PROGRAMME NEWS - Progress around the world

SCN News publishes reports received on programmes from international organizations concerned with nutrition - please send us information you would like others to know, and we will try to include it.

DHA (UN Department of Humanitarian Affairs)

United Nations International Emergency Network

In a joint venture with other UN Agencies, Intergovernmental and Non-Governmental Organizations, DHA, Geneva is supervising UNIENET - the United Nations International Emergency Network.

UNIENET is a network of computers linked together electronically which places members of the world-wide disaster management community in direct contact with each other, and provides them instantaneously with both background and operational disaster-related information. Services provided by UNIENET include “electronic mail” - which allows exchange of messages by computer with others having an interest in disaster management - and bulletin boards and databases of disaster-related information. It is possible to send telexes and faxes via the network as well as to access commercial databases.

Electronic-mail is less expensive than an overseas phone call or telex, much faster than the latter, and unlike a telephone conversation, the text of the message is available for later reference.

In order to use UNIENET, either a computer terminal connected to the UN International Computing Centre in Geneva is required, or a personal computer with communications capability: communications software, a modem, a telephone line, and access to “packet switching” - a special high speed telephone connection between computers, available from most telephone companies.

Any organization or individual dealing with disaster management and needing the information or communication facilities provided by the network can apply for access to UNIENET.

There are two types of charges:

1) Telecommunications. Most telephone companies charge between US$4 and US$12 per hour for the connection to UNIENET.

2) Computer access. Basic access (use of Email, bulletin boards, and UNIENET databases) is US$9 per hour during the day (NY Time) and US$5 per hour at night, plus US$0.05 per 1000 characters transmitted. Additional features such as telex and fax transmission, access to commercial databases, and storage of files carry surcharges.

(Source and contact for further information: DHA, Palais des Nations, 1211 Geneva 10, Switzerland. Tel: (41 22) 917 2661 Fax: (41 22) 917 0023)

“It isn't just that the software is outdated. Now the beads are stuck.”

FAO

Linking Food, Population and Nutrition Issues in Agricultural and Rural Development

The rate of population growth has declined in many developing countries during the 1970s and 80s. However, despite the decreases, growth rates in different sectors such as food production, health and education have not been able to catch up with the rate of population growth in many countries of Africa, Asia, Latin America and the Near East. This is reflected, to a large extent, in continuing high rates of malnutrition affecting children under five years of age in many poor countries.

Protein-energy malnutrition is recognised as a multi-causal problem, of which poverty is one of the main contributory factors. In order to solve the problem of malnutrition, different interventions such as poverty alleviation, and economic and agricultural development are necessary. As these are long-term programmes, complementary action is required to address those factors which can bring about change more swiftly, and support the longer term goals. These include, educating people on the advantages of smaller and healthier families, promoting the production of nutritious foods and better eating habits, in addition to adopting sound environmental practices.

A five-year training programme to raise awareness of these issues among professionals and field workers from different sectors such as agriculture and rural development, education, population and health is being carried out by the Food Policy and Nutrition Division of FAO in Africa, Asia, Latin America, and the Near East, with financial assistance from the Government of the Netherlands. The main activity of the programme concerns training on the relationship between food, nutrition, and population.

For this training programme, FAO makes use of training materials on population and nutrition prepared, published and tested with financial assistance from the Government of the Netherlands as part of an earlier project. The training materials are supplements to existing materials, viz: Field Programme Management: Food and Nutrition; and Food, Nutrition and Agriculture, both of which have been published in different languages. The materials have been designed for use in formal (i.e. diploma and higher level training) and in non-formal (i.e. field worker or certificate level training), pre-service and in-service training courses, respectively.

The training materials on population and nutrition are:

1. Population and Nutrition. Version for Africa. (Supplement A to the training pack on Field Programme Management: Food and Nutrition). Languages: English, French, Spanish and Arabic.

2. Population and Nutrition. Different versions for Asia, Africa, and Latin America. Supplement to Curriculum Guidelines on Food, Nutrition and Agriculture and to the teaching pack Food, Nutrition and Agriculture (i.e. the textbook, teacher's manual and student's workbook). Languages: English, French, Spanish, and Arabic.

One of the main objectives of the project is to make population education and nutrition a regular component of training activities in pre- and in-service training of agriculturists, rural development workers and other field staff. It is anticipated that particularly through field worker training on population and nutrition, information on this important issue will be disseminated among rural populations, and thus contribute towards a change in fertility behaviour and improvements in nutrition.

(Source: FAO, 1992)

Body Mass Index: Promising Perspectives for its Use

The nutritional status of a population is reflected in part by the anthropometry of its individuals. Although these data can include variables such as height, weight, skinfold thickness at various points of the body, and arm and head circumferences, data on body height, and weight in particular are easy and inexpensive to collect. When carefully analyzed with other single variables (e.g. demographic, socio-economic, or geographic variables) they can provide substantial information on the nutritional situation of the population. Any biological or nutritional assessment remains incomplete and impoverished by the absence of data on height and weight.

Heights and weights of children, particularly those less than 5 or 6 years of age, and pregnant or lactating women, are accepted measures for monitoring their growth and nutritional status, and are also considered as an indicator of the nutritional status of the entire community. But children, and pregnant and lactating mothers are considered vulnerable groups because they are sensitive to nutritional problems, especially in a poor socio-economic or sanitary environment. When the assessment of the nutritional situation of a population does not include all population groups, and concentrates on only specific groups, there is a major risk of biased conclusions.

Although FAO has been advocating the collection and analysis of adult anthropometry for the past twenty years, this activity only received momentum from the IDECG meeting in Guatemala City from 3-7 August, 1987, on “Chronic Energy Deficiency: Consequences and Related Issues”. The subsequent working group convened to determine an operational definition of Chronic Energy Deficiency. Over the past three years FAO has been investigating the functional consequences of Body Mass Index or Quetelet Index (BMI = Wt/Ht²) for assessing the nutritional situation of population. BMI has been extensively adopted as a graduated indicator of obesity and risk of mortality, particularly by life insurance companies. However, little use has been made of the BMI scale as a reflector of the health and nutritional status of a population.

Jointly with the Rowett Research Institute in Aberdeen, Scotland, and a number of institutions in the developing world, FAO has noted a number of interesting consequences associated with low BMI. Results are preliminary and any conclusions must be interpreted with caution, but low adult body weight does have a negative influence on the capacity to work and is also highly correlated with periods of illness and low physical activity. In addition FAO is pursuing the possible use of the BMI as a simple indicator of nutritional well-being in a community.

A Rowett report to FAO prepared in July 1991 attracted much interest and comments, and an expanded version of this report was scheduled for publication in 1992. IDECG was one of the principal groups attaching importance to this report and, at the February 1992 ACC/SCN meeting in Rome, gave its full endorsement to the continuation of the work. An informal meeting, hosted by FAO in collaboration with WHO, UNU, IDECG and Rowett Research Institute, on the functional consequences of low BMI was held in November 1992.

Among the topics which were addressed were:

- Relationships of BMI and illness
- BMI thresholds for males and females
- BMI and housing/socio-economic conditions
- BMI and seasonably
- BMI and pregnancy
- BMI and staple foods/types of diet
- BMI of mothers vs. nutritional status of under-5 children
- Use of BMI for monitoring impact of socio-economic changes on nutritional status.

Selection of Candidates for Assistance Programmes

The Food Policy and Nutrition Division of FAO in cooperation with the Institute of Industrial Economy, Federal University of Rio de Janeiro (IEI/UFRI) hosted in this same city, from 1 to 6 July 1991, a “Meeting of a Working Group to Identify and Select Populations Affected by Structural Adjustment”.

High-level officials from Brazil, Colombia, Mexico and Venezuela dealing with this subject in their own countries participated in the meeting and presented related technical documents. The meeting focused on the use of statistical data on social issues and nutritional status for this purpose. A practical demonstration was presented and a qualification form was elaborated to serve as a screening tool for selecting candidates for food assistance programmes.

A joint publication, FAO-IEI/UFRJ, on this subject is available for consultation at the FAO Representation libraries in all Spanish-speaking countries of Latin America and Brazil, as well as IEI in Rio de Janeiro.

(Source and contact for further information: R.J. Dawson, Food Policy and Nutrition Division, FAO, Via delle Terme di Caracalla, 00100 Rome, May 1992.)

Vitamin A Programme

The Vitamin A Programme is FAO's contribution to the “Ten-Year UN Action Programme to Control and Prevent Vitamin A Deficiency, Xerophthalmia and Nutritional Blindness”. It depends for its operation on three sources of funds: funds from the Regular Programme of FAO's technical division; funds from the FAO Technical Cooperation Programme; and extra-budgetary resources from UNDP and donors.

The contribution of key technical divisions increased significantly in the years 1991 and 1992 - providing funding to cover the costs of staff time, travel, and consultants' services for project formulation. In the reporting period, the Technical Cooperation Programme has supported two primarily short-term projects aimed at initiating actions in countries, assuring new technology transfer, and supporting technical cooperation between developing countries. Extra-budgetary resources were provided for two projects during the years 1991-1992 (one for an African country; one for an Asian country). Long-term projects have been formulated in addition for 7 countries and 2 regional projects. These projects are the following:

Ghana	Prevention of Vitamin A Deficiency in Upper East and Upper West Regions.
India	Prevention of Vitamin A Deficiency in Backward Rural Areas of West Bengal.
Nepal	Household Gardening for Better Nutrition and Prevention of Vitamin A Deficiency.
Nigeria	Prevention of Vitamin A Deficiency in Kano State.
Tanzania	Nutrition Improvement with Special Reference to Vitamin A Deficiency through Increased Production and Consumption of Appropriate Crops.
Vietnam	Phase II - Nutrition Improvement with Special Reference to Vitamin A Deficiency through Increased Production and Consumption of Appropriate Foods.
Zambia	Improving Household Food Security and Nutrition through Promoting the Production and Consumption of Vitamin A-rich Foods in the Luapula Valley.
Sahel	Transformation et conservation des aliments riches en vitamine A pour améliorer la consommation et la nutrition au niveau villageois.
Eastern Africa	Preservation of Vitamin A - Rich Foods and Nutrition Education. (Kenya, Malawi, Tanzania, Zambia, Zimbabwe).

(Source: FAO Vitamin A Programme Fourth Summary Progress Report 1991-1992 (1992). The report is available in English, Spanish and French from the Food Policy and Nutrition Division, FAO, Via delle Terme di Caracalla, 00100, Rome, Italy)

GTZ

Recent Nutrition Activities

The Deutsche Gesellschaft für Technische Zusammenarbeit or German Technical Cooperation, GTZ, is a wholly-owned executing agency of the Government of the Federal Republic of Germany which has been providing technical assistance to developing countries in the fields of health, population and nutrition for the last twenty years. Commissioned and funded predominantly by the German Government to contribute to the planning and implementation of technical cooperation projects, GTZ is contracted either by the Ministry of Economic Cooperation or by other agencies and governments. One principal objective of its activities, carried out in collaboration with organizations in partner countries, is to strengthen the primary health care systems of these countries by offering a range of advisory services. These services include programme planning, implementation and management, training and qualification of counterpart personnel and the improvement of the infrastructure through building construction and maintenance, and procurement of equipment.

In its approach to the planning, implementation and evaluation of health projects, in cooperation with international and national organizations and institutions such as WHO, the Universities of Heidelberg and Giessen, and others, GTZ is guided by the principle of fostering sustainability and self-responsibility of the national partner organization. The strategic guidelines which are adhered to are: adaptation to the local context; multisectoral commitment; participation of all target groups; self-help orientation; and, decentralization of decision-making.

In 1991, GTZ had many achievements in the area of nutrition. Primary health care projects were encouraged to incorporate nutrition interventions as a component of their activities. These interventions included growth monitoring and promotion, nutrition education, promotion of breast and appropriate child feeding practices as well as dietary intake of micronutrients.

Staff collaborated closely in developing a nutrition policy concept which will be adopted by the German Ministry for Economic Cooperation. This will describe the German Government's strategy with respect to nutrition in aid projects. Other progress made was the finalisation of a “Handbook for the Appraisal of the Nutritional Situation in a Target Population” and the continuing development of a user-friendly computer programme for data analysis in nutrition surveys. The computer package was field-tested in the summer of 1992.

Nutrition activities in 1992 included the preparation of a concept paper on nutrition programmes for refugees, the preparation of a strategy paper on “Urban Nutrition” which aimed to summarize the experience concerning nutrition in urban and metropolitan areas and, the revision (second draft) of the handbook “Nutrition Interventions”.

(Source: GTZ Annual Report 1991: Health, Population and Nutrition. (1992). GTZ, Eschborn, Germany)

Training Programme in Community Nutrition in South-East Asia, 1992

The SEAMEO-TROPMED Centre in Indonesia offers a training programme in Community Nutrition at the University of Indonesia, with special attention given to the management of nutrition programmes. The Centre has been active in the training field of human nutrition since 1970. Recently, the curriculum of the training programme was changed in order to bring it up-to-date with the needs and nutritional problems experienced by communities in South-East Asia. Emphasis is placed on the applicability and adaptability of methods in epidemiology, management and communication to meet local needs and requirements, rather than basic non-applied science. The training programme is assisted by the German Agency of Technical Cooperation, GTZ, the Canadian International Development Agency, CIDA, the International Council for Development, ICD, and North American Universities. The following training programmes are offered: Short Courses (1-3 weeks), Field Study Programme (6 months), Diploma Programme (6 months), Professional Master's Programme (12 months), MSc Programme (2 years) and PhD Programme.

(For further information please contact: The Director, SEAMEO-TROPMED Centre Indonesia, University of Indonesia, 6 Salemba Raya, Jakarta 10430, Indonesia. Tel: 62-21-330205, Fax: 62-21-3106986)

Report of the Second Latin American Workshop on Nutrition and Health in Urban Areas

The 2nd Latin American Workshop on Nutrition and Health in Urban Areas was held 2-6 March 1992 with technical and financial assistance from the German Agency of Technical Cooperation, GTZ, in its planning and implementation. The meeting was under the auspices of the International Institute of Nutritional Sciences and jointly organized by the National Institute of Nutrition “Salavador Zubiran”, the Colegio de Mexico and the National Institute of Public Health. The objective of the gathering, which included participants at senior level in governmental, academic and nongovernmental institutions, was to stimulate nutrition projects and programmes and their research and interventions in urban areas. A specific feature of the workshop was the opportunity for participants to discuss and formulate interdisciplinary research proposals and interventions for nutritional problems in urban settings. The proceedings are to be published in Spanish and English in the Archivos Latinamericanos de Nutricion.

(Source and contact: GTZ, Postfach 5180, D-6236, Eschborn. Tel: (0) 6196-790 Fax: (0) 6196-79-7104)

ICCIDD

Update on IDD Activities

The International Council for the Control of Iodine Deficiency Disorders (ICCIDD) has reported excellent progress in activities related to national IDD control programmes in Africa. Since the 1987 WHO/UNICEF/ICCIDD Intercountry Meeting in Yaounde, there has been an increase, from 4 to 26, in countries showing important developments.

As part of a universal salt iodisation master plan which is gradually being implemented, a salt iodisation workshop was held in Botswana in April 1992. Useful discussions were had by the 60 participants from 8 countries including 6 representatives from the salt industry in Botswana, Namibia, Mozambique and South Africa. Consensus was reached on salt iodine levels and follow-up arrangements made in 7 countries. A similar intercountry workshop to discuss West African Countries was planned for Senegal at the end of September 1992.

The 7th International Salt Symposium was convened in Kyoto from 5-9 April, 1992 and included presentations from ICCIDD experts on salt iodisation. A special meeting of 20 salt producer representatives was held by ICCIDD. A working group has been formed to facilitate the production of iodised salt.

A workshop on “Iodine Deficiency in Europe: A Continuing Concern” was held in Brussels, 24-28 April, 1992, under the joint sponsorship of WHO/UNICEF/ICCIDD/ETA and the European Community. The workshop, which was attended by more than 150 scientists, industry representatives and public health specialists from every European country with the exception of Albania, concluded that there is still inadequate control of IDD in most European countries and consequently, iodine deficiency-related impaired brain development remains a problem of neonates. The meeting called upon governments to initiate adequate legislation, and other necessary measures, to ensure the availability and use of iodised salt, an appropriate method of iodine supplementation. Recommendations on iodine nutrition for mothers and infants in Europe were agreed on and will be promulgated in due course.

An ICCIDD/WHO/UNICEF Symposium on IDD control in the ex-USSR was convened in Tashkent from 18-22 November 1991. It was attended by 98 scientists from 11 of the 12 republics. Although very little data on iodine deficiency in this region is available, the Symposium resolved to initiate appropriate action as soon as possible. Country technical support will be provided by the ICCIDD.

(Source and contact: Dr Basil S Hetzel, Executive Director, ICCIDD, c/o Health Development Foundation, 8th Floor, Samuel Way Building, Adelaide Medical Centre for Women and Children, 72, King William Road, North Adelaide, 5006, Australia)

IFPRI

Research Priorities in Food Consumption and Nutrition

In the context of the overall strategy of the International Food Policy Research Institute (IFPRI), the Food Consumption and Nutrition Division (FCND) of IFPRI, comprising a group of 25 researchers, has recently re-emphasised and narrowed its research priorities. As part of the Consultative Group for International Agricultural Research (CGIAR), FCND is linked to an international network of researchers. FCND research aims to achieve favourable impacts on policies for food security and nutritional improvement. To identify research needs in food policy, FCND interacts on a continual basis with policymakers, IFPRI's clients and partners, and the ultimate beneficiaries - the food insecure and the malnourished poor.

FCND has identified three priority research areas:

1. Policies for preventing food and nutrition insecurity arising from seasonality and shocks (famine). FCND research on seasonality of malnutrition addresses transitory food consumption and nutrition problems. Policies to mitigate adverse consumption, nutrition, and productivity consequences of persistent or erratic fluctuations in food supply and entitlements are studied. Ongoing research on famine in Africa examines the potentials and limitations of market-oriented policies and public interventions for famine relief and prevention.

2. Environmental stress, agricultural change, and nutrition: policy implications. This research aims to generate policy-relevant information relating food security, health, and nutrition welfare to sustainability of natural resources. FCND research on health improvement aims to improve the understanding of the linkages between technology, environment, and resource utilization with consumption, nutrition and health. The nutrition impact on the poor of different types of agricultural technologies such as irrigation is specifically explored. This area builds on past FCND research on the food security and nutritional effects of technological change and commercialization in agriculture. Synthesis of the research on agricultural commercialization, food security and nutrition linkages is nearing completion.

3. Factor market interventions (labour and capital) for food security and income-generating activities. Ongoing research on the food security and nutritional effects of factor market interventions focus on the income earning side of the household food equation with a view to creating sustainable consumption and nutrition improvement. Specifically, labour-intensive public works for food security and provision of credit for consumption stabilization are being studied. Particular attention is paid to gender aspects. The implications of “missing” financial and insurance markets are pan of the research agenda that focuses on credit in the context of risks for the poor and support for coping with these risks in order to achieve nutritional improvement.

The research priorities and cross-cutting issues are addressed by tightly defined research projects that mostly have a regional or country focus. They frequently involve case studies, including data collection in collaboration with national or regional partners. Field-based research is underway in a number of countries. In Pakistan, the research project on “Food policies, food security, and health linkages in Pakistan” is collecting detailed panel data on consumption, nutrition, production, education, and so forth from rural households in poor districts to enable it to conduct detailed modelling of household decision-making. In Central America, a participatory grassroots based research project is underway to examine food security, health, and nutrition linkages among the poor. In Ethiopia, in-depth data collection is taking place to analyse the effects of seasonal food deprivation on agricultural production and household welfare. Fluctuations in intrahousehold time allocation, and changes in bodyweights for adults and growth of children are being examined to acquire a better understanding of which household members are more likely to become vulnerable during periods of food deprivation.

FCND's research priorities emerge from both insights gained from past research at IFPRI and elsewhere and from changing food security and nutrition conditions. The priorities of research collaborators and policymakers in developing countries are a most important input in the priority setting process at FCND.

(To obtain a copy of “The Food Consumption and Nutrition Division at IFPRI: Priorities and Current Research Projects 1992”, contact Rajul Pandya-Lorch, IFPRI, 1200 17th Street NW, Washington, DC 20036-1998, USA. Fax: 202-467-4439. Cable: IFPRI. Tel: 202-862-5600.)

Famine Research at IFPRI

In the aftermath of severe famines in several African countries in the mid-1980's, the Food Consumption and Nutrition Division at IFPRI embarked on a long-term, in depth research project in Sudan and Ethiopia that was prompted by the desire to prevent famines of such magnitude from recurring and to minimise the effects of famines. The objective of this research project is improve the basis for cost-effective policymaking in the fight against famine in Africa. Among the central research questions posed are: What roles do production fluctuations, policy and market failures play in the development and evolution of famine? and, how should food and agricultural policies, programmes, and projects be designed so that the worst consequences of future famines are avoided?

The research approach adopted is to examine famine events at national and household levels. Special attention is paid to how and whether markets functioned during times of crises. Primary household data have been collected in famine-prone areas of Ethiopia and Sudan. Analysis of household level data, together with secondary information from national and international agencies active in famine relief, suggest key findings:

* While drought is a primary agent of famine in Africa today, production failures caused by drought, even those lasting several years, do not necessarily result in famine unless other socioeconomic and political conditions are present. Such conditions can include inappropriate macroeconomic policies and excessive state interference in economic activity, lack of rural roads and transportation facilities, armed conflict, weak popular participation and nontransparent political decision-making processes, and poverty.

* There is no one universal response to offset the impact of production shortfalls and fluctuations, but there are broad commonalities in the type and sequence of household responses. Knowledge about these responses is critical for effective public policy for famine prevention.

* Food insecurity and famine are inseparable from poverty. Political and military conflict and drought contribute to famine mainly where people are very poor in the first place.

* Famines do not happen suddenly. They are an accumulation of events and policies that progressively erode the capacity of poor households to deal with short-term shocks to the local economy.

* Famines and food insecurity are preventable. The fact that famines continue to be a threat to some countries in the 1990's must be blamed on a failure of policy, that is, a failure to give priority to the conceptualisation, analysis, preparation, and implementation of preventive measures. Promotion of agricultural growth, improvement of rural infrastructure, provision of basic health and sanitation services, and provision of education are among the key elements of a famine prevention and food security improving strategy.

Dr Joachim von Braun is the project manager. The field research and country studies are guided by Dr Tesfaye Teklu in Sudan and Dr Patrick Webb in Ethiopia.

(For a copy of Drought and Famine Relationships in Sudan: Policy Implications (Research Report 88) by Tesfaye Teklu, Joachim von Braun, and Elsayed Zaki or for a copy of A Policy Agenda for Famine Prevention in Africa (Food Policy Report) by Joachim von Braun, contact Rajul Pandya-Lorch, IFPRI, 1200 17th Street NW, Washington, DC 20036-1992, USA. Fax: 202-467-4439. Cable IFPRI. Tel: 202-862-5600.)

UNICEF

Child Growth Monitoring

The UNICEF Nutrition Strategy is based largely on the recognition that households and communities have many strategies for reaching favourable nutritional outcomes while coping with limited resources. A model for the method by which decisions are made on the best actions to take is the “Triple-A Cycle”. Individuals, households and communities will first assess the presence and severity of a nutritional problem and analyze the probable causes. Based on the conclusions they reach, action will be taken according to available resources. How the action they take affects the original problem (favourably or unfavourably) allows modification of the analysis of causes and appropriate action - and so the cycle continues.

Growth monitoring has been advocated for more than 20 years by UNICEF, which has used it in many of its own programmes. It can be seen as a method of providing data to aid households and communities in their assessment of a nutritional problem: an assessment is made through weighing the child; an analysis is made through comparing the child's weight with the weight during previous weighing and growth retardation is observed; the child caretaker is counselled about possible causes and suggestions are made about more relevant actions.

There have been successes and failures with the implementation of growth monitoring and promotion (GMP) - and in 1989, several members of the UNICEF Executive Board, taking into account the mixed experiences with GMP, asked for a comprehensive evaluation of experiences to date. In 1990, UNICEF (Evaluation Office and Nutrition Cluster, Programme Division), New York, formed a reference group to guide a process of evaluation of GMP. This process involved evaluations in seven countries (China, Ecuador, Indonesia, Malawi, Thailand, Zambia and Zaire) where UNICEF had been supporting national and local capacities to use GMP.

A technical workshop organised by UNICEF in Nairobi on 7-9 May, 1992, has reviewed the findings and lessons learned from each country's evaluation, and has put together a general set of recommendations for application in UNICEF-supported nutrition programmes. Following this workshop, an international colloquium was held in Nyeri, Kenya (11-13 May, 1992). The purpose of this meeting was to reach an international consensus on how to promote the growth of all children in the future, taking into account the experiences of the 1980s and the views of proponents and opponents of GMP. The “Nyeri Declaration on Growth Promotion for Child Development” (see box) is similar to the recommendations of the UNICEF meeting.

Towards an Improved Strategy for Nutritional Surveillance

In Mid-1991 UNICEF initiated a process to re-conceptualize nutritional surveillance, and, based on the accumulated experience from developing countries, to identify ways to improve the impact of nutritional surveillance on decision-making. This process included an initial meeting with experienced persons from donor agencies, developing countries and universities, visits to seven countries by consultants to learn from successful elements in these countries, and a follow-up workshop to discuss the findings and identify components of a strategy to strengthen nutritional surveillance.

The follow-up workshop took place in New York on 29-30 January, 1992, and focussed primarily on five themes related to implementation of nutritional surveillance and its impact on decision-making. These were:

A. Strategies to increase awareness and communication of nutrition problems.

B. Methods of assessing nutrition problems, including indicators of nutritional outcomes and contributing factors

C. Issues related to the analysis of nutrition problems and solutions

D. Distinguishing surveillance of nutritional status from surveillance of nutrition problems, the latter implying a broad consideration of contributing factors and solutions

E. Factors influencing the impact of surveillance on decisions.

1. Consensus on Concepts and Policies Regarding Nutritional Surveillance: This includes consensus among UN agencies, within countries and among all parties supporting surveillance (consultants, training centers, etc.)

2. Accountability and Demand for Nutrition Information: The ethical aspect of the human development goals for the 1990 has created a new political environment in which governments increasingly will be seen accountable for the achievement of these goals. This will generate an active demand for nutrition information.

3. Strengthen Institutional Capabilities: At least seven different types of “analysis” were identified as being relevant to surveillance (including conceptual and empirical, quantitative and qualitative). These have corresponding variations in requirements for skills, training and institutional loci of the analysis. Accordingly, it was recommended that a review of training requirements be undertaken; that the surveillance strategy consider the purpose, scope and configuration of a “central” surveillance unit in a country; and that the strategy consider how such a unit might catalyze and support the “analysis” within individual sectors (i.e. planning sections within ministries) which cannot be undertaken by the central unit itself.

4. Methodological Development: Whereas the methodologies for assessing nutritional status are well-advanced, these are much weaker with respect to factors contributing to nutritional status (e.g. child care, household food security and health-related factors). These methodologies should be strengthened, recognizing that indicators of these latter factors may be highly situation-specific.

5. Exchange of Experience: There are positive elements of surveillance activities in many countries, and this should be increasingly true as the new strategy is implemented. Information on these positive elements, and on experience in general, should be exchanged across agencies, countries and other parties in order to reinforce the common conceptual framework and accelerate developments in other countries. The UN can play a key role in this exchange.

6. Broader-Based Approach to Surveillance: The future surveillance strategy should explicitly promote a focus on priority aspects of the nutrition “problem” rather than nutritional status per se. This has far-reaching implications for the design and implementation of surveillance activities in a country, including types of decisions, types of data required, location and type of analysis, and so on.

7. Re-Consider the Term “Nutritional Surveillance”: In light of the improved conceptualization of nutritional surveillance it was suggested that this term may no longer accurately reflect the underlying purposes and activities. The term should therefore be re-considered, but proposed alternatives should reflect the seriousness of the endeavor and should not harm the credibility of future efforts.

The Nyeri Declaration on Growth Promotion for Child Development “The participants at the Colloquium on Growth Promotion for Child Development in Nyeri, Kenya, 11-13 May 1992, recognise that it is morally unacceptable that malnutrition is a major contributing cause in 10 million out of the 15 million deaths of children in the world each year. The World Summit for Children and the International Convention on the Rights of the Child affirmed, as a global ethic, that the protection, development and survival of the child is a human right. Nations should give priority to children in the allocation of resources. “The Colloquium recognized that growth monitoring is being implemented in many countries for millions of children. Too often, this monitoring has not promoted growth because the weighing and charting has not been followed by action. “The Colloquium recommends that: 1. Growth promotion for child development should use cyclical problem-solving approaches based on assessment, analysis and action. 2. Physical growth is normally a reflection of child development. Cognitive and psychosocial development also need attention. Causal factors of poor growth and development need to be understood for effective action to be taken within local resource constraints. 3. All levels of society should support families in their responsibility for promoting child growth and development, and should strengthen the capacity and resources of households in providing food security, appropriate care and protection from infection, and other illnesses. 4. Communities have responsibility for identifying and analysing the factors causing poor child growth and development, and mobilizing resources for sustainable action to provide better child care, feeding and health. Communities should be empowered to demand support from governmental and non-governmental agencies. International agencies should facilitate this process. 5. Supportive services should work with communities to ensure that resources reach the most needy children. This requires mechanisms to identify populations and sub-groups where growth faltering is most prevalent, to define major causes of poor growth, and to mobilize resources and actions. 6. National responsibility for growth promotion should include: macroanalysis of factors contributing to growth faltering. Supportive policies and a framework for planning and action at all levels. 7. These objectives will be achieved if appropriate management information systems and applied research are used to build capacity for improved problem-solving and decision-making at all levels. 8. Use of information for growth promotion falls into two general categories: a) growth promotion for individual children involves information from, and assessment by, mothers, community volunteers and service personnel using: - growth monitoring by weighing and charting, to reflect the dynamics of individual growth in the early years of life; - occasional weighing without the use of growth charts; and - other methods of assessment including traditional practices and measurements other than weighing. b) community-based nutrition surveillance using periodic assessment of nutritional status, either by anthropometric or other surveys of populations, in order to focus on children in greatest need. This declaration calls for a concentration on growth promotion, rather than on standard growth monitoring as currently practiced. It suggests that for individual children, growth promotion programmes should, almost always, first include assessment based on information from the mother, the community and the health workers (or volunteers). Secondly, depending on local conditions and availability of resources, the assessment should consist of one of the following: (1) Growth monitoring by regular weighing and charting (GMP). (2) Occasional weighing without the use of charts, the weight being used for diagnostic or other purposes. (3) Other methods of assessment of growth, and of causes of growth faltering, without weighing. “In each case, the information from these assessments should lead to an analysis of the factors influencing the growth and health of the child, and then, most importantly, to appropriate advice and actions. This would be followed, at intervals, by reassessment, leading to further analysis and actions. Programmes such as this could be clinic- or community-based.” Source: UNICEF Evaluation Office & Nutrition Cluster (1992). Evaluation of Growth Monitoring and Promotion Programmes, Nairobi, 7-9 May, 1992: Workshop Report, UNICEF, New York.

USAID

IMPACT - Food Security and Nutrition Monitoring Project

The Food Security and Nutrition Monitoring Project (IMPACT), funded by the A.I.D's Office of Nutrition, provides technical support in food security and nutrition monitoring to A.I.D. field missions and offices, host country institutions and PVOs. IMPACT assists in building local capacity to acquire and use information to improve food security and nutritional status. It helps design systems to measure the nutritional and food consumption impacts of policies, programmes and projects in agriculture, health and other sectors.

With expertise in information systems design and in identifying indicators of impact and performance, IMPACT is a technical resource to:

· develop information systems to assess the impact of one or more development programmes, projects and policies, including food aid programmes;

· aid in the design of projects in agriculture, rural development and other sectors to maximize the positive impacts on food consumption and nutrition;

· design timely and economic nutrition monitoring systems; and

· develop host country capacity to maintain such information systems over time.

1. Nutrition/Agriculture Linkages, Kintampo District, Ghana

This activity is being conducted by the International Food Policy Research Institute (IFPRI) in Ghana, where a combined credit and nutrition programme is being implemented. It tests the hypothesis that credit directed to women in combination with nutrition activities will be more effective in improving nutritional status than either one alone, or no intervention at all. Its objectives include: to evaluate the impact of its agriculture/nutrition linkages; to implement a local level food and nutrition monitoring system in conjunction with an on-going agriculture/nutrition project; and to assess the importance of community participation as part of the implementation of agriculture/nutrition activities.

A protocol has been developed for the IMPACT study of the Kintampo District credit and nutrition programme. Field staff will be recruited and trained and a survey will be designed. The activity will also involve setting up a self-sustaining food and nutrition monitoring system that can be integrated into the local infrastructure.

2. Integrating Nutrition and Food Security Components in Agricultural Projects, South Nyanza, Kenya

The main hypothesis of IFPRI's study is that nutrition activities in combination with agricultural policies stressing income generation will have a greater impact on household food security and nutritional status than either approach used alone. Prior studies have indicated that cash crop production, while leading to increased income, did not result in significant improvements in child health or nutritional status. This activity will test the feasibility of integrating nutrition and food security components into a commercial agriculture scheme, and a local level monitoring system will be designed and implemented in conjunction with the district government.

To date, a research protocol has been developed, local staff have been recruited, and field training is underway.

3. Field Testing of Alternative Indicators in the International Crops Research Institute for Semi-Arid Tropics (ICRISAT) Villages, Andhra Pradesh, Central India

This activity aims to field-test and document the validity and reliability of alternative indicators of food and nutrition security in Andhra Pradesh, Central India. Together with ICRISAT, IFPRI is testing the hypothesis that relatively simple, “non-traditional” or “alternative” indicators can perform well in locating the food and nutrition insecure.

The activity planned field surveys in lean (March-May) and peak (October-November) seasons in 1992 in six villages. Nutritional and economic data were collected from 50 households per village. A protocol was developed and the survey instruments were field tested. Data analyses will be conducted later in 1993.

4. Africa Regional DHS Nutrition and Family Health Analytical Initiative

This activity, conducted by the Demographic and Health Surveys (DHS) Division of the IRD/MACRO International, aims to make the results of DHS finding in Sub-Saharan African countries available to policy makers and planners, and to undertake further analyses of these data. The project comprises of the following activities related to the nutrition status and feeding practices of young children in Sub-Saharan Africa:

· Briefing packets containing summary graphs, updated as new DHS surveys become available.

· National Nutrition reports describing the nutritional status and feeding practices in each country.

· In-depth analyses which may include comparative studies across countries.

· Training materials for host country use including diskettes with graphs and tables.

The major part of the Project's services are procurable through USAID buy-ins. Missions may request technical assistance or training under IMPACT by preparing P/IOTs, which will prompt the development of detailed proposals and budgets by Project staff.

(For more information please contact Barry Sidman, Project Director, at 1616 North Fort Myer Drive, Suite 1240, Arlington, Virginia, 22209, USA. Phone: 703-841-1595; Fax: 703-841-1597.)

The Nutrition of Adolescent Girls Research Program

The period of adolescence is viewed as a window of opportunity for enhancing the nutritional status of girls in developing countries. Improved nutritional status is expected to help girls to more fully realize social and educational opportunities, as well as manage their home and market responsibilities more effectively. Additionally, interventions during adolescence will better prepare girls for future work and reproductive demands.

Currently, maternal and child health programmes focus on pregnancy, when women experience the greatest health and nutrition risks. Recent experience suggests that preventive efforts before and during pregnancy can substantially reduce these risks. While programmes are successfully addressing the need for more prenatal care, efforts to improve the health and nutritional status of women before they become pregnant are lagging behind. An ideal time to focus on preventive efforts before pregnancy is during girls' adolescent years.

Little information, however, is available to guide the formulation of policies and programmes that improve the nutritional status of adolescent girls. To meet this need, the International Center for Research on Women recently established the Nutrition of Adolescent Girls Research Program, funded through a cooperative agreement with the Office of Nutrition, U.S. Agency for International Development. The Program will provide needed information on factors that have implications for adolescent nutritional status including family structure, girls' educational level, social status, self-perceptions, physical growth, morbidity, food intake, energy expenditure, intrahousehold food distribution, family structure and economic status. Research results will help identify ways in which interventions can reach adolescent girls.

The Program has four components:

· A research grants program that supports nine research projects: four from Latin America and the Caribbean, four from Asia, and one from Africa.

· An ICRW research project, in collaboration with a developing country research team, to investigate psychosocial factors in girls' lives and their nutritional status.

· Technical support to research teams for developing proposals, data collection methods, and analysis procedures, and interpreting results for policy and program formulation.

· Synthesis and dissemination of the research findings through publication of papers, conferences, and other mechanisms.

RD/N To Assist with National Micronutrient Survey in Nigeria

The Bureau for Research and Development, Office of Nutrition (RD/N) Vitamin A Field Support Project (VITAL) is providing technical and financial assistance to the Federal Ministry of Health (FMOH) to plan and carry out a national prevalence assessment of key micronutrient deficiencies - vitamin A, iron and iodine. The survey field work will take place in March 1993.

This survey represents a critical element of Nigeria's national food and nutrition strategy, in which USAID, World Bank and UNICEF are collaborating. The National Committee on Food and Nutrition (NCFN) has identified micronutrients as a priority component for inclusion in its strategy, but concluded that there was inadequate information about the prevalence of the problems from which to develop a strategy and policies. Consequently, the NCFN assigned responsibility to the FMOH to arrange for a prevalence assessment. At the request of the NCFN and FMOH, USAID agreed to provide the services of VITAL for this purpose.

The survey headquarters will be at the Ibadan University College of Medicine and a number of leading Nigerian health and nutrition experts from around the country will participate. The World Health Organization and UNICEF will also assist with the survey. The USAID-funded survey of 1991 provides an excellent overall information base about the relative prevalence of protein energy malnutrition (PEM) in the country, and this micronutrient assessment will permit accurate targeting of appropriate intervention strategies to combat micronutrient malnutrition.

Baseline Survey Completed in Nepal for Monitoring Impact of Home Gardening on Food Consumption and Nutrition Status

The RD/N Vitamin A Field Support Project (VITAL) recently completed a baseline survey in Nepal in collaboration with CARE/Nepal and the University of Arizona. This survey collected baseline data on nutritional status, dietary patterns, clinical eye signs and food provisioning strategies in two districts of the country in preparation for monitoring the impact of home gardening activities on the consumption of vitamin A rich foods by children six months to six years old. The multidisciplinary study also included a rapid rural appraisal (RRA) focussing on diet and strategies for acquiring food, training in nutrition education, and the development of a nutrition strategy for two CARE projects including food preservation and preparation techniques.

Preliminary findings from the survey indicate that the current drought in western Nepal, described by several farmers as the worst drought in 29 years, has contributed to a major food shortage in the region with a subsequent decline in dietary diversity. Although nutritional status information is still being analyzed, preliminary mid-upper arm circumference (MUAC) results have found between 15-27% of children in western hill villages severely malnourished as determined by MUAC measurements less than 12.5 cm. Farming households with access to irrigated fields appeared to be less affected by the drought conditions. For children living in the Terai, rates of malnutrition were slightly less than those in the west, but nutritional problems were generally observed to increase from north to south.

The RRA component of the survey also collected information on crops grown, types of animals owned, foods purchased and gathered, sources of income for purchasing foods, access to credit, types of food consumed and their seasonality. Systematic collection of these alternative indicators should enable CARE/Nepal to better monitor household food insecurity by monitoring changes in survival strategies of vulnerable households.

Vitamin A Deficiency in the South Pacific

Based on the findings of surveys in Truk Island and the Republic of Kiribati in the South Pacific, the Vitamin A field Support Project (VITAL) was requested by the health, Population and Nutrition Office of the USAID Regional Development Office/South Pacific in Suva to conduct xerophthalmia surveys in Tuvalu, Vanuatu and the Solomon Islands to determine if vitamin A deficiency poses a public health problem in these countries.

Xerophthalmia surveys were planned and conducted by the Ministries of Health of these countries and VITAL to assess the presence and magnitude of existing clinical vitamin A deficiency, and to provide data which could be used for future nutrition planning by the Governments of Tuvalu, Vanuatu and the Solomon Islands.

Children between the ages of six months and six years were examined for eye signs and symptoms of xerophthalmia in areas thought at greatest risk for malnutrition. Families of the children were interviewed to assess health and socioeconomic conditions and an assessment of dietary intake and anthropometric measurement was carried out on a subsample of the children to determine vitamin A food sources and nutritional status.

The survey results indicate that vitamin A deficiency is not a significant public health problem in Tuvalu or Vanuatu. Consumption information indicates that traditional child-feeding practices include frequent consumption of vitamin A-rich foods and appear to protect against vitamin A deficiency among the pre-school population in both countries. However in the Solomon Islands vitamin A deficiency was found to be a significant public health problem, with 1.52% of the survey population having one or more active clinical signs or symptoms of xerophthalmia, well above the World Health Organization criteria for a public health problem:

Nightblindness (XN)	0.52%
Bilot's spots (XIB)	1.42%
Corneal xerosis (X2)	0.07%
Corneal ulceration/Keratomalacia (X3)	0.00%

Dietary information found that children with clinical signs of xerophthalmia consumed vitamin A-rich foods significantly fewer times per week than normal children did.

Throughout the South Pacific region imported foods (such as rice and tinned meats) which provide inadequate vitamin A have been introduced and have begun to replace traditional island foods in the diet, including a variety of vitamin A-rich food sources. Studies in Truk and Kiribati indicate that high rates of vitamin A deficiency result from these changes in dietary behaviour. To avoid similar deficiency in other South Pacific island nations, recommendations were made for governments to discourage the replacement of traditional vitamin A food sources with imported foods, and to educate health workers and the general population about the importance of traditional foods for child health.

Vitamin A Deficiency in Latin America and the Caribbean: An Update

Heightened attention is being given to vitamin A deficiency in the Latin America region as a result of recent epidemiological studies that have documented the relationship between marginal, or subclinical, vitamin A deficiency and higher mortality and morbidity rates from infectious diseases in children. A number of Latin American countries are currently conducting vitamin A deficiency prevalence assessments to determine the extent of this deficiency problem, clinical and subclinical, throughout or in specific high-risk regions of their countries. All surveys are evaluating serum retinol levels as well as dietary intake of vitamin A-rich foods as measured by the IVACG Simplified Dietary Assessment Guidelines to assess risk of inadequate vitamin A intake. In some cases, the populations are being screened for clinical signs and symptoms of xerophthalmia as well. The United States Agency for International Development (USAID), through its Vitamin A Field Support Project (VITAL) and directly from its country missions is providing technical and financial assistance to the ministries of health and private organizations conducting these surveys.

The Centro Nacional de Investigaciones en Salud Materno Infantil (CENISMI) in the Dominical Republic has recently completed an assessment of vitamin A deficiency in the most economically depressed southwest region of the country - and in Peru, the Instituto de Investigacion Nutricional (IIN) has completed an assessment in regions of Piura and Puno, as well as in the city of Lima.

In both Bolivia and Panama, vitamin A deficiency assessments are being completed by the Nutrition departments of their respective Ministries of Health with VITAL assistance. VITAL is also providing technical assistance to the Ministry of Health in Ecuador to conduct a vitamin A deficiency assessment in the poorest regions of the country.

The overall impact of these vitamin A deficiency prevalence assessments will be to provide more insight into the extent and distribution of the vitamin A deficiency problem in the Latin America region and to assist public and private institutions in these countries to develop strategies and programmes to prevent and treat vitamin A deficiency where populations are at risk of facing this public health problem.

(Source: USAID, June 1992)

WFP

Food Aid and Micronutrients

To manage the problem of the lack of specific micronutrients in local foods, the World Food Programme, WFP, has taken measures to ensure that the food it provides meets micronutrient requirements as well as supplying extra caloric energy. In the distribution of fortified commodities such as iodised salt; vitamin A fortified dried skimmed milk; edible oils and flours; and blended foods fortified with a variety of vitamins and minerals, the institution helps to prevent and alleviate micronutrient deficiencies in many situations.

The protracted feeding situation in refugee camps often gives rise to micronutrient deficiencies. WFP addresses these inadequacies by changing the composition and quantities of commodities and occasionally by fortifying specific food items. A publication “Guidelines for Calculating Food Rations for Refugees”, distributed by WFP in November 1991, represents a joint effort by WFP and the United Nations High Commission for Refugees (UNHCR) to provide a framework for planning food distributions, and has the technical input of health and nutrition experts regarding the adequacy and appropriateness of food rations for refugees and displaced persons.

WFP's development activities can also help overcome local micronutrient deficiencies. In landlocked, poverty-stricken Paraguay, where nearly half of all students between 6 and 15 years of age and four out of ten pregnant women suffer from goitre, one of the consequences of iodine deficiency, WFP uses its food aid distribution system to provide LUGOL, an iodine solution which is being given out as an interim measure until iodine-fortified salt becomes more widely available.

In Panama WFP, in association with the Institute for Nutrition in Central America (INCAP), has recently established the technology to fortify biscuits made from WFP commodities with vitamin A, some B vitamins, iron and iodine. INCAP is to undertake studies on the alterations in micronutrient levels that take place under cooking and storage conditions as well as the nutritional impact on children that consumption of these biscuits will have in areas with high prevalence of vitamin A, iron and iodine deficiencies. If it is proven that the fortified biscuit is an effective nutrition intervention, WFP will support its use in other countries with endemic micronutrient deficiencies.

Film and Radio Programmes on Food Aid and Nutrition

The World Food Programme has produced a 9-minute film, “Building Blocks of Life”, about food aid and nutrition. Some topics raised: how food-for-work projects can improve household food security; food aid for pregnant women and young children; weaning foods; adding micronutrients; women as managers of household food security and nutrition; meals for schoolchildren; and nutritional status of refugees. The film is available from WFP, free of charge, in English. A Spanish and French version will soon follow.

WFP has also produced a series of radio programmes in English, French and Spanish about food aid and nutrition, available, free of charge.

(Please write to: Karen Watson, Public Information Branch, via Cristoforo Colombo 426, Rome 00145, Italy.)

(Source: Dr J Katona-Apte, Senior Programme Adviser (Human Resources), WFP, May 1992)

THE WORLD BANK

Growth Industry

With some 20 new major nutrition operations now under active preparation or appraisal, nutrition is moving closer to the mainstream of Bank lending. Free-standing Nutrition Projects are being readied for Bangladesh, India, Mexico, Nigeria and Pakistan. Food Security and Nutrition Projects are at the appraisal stage in Madagascar and Mozambique, and one for Burkina Faso has just been approved. Preparation for combined Nutrition and Health Projects is moving along in Argentina, Burkina Faso, Egypt, Guatemala, Guinea, Honduras, Kenya, Peru and Zambia. Also, Child Development and Nutrition Projects are being prepared for Bolivia and the Philippines and a specialized Urban Health and Nutrition Project for the Philippines is ready for appraisal. Nutrition, in addition, is increasingly figuring large in Social Fund Projects (e.g. in Nicaragua) and Social Safety Net Adjustment Projects (India).

Special Grant for Micronutrients

A Special Grant to the tune of a quarter of a million dollars has been approved to support the Bank's efforts in micronutrients. The grant will be matched by other donors, and the programme characterised as a global micronutrient initiative. Countries will be helped to identify their micronutrient problems and strategies and programmes devised to address them.

One country which has launched an all-out attack against micronutrient deficiencies is Morocco which has recently started a series of studies aimed at developing a national micronutrient programme. These studies will examine the technical and financial feasibility and commercial viability of incorporating iron into sugar in Morocco as well as the willingness of the consumer to accept the product. At the same time the Ministry of Health will check the efficacy of iron supplements for pregnant women and the cost and feasibility of the programme in selected areas.

Emergency Food Aid for Africa

In a major recent departure, the Bank has been financing emergency food imports, mainly through adjustment operations. To stave off malnutrition and possibly starvation due to one of the worst droughts in decades in southern Africa, the Bank has allocated $310 million for: Zimbabwe ($150 million), Zambia ($100 million), Malawi ($50 million) and Mozambique ($10 million). Although food is commonly financed in nutrition development operations, financing of food imports for emergency use has not been a regular feature of Bank work.

Food Security & Nutrition Project

The $12.8 million Burkina Faso Food Security and Nutrition Project includes income-generating micro-projects to be designed and implemented by women's groups from households with insufficient food - a main purpose being to reduce food energy expenditure through labour-saving devices in, for instance, food processing. Other components support the strengthening of an early warning food surveillance system, a locally-made weaning food, operational research and a participatory behavioural change program in which the villagers themselves make up the nutrition education messages.

Collaboration with CARE

The Bank's first collaboration in nutrition with CARE is now underway in Cameroon, where a $1.5 million nutrition education component is part of the recent food security project. The NGO's staff will implement the project: in addition, CARE/Canada has added $300,000.

Loan to Romania

The $400 million structural adjustment loan approved in June for Romania includes, along with phasing out of generalized consumer food subsidies, an expansion of food coupons, a free meals program, and special support for families with qualifying children.

Malnutrition in Kyrghyztan

Kyrghyztan's ambassador to the US, Roza Otunbayeva, told World Bank staff last month that malnutrition is a major problem in her country - and getting worse. That country is undertaking reforms more aggressively perhaps than any of the newly independent countries of Central Asia. But, on return from mission there earlier this year, consultant David Sahn (of Cornell University's Food and Nutrition Policy Program) wrote he was “left deeply concerned that the impact of reforms may indeed be devastating for nutrition.” A human resources sector and project identification mission, now in the field, is looking into this.

Direct Financing - Food Coupons in Honduras

The provision of $18.4 million to the Honduras Health and Nutrition Project for the support of food coupons represents an historic occasion for the Bank. The lending institution has previously directly financed food supplements as well as large-scale experimental studies that included food coupons and the supportive services required for them. However, this is the first time that the Bank will be directly providing support for food coupons. The project is an outgrowth of a pilot nutrition programme which targeted food coupons to 177,000 needy children and women in primary schools and health centres and which witnessed a dramatic impact on both the growth in school enrolment and the use of health centres.

(Source: The World Bank, 1992)