THE PROBLEM AND ITS CAUSES
RELEVANT ACTIONS
OPERATIONALISING RELEVANT ACTIONS
Nutrition as a highly effective preventive health measure
Measuring malnutrition and infection
Interactions between nutrition and infection, to produce the 'malnutrition/infection complex' (see Figure 1.3) cause the major public health problem in the world (Tomkins and Watson 1989). Infection can cause malnutrition through its effects on intake, absorption and utilisation of nutrients and in some cases the body's requirement for them. A child's rate of growth may be retarded by too little food and/or too many infections or parasites. Growth retardation has been shown to have a synergistic relationship with disease (Scrimshaw et al. 1968; Black et al. 1984; Tomkins and Watson 1989). Infections can lead to a loss of appetite (Mata et al. 1977; Martorell et al. 1980), decreased efficiency of food and nutrient utilisation (Briscoe 1979), to increased energy requirements (Tomkins 1983), and to decreased rates of child growth (Rowland et al. 1977; Baumgartner and Pollit 1983). The relationship between diarrhoeal disease and physical growth in children has been shown in several studies to be particularly close (Levinson 1978; Chen et al. 1979; Prahlad Rao 1980; Martorell et al. 1984). It is thus usually meaningless to attribute malnutrition to either low food intake or infection, as both are bound up synergistically, while other wider socio-economic factors may have contributed. Nonetheless food and non-food causes of malnutrition can be regarded as deficiencies in two fundamental entitlements: one for food and one for hygiene or health (Osmani 1990).
A number of detailed and specific studies (both population based and more narrow) have helped elucidate malnutrition-infection interactions. Many are cited in Tomkins and Watson (1989), a considerable number involving longitudinal assessments of infection, growth and other factors in individual children. Only a few succeed in assessing dietary intake at the same time in individuals, because of the extreme difficulty of such measurements.
While policies that are being drawn up to deal with the combined outcome of malnutrition-infection interactions on the child have merit, they do not deal with the decisions needed at a household level on the allocation of resources (Payne 1985). The nature of these linkages is important to understand, and use as the basis of policy. This is well illustrated by the mother's pivotal role concerning decisions regarding the feeding and health care of infants. An understanding of the linkages within the 'complex' will allow the relative value of women's time allocated to income-earning to be weighted and compared with the time she spends in improving sanitation around the home, or caring for a sick child (see chapter 4).
Both individuals and households may be vulnerable to the physical and economic effects of ill-health. For instance, Pryer (1989) found a strong association of severe child malnutrition with the ill-health and consequent inability to work of breadwinning adults in slums in Bangladesh; households where an adult earner had been sick during the previous month were 2.5 times more likely than others to have a severely malnourished child. Other studies bear out the need to consider the economic costs of ill-health (see Corbett 1989 for a review). Sickness makes poor people poorer through delayed treatment, the costs of treatment and the loss of earnings. One main asset of a poor person is his/her body as it affects the ability to work. At the same time, it is the poor who are particularly vulnerable to malnutrition and sickness. The costs of ill-health include those due to the loss of income (or even employment) as well as those for treatment. In fact, where illness is chronic, the body turns from being an asset into a liability as it has to be fed, clothed, housed and treated. Other income-earners in the family may have to divert time and forego wages so as to care for the sick. Such ill-health in a household may become a 'poverty ratchet' i.e. a contingency which make a household permanently poorer as assets are irreversibly disposed of to meet these costs (Chambers 1983).
Such types of vulnerability may be becoming more widespread as several trends become evident: for example, conventional health care is becoming more expensive (Corbett 1989) and a common component of structural adjustment is the introduction of cost recovery through user charges. A major policy prescription flowing from studies of vulnerability and health is free or low-cost, accessible and effective health services. Imposing high costs for use of health services hits precisely those who are most in need and least likely to afford to pay them. In the foregoing of treatment, acute conditions may become chronic, irreversible and if not fatal often disastrous economically through labour days lost. If humanitarian grounds are not sufficient, maintaining free or low-cost services, even in times of austerity, may turn out to be cost-effective as the means to reverse impoverishment are usually more expensive than those that prevent it. Publically organised health insurance schemes and other social security measures will also have relevance here. Another implication for policy is a re-consideration of targeting criteria; while nothing should detract from attention focused on women and children, the well-being of the main earner, whether male or female, is clearly of fundamental importance for the health and nutrition of dependents.
Exposure to most of the major diseases, which in turn interact with nutrition, can be reduced by preventive measures. These are primarily environmental, or through immunization. Environmental sanitation will reduce exposure to gastro-intestinal pathogens; improved housing and reduced crowding are important in controlling respiratory tract infections (of which pneumonia is by far the most lethal) and malaria to some extent Water quantity and quality and sanitation may have a considerable impact on nutritional status whether through diminished morbidity, savings in maternal time and energy or improved food production, (Tomkins et al. 1978; Henry 1981; Tomkins 1983; Esrey and Habicht 1985).
Reduction in infant and child mortality rates is undoubtedly closely related to the success in extending immunization coverage. The importance of immunization especially for measles is well known, in the context of nutrition. However, below a certain level of infant and child mortality, in other words where deaths due to immunizable disease have already been prevented, further improvement is likely to depend on other factors such as nutrition. Particularly important here are diarrhoea and acute respiratory infections.
Good nutrition is itself part of preventive health, as deficiency of protein-energy and many micro-nutrients compromises the immune system, and in many cases the integrity of epithelial tissues, which lowers defences to pathogenic invasion (see Figure 1.3). Studies have shown that malnutrition is related more to the duration, severity and outcome of an illness, than to its incidence (Black et al. 1984; Tomkins 1986), although the latter may be associated with severe malnutrition.
The case for nutrition as a preventive health measure has been made with particular force by McKeown (1988, see also SCN News No. 4). The policy issue here is then how effective (or cost-effective) is attention to good nutrition as a preventive health measure, compared with the more conventional preventive health interventions. To investigate this, one would need to look at health outcomes in relation to nutrition (probably separating different nutrients) controlling for health services and environmental factors. The results are probably largely unknown in an epidemiological sense, and the supporting evidence is more from recent and increasing knowledge of the mechanisms. Specifically, effects of malnutrition, even mild, on the immune system and integrity of epithelial tissues are becoming increasingly emphasized with new research (see Tomkins and Watson 1989). Thus it may be justified and important to begin to re-emphasize the role of nutrition as a general preventive health measure.
Malnutrition and infection can be measured by well-established methods, including anthropometry often through growth monitoring in children. The caveat of careful definition of terms and concepts has been stressed earlier. Anthropometry is an indicator of nutritional status, and specific applications (discussed in detail in ACC/SCN 1990a) distinguish between individuals and populations, cross sectional and longitudinal measurement, and situations ranging from emergencies to chronic.
Anthropometry is non-specific, indicating problems but not of itself defining causes. In principle, we know that acute infection causes growth faltering in children, and in early stages this affects soft tissue, hence an acutely sick child becomes wasted first. However, in the absence of other information, one cannot confidently interpret wasting prevalence as indicative of infection (although these may often be correlated). It is clear that low values of weight-for-height and/or height-for-age (or weight-for-age) measure malnutrition/infection, but do not well, of themselves, distinguish inadequate food intake from infection (which themselves are related). It is however probably true to say that anthropometric measures provide for adequate assessment of the overall malnutrition and infection complex in children.
For adults, there is not such extensive experience and study as for children. Attained height itself is obviously not useful for current nutritional status. Measures of wasting or thinness are used - presently arm circumference or body mass index (BMI - weight/height2), although development of reference weight and height data would ease interpretation. Measures of wasting, notably BMI, have been related to chronic energy deficiency rather than infection. However, the proviso is clear that the presence of chronic diseases, such as tuberculosis or now importantly AIDS, must be taken into account. Thus Ferro-Luzzi et al. (1988) have proposed that below a certain level of thinness (BMI less than 16) chronic energy deficiency can be asserted without food intake data. Above a certain value (BMI greater than 20) chronic energy deficiency will not be present. In the intermediate area (BMI 16 - 20) food intake data on the individual is needed, although it is likely that in this range infection effects will not be readily distinguished from dietary intake.
Assessing problems relating to nutrition and infectious disease control is relatively straightforward in principle. Data are available from service or administrative sources in some cases, in others from household surveys. In more administratively developed countries causes of death may also be available from vital registration, and epidemiological surveys are common (although not so frequently used in nutritional assessment). Some relevant indicators are proposed below (and also dealt with later in chapter 5). Those generally only available from household surveys are designated (S), although data availability (and reliability) from service or administrative sources will vary greatly and may also require special surveys.
For assessing management of infectious diseases, the following indicators (usually as percentages) may be important case fatality rates by disease (e.g. diarrhoea, pneumonia, measles); measles cases given vitamin A; individuals with chronic diseases given food and/or micronutrient supplements; proportion of mothers breastfeeding during child's illness (S); feeding patterns and frequency during child's illness (S); aspects of child care during illness including use of oral rehydration therapy (S).
For assessing disease prevention, the following indicators should be considered: incidence of low birth weight; age at first pregnancy; proportion of short birth intervals (e.g. less than 24 months); contraceptive prevalence rates. Other important information may be obtained from such data as: proportion of infants exclusively breastfed for four to six months (S); feeding frequency, weaning food preparation, with respect to both quantity and quality (S); vitamin A supplementation and disease-specific mortality (S).
Infectious disease control for nutritional improvement may be assessed by a number of standard methods, generally involving household or individual surveys, which would include: immunization coverage rates; coverage of programmes for control of diarrhoeal disease, acute respiratory infections, parasites; proportion of individuals receiving effective primary treatment of infections. It should be noted that morbidity data obtained by questionnaire from mothers is usually unreliable, as it is commonly confounded by better-educated mothers from higher income groups more readily reporting sickness in children than less-advantaged mothers.
At the national level, there are several indicators of health service development e.g. percentage government expenditure on health, intra-sectoral allocation of health resources (urban/rural; hospital/peripheral; doctors/nurses), type of health care (preventive/curative) and access to health services (population per health worker, etc.). Indicators of environmental health too (e.g. access to safe water supply) are important.
Supplementary Feeding
Breastfeeding Promotion and Improving Weaning Practices
Growth Monitoring And Promotion
In Chapter 5, 'disease management', 'disease prevention' and 'infectious disease control for nutritional improvement' are used as headings, while in this section we give details of the types of services or programmes that relate to these goals (the “what to do”). Priority actions in this context are supplementary feeding for children and pregnant and lactating women, promotion of breastfeeding and improved weaning practices, and growth monitoring and promotion. Figure 3.1 outlines the different life-cycle stages of vulnerability of mothers and children to the malnutrition-infection complex, and the place of such specific actions for counteracting this. All of the specific actions shown in Figure 3.1 are described in this chapter, except nutrition education which follows in chapter 4. In the subsequent section the means available for effectively operationalising these actions (the “how”) is discussed.
Figure 3.1: Stages of Vulnerability to Malnutrition/Infection and Types of Appropriate Interventions
Children
Pregnant and lactating women
Supplementary feeding programmes are aimed at increasing the energy consumption of vulnerable individuals through free or subsidized food distribution. Food distribution may be on-site, take-home or within nutrition rehabilitation centres for the severely malnourished. A variety of foods are usually distributed, both imported and locally produced, including cereals and legume blends, dried skim milk, sugar and oil, and sometimes weaning foods (see next section). Theoretically, amounts distributed should relate to the calorie deficits of recipients' diets, although, they will also depend on resources available, while 'leakages' will reduce amounts actually received.
Programmes are generally targeted to vulnerable individuals, for example by the age of the child or the state of pregnancy or lactation of the mother. Targeting of supplements is more often on the basis of nutritional indicators than income, and may initially be geographic - to clinics which distribute the supplementary food. School feeding is one alternative to clinic-based feeding, although it lacks the potential synergism with health services, and targets a different group (though both types may discriminate against the poor). Only school-enrolled children will benefit from school-feeding, although the availability of subsidized meals may encourage enrolment of children from poorer households.
In reviewing child supplementary feeding programmes, it is necessary to differentiate intervention trials that seek experimentally to estimate the effect of feeding on child nutritional outcomes (i.e. efficacy), from actual large-scale programmes that have been implemented with or without an in-depth evaluation component (i.e. effectiveness). Regarding the former, many studies (e.g. Gopalan 1973, Martorell et al. 1980, Mora et al. 1981) have shown that raising dietary intake through supplementary feeding can have beneficial nutritional consequences. The impact may be divided between effects on outcomes such as growth, activity, cognitive development and compensation of energy lost during illness. From 1969 to 1977, the Institute of Nutrition of Central America and Panama (INCAP) carried out a longitudinal nutrition intervention study in four Guatemalan villages to investigate the effects of child supplementation. Important effects on physical and mental development were noted in early childhood. The benefits were greater in children with lower socio-economic and nutritional status and higher prevalence of morbidity. The long-term effects were recently investigated in the Guatemalan Oriente Study 1969-1989 (IDECG 1990) which followed-up the children originally supplemented to assess effects in adolescence. Results show that after 15 years with no additional intervention, the group that received the supplement as young children maintained most of the original gains in height and weight, showed increased physical capacity and had better performance on various cognitive and behavioural tests (IDECG 1990).
Further light has also recently been thrown on interactions between nutrition and health, with implications for supplementary feeding programmes. Supplementation has been found in studies in Colombia and Guatemala (Lutter et al. 1989, Martorell et al. 1990) to modify the negative effect of diarrhoea on growth - the more severe the diarrhoea, the more the positive protective effect of feeding. Thus it is crucial to ensure satisfactory dietary intake during infection. This is made more difficult by the anorexia that commonly accompanies infectious disease, and by the low energy density of many weaning foods.
Regarding evaluations of the effectiveness of large-scale supplementary feeding programmes in the real world, two reviews in particular are informative. Firstly, the study by Beaton and Ghassemi (1982) in which over 200 reports of past food distribution (take-home or supervised feeding) programmes for young children were reviewed. They found that the net increase in the food intake by the target recipients was 45 to 70 per cent of the food distributed. The chance of a detectable weight response was increased if supplementation were targeted on undersized children. 'Leakages' are likely to benefit households of which the children are members. Most of the programmes reviewed used imported foods, either donated or purchased by the local government. Conflicting evidence was found as to the costs of using local foods instead. Costs to the family was the most important determinant of participation, rather than source, familiarity or knowledge of appropriate use. Beaton and Ghassemi (1982) concluded that such programmes have been rather expensive for the measured benefits but caution: “we remain unconvinced that the benefit usually measured, physical growth and development, is either the total benefit to the family and community or even the most important benefit. Therefore, we judge that it would be unwise to withdraw such food distribution programmes until researchers have had an opportunity to assess their true effects and benefits.”
Secondly, in a comparison of five supplementation programmes in India, Pakistan, Costa Rica, Colombia and Dominican Republic, Kennedy and Alderman (1985) found actual results in terms of measured anthropometric change in children to be discouraging. Rations were insufficient generally to have filled caloric gaps, and many recipients were not very undernourished initially anyway. A number of approaches were suggested to raise the net caloric increments in individual children e.g. designing a programme to be perceived as a snack, focusing on the 'food as medicine' approach, and using a nutrition education programme. It should be re-iterated that before effects are manifested anthropometrically, there may be significant increases in voluntary activity by children (Rutishauser and Whitehead 1972), which promotes cognitive development Figure 1.1 shows how the benefits of increased dietary intake in an individual (e.g. through supplementary feeding) may not all be manifested in enhanced growth. The latter may be one, albeit very important, outcome along with increased physical activity and reduced morbidity.
As well as the amounts of distributed food, the nutritional status of recipients, the timing of supplementation in an individual's life-cycle and duration of participation influence effectiveness of supplementary feeding.
Regarding nutritional status, it would be unwise to ignore the possibility that targeting by the nutritional status of a child may prolong his or her selection for feeding. As long as a child is eligible for feeding (i.e. sufficiently undernourished), household food resources may be freed for other members and to some extent the onus of care falls on the feeding programme administrators. The worry here is that the child may be kept underweight to maintain eligibility for feeding. This calls again for the need to look at the household and to aim to ensure that household level basic rations are adequate while supplementary feeding of individuals is being undertaken. If household level rations cannot be ensured, then children should be fed at least as much as they would be at home, to reduce the adverse effects of disincentives to feeding at home. Otherwise, supplementary feeding should be considered more as a form of income transfer to the household, with its effects on the target individual less likely to be manifested (despite considerable household-level benefits being possible).
Timing of supplementation is important to consider. Responsiveness to interventions may be age-dependent with true growth failure only responsive during the period that failure is occurring (not when it has been converted to the 'state of being small'). If enhanced growth is the main objective, then this points to the need for targeting most children in their first year of life. By two years of age, growth has been irreversibly programmed, and may not be responsive to attempts to make up any environmentally-induced deficits suffered in the past Furthermore, the voluntary intake of the child will match the requirements of his or her reduced body size. This is supported by recent evidence from age-specific cross-sectional survey data from a number of countries (Zerfas and Teller 1990). Deviations from reference data started at around 6 months and were complete by about 18 months in most cases, and by 24 months by a few. This is followed by essentially normal growth for the reduced body size. This does not however necessarily contra-indicate supplementary feeding for over-two year olds if benefits other than growth are sought. As Figure 1.1 has shown, other outcomes potentially achieved through increasing dietary intake include increased activity and enhanced psychological development (ACC/SCN 1990a) - outcomes which cannot be measured by anthropometry.
Finally, with regard to duration of participation, on-site and take-home feeding takes much longer to produce a significant growth increment than do nutritional rehabilitation centres. Anderson et al. (1981) suggest at least one year is required for on-site and take-home programmes to show any effect.
Supplementary feeding thus can have both short and long-term benefits for children, particularly undernourished under-twos, even if anthropometry is not sensitive to all effects. For it to be a worthwhile intervention, it needs an adequate infrastructure and resources (both economic and human) for the sustained delivery of food of the right quantity and quality to those who could benefit. Supplementary feeding may best be undertaken as a selective component of a health and nutrition package (see boxes on such Indian programmes).
Studies have examined the effects of supplementation on maternal weight gain, activity, birthweight and breast milk intake of infants. Whereas little effect was seen on maternal weight gain (Adair et al. 1983; Prentice 1987) or activity (Lawrence 1988; Roberts 1982), significant improvements were seen in birthweights. The more malnourished the mother, the greater the positive impact. Owing to the association between birth weight and mortality risk in infants, the supplementation of pregnant women may be one important means for reducing infant mortality rates. Tall thin women have been found to have larger positive birthweight responses to supplementation than short, thin women in a Taiwan study (Adair and Pollitt 1985). This is one further illustration of the detrimental and irreversible effects of childhood stunting - girls who become stunted will be less responsive later in life as mothers to attempts to improve birthweights through maternal supplementation. The cycle of stunted child - short adult - low birthweight offspring - stunted child is thus more likely to be perpetuated.
Programmatic implications of these findings suggest the need to target supplementation to those mothers who are more likely to have a beneficial response with increased birthweights i.e. tall, thin women. Again, childhood stunting should also be vigorously counteracted so as to keep such options open to young mothers (in addition to the many other reasons). An important caveat to bear in mind here is that a poor environment may affect birth weight and subsequent infant mortality - e.g. through infection or through maternal workload. Birth weight (especially if only slightly reduced) may not be causally related to survival. Hence a specific intervention like maternal supplementation could increase birth weights with only minor effects on infant mortality if other factors are unchanged.
In lactating women, supplementation has not been found to have a marked effect on breast milk intake of the suckling infant (Prentice 1980,1983). This may in any case be hard to separate from the effects of supplementation during pregnancy as breast milk production depends on the intensity and frequency of suckling by the child which is a function of its birthweight and thus also supplementation during pregnancy.
A mother who is malnourished, however, is less likely to maintain breastfeeding and more likely to introduce complementary foods at an early age. Under poor environmental conditions, the detrimental effect of infections due to contaminated complementary foods has been found to be worse than if the mother persisted with exclusive breastfeeding, despite inadequate milk production (Martines et al. 1989). Thus programmes that aim to improve maternal nutritional status in the pregnancy, or even pre-pregnancy, periods may, if successful, both improve the chances of child survival both immediately (via increased birth weight) and later (via maintenance of exclusive breastfeeding). The fact that both these effects are likely to be enhanced where environmental conditions are good is one more example of a beneficial interaction between preventive health (this time via an improved environment) and nutrition.
Maternal supplementation, as part of an ante-natal care system, to women from early pregnancy is likely to confer significant benefits on birth weights and the subsequent survival prospects of the child. The case for supplementing lactating women, on the other hand, is not strong. Taking a broader perspective, supplementing adolescent girls in an effort to maximize growth as well as postponing first pregnancies may be beneficial both for the mother and the first child.
Breastfeeding both prevents and manages disease in a child, as well as benefiting the mother. Exclusive breastfeeding for four to six months is advised. It helps to prevent diarrhoea by minimizing the infant's exposure to diarrhoeal pathogens, common in other foods and in water. At the same time, breast milk provides anti-bacterial activity in the infant's gut, reducing the risk of disease if contaminants should be ingested. Similarly, breastfeeding has direct benefits in preventing other diseases, from acquired passive immunity from the mother. It also probably prevents malnutrition, not only secondarily to diarrhoea, through the cycle of suckling promoting production of maternal milk. Continued breastfeeding during a child's second year may thus prevent disease both by providing some continuing direct protection against infectious agents, as well as indirectly by contributing to adequate nutritional status.
Lactational amenorrhoea, prolonged by breastfeeding, is also of great benefit through increasing birth intervals. This will reduce the likelihood of cumulative reproductive stress in the mother and improve her ability to adequately care for her child. The individual child too will benefit from birth spacing and maternal health through more adequate feeding and care practices.
Breastfeeding should be continued when a child has an infection, especially in cases of diarrhoea, measles, respiratory tract infections, and malaria. During episodes of diarrhoea, continued exclusive breastfeeding (with increased frequency and duration of feeds if possible) is the most important nutritional aspect of management. If such infants nonetheless become dehydrated, rehydration therapy may be required. When breastfeeding is maintained during diarrhoea, the growth faltering commonly associated with diarrhoea is rarely seen, and the risk of death is minimized. Continued breastfeeding, sometimes with increased frequency, is also central to the management of other acute infections, such as measles and acute respiratory tract infections, of which pneumonia is the most serious. Many more benefits of breastfeeding have been set out in an important publication “Facts for Life” (UNICEF/WHO/UNESCO 1989).
Activities designed to promote breastfeeding include those that empower women with the knowledge of the benefits of breastfeeding (see 'nutrition education' section in chapter 4) as well as those that motivate and support them in this. The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (WHO/UNICEF 1990) outlines some such measures, which include the removal of constraints to breastfeeding within the health system, the workplace and the community. This requires “a responsive and comprehensive communications strategy involving all media and addressed to all levels of society”. Ten specific actions which can be undertaken by maternity services to protect, promote and support breastfeeding have been outlined in a joint WHO/UNICEF statement (WHO/UNICEF 1989). Measures to ensure adequate maternal nutrition and access to family planning services are also advocated in the Declaration. Governments should develop national breastfeeding policies and set appropriate targets, which should be monitored using indicators such as the prevalence of exclusively fed infants at discharge from maternity services, and the corresponding prevalence at four months of age.
An integration of services for health care, nutrition and family planning, as breastfeeding is likely to be beneficial in each area. In the past, integration between nutrition and family planning programmes may have been hindered by the fact that different targets were being addressed - with family planning programmes focusing primarily on women, and nutrition programmes on the child. Breastfeeding promotion is the one activity that links both targets and can form the cornerstone for an integrated programme. Programmatic considerations as to how to integrate family planning and nutrition interventions, in terms of policy formulation, programme planning, training and the support of community level initiatives present several challenges, which were addressed in the ACC/SCN symposium on 'Nutrition and Population' (ACC/SCN 1991c). They include the need for:
- appropriate training of health and family planning workers (the motivation to support and counsel women should emerge from common goals);- reconciling programmatic priorities of agencies that differ in their support for the concept and practice of integrated breastfeeding and family planning strategies;
- recognition of constraints on exclusive breastfeeding due to competing demands on women's time, misinformation and other factors, hence the need for appropriate programmatic support to enable women to practice breastfeeding;
- resource mobilization to provide relevant information, education and communications to promote the practice of breastfeeding and the adoption of contraceptives, including research on beliefs and obstacles to family planning and infant feeding.
Complementary feeding is necessary in the latter half of a child's first year, before it can eat the adult diet. A number of issues arise here, concerning energy density, nutritional value, and food hygiene. It is essential to promote frequent feeding of foods of adequate energy density (including use of amylase-rich flours). Microbial contamination may be reduced using fermented foods. In some circumstances, notably in urban areas, special low-cost weaning foods may be marketed. For weaning practices to be improved, several prerequisites have been suggested (Dijkhuizen 1991): Mothers (or caretakers) must be convinced of the importance of good weaning food practices, the new weaning food must be affordable (2-3 times the staple food price seems acceptable), easily prepared, continually available, and it must have a built-in incentive - or 'status'. Failures of nutrition education programmes (see chapter 4) to introduce new weaning food mixes, where these have occurred, can be traced to their not meeting all these prerequisites. For example, although the new food may be excellent nutritionally, it may take more time to prepare, which is not compensated by increased appeal or status. A comprehensive evaluation of the impact of several weaning schemes (Orr 1972, 1977) found that most schemes at this time had not made an impact on those children most at-risk due to such reasons as the high cost of ingredients, processing and packaging, which priced the products beyond the reach of the poor, difficulties of access, and problems of cultural unacceptability and poor promotion. More recent developments have learnt from these mistakes.
Growth faltering in children is a warning sign of health and/or nutritional problems. It is commonly detected through regular measurements of a child's weight Of itself, growth monitoring has no merit. As well as a means of problem diagnosis, it should facilitate and accompany actions designed to remedy the causes of growth faltering. It has been used for many purposes - for example, to evaluate the effectiveness of other child nutrition interventions, to select beneficiaries for supplementation programmes, to estimate prevalence rates of underweight children in nutritional surveillance, to follow up the efficacy of treatment of sick or malnourished children, to trace children not attending or not returning to health centres for immunization, etc. (Lotfi 1988). In the Tamil Nadu Integrated Nutrition Programme (TINP), for example, growth monitoring is the criterion for both entry into and discharge from a supplementary feeding programme. The Iringa project in Tanzania is another successful example, which used child weighing both as a means to screen children for supplementary feeding and as a vehicle for maternal nutrition education.
The following definition from National Institute for Public Cooperation and Child Development, New Delhi (UNICEF 1987) clarifies the concept and its operational implications: “Growth monitoring and promotion is defined as an operational strategy for enabling the mother to visualize growth or lack of it, and to receive specific, relevant and practical guidance in ways that she, her family and community can act to ensure health and continued regular growth of the child.”
Where growth monitoring and promotion has not worked in the past, this may have been due to a lack of appreciation of its promotive nature (as opposed to curative), its utilization for behavioural change and its linkages with other nutrition-relevant activities. In many cases, subsidiary objectives overshadow the main purpose of growth monitoring. For example, growth charts may serve primarily as a record of a child's immunization history, or the dosages and dates of vitamin A capsules or iodized oil injections. The main objective of growth promotion can be attained through linking monitoring to the identification of at-risk children, individual counseling and appropriate subsequent actions to at least prevent further deterioration. The importance of frequent social interactions between health workers and mothers to facilitate this is evident in the relative success of small-scale programmes, where this is easier to achieve than in large-scale programmes. Particular attention needs to be paid to such aspects of implementation in the scaling-up of small-scale programmes.
Growth monitoring thus should be seen as an integrating tool, not an isolated activity. It is not an end in itself, but a start of a dialogue between the mother and health worker on appropriate actions to maintain healthy growth in a child or deal with growth faltering. It may be linked with such programmes as immunization, water and sanitation, oral rehydration therapy, income generation etc. and serve as an effective forum for behavioural change.
Health Services
Conventional Nutrition Interventions
Other Sectoral Actions
In this section, the various means available for operationalising or delivering the actions described above are outlined, with services being differentiated from programmes. First, we discuss the contribution of health services to nutritional improvement, as dealing with the malnutrition and infection complex clearly involves most of the activities of the health sector. It is also useful to define specific actions that can be channeled through the health services and enhance nutritional impact - similar perhaps to considering measures whereby food security contributions to nutrition may move ahead of economic development Such actions are not necessarily nutrition programmes as such, although they usually require collaboration between nutritionists and those responsible for planning and managing primary health care.
Secondly, we discuss the role of programmes in improving nutrition. These include free-standing 'nutrition interventions' and integrated health and nutrition interventions, which are often the responsibility of the health sector, although they may be successfully run, for example, by social services or specially established organizations. Much debate has occurred about whether such direct interventions are an appropriate and effective way of having a wide enough impact on nutrition to be significant Indeed, this debate continues: “... although nutrition programmes were often successful in narrow technical terms, they had not been effective, sustainable or widely reproducible at an acceptable cost...” (FAO 1989). Perhaps the question to ask is where - for which people - and when in the course of development are different types of nutrition programme most appropriate? The answer seems likely to lie between “never” - implied above - and “always”, which even the strongest advocate might hesitate to claim.
Finally, we briefly outline how other sectoral actions, such as those in urban development, housing, agriculture and education, can influence nutritional outcomes via their effects on the malnutrition-infection complex.
We may at this point need to pause to consider the roles of services and programmes in a developing country's attempts to reduce nutritional deprivation. At a certain stage of economic growth, direct nutrition interventions may be useful as an interim measure to nutritionally buffer vulnerable social groups, while poverty is tackled in the long-run. While economic growth and improved environment and services will be the eventual solution, doing nothing while waiting for this - many decades for a lot of countries by most projections - should be unacceptable. However, in some of the poorest areas of the poorest countries, with hardly any rural infrastructure or capability for service delivery, the very first priority may be to develop some kind of health care, communications, etc. with nutrition programmes of somewhat lower urgency. Policies aimed at improving household food security (agriculture, price, distribution, employment, credit), may also be less demanding on service-delivery systems, and possibly of greater priority for the poorest countries (see chapter 2). At the other end of the development spectrum, priority for nutrition programmes as such may tail off as countries industrialize, food becomes plentiful, and health care extensive. More developed economies can then move into establishing systems of social welfare and enacting legislation designed to provide safety nets. As suggested in chapter 1, such systems may ultimately be the major insurance against malnutrition.
The synergism between disease and malnutrition provides the essential reason for the health sector's major responsibility in addressing malnutrition. Health measures by themselves will not relieve all the underlying causes of malnutrition, so long as food entitlements are chronically inadequate, although food interventions may be delivered through the health services (see 'supplementary feeding' above). Effective health services are thus among the most important interventions for dealing with malnutrition. Many details are given in such documents as “The Role of the Health Sector in Food and Nutrition” (WHO 1981). Even in the absence of specific nutrition interventions, general health measures can have an important effect on nutritional status. For example, the incidence of gastro-intestinal infections and parasitic infestations can be significantly reduced by improved sanitation and provision of safe drinking water. Malaria control and immunization against six childhood diseases will reduce negative influences on nutritional status. Certain aspects of health services as they relate to nutrition are now being re-emphasised (see Tomkins and Watson 1989): for example, vitamin A delivery with immunization services; promoting feeding during diarrhoea, especially persistent diarrhoea; nutrition and respiratory tract infections; iron and malaria.
Irrespective of nutritional considerations, basic levels of health care (preventive and disease management) are always necessary. When the outreach and support of health services is minimal, such as in the poorest African countries, it has been argued that selection of priority health measures is required. The argument for selective primary health care was put forward by Walsh and Warren (1979), and is related to the thrust for oral rehydration and immunization as top priorities. On the other hand there is the institution-building approach, which uses the primary health care concept developed at Alma-Ata (Mahler 1981) and envisages a much wider package of health measures, including nutrition. The priority in this case would be to build the capability and infrastructure before progressively extending health services at community level throughout the population.
Focusing on selected interventions such as ORT saves lives - unarguably desirable - but does not directly cut into the cycle of malnutrition and infection. Consequences other than immediate mortality, particularly continued depressed immunity (hence future morbidity and mortality) are not affected. Similarly, developmental disadvantages are not reversed. In practice, emphasis on selected interventions such as ORT, if delivered campaign-style, not only crowd out other interventions, but can actually damage the institutional capability. It has been observed that everything else gets dropped in favour of the current priority, so facilities, supplies, training, and motivation for other interventions actually deteriorate. To this extent there is a risk that selected interventions have a residual negative effect. A nutritional perspective would argue more for a longer-term broader institution-building approach to primary health care - one that fully recognises, and aims to deal with, the synergisms between malnutrition and infection.
Health services 'intensity' may be important i.e. there may be a certain minimum threshold of health services development at which an impact (on health or nutrition) begins to be seen, in other words that the response is non-linear (see, for example, Habicht et al. 1984; Drake et al., 1980; Heaver 1989). A similar consideration is likely to apply to nutrition programmes, whereby an annual expenditure of about US $10-30 per beneficiary appears to be of the order required for a programme sufficiently large to have a potential impact (see later section on programme costs).
It is also likely to be the case that there is a certain point in health services' development at which it becomes possible to begin to introduce extra nutrition actions. If so, the aim would be to invest in basic services and infrastructure so as to raise the input to above this threshold level, before extending outreach or adding new activities. The level of health expenditure currently observed in developing countries is informative in this regard. Many countries have annual health budgets of under $2 per person per year (see, for example, India, Pakistan, Indonesia and Nigeria in Table 1.2, chapter 1; also Chandler 1984). A major priority in these countries will be to build health infrastructure.
Nonetheless, some experiences of successful delivery of health care on very low budgets have indicated factors important for success. Experiences have been reviewed in China, Sri Lanka, Kerala (India), Costa Rica, Chile and Cuba, where marked health improvements occurred despite moderate to low per capita income (Halstead et al. 1985; Horwitz 1987). These are countries (or states) which have shown firm commitments to public support during their economic growth. Costa Rica illustrates the degree of positive nutritional impact a comprehensive, adequately funded and managed health care system can have (see box).
Nutrition actions within the health services
Nutrition has certain contributions to make to the prevention and management of specific diseases through actions which can be incorporated within a country's health services. For example, persistent diarrhoea has a higher mortality per episode than acute diarrhoea - not from dehydration but from debilitation - and maintaining adequate dietary intake is thus crucial to management As rehydration is often not the major issue, oral rehydration therapy (ORT) is not the answer. A number of other important opportunities for nutrition actions in relation to prevention and management of disease have been laid out in “Malnutrition and Infection” published by the ACC/SCN; the introduction summarizes the operational implications, and the review by Tomkins and Watson (1989) gives the scientific background and details some important nutritional contributions as summarized here:
- exclusive breastfeeding related to prevention of diarrhoea in children up to 4 - 6 months of age;- continued breastfeeding for management of diarrhoea;
- adequate feeding during persistent diarrhoea, and in convalescence;
- micronutrient prophylaxis;
- vitamin A and measles, both in prevention and treatment;
- supplementary feeding and measles, to reduce severity and in post-measles recuperation;
- respiratory tract infections, breastfeeding, vitamin A and supplementary feeding;
- intestinal parasites and supplementary feeding.
These actions are being increasingly incorporated in the advice given at international level, for example by WHO. The extent to which they are operationalized in country programmes is not yet known to us. It seems reasonable that an essential move in addressing malnutrition-infection, at a minimum, perhaps before more extensive efforts to promote nutrition programmes, would be to vigorously promote such actions within the health sector. This is elaborated in chapter 5.
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Health Care in Costa Rica Context; About half of the population of 2.8 million (1987) live in rural areas, the climate is tropical in the coastal lowlands and temperate in the highlands. During the 1980s, political conditions were stable. Main issues facing the new government in 1982 were a domestic economic crisis and tensions arising from civil strife in the region. The years 1979-1980 marked the beginning of the crisis, with recession, inflation, unemployment and drastic devaluation of the national currency. Most Latin American countries experienced similar economic difficulties, but the effect was particularly severe in Costa Rica. The rising cost of petroleum and the declining coffee prices eroded the balance of foreign trade to a point where the external debt amounted to more than 10 per cent of GDP in 1982, the third highest in Latin America. At the same time, inflation rose from 9.2 per cent in 1979 to 37.1 per cent in 1981 and 90.1 per cent in 1982, also the third highest in Latin America. During 1980-1982, the annual per capita GNP growth rates were negative. The effects of inflation during this time were shown in the increases from 40% to 60% of households spending at least 50% income on food. Once inflation was under control in 1985, this dropped to 37%. There is some evidence that the adverse trend had slowed down by 1982-83, with relative stabilisation of the currency and some control of inflation. In 1986, a commitment was made to increase social investment, particularly in housing and employment-generation, although this came partly at the expense of other social programmes. During the 1980s, total food availability from all sources rose slowly despite declines since 1985 in cereal availability. In 1985, the government embarked on a programme of export promotion and import substitution which led to increases in exports of coffee and sugar contributing to foreign exchange earnings and a balanced trade account. Debt service requirements in the mid-1980s, however, were very high; in 1983, for example, more than 50% foreign exchange earnings were being used to service debt. Health and Nutrition: In the 1970s, health indices in Costa Rica approached those of some advanced industrialised nations, defying the orthodox concept (as in Sri Lanka and Kerala (see Halstead et al (eds) 1985)) that it is necessary to attain economic and industrial development in order to improve the health conditions of a society. The likely determinants of this rapid improvement, according to Mata and Rosero (1988) were: i) emphasis by all administrations on social rather than economic development, ii) improved environmental sanitation, housing and income, iii) emphasis on education without sex discrimination, iv) extension of primary health services to most of the rural areas, v) adoption of health and medical technologies to tackle the main health problems, and vi) intersectoral action in planning and executing health programmes. These elements were brought together through more than 100 years of historic evolution, during which time education, democracy, observation of human rights, and peace were fostered. The absence of a military establishment has prevented the concentration of power and released substantial resources for education and health - now budgetary priorities in Costa Rica. The basic primary health care instruments were the rural health programme (begun in 1973) and the community health programme (1976). By 1980, 60 per cent of the population had been reached by domiciliary services in both rural and urban areas. Immunisation campaigns against measles, diptheria, pertussis and tetanus were important. Sanitation activities (provision of potable water and sewage disposal) in rural areas were intensified, and community participation in health programmes encouraged. The nutritional status of women and children did not deteriorate during the economic crisis in 1979, due, many believe, to the decades of investment in health and education (Mata and Rosero 1988). In a study by Rosero-Bixby (1986), health interventions were singled out as the main determinant of the marked fall in the infant mortality rate during the 1970s (from 67/1000 in 1970 to 21/1000 in 1980). Multiple correlation analyses suggest that up to 75% of the fall was a result of health programmes in general, and around 40% of the decline was due to primary health care. Furthermore, because less-privileged sub-populations were targeted, primary care reduced the differentials that prevailed in child mortality. The total percentage of GNP invested in health remained high
in the early 1980s, and even tended to increase despite the deterioration of
some services. This contradiction was due to continued heavy investment in the
school lunch and food distribution programmes which have been criticised as
being overly developed, with a low benefit-cost ratio (Mata 1978) and
inefficient due to minimal targeting (Selowsky 1991). The whole concept of
supplementary feeding in a country like Costa Rica may be obselete, as there is
no evidence of food shortage, even during times of crisis. Rather, “when
(growth failure) is confined to infants and young children....the primary causal
role is infection and social pathology rather than inadequate food supply”
(Mata 1982). Selowsky (1991) believes that the large fraction of governmental
health expenditure going to such feeding programmes with little targeting could
be better directed to those better targeted - like those delivered by Nutrition
Centers to reduce severe malnutrition - which currently receive a small share of
resources. |
Integrated health and nutrition interventions
Programme costs
'Nutrition interventions' in practice have generally included one or a combination of food supplements, growth monitoring, micronutrients distribution, promotion of home gardens, health and nutrition education and family planning technology and information. Figure 3.2 shows the frequency of types of activity to improve nutrition, based on a review of 15 large-scale nutrition programmes, reported at the ACC/SCN workshop at the IUNS Congress in Seoul, Korea in August 1989 (see ACC/SCN 1991).
Nutrition interventions are usually explicitly designed to deal with at least one of the necessary conditions for adequate nutrition i.e. household food security, infectious disease control and caring capacity. As such the term 'nutrition intervention/programme' may not be sufficiently descriptive for this analysis. Here each component is described as it logically relates to each condition e.g. home gardens in chapter 2 (household food security), supplementary feeding, growth monitoring and promotion and health-related services in this chapter (infectious disease control) and nutrition education in chapter 4 (caring capacity). It may be argued that supplementary feeding is a household food security initiative, or that growth monitoring and promotion relates more directly to caring capacity. This only emphasizes that effects on nutrition (as the outcome of concern) may be achieved via effects on more than one of the necessary conditions.
Figure 3.2: Typical Components of Nutrition Programmes in 15 Examples
|
Component |
Number |
Frequency (%) |
|
Nutrition education |
14 |
93 |
|
Health-related services |
11 |
73 |
|
Supplementary feeding |
12 |
80 |
|
Growth monitoring |
10 |
67 |
|
Micronutrient supplementation |
4 |
27 |
|
Home gardens |
3 |
20 |
The synergistic relationship between nutrition and infection has important implications also for the integration of nutrition and health interventions. Food is usually a necessary but insufficient component of any nutrition intervention - additional health services will involve additional costs, but are likely to increase nutritional impact. Anorexia brought on by chronic morbidity in children may result in their refusing to eat offered food and so an appropriate intervention will usually need to include elements of disease control as well as feeding. Moreover, the recognition of the linkages between the process of growth failure in children and constraints - both food and health-related - of the environment has obvious implications for integration. Many health and nutrition activities are thus compatible and mutually enhancing in their effectiveness and a greater efficiency of service delivery may be achieved through integration.
Integrated health and nutrition interventions may include diarrhoeal disease control, breastfeeding promotion, feeding programmes, vitamin and mineral supplementation, nutrition education and immunization against the six communicable diseases. The distribution of iron tablets to all pregnant mothers and capsules of high-dosage vitamin A to children in order to prevent anaemia and xerophthalmia, respectively, are clear examples.
Integrated health and nutrition programmes may be run through the health services or be free-standing. Channeling extra actions through the health services may be demanding on administrative and institutional capabilities, especially where the nutritional component involves food distribution. Problems of health service outreach and infrastructure development will also limit nutrition interventions channeled through the system. The coverage of the population by health services has often been inadequate, with groups in greatest need often having the poorest services. As mentioned above, there may also need to be a minimum threshold of basic infrastructure for the delivery of health services after which an impact (on health or nutrition) begins to be seen. These considerations may explain some of the disappointing results of delivering nutrition interventions through the health system in the past. Nutrition interventions also risk overloading the health services and in any event could divert resources from the possibly greater priority of raising investment above threshold levels where services exist before extending infrastructure. Once this stage has been reached, may be the time to consider channeling nutrition interventions through the health sector. Where the health services are less developed, other approaches to reach the nutritionally vulnerable may need to be sought, as for example with Tamil Nadu Integrated Nutrition Programme (TINP) in India - a successful integrated health and nutrition programme which is not channeled through the health sector.
Integrated nutrition and health interventions in India, for example, have generally included one or a combination of food supplements, health care, health and nutrition education, and family planning technology and information. The first component dominated public policy during the 1950s and 1960s in India, when supplementary feeding programmes of various kinds were introduced. In 1959, the Applied Nutrition Programme was initiated for pre-school children and pregnant women. This was followed by school lunch programmes for improving school attendance as well as child nutrition. A modicum of geographical targetting was introduced under the Special Nutrition Programme in 1970-71 which aimed at providing food to children below six years, and to expectant and nursing mothers living in urban slums and tribal areas. During the mid 1970s, in addition to interventions, such as the Integrated Child Development Services (ICDS), described below, health interventions such as prophylaxis against Vitamin A deficiency, nutritional anaemia and endemic goitre were also introduced. The ICDS and TINP programmes are described in the boxes.
Many free-standing nutrition programmes are too small-scale to have a major impact upon total communities or countries. If they were to expand to a point where they could exert a significant impact, objectives would need to be further defined. For example, are such programmes to be used as a means of redistribution of effective income/demand (with the household or community as target), or are they to be designed to improve the nutritional status of targeted high-risk individuals? The design of the programme should relate to the type of problem. For example, is it primarily health- or food-related? If the latter, is it calories or micronutrients that are deficient; for whom and when? At what time are targeted individuals actually responsive to the intervention? Time-bound objectives should focus on a few critical needs; management should be facilitated by a strong component for regular training; realistic staff-to-client and supervision ratios need to be set, and periodic re-appraisal undertaken on the basis of the results of monitoring and evaluation. Permeating all this, there needs to be a high level of active community involvement, borne from an accurate assessment of local needs at the problem definition stage along with appropriate subsequent training. The overall effectiveness of a programme, that has been seen to be successful on a small-scale, will depend on its coverage of families or individuals relative to the total numbers in need in any one country. Sustainability then is important, particularly as individuals may become worse off following abrupt termination of an intervention, due to their inability to reestablish previous states of environmental adaptation.
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Integrated Child Development Services (ICDS), India This is mainly a health intervention which adopts a holistic approach aimed at improving both the pre-natal and post-natal environment of the child. It is a Centrally-sponsored, State-administered scheme consisting of maternal health care in pregnancy and growth monitoring and nutritional supplements for children - services received at community centres or anganwadis. The nodal department may be Social Welfare, Women and Child Development, Rural Development or Health, depending on the state. Health departments have responsibility for the health component. Its objectives are: · To improve the nutrition and health status of children aged 0-6 years. Programme components: · Supplementary Nutrition is provided to 0-6 year olds and pregnant and lactating women. The “most needy and malnourished” are selected as beneficiaries. Women belonging to families of landless labourers, marginal farmers, scheduled castes or tribes, or very low income groups, or requiring feeding on health grounds are selected. Children are enlisted on the basis of mid-upper-arm circumference (MUAC) under 13.5 cms and weight-for-age (Grade II and below) measurements. Moderately malnourished children receive a food ration of 300 kcals and 8-10 grams protein per day for 300 days in the year, while severely malnourished children receive twice this amount. Pregnant/lactating women receive 500 kcals and 20-25 grams protein from the third trimester of pregnancy up to six months of lactation. Ready-to-eat supplements are used in some areas, while in others locally available cereals are cooked and fed on site. Children aged 1 - 5 are also given six-monthly doses of vitamin A (200,000 IV). Iron supplements are provided for 100 day periods based on an assessment of need by the Auxiliary Nurse Midwife (ANM). Children receive daily doses of 20 mg iron +0.1 mg folate, while pregnant/lactating women receive 50 mg iron + 0.5 mg folate. In theory then ICDS targets regionally and individually
according to criteria of need, although, according to Subbarao (1989), there has
been little of the latter, with the objective of reaching the malnourished being
sought through a judicious location of projects, rather than beneficiary
selection following nutritional screening. This mismatch between the
distribution of severely malnourished children and those receiving ICDS services
is accentuated in some states by long delays in operationalising sanctioned
projects. Its overall coverage in 1985-86 was found to be low (only 1.5 million
mothers and 6.5 million children in 1985-86), and its focus on anganwadis often
excluded the poorest who cannot dress their children suitably for attendance
(Clay et al. 1988). Hundreds of impact studies of the ICDS have been carried out
since its inception in 1975, though, according to Sharma (1987) “the
integrated package has been studied in a disintegrated manner”, and the
findings are often conflicting. Subbarao sums up his recent review of these
studies by saying that the ICDS “undoubtedly (has) immense potential for
reducing malnutrition in India”, but that at present (1989) it suffers from
weaknesses in the targeting of beneficiaries, the recruitment and training of
core workers and eliciting community participation. |
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Tamil Nadu Integrated Nutrition Programme (TINP) TINP started in October, 1980 and is implemented by the Government of Tamil Nadu/Department of Social Welfare and TINP Project Coordinator's Office, with external support from the World Bank. In 1989, TINP covered 9000 villages (total population over 10 million), in 6 districts of Tamil Nadu with the lowest per capita calorie consumption. TINP was developed within an administrative structure that was already strong. The infrastructure for nutrition service delivery was set up by recruiting, training and deploying a community worker in each of the 9000 villages, as well as instructors, supervisors and nutrition officers who supported the system. TINP's overall objectives are to reduce malnutrition and consequent high mortality in children under-three, and to improve their health and nutritional status and that of pregnant and lactating women. Its operational objectives are: · Nutrition surveillance through regular growth monitoring of all children in the age group 6-36 months; Programme components: · Nutrition services delivery formed the core of TINP I. A Community Nutrition Centre was established in each village (population 1500) and run by a Community Nutrition Worker (CNW). The CNW surveyed all households in the area (survey updated every quarter) and registered target children in the age group 6-36 months. These children were weighed each month and their weights plotted on growth charts to determine their nutritional status on a weight-for-age basis and to monitor their growth. Children determined to be at risk (i.e. with Grade III/IV severe malnutrition, or showing signs of growth faltering - losing weight, failing to gain weight or showing inadequate weight gain between successive weighings) were admitted to a short term supplementary feeding programme. Pregnant women were also selectively fed. The CNW administered Vitamin A prophylaxis to all children, along with deworming treatment. Iron and folic add was distributed to pregnant/lactating women. Monthly weighing sessions also provided workers the opportunity to check on the children's health needs (e.g. immunisation, management of diarrhoeal episodes) and to educate mothers. The annual per capita cost has been estimated as US $0.81
compared with US $1.49 for comparable services in the state in the ICDS (Berg
1987). This relatively low unit cost is largely due to its participative nature
(with a cadre of trained female para-professionals). Moreover, as the programme
starts to improve the nutritional status of participants, annual food costs
decline. On average, ICDS weighs fewer children per post (43 compared to 60),
but feeds relatively more of them at any given time (100 per cent against 27 per
cent for TINP) since everyone who is weighed is fed. Despite the lower direct
costs, primarily the result of proportionately fewer children being eligible for
feeding, TINP appears to have had a greater impact on child nutritional status.
Mid-term evaluations showed that severe malnutrition had been reduced from 15-20
per cent to 8-9 per cent over 4 years (Subbarao 1989) and, unlike in ICDS, which
achieved reductions in severe malnutrition of 20-25 per cent in the same period,
such progressive reductions were noted in every project area. The three main
qualitative differences between the ICDS and TINP relate to the coverage of
beneficiaries, the involvement of mothers and the recruitment and supervision of
workers. The TINP is seen by the World Bank as an example of how freestanding
nutrition projects should be narrowly focused and “consisting of no more
than three or four well-integrated nutrition interventions that (do) not require
extensive managerial skills” (Berg 1987). |
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Features of Successful Nutrition Programmes A recent source of information on large-scale nutrition programmes in operation is the ACC/SCN Nutrition Policy Discussion Paper No. 8 “Managing Successful Nutrition Programmes” (ACC/SCN 1991) which emerged from a workshop held at the IUNS Congress in Korea, August 1989. Rather than re-iterating the detailed characteristics of these programmes, we will summarise some of the features found to have related to their success: Objectives Achievable time-bound objectives should be set in programme design, and subsequently determine the implementation and evaluation of the programme. One outcome of Berg's (1987) review of several World Bank-funded nutrition interventions - in Brazil, Colombia, Indonesia and India - pointed to the need for limiting the number of project components and focusing actions on a few critical needs, recognizing that these are likely to cut across sectors. The choice of intervention should be based on a careful analysis of the actual problem - for example, supplementary feeding programmes will have little impact where ill-health is mainly related to environmental conditions. |
Certainly, no matter how effective these programmes might be, they should be affordable and within the means of governments in countries where implementation is intended. This is crucially important if these efforts are to be sustained after external assistance - if in place - has been withdrawn.
Cost assessment is perhaps one of the most difficult aspects of any programme evaluation. There are always hidden expenditures, like cost to the beneficiary e.g. time spent travelling and waiting in the line. Theoretically, costs to the beneficiary using the services should be set against the costs the beneficiary has saved through participation in an effective intervention. Examples are having a better pregnancy and lactation outcome, having a healthier child, less episodes of disease in the family, use of knowledge gained in the areas of nutrition and health for siblings not in the programme, or benefits for the family as a whole.
The problem of cost comparing of different programmes is not only related to the variations in their objectives, components or size, but also to differences in the whole context and environment in which these have been implemented. Cross-project comparisons are therefore complex.
In fact, costs or related data are seldom addressed in individual nutrition programme reports. Where data are available, cost components (food and non-food costs, management costs, etc.) have often not been distinguished clearly. Total costs, even when reported, have limited value by themselves. Frequently the cost of reaching an individual using the provided services (cost per beneficiary or recipient per year) is calculated (see Table 3.2), and this provides for some standardization for comparative purposes, although there are a number of limitations. First, it does not reflect the quality of services provided, nor does it show whether the programme has had any impact on the recipients. In the Tamil Nadu Integrated Nutrition Project (TINP), the cost/child in the programme fell by 19% between 1982 and 1985. Here, from the cost per beneficiary value alone, it is not clear whether this has been due to a change in coverage, or that fewer children required the rehabilitation feeding as a result of the programme's positive impact on the recipients (as was in fact the case). Second, it is not known how many of the beneficiaries were in fact those targeted. Third, there is a trade-off between close targeting to those who will respond (e.g. the most underweight in a feeding programme), the costs of this targeting, and the lowered effectiveness if many non-responders are included among the beneficiaries. For this reason, in many supplementary feeding programmes the cost per individual enrolled in the programme has been several times lower than the cost calculated for those actually having been helped by the programme.
Previous reviews of nutrition programmes have tried to estimate costs-per-beneficiary, as well as per-caput, in project areas. We will focus on the former. In one review (Beaton and Ghassemi, 1982) it has been calculated that generally the annual cost of providing 300-400 kcal/day would range from $15 to $25 per child (1976 US$ equivalent). The reviewers noted that the cost would be different for different types of food distribution. Another review (Anderson et al. 1981) has reported a somewhat wider range: $10-30/year per child fed in take-home and on-site feeding programmes. A third review (Kennedy and Alderman 1989) has shown the difference in the costs of delivering a certain number of calories, citing examples from two programmes in the Philippines. The average cost of the Mother and Child Health Programme ($ 31/beneficiary) was higher than the cost of the School Feeding Programme ($12/beneficiary). Yet in terms of the delivery of 1000 kcal., the former programme becomes cheaper than the latter ($0.25 versus $0.43 per 1000 kcals).
In the community-based Iringa programme in Tanzania (JNSP 1989), the total cost of $17 per beneficiary was divided into i) start-up cost ($3.6), ii) expansion cost ($5.3) and iii) ongoing cost ($8.05). Such disaggregations are helpful as, for example, the degree of financial sustainability could be proxied by the latter figure.
In the Philippines Food Subsidy Scheme (see chapter 2), 84% of the cost was the subsidy itself, 9% was administrative with 7% being an incentive payment to retailers to ensure efficient food distribution. The fiscal cost of each $1.00 transferred to participating households was $1.19, or, if only transfers to malnourished preschoolers are considered a benefit, the cost increases to $3.61. Cost-effectiveness is thought to be favourable. Costs were low because, first, geographical targeting based on growth monitoring costs less than targeting based on household income levels; second, the use of existing private sector retail outlets for the distribution of subsidized foods costs less than a separate distribution network; and third, the use and expansion of existing local bureaucratic structures cost less than the creation of a new and independent structure.
Seven out of the ten pilot nutrition and health interventions reviewed by Gwatkin et al. (1980) had reported cost values, although cost per person in the project area could not always be distinguished from cost per beneficiary. In all the seven projects discussed, nutritional services were complemented by health measures, with the exception of project in Etimesgut, Turkey, where services were predominantly medical support and family planning. The annual per capita population costs of these projects ranged from $0.8 to $7.5 or approximately 0.5-2.0 per cent of the annual per capita GNPs of the countries concerned for the year to which the costs in each instance refer. This is similar to the levels of governmental health expenditure in many developing countries (see Table 1.2).
Nutrition education programmes are among the least expensive. For example, the Indonesian Nutrition Education Programme cost only $4 per beneficiary per year initially, decreasing to $2 during expansion (Berg, 1987). These calculations did not include food provision, but when food cost was added the total cost came to around $11/beneficiary/year (Yee and Zerfas, 1987). The Indonesian weighing and feeding programme (NIPP), at $56/beneficiary/year, was much more expensive. The annual costs of weaning education in six countries were found (Ashworth and Feachem 1985) to fall in the range of $2-10 per participating child per year, although these costs are not directly comparable, due to differences in programme design and methods of cost calculations. It was concluded, however, that weaning education may be an economically attractive diarrhoeal control measure in some countries.
The cost of micronutrient deficiency control programmes has been estimated as very low compared to the dramatic benefits usually obtained. The cost is mainly related to delivery, rather than supplies, which in turn depends on targeting strategies and availability of services. For vitamin A capsules, the costs have been estimated as 2 cents/beneficiary/year. This would be increased to 20 cents for capsule dose taken (West and Sommer 1987). Salt iodization from the experience in S.E. Asia cost 5 cents/beneficiary/year, while intramuscular oil injection is reported to cost twice this figure from such programmes in Zaire and Nepal (Hetzel 1988). Fortification of salt with iron costs 5-9 cents/beneficiary/year, and that of centrally processed grain products with vitamins and minerals would cost about 8 cents/person/year (Berg 1987, p. 116).
Annual cost per beneficiary estimates available for several nutrition programmes are summarized in Figure 3.3. An important factor explaining the differences between amounts is whether or not food (or feeding) costs are included. Generally, the health and education programmes have the lowest cost/beneficiary/year, although these are less directed toward malnutrition. Overall, the amounts are in line with - if somewhat higher than - those calculated from previous studies of smaller-scale projects. But they tend to confirm that the range of US $10-30 per beneficiary per year is around that needed for programmes with sufficient scale to be likely to have a positive effect The expected relationship between expenditure and effects is usually non-linear (Habicht et al. 1984). US $10-30 may approximate the minimum level necessary to begin to affect nutrition. One conclusion from this is that it has to be considered worth sustaining an expenditure of about this magnitude if direct nutrition programmes are to be undertaken.
Figure 33: Comparing costs per beneficiary (US $) for selected programmes
|
Project/country |
Main programme components |
Cost per beneficiary (US $) |
Notes and sources |
|
Drought Relief Programme/Botswana |
Direct feeding |
7 |
1985, direct feeding programme |
|
38 |
1985, for all programmes. Quoted from Quinn, et al. (1988) |
||
|
National Nutrition and Holistic Care Programme/Costa Rica |
Preschool and school feeding |
21 |
1982, quoted from (ACC/SCN 1991) |
|
Health and Social Development Programme/Costa Rica |
Health services |
2 |
1982 |
|
3 |
1983 (see ACC/SCN 1991) |
||
|
Institutional Support for Health and Nutrition/The Gambia |
Growth monitoring |
55 |
ACC/SCN 1991 |
|
Tamil Nadu Integrated Nutrition Programme (TINP)/India |
Growth monitoring |
9 |
Overall cost |
|
7 |
Weighing-screening |
||
|
12 |
Weighing-feeding (Berg 1987) |
||
|
Integrated Child Development Services (ICDS)/India |
Growth monitoring |
7.5 |
Not including food (ACC/SCN 1991) |
|
Family Nutrition Improvement (UPGK)/Indonesia |
Growth monitoring |
2 |
Weighing |
|
11 |
Weighing and feeding. Quoted from Yee and Zerfas (1987) |
||
|
Pilot Food Price Subsidy Scheme/The Philippines |
Consumer food subsidy |
9 |
1984, quoted from Garcia and Pinstrup-Andersen (1987) |
|
Joint WHO/UNICEF Nutrition Support Programme/Iringa, Tanzania |
Growth monitoring |
8 |
Recurrent costs |
|
17 |
Total costs. (JNSP Evaluation Report, 1989) |
Finally, the prevention and control of infectious disease often requires substantial inputs from sectors other than health to be effective. The priorities of those sectors may not be compatible with those of the health sector in terms of nature, area, targeting or timing. Physical planning and housing policies, for example, determine the adequacy of the physical (and often social) environment and the degree of overcrowding. The redevelopment of urban slums is a costly and sometimes disruptive process, and the extension of water and sanitation to temporary settlements often conflicts with longer term plans for permanent developments.
Malnutrition in preschool age children may adversely affect subsequent school performance - an important linkage fully described in a statement made at the 16th Session of the ACC/SCN (ACC/SCN 1990c). Adverse effects of malnutrition may be manifested through school enrolment, aptitudes, time spent in school, (i.e. attendance, drop-out rates) and achievement. Severe nutritional problems (e.g. cretinism, blindness due to xerophthalmia, marasmus), as well as mild and moderate forms of these deficiencies, are known to be important factors contributing to the educational problems facing developing countries. This should be a strong enough reason for the education sector to invest in nutritional improvements of young children. Moreover, school age children cannot often compete with the pre-school child for health sector resources, and may thus be neglected. The statement goes on to suggest activities the education sector can initiate to combat childhood malnutrition and thus invest in human capital: “School feeding programmes may also contribute to the correction of specific nutrient deficiencies and short term hunger. Vitamin and mineral supplements may be required. Efforts should also be included to combat parasitic diseases when appropriate. In general, feeding and health programmes should be so placed that they facilitate unconstrained growth and development throughout the school age period, including meeting the special needs of adolescents”.
Agricultural policies may have important implications for nutrition, not only through household food security, but also via their effects on health factors. Changes in agricultural patterns resulting in greater involvement of women and children can affect health care and exposure to infectious diseases (e.g. malaria, hookworm). Irrigation schemes, for example, can markedly extend the distribution of schistosomiasis. In an important WHO publication, Lipton and de Kadt (1988) described the linkages between agriculture and health and their implications for the adoption of an agriculturally-based strategy as one route to “health for all”. The energy costs of agricultural labour and searching for work, labour hazards (e.g. pesticides, machinery, back injury), women's trade-off between agricultural and domestic work (see chapter 4) and the seasonal co-incidence of high labour demands, peak disease exposure and food shortages, are all immediate examples of linkages between agriculture and health. There are also major feedback effects: healthier workers are often more productive and may earn more; a family's health security (or lack of vulnerability) may allow for more experimentation with crops and methods; the lack of adequate health care may be one factor promoting rural emigration.
