual analysis (fig. 1) and an operational analysis (fig. 2).
Figure 1: CONCEPTUAL FRAMEWORK FOR THE DETERMINANTS OF MALNUTRITION
Figure 2: THE TRIPLE ‘A’ CYCLE
In the factual analysis, malnutrition is considered as the ultimate manifestation of various social and biological processes in society. This manifestation may be in the form of Protein Energy Malnutrition (PEM), chronic diet related diseases, or micronutrient malnutrition of which the deficiencies of iodine, iron and vitamin A are the most prevalent. The problems are then analyzed at varying depths of causality.
The immediate causes of malnutrition are those most proximal factors which finally precipitate malnutrition. They are related mainly to physiological relationships and their interventions are mainly based on service delivery and have traditionally been more visible. Given alone, the impact of such interventions is short-term. The causes have been identified as inadequate food intake (low feeding frequency and low energy density of foods as eaten) and diseases which usually interact in a mutually reinforcing manner. Diseases notably malaria and measles cause loss of appetite and the increased metabolism associated with the high fevers increase the body’s need for food. Diarrhoea which is most often associated with vomiting decreases food intake and results into the loss of food already eaten. This worsens the nutritional state of an individual. Likewise the impact of disease is made much worse by the malnourished state, since malnutrition lowers the body’s ability to resist disease.
The underlying causes of inadequate food intake and diseases are inadequacies in food security, caring capacity and essential services like health, education, housing, water and sanitation. Interventions at this level of causes are mainly capacity building in nature and the impact is medium-term. The underlying reasons are related to the availability and economic and social accessibility to these services which is determined in turn by economic, human and organizational resources.
The development of these resources and their allocation towards the amelioration of malnutrition depends at the basic level on the development and structure of the economy, the prevailing political ideology, and social and cultural factors related to gender (women’s workload, the decision making process and resource allocation) and nutritional behaviour. Ecological and environmental conditions like climate, drought, floods, deforestation and other types of environmental unfriendly behaviour also affect nutrition. Interventions at the level of basic causes results in the empowerment of people and the impact is long term. This type of analysis also defines the concept of empowerment in nutrition intervention. Thus interventions at the level of immediate causes (service delivery) is the least empowering and those at the level of basic causes most empowering.
The second component of the conceptual framework emphasizes the operational approach of a process of assessment of the situation, an analysis of the specific causes, and deciding and designing actions to improve the situation (fig. 2). Since the various biological and social processes which determine the nutrition situation are not static but constantly changing a self starting cyclical process of assessment, analysis and action (triple A cycle) is needed in order to capture the changing situation and better focus the actions. Effective nutrition programmes will have the triple A cycles operating at all levels from the community to higher levels of government and concerned agencies and institutions in order to ensure programme sustainability. It is important for whoever wants to start a programme to work closely with the government because while some NGOs may come and go governments though may change remain a permanent structure in all communities. The role of the Tanzanian Government in promoting community based nutrition programmes is a case in point (Yambi, Jonsson and Ljungqvist, 1989). Since the triple A cycles are already operating as a normal logical way for problem solving, advocacy is needed as a driving force to make the triple A cycle and focus them on nutrition improvement. Ljungqvist (personal communication, 1993) compares the triple A cycles to the way the human body works; the driving force of advocacy (and information, education and communication) as the heart; assessment as the eyes, ears and other senses; analysis as the brain and action as the hands.
The depth of analysis is the first dimension of the conceptual framework. The second dimension is the level of society at which the analysis is performed. This can be at the level of the household, the village, the district, the region, the nation and even at the international level. The immediate causes of malnutrition operate mainly at the lower levels of society while the underlying and the basic causes operate at the higher levels. Programmes aimed at addressing the immediate causes may have an immediate impact on the nutrition situation in the short run, but their sustainability and, therefore, impact on the long run is low. Thus while programmes aimed at addressing the underlying and basic causes of malnutrition may not show an immediate impact, they are usually sustainable in the long run.
However, it should be realized that a combination of actions at all depths of causes is necessary. For many communities the immediate causes notably diseases constitute an area of urgent action if active community participation is to be secured. The logic is simple: survival must be assured before engaging in ancillary survival and development activities (probably the logic behind UNICEF’s child survival and development programmes). Thus actions at the immediate level are a necessary entry point for actions at the underlying and basic causes.
Time is the third dimension of the conceptual framework. All factors related to nutrition at any particular moment are the result of a historical process. At the level of basic causes economic, cultural, and political changes take varying periods of time to reflect on the nutrition situation. Climatic shifts resulting from environmental degradation is so gradual in time perspective that the common person does not easily make the connection. Even at the level of immediate causes, time plays an important role. Diseases like malaria, diarrhoea etc also have their history. There is a period called the incubation period between contact with the disease causing organism and the manifestation of disease. The seasonal fluctuations in the nutritional situation of communities is another example of the time dimension. Thus though in this review the last decade will be the historical frame for the analysis, there will be frequent reference to longer historical perspectives. Certainly, history taking so important in some disciplines like Medicine is also extremely important in Nutrition.
