ACC/SCN Symposium Report: Effective Programmes in Africa for Improving Nutrition, including household food security

Presented here is an overview of the Symposium 'Effective Programmes in Africa for Improving Nutrition, including Household Food Security' which was held at the SCN's 23rd Session in Accra, Ghana in February 1996. A summary of the main conclusions and cross-cutting themes arising from the Symposium was presented in SCN News No. 14; this article reports details of the fourteen presentations given at the Symposium.

"Nutrition is central to the human challenge in Africa today. With the long struggle in many countries against poverty, and with declining incomes and declines in the public services, it is not surprising, though it is still tragic, that we have seen evidence of deteriorating nutrition in many countries. We know why nutrition is deteriorating. Extreme poverty, severe drought, conflict and military spending. Africa is a continent where 179 soldiers exist on average for every 100 teachers or health workers. We also know that the underlying problems of chronic malnutrition are due to marginal access to food, seasonality problems, inadequate diet quality, and the chronic lack of basic services, health, water and education. But there are successes, and one of the exciting features of this Symposium is that we will hear of practical experiences from people in different parts of Africa, commented on by people with a great deal of experience from other continents, in the hope that the lessons learned can be applied to future programmes to improve nutrition". Richard Jolly, Chairman, SCN. Remarks in the Opening Ceremony

INTERVENTIONS TO ADDRESS HOUSEHOLD FOOD SECURITY IN KENYA - Ruth Oniang'o

"Household food security... ensuring enough food of the quality and quantity for every member of the house-hold to maintain, a healthy and active life throughout. That is a tall order... even for Kenya. In the 1980s, many achievements were made in Kenya, but muck of this seems to have stalled - what lessons can we learn from this?"

The Kenyan government, in collaboration with NGOs and other agencies, addresses nutritional issues ranging from the rehabilitation of severely malnourished children, to broad policies and actions that have an indirect impact on nutritional status. Examples of country programmes that address nutrition and household food security include the rehabilitation of severely malnourished children, feeding programmes, and nutrition education and training. Through improved nutrition and emergency medical care provision, rehabilitation programmes have been successful, but often fail to tackle the root causes of the problem. Feeding programmes vary from feeding the malnourished to maintaining good health of those who are vulnerable or at risk. Nutrition education and training is an area constrained by limited human and financial resources. The ratio of nutritionists to the population in Kenya is around 1 per 40 000, and although the MoH train nutritional field workers, the number of trainees produced per year is too small to make the desired impact on nutrition at the household level. Furthermore, the lack of re-training results in some nutritionalists using old information to address new problems. Despite all these constraints, Kenya has a cadre of field staff with direct links to grass roots problems. Given the necessary support and re-training, they could make a considerable impact on the current nutrition situation.

What lessons have been learned?

· Community participation is a must for sustainability.

· Many aspects of communities are still very traditional and programmes must work within this framework.

· It cannot be assumed that every women's group or welfare organization will turn into a business group.

· Donors want to see impact and measurable achievements quickly, but time is necessary to allow this to happen. Just going, listening, getting people to accept you - it all takes time.

· It is easier to work with a community after their immediate needs have been addressed.

· Although adult literacy classes are full of women, education is now even more crucial as more girls are dropping out of school, and families who must now pay for primary education often choose to take boys to school rather than girls.

· Indicators to monitor programme success must be discussed and agreed with the community.

· It is easy to mobilize a community around water because water is seen as a real need. Focus on water and an immediate benefit will be seen, then the other issues can be addressed.

· Collaboration between governments, academics, implementers, communities, donors and agencies is key to a successful programme.

· Capacity building must focus on what the community already has and invest in training people.

Policies. To effectively address food security at the household level, a review of existing policies and formulation of new policies are required.

Land. There is a need to review the land tenure system to ensure that land should not be subdivided into uneconomical sizes, and that those who farm the land own the land.

Holistic approaches to the food system. At the household level, on-farm processing and storage should be a major area of focus for purposes of minimizing post-harvest losses and enhancing food accessibility. At the macro-level, food security should be ensured through more efficient mechanisms of storage, distribution and pricing.

Linkages. Linkages between various agencies, organizations and disciplines are likely to ensure focused targeting and result in a greater impact while eliminating duplication of activities. Existing structures within the community such as self-help groups should be used as entry points wherever feasible, and community participation should become a practical reality.

Extension services. Extension personnel link directly with farmers, and are therefore crucial to bringing about needed change. In the area of food production, drought resistant indigenous food crops should be promoted. On the health and nutrition side, reinforcement and re-orientation towards an outreach community approach is required. School feeding programmes should aim to target the most needy and utilize locally available food items for cultural acceptability and cost effectiveness. Education of women should be a priority.

Employment. The root cause of hunger and malnutrition is poverty. Resource-poor people are unable to produce enough food to feed themselves and at the same time are unable to buy food from markets. It is important to develop the off-farm employment sector to enable the landless to earn incomes for livelihood.

Cash and food crop balance. Households need food but they also need cash. Farming households use their own produced food to achieve both, however if households use too much land for cash crops at the expense of growing food for their own needs, they will experience hardships and food insecurity.

With political goodwill and concerted efforts on the part of all Kenyans, household food security is achievable.

HOUSEHOLD FOOD SECURITY, GHANA - Rosetta Tetebo

Two major projects incorporating household food security components have been implemented since the ICN. The first is a UNICEF funded project which addresses community participation in development. The second is an FAO funded project on 'Promoting Household Food Security and Improving Nutrition through Nutrition Education and Training'. This examines the effects of processing and storage procedures on the nutrient quality of traditional and indigenous fruits and vegetables. This is a young project, but much is being learned from it. Other projects aim to minimize food wastage during processing and storage by developing new processing machinery for use by rural households.

Women's issues have become central since the ICN and there is increased support from both government and non-government sources to help women with food production and processing.

URBAN HOUSEHOLD FOOD SECURITY, MADAGASCAR - Jayshree Balachander

The Madagascar Food Security and Nutrition project is one of the most successful projects in the World Bank's portfolio on Africa. Since 1993, 28 000 children under five years of age from 300 000 families in two provinces (about 66% of the total number of children under five), have been weighed each month, and malnutrition rates have decreased from 46% to 37%. The nutrition element of this project consists of four components: a targeted nutrition intervention, a referral service for severely malnourished children, an iodization component and a microcredit component.

A community nutrition worker is selected from among the mothers and trained in growth monitoring of all children under five. Children identified as being severely malnourished are referred to rehabilitation centers for therapeutic feeding for up to three weeks, and support and nutrition education are also offered to mothers. The problem with this programme however, is that mothers cannot stay for long periods of time. The iodization component consists of capsule distribution and a long term salt iodization programme supported by UNICEF and the World Bank.

The final component is microcredit. Although not originally in the project, it became clear as the project progressed that this would increase both the level of interest in the programme and the effectiveness of the intervention.

	What are the success factors of this project?
·	Effective collaboration between the government and NGOs.
·	Capacity building through investment in training of community workers.
·	The quality of the community nutrition workers. Candidates were selected by the communities themselves according to their set criteria.
·	Community involvement in the selection of community nutrition workers and in the ongoing dialogue with the NGOs.
·	Government commitment.
·	Flexible project design allowing the NGOs to add inputs as necessary in response to community needs, whilst focusing on the core nutrition interventions.

Discussion by Eileen Kennedy

The three presentations highlight the complexity of household food security. Household food security is analogous to a picture puzzle: there are many pieces; some bigger than others and therefore contributing more to the puzzle, but all are needed to make the overall picture.

Three themes cut across the three country presentations; firstly the links between national level food security policy and household food security policy. Decisions at the household level that are motivated in part by macro policy, feed back into national level policy and cause a readjustment. It is a very iterative process - national policy affects household policy, which then loops back. These micro-macro linkages will continue to be important. A second theme is the importance of women's roles in household food security. One clear finding from the Ghana work is that in areas where women were actively involved in the design of the credit schemes, the schemes were more likely to be successful in raising women's income. The final theme is the link between household food security and broader issues such as nutrition education, targeting to women, social mobilization and rehabilitation.

FOOD SECURITY AND NUTRITION PROGRAMME, BENIN - Joyce Gbegbelegbe

From 1990-1994, the Benin government and the World Bank planned a pilot project that aimed to improve household food security through production and income generating activities. Results showed that stocking (reducing losses) and selling food crops promoted access to food in villages, and that the small development projects - building roads and bridges, increased movement and rendered food more accessible.

This pilot project resulted in a five year programme, which incorporates nutrition in addition to the household food security objectives. The nutrition component of this programme aims to reduce malnutrition through education and the empowerment of women to take charge of the problems in their village. Areas where food production does not cover the needs of the population are identified and targeted using national statistical data.

NUTRITION PROGRAMMES IN TANZANIA - Wilbald Lorri

Four major types of programmes are being implemented in Tanzania to reduce malnutrition.

The Child Survival Protection and Development Programme (CSPD). During the early 1990s, total malnutrition levels in areas implementing integrated nutrition programmes decreased from 50% to around 30% in children under five years of age, and severe malnutrition levels decreased from 6% to around 2%. Treatment of severely malnourished children in nutrition rehabilitation units however, does not prevent recurrence of malnutrition nor its appearance in siblings. In contrast, community-based nutrition rehabilitation, where treatment is carried out in the community, emphasizes the role of parents and community leaders. This results in a more sustained improvement of the rehabilitated child and other family members.

Severe Young Child Malnutrition in Six CSPD Programmes, 1984-1992

The National Micronutrient Malnutrition Control Programme. Separate programmes for prevention and control of iodine deficiency disorders (IDD), vitamin A deficiency (VAD) and iron deficiency anaemia (IDA) have been formulated. The IDD control programme consists of targeted distribution of iodized oil capsules, with universal salt iodization as the long-term goal. The VAD control programme consists of vitamin A capsule distribution and stimulation of demand for foods rich in vitamin A. The programme on IDA is mainly targeted at pregnant women and promotes the production and consumption of iron and folic acid rich foods.

The Nutrition Surveillance Programme. This is implemented at three levels. At the national level, the aim is to systematize data for use by national decision makers in the planning process; at the district level, the aim is to improve district capabilities to organize, analyze and communicate nutrition data generated from the community based systems; and at the community level, the aim is to empower communities to generate, organize and present nutrition-related data for decision making.

The Household Food Security Programme. This programme focuses on factors which affect food availability and stability of supply, economic and social accessibility to food, and food intake and utilization. A National Consultative Group on Household Food Security has been formed under the Tanzania Food and Nutrition Center to coordinate these activities.

Future action for improving the nutrition situation in Tanzania is presented in the context of the National Plan of Action for Nutrition. Experience in Tanzania indicates that success in nutrition is possible if there is the political will and commitment from the government, a mobilization of resources and the capacity to implement programmes.

COMMUNITY BASED NUTRITION PROGRAMMES IN NIGER - Jean Michel Ndiaye

The nutrition programme in Niger is built on a triple A approach (assessment, analysis, action), with emphasis placed on improving household food security, increasing self-empowerment of the villagers, and improving child care, feeding practices and access to health services. Working in 75 villages covering 80 000 people and including 17 000 children under the age of five, results have shown some success, but there are also lessons to be learned.

To achieve sustainable results, an integrated approach to community-based programmes has to be adopted. The legitimate concern of individual programmes is to be successful. This can lead to self-centered attitudes when resources are widely available, requiring integration when the situation becomes less enabling. The communities are tired with almost daily demands from each programme. There is donor fatigue, but there is also population fatigue. Deterioration of the financial situation, similarity of approaches and identical target populations should urge policy makers to develop community-based approaches capable of creating synergy among the various programmes. Activities need to be coordinated so that it is possible to:

· accelerate the achievement of national objectives;
· meet more adequately the needs expressed by the communities;
· rationalize the use of human and financial resources;
· create synergy amongst various
· programmes;
· implement broad-based strategies.

Discussion by Kraisid Tontisirin

It is necessary to re-emphasize the community-based approach, where people are involved in participation and become empowered by training. Extension services and social services are required to support communities. The roles of breastfeeding, and complementary feeding that can occur in households based on locally available foods should also be emphasized. A final point is scaling up the experiences which requires mechanisms at district, province and national levels.

EFFECTIVE PROGRAMMES FOR IMPROVING NUTRITION IN GHANA - Rosanna Agble

In the mid 1980s, a project was initiated to improve infant nutrition and weaning practices in Ghana. The project provided corn milling machines (donated by UNICEF) to over 50 communities for the production of an improved cereal and legume-based weaning food ('Weanimix'). Training was provided and a nutrition education component included in the programme. After several years of producing weaning food, another dimension was added to this programme to improve the income generation of the community. This involved using the income generated from the milling process to support other community-based activities.

Results show that more mothers are using the new weaning food, and maternal knowledge in basic nutrition is significantly better in project communities compared with control communities. There has been an improvement in household food security and nutritional status of children in these communities has improved.

Flow Chart for Weanimix Preparation

What lessons have been learned?

· The quality of the milling machines must be high and the rate of breakdown low to maintain interest.

· Collaboration between agencies and NGOs and defined roles for all is important.

· The communities who have benefited most from this project and who have achieved its objectives are those located far from urban centres.

· Womens' groups within the community manage the project. It is better to use existing womens' groups rather than to create new ones.

· A simple record keeping system to monitor progress is important.

· The frequency of supervision by the implementing agencies may affect the project. If this is done too often the community tend not to use their own initiative. If supervision is too sparse, it creates laxity in the community.

· The question of incentives for the various categories of people connected with the programme remains problematic.

COMMUNITY FOOD AND NUTRITION PROGRAMME, ZIMBABWE - Julia Tagwireyi

The Community Food and Nutrition Programme provides the framework for food and nutrition programme implementation in Zimbabwe. This programme started as a community-based child supplementary feeding programme following the destruction and displacement of communities during the independence war. It has since evolved into a community-based food and nutrition programme in which communities receive technical and resource support from a multisectoral infrastructure at national, provincial, district and village level. The programme has thus evolved from food relief to food production and has access to over a million people in some of the most food insecure and nutritionally at risk areas of Zimbabwe.

The programme involves several components. The group feeding component at pre-school day care centers emphasizes the use of locally available foods. The communal food production component initially provided bean and groundnuts to the communities, and this has since diversified. The nutrition education component looks holistically at the food and nutrition problems of communities and how the community can address these problems. Extension support is provided by the multisectoral training and education component, and the community-based growth monitoring and promotion component continues to reassess the targeting of the programme to vulnerable groups.

Programme achievements

During the 1992 drought - 'the worst in living memory' - over one million children received a daily supplementary meal through more than 20 000 feeding points in villages throughout Zimbabwe. The programme significantly reduced the number of hospital admissions for clinical malnutrition and improved the nutritional status of children receiving the supplementary meal. Several evaluations highlighted a high level of community awareness of nutrition. General extension support by key development sectors (agriculture, family planning, health education etc.) has been enhanced, and intersectoral collaboration has been facilitated. This has resulted in a demand for an institutional and policy framework to allow certain sectors such as agriculture, to play their role in food and nutrition in a meaningful way.

	What lessons have been learned?
·	Community level organizations are able to manage and implement cost effective nutrition interventions but the support mechanisms must be in place.
·	Programmes need to be flexible to allow for community innovation and variations.
·	Intersectoral action for food and nutrition is possible but there is a need to work on a specific activity with clearly defined and agreed roles for all the actors.
·	Investment in intersectoral training is crucial.
·	Targeting is more effective when all the data sources and information from different key sectors are combined.
·	Long term commitment and support from the government and donors is essential to allow programmes to evolve.

NUTRITION SURVEILLANCE AND INTERVENTION, SOUTH AFRICA - Robert Fincham

Under the apartheid regime there was no national framework for development in South Africa. Now, for the first time in South Africa, the government of national unity has provided a framework for development. This is a people-centred development strategy that calls for intersectoral collaboration and a vision for community involvement. Within this framework, the Department of Health has developed an integrated nutrition programme with a health-based component and a community-based aspect.

There is now a movement towards community-based programmes and nutrition surveillance. Although it is still early, there are some lessons that can be learned from these programmes:

· growth monitoring can be used to promote community-based surveillance, and to provide information upon which the communities can act;

· training, supervision and information dissemination is essential. It is also important to identify indicators to monitor success;

· building on existing infrastructure and capabilities within communities and linking up with NGOs and other organizations who have long standing relationships with the communities is essential;

· identifying and capitalizing on indigenous resources and capabilities within countries is important;

· there has to be political commitment.

Discussion by Sadia Chowdhury

All three presentations talk about how nutrition has been used as an entry point for much larger activities - in the case of Zimbabwe and Natal, it has been used for dealing with development of the community, going from a crisis situation into a much bigger issue. Nutrition should not be considered separately, but as part of an overall integrated development programme.

A clear message that emerged is the need for political will and support. This can be national, but it has to be local. In addition, there has to be continuity in support and a commitment from donors. The presentations also demonstrated that given the relevant support, community-based organizations and groups are capable of implementing and managing programmes.

There is no real stereotype of a successful programme, but flexibility, innovation and experimentation is very important. NGOs are in a very good position to do this, but require support and commitment by the national bodies, policy makers and donors. Finally, there is not enough sharing of experiences around the world. There needs to be more information dissemination through documentation of what works and what doesn't work. This dissemination needs to be done nationally, regionally and internationally.

VITAMIN A PROGRAMME, UGANDA - J. Sabiiti & D. Lwamafa

Baseline assessment surveys conducted in Kamuli District, Uganda, indicated high risk (50%) of Vitamin A deficiency (VAD) among children below 6 years. A VAD control project was initiated in Kamuli, which focuses on nutrition awareness building, nutrition education and training, diet diversification, high dose vitamin A capsule supplementation and food fortification. The specific objectives of the programme are to eliminate VAD as a public health problem among children below 6 years of age, and to serve as a pilot project to refine strategies and methods for addressing VAD nationally.

There is not enough sharing of experiences around the world. There needs to be more information dissemination... regionally, nationally and internationally... through documentation of what works and what does not work

Community participation is a major component of the programme and involves voluntary land donation, planting and raising seeds and seedlings for sale, and establishing household food gardens with foods rich in vitamin A. Although it is too early to conduct an impact evaluation assessment, there has been district-wide coverage of capsule supplementation and 15 demonstration gardens have opened.

	What lessons have been learned?
·	There is a need for baseline information and continuous monitoring and evaluation to assess progress towards the achievement of goals and objectives.
·	Political commitment is essential.
·	The availability of a national policy framework is crucial to guide action towards the elimination of VAD at district level.
·	A multisectoral approach greatly assists implementation.
·	The integration of VAD control with other ongoing public health programmes is beneficial because existing structures and personnel can be utilized.
·	Awareness building and nutrition education must be continuous to maintain interest and to achieve behavioural change in terms of food production, use, preparation, storage and habits.
·	Prevention of iodine deficiency and iron deficiency anemia can be addressed concurrently to promote delivery of a comprehensive package of micronutrient deficiency control.
·	Reliable donor commitment (in this case, UNICEF, Uganda) is essential.

SALT IODIZATION PROGRAMMES IN AFRICA - Festo Kavishe

The story of iodine deficiency disorder (IDD) control in Africa is one of success, and provides the best example of how Africa can make rapid progress in the area of health and nutrition. This progress is largely a consequence of affordable cost-effective technology and an unprecedented alliance between governments, the private sector and international agencies. The remarkable feature of the African story is the impetus towards universal salt iodization (USI). By the end of 1995, almost all of the 50 countries in Africa estimated by WHO to have a significant IDD problem were implementing IDD control programmes using iodized salt as the long term strategy. In February 1996 it was estimated that more than 50% of the salt consumed in Africa was iodized.

In addition to the rapid increase in salt iodization, indicators show that the proportion of households consuming iodized salt is also increasing. There is evidence that the increase in salt iodization is making a difference to the IDD situation in Africa. For example, the graph shows that the prevalence of goitre in three districts of Kenya declined rapidly after the introduction of legislation.

The achievement of objectives in terms of process (USI) and outcome (IDD elimination), capacity building and sustainability define success in IDD programmes. Success factors of salt iodization programmes in Africa can be grouped into four categories: international and national commitment; interagency, public and private sector collaboration; intensive capacity building (training to build up national human resource capacity); and strong networking.

Trends in Goitre Prevalence in three districts in Kenya, 1964-1994

There are indications therefore, that despite scepticism, the elimination of IDD in Africa may be a reality during the beginning of the next millennium. This will be a remarkable achievement in the area of public health and nutrition in Africa. Major challenges to complete and sustain USI will require sustained advocacy, resource mobilization and monitoring and evaluation.

Discussion by Ricardo Uauy

The presentation on iodization and conquering iodine deficiency in Africa is a good example of how international agencies and local catalysts are inducing change, and how this has been translated into regulation and legislation.

The need for local capacity must be emphasized. Local capacity not only to implement programmes but also to analyze them and took for innovative solutions. The local autonomy that we are looking for depends not only on the applied research and training, but also in building institutions. In the case of vitamin A, the approach taken in the Ugandan programme of using food diversification and using specific intervention, is appropriate. In other settings, the use of fortified foods is one of the most practical ways of controlling micronutrient deficiencies.

How do we elicit political will and bow do we get governments to act? The commitment of governments is essential to see long term and sustained solutions. The way to obtain government commitment is related to the way governments work-a government's priority is not only to serve the country, but also to be re-elected. Chile. Costa Rica and Cuba provide good examples of how to get government commitment. In all these countries through various political regimes, a key factor in getting commitment is having nutrition as a political issue. In the Chile election of 1970 for example, the government was elected after saying, amongst other things, that every child will have half a litre of milk.

We cannot neglect the interface between the role of local institutions, governments and universities. If we over-emphasize NGOs, who may be very effective in implementing and managing programmes, the governments may not take responsibility for the issue. The role of the NGOs and universities should be to create linkages between governments and communities. The role of the international donors is justified only if there is no local institution, and their role, rather than to interact with government community is to support the local catalyst. No amount of international cooperation will do what the local communities and institutions need to do. Partnership means being able to work together, but the definition of what needs to be done should be defined by the local institutions. If international agencies take over this process then there is less likely to be local commitment. One of the ways this process can grow is by the international donors requiring that in any project there is a counterpart that is also investing and is building up the sustainability of the project. There should be a commitment from local governments - it is up to the local institutions, the NGOs and the universities to be more demanding in this role and only in this way can there be success and a sustainable effect.

WEST AFRICAN NUTRITION NETWORK - Kwadwo Okyere

SADAOC is the French acronym for sustainable food security in Central West Africa. It is a network that addresses food security issues at a sub-regional level. Recognizing the need for a broader approach oriented towards sustainability, the Netherlands Ministry for Development Cooperation in 1989 initiated the creation of a multi-disciplinary alliance of research institutes, universities and government institutes to embark on food security research with emphasis on sustainable development. The initiative is unique in that it defines a joint responsibility of researchers and policy makers for research findings, and the application and implementation of the research recommendations.

The biggest achievement of SADAOC is its contribution to capacity building and institutional development for food policy in West Africa. Capacity for analytical work has been enhanced through the provision of training, development of data banks, and appropriate research methodologies. Research links have been established and the initiation of dialogue among policy makers through the activities of a food policy management group, has promoted discussion on sub-regional issues.

The second phase of SADAOC has now started. The primary aim of SADAOC 2 is to contribute to the design and implementation of national and sub-regional policies for sustainable food security through the strengthening of institutional and research capacity and coordination.

REGIONAL TRAINING NEEDS IN ECSA COUNTRIES TO IMPROVE NUTRITION PROGRAMMES - Catherine Siandwazi

The activities of ECSA (East Central and Southern Africa) are coordinated from the Commonwealth Regional Community Health Secretariat, located in Arusha, which covers 14 countries in southern and eastern Africa. The programme focuses on capacity building to plan, implement, manage and monitor food and nutrition programmes. This is done using training, research, policy advocacy, networking and information dissemination and communication. Some achievements of ECSA include raising regional awareness and setting up nutrition units in appropriate ministries.

In 1991 and 1995, training needs assessments were carried out. Results showed that there were inadequate training opportunities to meet staffing needs, inadequate or inappropriate training content, a lack of training resources and materials, a lack of training standardization in ECSA, and a lack of training fellowships. Countries also reported poor linkages between training and programme management and limited training in programme planning and management.

Several recommendations were proposed to address these problems. It was proposed that modules in pre-service training institutions be strengthened - for example, breastfeeding modules should be incorporated in medical school, nursing school and nutrition training institution curricula. In addition, a long list of training areas and linkages between different organizations has been developed with the aim of linking up research issues that address programme needs.

REVERSING NEGATIVE NUTRITION TRENDS IN AFRICA - Richard Heyward

In Sub-Saharan Africa, with a population of some 600 million people, the nutrition situation is not improving. Nearly 40% of the population is undernourished as measured by dietary energy supply. Forty-two percent of children are stunted and 30% are underweight. Iron deficiency anaemia is widespread, with some 40% of women and children and 25% of men affected, making a total of around 235 million. Iodine deficiency affects around 175 million people and 21 million people are at risk of vitamin A deficiency¹.

¹Editor's note: In January 1997, WHO's Division reported that the estimated population with iodine deficiency disorders in the Africa Region, as of January 1997, is 145 million (23%). Source: Elimination of Iodine Deficiency Disorders in South-East Asia. WHO. New Delhi. 1997.

Possible reasons for the neglect of nutrition · The emphasis has been on the young child and this may have led to the misconception that nutrition is not a problem of the general population. · Decision makers do not see good nutrition and nutritional improvement as a contribution to productivity, poverty reduction and national development. · It is not widely known that there actions readily available. The opportunities offered by the enormous number of community associations and existing community structures are not used. The small scale successes are not well documented and widely reported. · Linkages with other major national problems which countries are facing are not seen.

What can be done? African countries can improve the nutrition of their populations through macro-policy and programmes, and through community-based activities using existing channels, for example, in the sectors of rural development, agricultural extension, health education and women's affairs. In view of economic and financial constraints, it is unrealistic to plan on a substantial increase of central government budgets, or on a separate service for nutrition. Improvement in nutrition should be seen as a factor of development with emphasis on households and communities taking responsibility for their own development. With the support of services that exist but often need strengthening, households and communities can improve their nutrition by actions in the fields of household food supply, eating practices, health and household care. There is little new in these activities; what is relatively new is the process by which communities undertake them. Africa has a wealth of community associations that can become a channel for community responsibility. For communities to become more active in the field of nutrition there is also a need for advocacy, guidance, and technical support.

The costs of adding a nutritional component to existing services are estimated to be some $1 000 million per year in Sub-Saharan Africa - a relatively small amount in relation to government tax revenue. To extend those services is more costly - some $9 000 million. However, the nutrition component would make the sectoral services more effective, and would bring a return in savings and benefits that would far exceed the costs.

External agencies can give valuable support to this community-based movement by contributing to capital and start-up costs, especially orientation and training, transport and other material aid. This implies some changes in their mode of operation: discussions need to be held at the district level as well as at the ministry level, and a degree of flexibility has to be adopted to adapt to community priorities and needs.

Action that Households and Communities can Undertake to Improve Nutrition Household food supply - better methods and inputs for cultivation; a return to more drought-resistant cereals; cooperative purchases of inputs and basic necessities, cooperative marketing of crops; better access to credit and land for women; better annual management of food supplies, especially in areas with a long dry inter-crop season; better methods of conservation; cereal banks Eating habits - diversification of diet - more groundnuts, beans and other vegetables, fruits and small livestock products; changes in eating practices; more frequent feeding of young children and use of enriched gruels incorporating germinated cereals; use of iodized salt; use of iron pots for cooking (against anemia) Health - birth spacing, deworming, immunization, protection of breastfeeding; community growth promotion and child weighing; use of latrines, use of safe water or disinfection of water; handwashing especially before meals; protection against malaria-vector mosquitoes and treatment of malaria Household care - increasing literacy and numeracy, reducing the excessive workload of women by use of more labour-saving equipment, greater participation of men, community production of complementary (weaning) foods.

The following steps could be taken by external agencies to increase their support to nutrition in Sub-Saharan Africa.

· Help national opinion-makers and decision-makers to recognize the nutritional state of the population as a major factor of national development as well as of individual well-being. Use nutrition as an overall indicator of social development ranking alongside GNP as an indicator of economic development.

· Help countries to reach a broad consensus on a conceptual framework.

· Encourage community responsibility and community-based actions prepared with prospects for sustainability.

· Advocate and if possible incorporate an appropriate nutritional content in their county programme cooperation, using all available opportunities.

· Modify if they have not already done so, the mode of programming that they recommend and assist, to include the district level as well as the capital.

· Make their plan of cooperation more flexible than a "blueprint" so that account can be taken of community priorities and readiness to participate, and of annual planning in districts.

· Encourage a more integrated, holistic approach by different services and their supporting agencies from the district to communities. This is easier for countries to do at the district level than at the centre, but as much central support as possible should be sought.

· Encourage communities to set service and impact targets for themselves, to strengthen the capacity of their associations to monitor them, and to arrange for the aiding of their operations.

· Support orientation and training, operationally-oriented, with emphasis on the training of 'practitioners' as discussed in Bellagio, 1994.

· Support operationally-oriented research.

We would like to thank Ruth Oniang'o (Jomo Kenyatta University; AGN member), Lilian Marovatsanga (University of Zimbabwe; AGN member) & Bill Clay (FAO) for their helpful comments during the preparation and editing of this report.

Summary of the Symposium "Effective Programmes in Africa for Improving Nutrition, Including Household Food Security The fourteen presentations from different parts of Africa, together with lively discussion, showed conclusively that programmes properly prepared and implemented, with strong community participation, could bring about rapid improvement of nutrition. Seven cross-cutting themes emerged from the presentations and discussion: · Community involvement and participation · Capacity building · Necessity of long-term investment · Scaling up: expanding small successes · Necessity of intersectoral and inter-agency collaboration and action · Networking and regional cooperation · Advocacy and raising awareness on nutritional issues at all levels. These themes were presented in detail in SCN NEWS No. 14.

Further information about the Symposium presentations may be obtained by contacting the participants:

Ruth Oniango, Food Science & Nutrition, Jomo Kenyatta University College of Agriculture and Technology, P.O. Box 62000, Nairobi, Kenya. Tel: 254 151 22646/9 Fax: 254 151 21764 or 254 2 631200 Email: oniango@form-net.com

Rosetta Tetebo, Ministry of Food and Agriculture, P.O. Box M 37, Accra, Ghana. Tel: 233 21 662253 Fax: 233 21 665282

Jayshree Balachander, World Bank, 1818 H St NW, Washington DC 20433. Fax: 202 477 2900 Email: jbalachander@worldbank.org

Eileen Kennedy, Center for Nutrition Policy and Promotion, US Department of Agriculture, 1120 20^th Street, NW, Washington DC 20036, U.S.A. Tel: 202 418 2312 Fax: 202 208 2321 Email: eileen.kennedy@usda.gov

Joyce Gbegbelegbe, Nutrition Officer, PILSA, B.P. 06438, Cotonou, Benin. Tel: 229 330905 Fax: 229 33 48 88

Wilbald Lorri, Tanzania Food and Nutrition Center, P.O. Box 977, Dar-es-Salaam, Tanzania. Tel: 255 51 41280 Fax: 255 51 44029

Jean Michel Ndiaye, UNICEF, WCARO, B.P. 3420, Ouagadoudgou, Burkina Faso. Fax: 22 6 314 779

Kraisid Tontisirin, Institute of Nutrition at Mahidol University, Salaya, Phutthamonthon, Nakhon Pathon 73170, Thailand. Tel: 662 441 9740 Fax: 662 441 9344 Email: directnu@mahidol.ac.th

Rosanna Agble, Ministry of Health, Nutrition Unit, P.O. Box M78, Accra, Ghana. Tel: 233 21 665500/662778

Julia Tagwireyi, Nutrition Department, Ministry of Health, P.O. Box 1122CY, Causeway, Harare, Zimbabwe. Tel: 002 634 792454 Fax: 002 634 791169/702293/793634/792154

Robert Fincham, Coordinator, Community based nutrition surveillance programme, University of Natal, Faculty of Science, Department of Geography, Provate Bag X01, Scotsville, Pietermaritzburg 3209, South Africa. Tel: 331 260 5341 Fax: 331 260 5344

Sadia Chowdhury, WHDP, BRAC, 66 Mohakhali C.A. Dhaka, 1212, Bangladesh. Tel: 8802 600106/7 Fax: 8802 883 542 Email: hpd@bdmail.net

J. Sabiiti, Ministry of Health, P.O. Box 8, Entebbe, Uganda. Fax: 256 42 21112

Festo Kavishe, UNICEF No. 11, Street 75, Sraschark Quartier, P.O. Box 176, Phnom Penh, Cambodia. Tel: 855 23 426 214 Fax: 855 23 426 284 Email: unicef_phnom_penh@unicef.org

Ricardo Uauy, Institute of Nutrition and Food Technology. University of Chile, Casilla 138-11, Santiago, Chile. Tel: 56 2 221 4105 Fax: 56 2 221 4030 Email: uauy@abello.dic.uchile.cl

Kwadwo Okyere, Chairman, SADAOC, Institute of Statistical, Social and Economic Research, University of Ghana, Legon, Ghana.

Catherine Siandwazi, Food and Nutrition Programme, Commonwealth Regional Health Community Secretariat for East, Central and Southern Africa, P.O. Box 1009, Arusha, Tanzania. Fax: 255 57 8292

Richard Heyward, c/o UNICEF, 3, United Nations Plaza, NY 10017. Fax: 212 326 7758.