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DE-EMPHASIZE NUTRITION GOALS AND TARGETS IN NUTRITION WORK: NOW Paul Arthur |
Global targets ignore inter-country and regional differences in the burden of the problem. Typically, they aim at single, but often gigantic leaps (i.e. to eliminate, control or half the problem), as opposed to going for more pragmatic, incremental and sustainable approaches to overcome the problem. It is assumed that the most obvious indicators for measuring progress are those that relate to the outcome, and rarely do they measure the processes that determine those outcomes. By highlighting outcomes, we ignore the contribution wider social, cultural and economic factors and forces make to the genesis of these problems, and thus can be found guilty of undermining the development of integrated sustainable programme approaches.
To keep programme actions focused, these goals must by necessity address very specific nutritional problems. So what is a ‘problem’ gets largely defined as a result of the strength of the international lobby convincing local public health nutritionists about the importance of their narrower specific areas of interest. The list of priority areas for intervention thus grows, not in response to the actual status of key problem areas in the affected countries, but in response to going along with the international scientific community.
Donor pressures, overt or subtle, force countries to respond to the calls for action. The resulting human and material resources shifts disrupt previously planned programmes of work, and undermine gradual and more sustained improvements in overall nutrition.
Where does this put us? The international nutrition community needs to realign its thinking and address overall nutrition deficits and their multi-layered determinants, as opposed to piling up single-problem approaches. This is highlighted by the fact that, in low income settings, except in very adverse ecological regions, it is unlikely that single nutrient deficiencies will occur in the absence of an overall nutrition deficit.
There are several related questions that need to be addressed:
· How can we more proactively incorporate the wider contextual issues that are relevant to nutrition during our discussions in international fora when they set the agenda for country programmes?Ironically, I am of the opinion that demphasising the current goals and targets would be the best way to reach those ‘other’ goals and targets I am talking about.· How can we articulate goals and targets that reflect such a realignment without losing the emphasis on nutrition?
· How can goals promote nutrition more as an investment in human development, deemphasising health and nutrition status outcomes?
· How can we ensure that donor countries buy into the longer term programme plans of recipient countries instead of attempting to reshape such plans to match the global goals?
Paul Arthur is Director of the Kintampo Health Research Centre, Ghana. Contact: parthur@ghana.com
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NEEDED: MORE EMPHASIS IN USING FOOD-BASED STRATEGIES TO IMPROVE HUMAN NUTRITION Shakuntala Haraksing Thilsted |
The focus on staple foods was well warranted. However, though important for contributing energy and nutrients, staple foods are not the only foods eaten. Small amounts of other foods such as vegetables, fish, pulses, fruits and spices are also consumed. These commonly consumed foods make up an essential part of the everyday diet and should play a much larger role in food-based strategies and the setting of goals. Focus on these foods is opportune as the thrust on grains has detracted attention from them and their production has diminished. In Southeast Asia, as the area under rice has increased, pulses are now grown on a smaller area and their production has fallen significantly.
Increasing access to these habitual foods for poor population groups is thus a goal that should be explicit in food based strategies. To achieve this, these foods first need to be identified and given the status and priority they deserve. In Bangladesh, fish is acknowledged as a food commonly consumed by the poor in their everyday diet, but efforts have been focused on increasing the production of large fish. This has not benefited the poor who eat small fish. Knowledge of this consumption pattern should lead to strategies that promote and enhance the production and consumption of small fish. In some countries, wild foods such as vegetables, fruits and animals are commonly consumed, greatly contributing to vitamin and mineral intakes. Therefore, strategies that promote and protect common property areas are important to ensure the continued access of such wild foods to the poor. Also, knowledge of the importance of these foods in the local food culture, as well as their nutrient density, is necessary in order to set specific goals regarding which foods should be given greater priority and how the areas where they are grown should be protected and managed.
Sound food based strategies must be firmly grounded in the food culture and meal pattern of the specific population group. Strategies that target only foods eaten during meals and not also those eaten outside meals can limit the effect of food based strategies. In some parts of the world, the largest proportion of nutrients such as fat, vitamins A and C are supplied from foods eaten between meals and consumed out of the house. Furthermore, seasonality of food intake is a common feature of food intake in developing countries. This should also be considered in food based strategies. Greater production and consumption of high-yielding vitamin A-rich fruits can build up needed vitamin A body stores. Breeding of new varieties that can increase off-season production of such foods can offset seasonal reductions in nutrient intakes. In addition, nutrition education, focused on promoting positive perceptions of foods in relation to health and nutrition, as well as beneficial local habits and customs must be made an integral, quantifiable goal in the strategies to be chosen.
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Strategies that target only foods eaten during meals and
not also those eaten outside meals can limit the effect of food based
strategies. |
It is generally accepted that animal foods are expensive and, therefore are not commonly consumed by the poor. In many Southeast Asian countries, small fish and other aquatic animals are an important part of the everyday diet of the poor and contribute considerably to the intakes of animal protein, iron, vitamin A, calcium and zinc. Recent studies have shown that calcium bioavailability from small fish eaten with bones is as high as that from milk. No inclusion of these foods in food based strategies has been made in spite of the fact that they are well liked, are relatively inexpensive, are frequently consumed, have high nutrient density and increase nutrient bioavailability.
In many developing countries, there are definite quantifiable targets for the annual supply of staple foods to be achieved at the national level. These targets are effectively used to direct strategies and set explicit goals with respect to productivity and other measures to ensure that the national supply is met. With respect to other commonly consumed foods, there are some general policy guidelines regarding increased overall production, but rarely are there strategies and goals set. The World Summit for Children in 1990 set specific nutritional goals regarding quantifiable reductions in single nutrient (iron, iodine and vitamin A) deficiency within a specific time frame. This enabled the formulation and implementation of supplementation and fortification programmes with defined strategies and goals. In the two conferences which dealt with food, the International Conference on Nutrition in 1992 and the World Food Summit in 1996, no specific goals were set with respect to foods, only broad policy guidelines regarding the overall role of foods in improving nutrition and food security. This may have contributed to the lack of specific direction and goals in food based strategies.
Even though one can agree that all food based strategies should have an overall long term goal of improving human nutrition, there is an urgent need to quantify goals in this area, giving specific time frames with respect to supplies, access and intakes of specific foods consumed by the poor. This is an important missing tool to enable the formulation and implementation of programmes at different levels with the aim of achieving better defined targets within food based strategies.
Shakuntala Haraksing Thilsted is at the Veterinary and Agricultural University, Denmark. Contact: sht@kvl.dk/thilsted@bangla.net
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THE ROLE OF NUTRITION GOALS AND TARGETS: Point/Counterpoint - Usha Ramakrishnan and Jay
Ross |
Usha Ramakrishnan
Goals are extremely important for advocacy; they spur policy makers to action. However, negative repercussions are not infrequent in the interpretation and implementation of goals; therein lies the bigger challenge. The desire to obtain results in a short time span typically brings about the pursuit of short-term and easy-to-attain approaches whose successes often are short-lived. Effective planning thus requires short, medium and long-term goals.
Let’s take vitamin A deficiency disorders. The causes of VADD are rooted in poor diets and infection, both typical of poor environments fraught with inequity. The availability of an effective and feasible technical intervention, namely high dose vitamin A supplements, has resulted in the promotion of vertical approaches that rely heavily on donor-dependent supplies and on the existing health infrastructure. No doubt, coverage has increased with considerable external funding and commitment; but what is not clear is whether these short-term successes are sustainable or will be reversed. Weak decentralisation policies and dwindling support for already overburdened health infrastructures in poor countries make these successes vulnerable. The other major concern here is donor fatigue, which further raises issues of sustainability, especially since the underlying and basic causes of the nutrition problem are most often not addressed.
Some nutritional problems, such as child malnutrition and nutritional anaemias, are simply not amenable to be solved overnight and require more comprehensive and sustained interventions. Goals for such problems have not been realistic and have not provided the solutions for success which typically rely on much broader approaches.
Therefore, less attention is paid to the more “intractable” problems such as iron deficiency and low birth weight since they are considered more complex and in need of interventions at all causal levels and over longer time frames, even generations.
Another pitfall is that goals may encourage the pursuit of single ‘short-cut’ intervention strategies. This in turn promotes an unhealthy competition for scarce resources between vertical nutrition programs, when more comprehensive/horizontal approaches may be more beneficial. For example, food based approaches that improve dietary quality overall and/or multi-nutrient supplementation have the potential of reducing more than one single nutrient deficiency.
Finally, goals tend to be general and often fail to address important specific issues such as priority setting and targeting of key interventions especially in resource limited settings. Goals are important, but should be implemented using a balanced approach that combines effective and proven interventions with strategies that will empower communities and strengthen health services delivery.
IN DEFENSE OF THE USE OF TARGETS IN NUTRITION POLICY ANALYSIS AND ADVOCACY
Jay Ross
One of the reasons for the relative neglect of nutrition in development programmes is the difficulty in making nutrition problems “real” for decision-makers, especially those outside our field. Apart from their most severe manifestations, nutrition problems are not generally visible or apparent to their victims, to health care professionals and to policy makers. There is, therefore a widespread lack of appreciation of the extent of malnutrition and the damage it does to health, survival, human capacity and thus development.
The use of nutrition targets alone cannot address this problem. For example, the policy maker who does not see that sub-clinical vitamin A deficiency is a problem may not be enlightened by the knowledge that it affects, say, half of all children in the population. And reduction of an invisible problem is also invisible. However, if this reduction can be translated into terms that the policy maker can recognise and understand - such as child mortality or illness - then both the consequences of malnutrition and the need for improving nutrition jump into focus. Although virtual elimination of vitamin A deficiency disorders may be an unrealistic target, depending on the situation and the time frame, it can still be used to quantify the hypothetical benefits of nutrition improvements in functional terms that programme planners and policy makers care about, thus providing a clear incentive for action. Quantifying potential benefits implies quantifying both the extent of the problem and its potential improvement. For this purpose, targets are absolutely necessary; they set the potential improvement.
A more obvious benefit of targets in policy analysis and advocacy is that they provide what the word literally implies: results to aim for and a measure of achievement or lack thereof. The recent trend towards results-based management are based on the same principles. Keeping measurable results in sight helps planners, managers and policy makers maintain their focus on activities that achieve those, i.e. more effective activities are favoured over less effective ones; diversions are more easily avoided. At the end of the day, targets provide a measure of accomplishment or lack thereof.
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Nutrition problems are not generally visible or apparent
to their victims, to health care professionals and to policy makers... reduction
of an invisible problem is also invisible |
The bottom line of this counterpoint is that, as a means of quantifying the potential benefits of nutrition improvements in terms that policy-makers will appreciate, and as a guide for action, as well as a means of measuring success, targets have an important role in nutrition policy analysis and advocacy.
Usha Ramakrishnan is Assistant Professor at the Rollins School of Public Health, Emory University. Contact: uramakr@sph.emory.edu
Jay Ross is with LINKAGES, Academy for Educational Development. Contact: jayross@aed.org
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Progress in Bangladesh towards the goals of the 1990 World Summit Using data collected in rural areas over the last decade, the Nutrition Surveillance Project (NSP), has reported that vitamin A deficiency among preschool children and child undernutrition rates have steadily declined in Bangladesh. However, at the end of the decade, a large percentage of children in rural Bangladesh were still stunted (55% down from 71% in 1991) and underweight (61% down from 72%), and more than half of women and children were anaemic. Many infants were not exclusively breastfed for long enough and were not given complementary foods at the right age. Clearly, more needs to be done. The review highlights the importance of having a good quality surveillance system to monitor these indicators. Without it, nutritional targets have little, if any, meaning. Contact: Dr Andrew Hall, HKI Bangladesh at
cd@hkidhaka.org |
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NUTRITIONAL TARGETS - UNREALIZABLE WITHOUT REDUCTION IN INEQUITY Michael Latham and Micheline Beaudry |
Over the last decade, several international conferences endorsed ambitious goals to reduce malnutrition by the year 2000. Most of these targets were not met. In 1992, at the International Conference on Nutrition1, all governments endorsed the goals of the 1990 World Summit for Children including the one halving the 1990 prevalence of underweight in young children2 and substantially reducing anaemia by the year 2000. Was setting these goals not disingenuous, and even a hindrance to progress, when these documents do not set targets, and suggest actions to (also) reduce inequity? Did endorsers not know that unless effective steps were taken to improve equity, the prevalence of underweight children was unlikely to be markedly reduced, and anemia would probably not be controlled, especially in South Asia and Africa where these problems are most prevalent?
Unless effective actions are designed to improve equity, stated goals to reduce undernutrition are empty promises. The inequity does not only manifest itself as a widening gap in incomes, but as gaps in access to education; to reasonable health care; to food security; to information; to clean water; to a sanitary environment; and more. Furthermore, inequities are often related to gender and even to social background or caste.
The goals and targets set in international conferences, and approved by governments North and South cannot possibly be achieved without improving equity and addressing some of its external causes such as globalization as it has been practiced; the current world economic order that is rigged against the powerless; the increasing power of transnational corporations increasingly merging into global oligopolies; the negative impact of structural adjustment and WTO rules; and the resulting weakening of national governments.
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Unless effective actions are designed to improve equity,
stated goals to reduce undernutrition are empty promises. |
It is recognized that progress has been made to reduce the prevalence of both iodine deficiency disorders, and vitamin A deficiency without paying attention to inequity. But sustainable control of vitamin A deficiency using measures to improve dietary diversification will also require improved equity.
We distinguish between equity and equality. Attempts to improve equity seek to reduce gross inequalities. The late President Nyerere of Tanzania put it this way: “No man needs to live in a palace, no man should live in a hovel”3. Why haven’t we produced the statistics focusing on the degree of inequity in different countries?, and where are goals and targets to reduce inequities to be found?
STRUCTURAL INEQUITY
Take the puzzling fact that prevalence rates of malnutrition (rate of underweight in underfives) continue to be higher in South Asia (44%) than in Sub-Saharan Africa (around 36%)4. Anaemia is equally more prevalent. Why does a country like India - the world’s largest ‘democracy’, now a nuclear power, with a thriving economy and reasonable industrialization, with a flourishing dot.com industry, and an agricultural system that has made the country self-sufficient in major staple foods - have higher rates of malnutrition than many African countries lacking all, or most of these attributes? Without doubt, inequity plays a very important role.
Two forms of inequity are much more marked in India than in most African countries. These are gender and caste related inequities which India has too easily shrugged off as ‘cultural’ characteristics. It has been suggested that differences in malnutrition rates between South Asia and Africa lie in gender related control over production and consumption, and differences in the degree of care which children receive from their mothers5, as well as the care mothers get during pregnancy and lactation.
Discrimination, and therefore inequity, on the basis of gender is very evident still in many parts of India where females are discriminated against from the womb to the tomb; where we see alarming rates of abortion of female fetuses, female infanticide, wives totally subservient to their husbands, and as widows, to their husband’s families. Many women have little control over the products and income they generate through their own labor. But another ‘culturally related’ cause of inequity also contributes to malnutrition: the one associated with discrimination against persons of low caste, a form of apartheid now outlawed in South Africa. We know it contributes to serious malnutrition in the affected population.
INCREASING INEQUITY AS A RESULT OF GLOBALIZATION
According to the 1999 UNDP Human Development Report6, more than 80 countries still have per capita incomes lower than they had a decade or more ago and 55 countries have had declining per capita incomes. The income gap between the fifth of the world’s people living in the richest countries and the fifth in the poorest was 74 to 1 in 1997, up from 60 to 1 in 1990 and 30 to 1 in 1960.
We have to ask ourselves: Is economic advancement dependent on a dismantling of free, or subsidized, social services such as education and health services, and the rejection of participatory democracy?7 Norway is one country that has maintained social democracy in the world of globalization, and it has done so quite successfully8. Cannot developing countries raise themselves out of poverty, attempting to improve their national economies, at the same time recognizing the importance of improved equity especially in terms of access to nutrition, education, health care and other services? Again, here the lessons to be learnt should come from policies adopted in Kerala, Sri Lanka and Cuba.
Globalization is being offered as the answer to improving the economies of poor countries. Yet so far it is often increasing inequities and reducing poor nations’ ability to achieve national/local food and nutrition security. It is important that nutrition scientists study these issues and work with activists in other fields to reduce such inequities, to oppose the growing negative impacts of current forms of globalization so far and to reign in the power of transnational corporations (TNCs). One important avenue is to support and get involved in the growing movement to universalise human rights. Such activism has in the past achieved some successes, most notably in countering the unethical promotion of breastmilk substitutes9.
The 1999 Human Development Report describes the WTO as: “the first multilateral organization with authority to enforce national governments’ compliance with rules”6. In Seattle, a public outcry slowed WTO’s attempts to strengthen its own power, to the detriment of developing countries.
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...it is by and large true that having ambitious goals to
reduce malnutrition serves to make leaders feel comfortable... Few want to rock
the boat and come out with statements that these are unrealisable targets - they
cannot be reached unless we improve equity. |
If we really hope to see hunger and malnutrition reduced and overcome worldwide, we need to join, and be active, in this new coalition. Those who state that nutritionists should not politicize nutrition problems or solutions are, by so saying, supporting the status quo. And that is a political statement. But such a status quo is morally unacceptable; it invariably leads to more inequity, more food insecurity and more malnutrition.
TRANSNATIONAL CORPORATIONS AND THEIR CONTRIBUTION TO THE WEAKENING OF THE STATE
Globalization, structural adjustment and free trade regulations have in the last quarter century weakened the power of many states; and this often in nations which only took up Western capitalism during this period. Many elected governments have increasingly lost the ability to fulfill their obligations (and their promises) to their electorate as economic and political power become entrenched in a small network of interest groups often led by TNCs whose vast resources can ‘influence’ politicians, government officials, the military, academia, aid agencies and others. The ethics of this influence is more often than not questionable.
Large corporations have influenced the public sector along the lines of their global interests and have weakened governments both North and South. The bargaining power of labor has been eroded: “Workers are being pitted against workers, and communities against communities as companies relocate from one country to another in search of new markets, the weakest unions, the most flexible rules on working conditions and the largest subsidies. The time has come to press for an economy that protects people not corporations”10.
The 15 largest TNCs (such as GM, IBM, Shell, Microsoft, Nestlé, etc.) have gross incomes larger than the GDP of over 120 countries, including all countries in Africa11. Close to two-thirds of world trade is controlled by TNCs. The giant firm Cargill controls 60% of world grain trade.
The “battle for the control of the world food system is now being waged, and its chief combatants are agribusiness and the state... the odds are depressingly in favor of agribusiness”12. Actions by ever larger TNCs impose uniform diets and tastes, reduce biological diversity, ignore local and national cultures, and damage local environments.
Where and how do we see the comparatively narrow nutrition goals and targets affecting this state of affairs?
In 1997, the SCN appointed an international Commission on the Nutrition Challenges of the 21st Century. One reason was to examine why goals set at several UN meetings to reduce malnutrition by half by the year 2000 had not been met. Our belief was and is that current forms of globalization, the increasing power of TNCs and the parallel weakening of the state are major causes of continuing high rates of food insecurity and malnutrition worldwide. The Commission requested us to write a paper expressing these views. In this paper, and in subsequent fora, we forcefully raised concerns about these issues. The Commission’s final report13 did not give prominence to our views.
CONCLUSIONS
For sure, it is by and large true that having ambitious goals to reduce malnutrition serves (mainly) to make leaders (and people) feel comfortable, because they are voting for something ‘good’. Few want to rock the boat and come out with statements that these are unrealisable targets - they cannot be reached unless we improve equity. So, together with those we purport to serve, we should be advocating for an additional set of more revolutionary policies that offer realistic chances to reduce inequity. If we, as nutritionists, are committed to really achieve major reductions in undernutrition and anemia we need to also be involved in activities to curb the many negative aspects of globalization and get directly involved in actions that improve equity, that change the current unfair economic order and that promote the universal respect of human rights, including rights to adequate food, health and care.
Acknowledgements
Three previous papers by the authors have been extensively used for the writing of this piece.
References
1. Bloom BR (1999) The Spread of Depression: Public Health Trends. International Herald Tribune, December 3.
2. Gillespie S, Mason J, Martorell R (1996) How nutrition improves. ACC/SCN Discussion Paper No. 15. ACC/SCN: Geneva.
3. Nyerere J (1982) The economic challenge: Dialogue or Confrontation? in Five Years of CCM Government - address given to the National Conference of CCM. Government Documents, Dar es Salaam, Tanzania.
4. ACC/SCN (2000) Fourth Report on the World Nutrition Situation. ACC/SCN: Geneva.
5. Ramalingaswami V, Jonsson U, Rohde J (1996) The Asian Enigma. Progress of Nations, UNICEF, pp. 10-17.
6. UNDP (1999) Human Development Report 1999. United Nations Development Program: New York.
7. Latham MC and Beaudry M (2001) Globalization and inequity a determinant of malnutrition: a clear need for activism. Ecology of Food and Nutrition, in press.
8. Elliott L (1998) Norway manages to keep the faith. Guardian Weekly: UK, April 12, p 19.
9. Latham MC (1997) Breastfeeding - a human rights issue? International Journal of Children’s Rights, 5:397-415.
10. Anon (1992) Power: the Central Issue. Editorial. The Ecologist, 223:157-164.
11. Marten (1996) From the many to the few: Privatization and globalization. The Ecologist, 26:145-155.
12. George S (1988) A fate worse than debt. Grove Press: New York, NY, 292 pp
13. Commission on the Nutrition Challenges of the 21st Century (2000) Ending Malnutrition by 2020: An agenda for change in the Millenium. Final report to the ACC/SCN. Food and Nutrition Bulletin (Suppl) 21:3-88. [See p. 53 for a review of this report. Copies can be obtained from the SCN Secretariat]
Michael Latham is Professor of International Nutrition, Cornell University. Contact: mcl6@cornell.edu
Micheline Beaudry is Professor of Public Nutrition, Université Laval. Contact: micheline.beaudry@aln.ulaval.ca
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What do you think? We welcome your comments. Write to us at: accscn@who.int |
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SHOULD NUTRITIONISTS GET RID OF POLITICIANS? Tonia Marek |
The 20th century is gone and we have to admit we failed to save millions of children from malnutrition; this, in spite of the fact that we knew exactly what to do and how.
We simply failed to put nutrition on the agenda of presidents, of ministries, of community leaders and of international organisations. We only succeeded in having leaders pay lip service to nutrition. We only managed to implement a few successful nutrition programs. We did achieve some decreases in malnutrition rates in Latin America and Asia, but what we did was far from enough. One in three children in the countries in the South is still malnourished, and in Africa malnutrition rates are actually increasing.
In the last decade, we held numerous conferences and seminars, we identified the success factors in nutrition programs1, we developed and deployed simple tools (such as the growth chart), we printed tons of materials to train trainers, many candidates graduated with PhDs in nutrition. Some of the best nutrition advocates were put in decision-making positions in UNICEF or the World Bank. We solemnly agreed to achieve goals and targets, yet most of them were not achieved.
Malnutrition being an outcome of poverty, one could argue that nutritionists alone cannot tackle this issue. True. Malnutrition rates will only decrease as poverty alleviation succeeds and inequities are reduced. But while the central issues of poverty and inequity are being tackled, we should at the same time improve nutritional status through specific programmes. There is evidence of this happening in various countries (Honduras, India, Madagascar, Senegal, Tanzania, Zimbabwe). Both tracks should be pursued at the same time.
WHY WAS IT THAT WE FAILED?
Nutrition programmes are still not mainstream. It is true that we are embarked in a long-term effort to curb malnutrition, and some progress has been made. But we could have done better - much better - if there had been the political will for which we failed to build the right constituency. Malnutrition mainly debilitates and kills children who have no voice. Those surviving often do not show terribly visible sequels. Malnutrition cannot be cured with expensive drugs, with the potential of generating huge profits. In those regards it is totally different from diseases such as AIDS.
But this is not the main reason why nutrition is not on the agenda, nor why we haven’t achieved so many of the goals set in 1990 at the World Summit for Children. The reason why nutrition is not on the agenda today is because we made two major mistakes:
First, we approached nutrition from too narrow a perspective. We basically restricted nutrition to the realm of the health sector, when it should have been tackled by many sectors. This was done partly because it was thought that the lack of an institutional home for nutrition created difficulties for implementing nutrition programmes. There was an attempt in the 70s to create inter-sectoral nutrition planning cells attached to offices of presidents or prime ministers. But this proved largely unsuccessful, one reason being that they were set up mainly as a response to external agencies’ pressures. We also made nutrition too complicated, not appealing to non-nutritionists: an example is the constant in-fighting among nutritionists arguing about which indicators to use, weight-for-age or weight-for-height.
Nutrition is far more than a health issue. Nutritionists must work with other sectors. They need to be familiar with notions of economics, of contracting with the private sector, they must know how to recognise opportunities to piggyback nutrition interventions on education, infrastructure, poverty or other programmes. For example, work with industry has been crucial in the iodisation of salt. However, experience shows that if nutrition activities constitute only a small part of such projects, nutrition components risk not being implemented2. Experience shows that nutrition improvements must be made one of the main objectives of such projects and must muster at least 30% of the project’s budget. Some will argue that this is too fragmented an approach to malnutrition. It would be if that is all that is being done. But, at the same time, we must be carrying out a policy dialogue with different relevant sectors along the lines of a comprehensive approach to fight poverty of which malnutrition is a most prominent, visible outcome.
Second, we failed to sell nutrition to politicians. The only programmes I have worked on, that succeeded, were those where presidents, prime ministers, or strong community leaders personally backed the programmes. Nutritionists must learn how to market their programmes, they need to have lobbying, advocacy and political analysis skills - if not themselves, at least somebody in their team or in their group of strategic allies. The question is, are we training them to take up such very real, everyday responsibilities?
As technicians, we naively thought that it would be enough to show results to have the continued support of decision-makers. So, we dutifully came up with goals and targets, we developed, gathered and aggregated nutrition indicators thinking these were inputs to empower decision-makers. Unfortunately, most of them were political animals, not scientific animals, and they never really consider (ed) outputs from our so well designed monitoring and evaluation schemes.
Only when presidents, prime ministers, party leaders, congressmen, community and other leaders of the world take an interest in nutrition will we have de facto commitments to and funds for programmes large enough to make a long-term difference. We thus need to identify what makes individual politicians and leaders ‘click’ and find out if that somehow overlaps with the technically identified needs of our nutrition programmes. We need to work with elected officials at all levels, to sell them the nutrition goals and targets, and to demonstrate to them how cheaply and rapidly they could reap the benefits of a successful national nutrition programme.
All politicians will say that nutrition is of the utmost importance, some will even be willing to put money into it. But, more often than not, these funds risk not being spent wisely. For example, many Latin American countries have expensive untargeted food distribution programs which were initiated for populist reasons and now cannot be closed, because the political cost would be too high. Political discourses are often insincerely generous, pretending to help the people, for instance by giving out food. Nutritionists missed seeing those as opportunities to more genuinely and equitably improve poor people’s nutrition thus making such programmes real win-win situations for the politicians.
True, there have been some advances, such as the participation of communities and NGOs, as well as the integration of nutrition goals and targets into development programmes (on paper at least). But overall, actions fall far short from what is needed.
We need to build a grassroots constituency that can effectively influence politicians to launch large-scale community-based nutrition programmes Although this can be done, it takes time and requires that something is already ongoing in large community-based nutrition projects. It is clear to me now that this approach needs to be complemented by an effort at higher levels, efforts to directly reach out to politicians so as to gain their support, i.e. the constituency-building approach must be two-pronged: at the community and at the higher political level.
We all know that sustainability depends on how much ownership is achieved, from the community, the local leaders, the participating ministries, NGOs, to the private sector. Many stakeholders need to be lobbied and convinced or co-opted. We need to make sure that women leaders, union leaders, party leaders, also become stakeholders.
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Nutrition is as political an issue as poverty...We need
to learn how to play the politicians’ game... |
Nutrition is as political an issue as poverty. We cannot continue to naively hide this fact. We need to learn how to play the politicians’ game by finding out what motivates them, only then will they lend us their weight.
We are guilty of having applied a restricted vision of nutrition, one that maintained it in the realm of basic needs. We have now moved into the realm of nutrition as a basic right. However, nutrition goes beyond basic needs. The fight against poverty and malnutrition is one and the same. It has to be fought in many fronts: social, political, economic, ethnic, religious, to name but a few. But foremost, the battle is fought in the political arena. Take the challenge and have a chance to succeed; disregard it, and set yourself up for yet another failure.
HOW I SEE THE FUTURE
· Nutrition is no longer managed by ministries of health; it has become a concern of every sector, because it is one of the main outcomes of poverty and because nutrition indicators are being used to measure progress in the battle against poverty.References· International organisations are putting nutrition on their agendas for policy dialogue in every sector, and invest substantial amounts of money in now better-conceived nutrition programs. Their employees are being promoted based on the impact their projects have on poverty reduction indices (among which malnutrition is key).
· Politicians are incorporating nutrition into the political programmes in their political campaigns, including actions to raise funds from the private sector to help finance the proposed nutrition programmes. They are being increasingly pressured by community leaders demanding that nutrition be placed in the political agenda
· Those who picket international meetings are becoming an international counter-power to be reckoned with. They are calling for needed economic vindications and for a brand of development that fosters true human well-being, especially of the poor. We have seen them fight for causes in the field of nutrition, e.g. against genetically modified foods, inadequate food safety, as well as against the inequities of malnutrition. Isn’t a convergence of such ideas with the ones here expressed the way to go? You, readers, be the judges... and then the protagonists.
1. Marek T (1998) Just taking stock or defining a new paradigm? Nine years of determining factors for successful community nutrition programs. SCN News 17:52-54. ACC/SCN: Geneva.
2. Rokx C (2000) Who should implement nutrition interventions? The application of institutional economics to nutrition and the significance of various constraints to the implementation of nutrition interventions. World Bank: Washington DC. (Draft).
The views expressed in this article are those of the author and do not necessarily reflect those of the institution the author works for.
Tonya Marek is with the World Bank. Contact: tmarek@worldbank.org
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NUTRITION GOALS AND TARGETS: MUCH ADO ABOUT NOTHING OR IMPETUS FOR ACTION? Meera Shekar, Roger Shrimpton and Bjorn
Ljungqvist |
· The virtual elimination of iodine deficiency disorders (IDD)After ten years, the IDD goal is close to achievement, there has been a fair amount of progress on the vitamin A goal, but the iron deficiency goal is far from being realised. What was different about these three goals?
· The virtual elimination of vitamin A deficiency and its consequences,
· A reduction of iron deficiency anaemia in women by one third of the 1990 levels* Soon after the World Summit for Children, the need for more immediate targets for the first five years was perceived. The rationale was that most politicians are only in office for five years. Thus decade long goals were not useful for holding them accountable or for advocating for their support during their term of office. From among the full set of WSC goals, a sub-set of goals was established for the mid-decade and approved by the UNICEF Executive Board.
THE STORY OF IDD
The mid-decade goal for IDD was revised to read “universal salt iodisation”. Evidence that the IQ of the overall population was reduced by as much as 10-13% wherever IDD was a significant public health problem, led to the decision of converting the intervention strategy from a targeted distribution of iodised salt and/or iodine oil capsules through the health system, to one of universal salt iodisation. Thus, the indicator of success shifted from being an impact indicator (IDD prevalence) to an outcome/coverage indicator (percent of salt iodised). This meant that verifying progress towards the goal would be easier and extensive pre- and post-intervention goitre palpation surveys were made redundant. In addition, the development of the salt testing kits empowered anybody to est salt in their own household, community and/or district. Anyone - from members of parliament in some developing countries, to ministers of health in others, from James Grant in UNICEF, to village health workers - could now test salt and advocate for its iodisation. That iodine deficiency affected the entire population’s intellectual development was communicated at all levels. The locus of partnerships for achieving the goal moved from the health sector to the salt industry, distributors and retailers. Equally importantly, the technology for iodising salt - which was simple and had been shown to be effective - was made available universally. Indigenous industries producing salt iodisation machines, and salt-testing kits sprang up in many countries. Data from simple field-based surveys showing that the strategies were working, provided encouragement at country level and proof that success was in sight. Moreover, the role of the private sector in salt iodisation was recognised, supported and promoted. Had attempts to iodise salt been pursued solely through the public sector, as has been the case for other goals, the goal of universal salt iodisation would not have been realised.
WHAT ROLE DID NUTRITION GOALS PLAY IN THIS PROCESS?
Goals provided an impetus for heads of state to rally around and reach an agreement, as well as to commit themselves politically. They provided a platform for advocacy and offered (in this case) a realisable end point. Goals raised awareness of the problem not only among the more obvious duty bearers (the state parties and international organisations), but also among potential donors. Would the support for salt iodisation from the Kiwanis have been realised without international goals and targets? Would donor fatigue have set in more easily in the absence of goals? We believe the answers to these questions are no and yes respectively. The IDD goals prompted action and competition among countries. When countries fell behind intermediate targets, the Progress of Nations reports were used to put pressure on governments. Thanks to international advocacy efforts, politicians and leaders in many countries were able to make informed statements about the benefits of salt iodisation and about the links between salt iodisation and school performance. Without clear, agreed goals, donor support, and concerted advocacy, none of this would have been possible.
THE VITAMIN A AND ANAEMIA GOALS
The story of the vitamin A goal is similar to the iodine goal. Once again, the long-term goal of virtual elimination was modified for the mid-decade to one of achieving 80% supplementation coverage. Improving vitamin A status had been shown conclusively to reduce young child mortality rates by a quarter1. It was only in 1998 that consensus was reached on the benefits of large scale prophylactic supplementation for populations with underfive mortality rates greater than 70 per 1,000 live births (recently changed to 50 at IVACG 2001 in Hanoi), regardless of the existence of clinical vitamin A deficiency signs. However, efforts were (and still are) under way to look for alternate non-health delivery systems for achieving and sustaining high coverage in countries with high mortality rates. These efforts were backed with vitamin A supplies provided by donors, especially Canada.
While on track in many countries, the realisation of the vitamin A targets is slower than it could have been. Perhaps the big difference lies with advocacy around vitamin A supplementation, which has been plagued with difficulties. While initial advocacy efforts sold vitamin A supplementation as a short-term strategy, later efforts to reinforce the need to maintain it as a medium to longer-term strategy have not been as successful. Similarly, the mortality reduction benefits of vitamin A supplementation have not always been clearly articulated in advocacy at country level so that, to-date, many policy makers in countries still believe that the primary public health importance for vitamin A supplementation is to reduce blindness. Despite many years of experience, more sustainable strategies for improving vitamin A coverage elude us, and most of the efforts are still channelled through the public sector. Under these circumstances, goals and targets have helped keep vitamin A on the agenda, have even provided impetus for action, but have not taken action far enough, soon enough.
The anaemia story is different. The goals themselves were never clear. Strategies to achieve these targets were not defined. While the benefits of reducing anaemia are relatively well known, the efficacy of iron supplementation as the sole intervention for controlling anaemia is still unclear, and effectiveness trials are not to be seen in the near future. Furthermore, though community action is essential for anaemia control strategies, efforts to involve communities have not been given priority. Not surprisingly, donor support for anaemia control has been insignificant.
Can the goals be expected to contribute anything in such a situation, or did we set ourselves up for failure in the first place?
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The goals themselves were never clear; strategies to
achieve these targets were not defined... did we set ourselves up for failure in
the first place? |
The World Food Summit goal in 1990 was set at reducing malnutrition rates among children under five by one half. For the mid-decade, perhaps in recognition of the unrealistic nature of these goals, the child malnutrition goals were not included. The malnutrition reduction goal has, by and large, not been achieved and the reasons are not very different from those for anaemia reduction. The goals themselves were ambitious, the strategies ambiguous with unclear efficacy and effectiveness; donor support was not forthcoming. Not surprisingly, the goals were never or seldom used for effective advocacy at any level, and resource allocations for the control of stunting and underweight are no match for the requirements implied by the goals.
The goal established at the World Food Summit (Rome 1996) is to halve the number of people suffering from malnutrition between 1990 and 2015. This means reducing malnutrition in children under five from 32% to 16% globally by 2015. Is this target feasible? Have communities and families been consulted to determine whether a reduction in child malnutrition is a priority, or whether/how it can be achieved? Have any efforts been made towards seeking consensus with communities? Experience with successful nutrition programmes in developing countries suggests that these have achieved reductions of 1-3 percentage points a year2. This means that if the under five malnutrition rate is 32%, a one percentage point a year reduction to 28% in five years is equivalent to a 12.5% reduction, whereas a more optimistic 1.5 percentage points a year reduction would reduce under five malnutrition to 26%, i.e. a 19% reduction over five years. This suggests that, over a five year horizon, a 12-20% reduction in child malnutrition is possible if the right programmes with the right strategies are put in place.
However, in reality, even if all enabling conditions were met, not all developing countries can be expected to keep pace with experiences from the most successful nutrition programmes at a national scale. In this context, the WFS goals may still be ambitious. And the need for specific country and community level targets remains.
To identify the right set of programmes addressing child malnutrition consensus is needed about what those strategies ought to be. This would allow the development of a set of intermediate coverage indicators for child malnutrition. To date, one of the problems that remains with the child malnutrition indicator of underweight is that whilst it covers all children under five, the processes that result in underweight and stunting have an effect mostly up to twelve months of age. After twelve months of age weight growth patterns are similar anywhere in the world3. This new piece of evidence calls for immediate action and for a change of course. The factors that determine growth failure are basically three: birth weight, duration of exclusive breastfeeding and adequacy of complementary feeding to twelve months of age. Strategies to tackle child malnutrition should concentrate on these three by tackling them in the context of the full conceptual framework using a Triple A approach. For instance, the strategy should include inputs to reduce household morbidity through preventive family/community level actions (the family-community component of IMCI). Another concern is that of the capacity of duty bearers. Recognising that communities are key duty bearers for the reduction of child malnutrition, there is a need to assess and analyse capacity gaps, and to include strategies for community empowerment, including participatory communication, capacity development, and gaining control over needed resources.
The reduction of child malnutrition is one of the main outcome indicators proposed for measuring the progress in global poverty reduction to the year 20154,5. If used strategically, this could translate into greater advocacy and donor resources for malnutrition prevention. However, in order for this to happen, two issues remain to be addressed. The first is the need for clarity and consensus on strategies and processes that have the potential to achieve these goals. The second is the need for inclusion of a clear nutrition target (rather than only an indicator) among the International Development Targets. This will mean an explicit recognition of the role of stunting and underweight reduction, not simply as a measure of poverty reduction outcomes, but also as part and parcel of poverty alleviation; to this one has to add the need to allocate significantly more resources for their control.
WHOSE GOALS ARE THEY ANYWAY?
The IDD goal was a top-driven goal, with most of the action at central levels and relatively little action sought at community and family levels. The vitamin A supplementation goal again can be achieved through primarily top-down strategies with some action needed at community level. The anaemia goal needs some action driven from the top, but also needs consistent action at community level (e.g. on dietary practices, and hygiene promotion). For the underfive malnutrition goal, most of the strategies and actions lie at community level.
This analysis of the four goals suggests that while externally actionable top-down goals such as the IDD and vitamin A goals are more easily achieved through international targets, when action is vital from within communities and families (as is the case for child malnutrition goals and, to a large extent for anaemia) external goals may be less useful. In such a case, it is even more important that goals are proposed and consensus reached first with communities and families (as the front-line duty bearers) to then bring them to the national and international levels. Such a process will ensure that the goals are owned by those who need to act upon them, and contribute toward creating social capital6.
UNDER WHAT CONDITIONS ARE GOALS USEFUL?
Seven conditions are necessary for goals and targets to be useful:
· First, targets must be realistic and consensus must be reached with all pertinent duty bearers in terms of their achievability.All of the above are necessary, but not sufficient conditions for success of goals and targets. Ultimately, capacity for and accountable action by duty bearers at the actionable levels shall remain the key to success.· Second, they must be set in partnership with and owned by the primary duty bearers.
· Third, strategies underlying the goals must be doable, clearly defined and proven effective in real life situations in developing country situations.
· Fourth, the goals must be creatively used for advocacy at all levels. Benefits must be clearly and unequivocally articulated and every opportunity for advocacy must be seized upon to foster political action.
· Fifth, the role of all stakeholders, including the private sector, civil society, as well as traditional duty bearers such as governments, families and communities must be explicitly spelled out and accounted for.
· Sixth, reliable mechanisms for measuring and reporting on the progress on the goals must be put into place. This may be made easier by building upon existing monitoring and evaluation systems and Triple A processes in countries.
· Seventh, resources to match the actions implied by the goals must be mobilised and made available to the relevant duty bearers on a long term and sustained basis.
References:
1. Beaton G, Martorell R, Aronson K, Edmonston B, McCabe G, Ross AC, Harvey B (1993) Effectiveness of Vitamin A Supplementation in the Control of Young Child Morbidity and Mortality in Developing Countries. Nutrition Policy Discussion Paper 13. ACC/SCN: Geneva.
2. Gillespie S, Mason J, Martorell R (1996) How Nutrition Improves. ACC/SCN Nutrition Policy Discussion Paper No. 15. ACC/SCN: Geneva.
3. Shrimpton R, Victora, CG, De Onis M, et al (2001) Worldwide timing of growth failure: implications for nutritional interventions. Pediatrics. 107(5) e75.
4. DAC Development Assistance Committee (1996) Shaping the 21st Century: The Contribution of Development Co-operation. Organization for Economic Cooperation and Development OECD: Paris.
5. IMF/OECD/UN/WB (2000) A Better World for All: Progress Towards The International Development Goals. Organization for Economic Cooperation and Development. OECD: Paris.
6. OECD (2001)The well being of nations: The role of human and social capital. OECD: Paris.
Meera Shekar is Senior Project Officer, UNICEF Tanzania. Contact: mshekar@unicef.org
Roger Shrimpton is a Consultant in Nutrition and Development, UK. Contact: rshrimpton@btinternet.com
Bjorn Ljungqvist is with UNICEF in Tanzania. Contact: bljungqvist@unicef.org
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GOALS AND TARGETS IN THE REALM OF NUTRITION RIGHTS George Kent |
Often the global community proposes specific targets to be met in the process of achieving goals. For example, the 1990 World Summit for Children called for reduction of severe and moderate malnutrition rates to half their 1990 level by the year 2000. Such targets are based on measurable indicators that allow judging whether the path is pointing towards the goal, and whether the progression is rapid enough to achieve the target by the intended time. With clearly formulated targets, when the time comes, it is possible to say whether the target has in fact been successfully reached.
Some goals are set in great detail. Very concrete goals in relation to nutrition were set at the World Summit for Children; they were subsequently endorsed by many other international bodies. Nations then may, or may not, have taken binding commitments to the goals. In most cases, these goals and targets are not legally binding for endorsing states. They are understood as strong recommendations for governments to formulate their own commitments.
Few of the targets set by the international community in 1990 with regard to children’s nutrition were met by 2000. Nevertheless, they remain useful for guiding the formulation of national commitments.
RIGHTS IMPLY GOALS, BUT NOT VICE-VERSA
The proclamation of goals does not necessarily mean that any individual has any rights in relation to the government/agency/programme that proclaim them. The goal may say that everyone ought to get a particular outcome or service (e.g., adequate nutrition), but that does not in itself mean that people are entitled to it. The core implication of a right is that if everyone is entitled to something, everyone has a legal claim to it. As a legal claim, there are specific actions that rights holders can take to remedy the situation if they do not receive what they are entitled to.
Goals do not imply rights, but rights do imply goals. Human rights declarations and covenants express global goals: there should be no slavery, no discrimination, no genocide, no malnutrition, etc. When states ratify international agreements, they make commitments to pursue the respective goals in their own countries. However, nations have in fact exercised considerable latitude in interpreting and applying these goals.
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Goals do not imply rights, but rights do imply goals...
When states ratify international agreements, they make commitments to pursue the
respective goals in their own countries. |
Setting clear goals and targets can be very helpful to governments as they design their social sector programmes. However, people having a right to a particular goal being realised requires more than just having the government set the goal. A substantial planning effort and commitment of resources must be made to achieve specific targets by specific times. These commitments can be made through an appropriate national law or decree.
Often goals are set loosely and governments are unable or unwilling to make the needed commitments, sometimes due to real or apparent resources constraints. Governments may make concrete commitments to more limited targets, e.g. only for children under three years of age, or with longer time horizons, e.g. over fifteen years. The point here is that nutrition rights mean that governments should make firm commitments to specific nutrition targets.
Clearly articulated goals and targets should be used as the basis for designing specific goal-directed strategic plans of action - backed by legally binding documents. The plans should set specific targets, i.e. specific levels of specific indicators to be achieved by specific dates. For example, the government may say that it will reduce the rate of malnourished children under two years of age by five percent in two years, and twelve percent in five years. In this approach, the process of realizing a right is pursued through a realistic step-wise strategy.
At all levels, strategies should be based on explicit intermediate goals and targets. Strategic planning and resource allocation should be guided by these plausible, concrete objectives. There must also be a possibility for mid-course corrections and the reallocation of resources. In other words, there must be continuous steering of the effort if the target is to be achieved.
Many social sector programmes define their tasks in terms of the services they provide, e.g. inputs such as nutrient supplements, school meals, etc. They often leave the ultimate goal unspecified, and thus function as if they expect to continue the same activity forever, not aiming at resolving the problems they claim to address. In doing so, these programmes may actually help to perpetuate the problems.
The entitlements corresponding to specific human rights can be described either in terms of inputs delivered to clients or in terms of desired outcomes, results, or targets that constitute steps toward the achievement of particular goals. Rights to specific inputs and rights to specific outcomes correspond to what in the human rights discourse are called “obligations of conduct” and “obligations of result”.
THE IMPORTANCE OF LOCAL PARTICIPATION
Careful attention must be given to the process through which rights are realized. The rights holders should not be treated as passive beneficiaries of government-directed programmes, but should be fully engaged, with high levels of participation, community ownership, sustainability, and empowerment.
This means that the beneficiaries should be active participants not only in the implementation of social programmes, but also in the formulation of their goals and targets. Goals and targets should emerge from broadly participatory consensus-building efforts. The goals and targets set out at the major global conferences or at national-level meetings of policy makers should not simply be imposed on local communities.
International human rights instruments articulate widely shared goals that are identified through broad participatory global consensus-building efforts. They acknowledge the reality and value of local differences and encourage localized interpretations and application of the agreed-upon principles. Rights need to be concretized locally as specific entitlements and specific local targets. The most important means of adapting global goals to local realities is to assure that local people participate in shaping the policies for achieving them. Outsiders coming in with their own analyses and their own remedies for local problems violate the right of local people to participate. Local people must be actively engaged not only in the implementation of the programs, but also in their design and management. They must share in the formulation of the goals, as well as in shaping the means for reaching them.
THE IMPORTANCE OF STRATEGY
Goals and targets do not fulfill themselves. They mean little in isolation; they become important when part of a coherent strategy for action. Consider, for example, the goal of ending stunting among children. If we are serious about this, we will need to mobilize the resources that will be needed and put in place the required actions to get there; it will further require that we get prepared to give the right incentives to the right individuals in the right places at the right times.
Human rights are an important instrument contributing to the achievement of social sector goals. We should go beyond saying that children ought to get the food, health, and care they need, to say that they are entitled to these things. The specifics of these entitlements will vary in different places according to local circumstances. However, we begin with the premise that every child is entitled to whatever it takes to assure that she or he is not stunted. That is not negotiable.
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Human rights are an important instrument in contributing
to the achievement of social sector goals... we begin with the premise that
every child is entitled to whatever it takes to assure that she or he is not
stunted. That is not negotiable. |
This sort of commitment establishes a clear incentive for using resources efficiently and effectively, and to assure that the efforts stay on track. Willingness to make this sort of commitment to allocate resources in a national law would be the clearest indication of genuine commitment by national governments for the achievement of the goal.
All people everywhere have the right to adequate food and nutrition. Clearly, many countries do not have the capacity to assure the realisation of this right. Thus, the international community has obligations to act to assure its realisation. There needs to be a commitment of significant international resources to help the poorest countries in their efforts to eliminate malnutrition. This assistance could take the form of food supplies and direct financial assistance, but in the long run the most important assistance might be in forms such as advisory services and capacity building.
Systematic strategies need to be formulated and implemented at every level if the goal of fulfilling every person’s right to adequate food and nutrition is to be achieved. In these strategies, there must be clear incentives for the actors to do what needs to be done, and there must be institutional mechanisms in place to assure that all actors are held accountable for doing their jobs. Just as the construction of a building or a bridge is only possible with detailed planning and periodic course corrections during the process of working toward the goal, the human right to adequate food and nutrition can only be fully realized through carefully designed and implemented programs of action. The formulation of strategies only begins with the formulation of clear goals and targets.
George Kent is Professor in the Department of Political Science, University of Hawai’i. Contact: kent@hawaii.edu
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AIMING AT THE TARGET: WHAT’S LEFT FOR THE DEVIL TO ADVOCATE? Claudio Schuftan |
Here I blend my own ideas with what I feel are loose ends in the collection of papers by my distinguished colleagues. I do this with the benefit of hindsight, having read their work. This then is additional, hopefully complementary, food for thought.
THE BIG HYPE
Clearly, large international conferences convened to set and monitor global goals and targets raise huge expectations and excitement. Whether these events are useful in moving programmes forward is a different matter. Keep in mind that setting goals is the result of a process in which public admission of dissent is difficult. Therefore, countries pledge, but do not really embark or comply.
The real challenge comes after the (usually expensive) international gathering. It comes during the process of preparing down-to-earth action plans, raising funds and implementing them. Unfortunately, this process is rarely participatory. And for this process, the international conference, more often than not is unhelpful, because the strategies to achieve the targets are left a bit in the air (or in the paper).
THE OUTCOME-PROCESS RIDDLE
Getting to where we want to go requires knowing and quantifying where we want to be. But the processes involved are even more important. Goals and targets address where we want to go. Processes are left to the planners and managers to implement - often excluding community representation. But it is the process that carries in it the seed of sustainability. Unfortunately, as nutrition professionals, we fear prescribing processes; we also fear discrediting processes that we know do not work. We have not spent the time to arrive at universally acceptable indicators that can measure sustainable progress in processes such as participation, social mobilisation and empowerment. Instead, we have spent time and money choosing and monitoring outcome goals and targets that have unduly over-medicalised the nutrition problem. Think about it.
BEING REALISTIC
With a pinch of self-criticism, some goals and targets set in the 90s called for a number of pretty unrealistic measures, unaffordable to most developing countries’ state coffers. With insufficient resources, one cannot but get low coverage rates. This is, by definition, not only ineffective, it is also wasteful. The danger I see is that we may be doing this again for goals being set for 2015. At the moment, we have no assurances that the new set of goals will mobilise leaders, the media and members of civil society any more than before. Business as usual will simply not get us there for anaemia, stunting and underweight. At present rates of progress, it will take us decades to halve the prevalence of child malnutrition.
Moreover, three serious concerns arise here. The first is who should be the judge as to what is realistic. Certainly not the technicians alone. Global, across-the-board (i.e. one fits all) targets actually need to be adjusted to local circumstances and this process takes much more than the technicians can offer.
Another related concern is the quality of data used to monitor progress. If data are of poor quality the intrinsic value of a number reflecting how far one is from achieving the target is simply misleading. This concern over data quality comes out clearly in the responses to the questionnaire sent to field workers (see p 19).
The third concern is that I still find colleagues saying that this or that goal may be too ambitious. I think the time has passed for ‘maybe’ positions. (I am reminded of a small poster hanging on the wall of my office which reads “I said maybe, and that’s final!”) The facts are out. After democratic consultation, we are expected to endorse concrete advice on directions and finish lines.
ON CONVERGENCE
An issue that was not touched by any of the contributed papers is the notion that progress towards achieving one goal can (and often does) help achieve another. The same is true for processes set up and for resources raised. Actions to overcome malnutrition can and should be seen as additive. For example, an effective vitamin A programme helps improve iron nutrition and thus reduce anaemia. Improvements in iron status can improve the appetite of a child. High rates of exclusive breastfeeding will impact upon many nutrition indicators. There are quite a few other examples. The bottom line is that actions to address micronutrient deficiencies and chronic malnutrition are complementary and inseparable and only then will they impact on the overall well-being of individuals and populations.
But this complementarity does not come automatically. It will be the result of applying the conceptual framework so that we address all causes of malnutrition and proactively embark on the processes needed to make changes sustainable. The processes still in need of more attention are those related to tackling the underlying and basic causes of malnutrition. Much more needs to be done on this, starting with de-medicalising goals, and focusing more on structural processes than on malnutrition itself which is an outcome.
THE HUMAN RIGHTS TWIST
As members of institutions and/or as individuals, many of us are moving towards a change in the paradigm giving direction to our work. What we may not have thought enough about is that goals and targets - many of them intermediate in nature - are, in a way, antithetical to the human rights paradigm. This is because the human rights paradigm is based on the principle that we cannot rest until the rights of all (i.e. 100%) are instated or restored, not ten years down the road, but the soonest possible. Consequently - and being realistic - we should be talking of steps to be achieved in the process of fulfilling the human rights of all claim holders. The issue here is nutrition rights and food as a right. For most of us this is a whole new approach.
A compromise could be to start working on goals and targets in reverse. We could express targets as an expected decrease in the number malnourished, or what it will still take to close the gap and uphold the rights of all.
THE EQUITY FACTOR
Reaching targets (usually followed by a congratulatory stage) can be misleading. Implementing effective interventions primarily amongst the easier-to-reach near poor - say the second lowest income quintile - can eventually lead to achieving national targets on schedule. However, this in turn can exacerbate inequity, as discussed by Latham and Beaudry. Here, I just want to bring to your attention what some are calling the distributional concerns of (sometimes short-cut) actions (imposed) to achieve goals.
ON ACCUSATIONS OF DEPENDENCY AND TOP-DOWN IMPLEMENTATION
The achievement of micronutrient goals has created dependency. How? Not only are many IDD and VADD schemes top-down - with an element of dependency there - but supplies and other resources are most often donor provided. In the long run, in terms of sustainability, what worries some of us is the ‘ownership-donorship’ interplay. At the end of the day, it is a zero sum game. I do disagree with what Shekar et al imply in their article (see p 10). These authors argue that solutions lie in a continuum from VADD, to IDD, to IDA, to stunting and underweight. In their view VADD and IDD call for vertical goals which need little action at community level. To be effective and sustainable in the long run, all nutrition programmes require community level action and involvement.
To me, the idea of some community action is nonsensical. Implying that for child malnutrition most strategies should be at the community level is like shifting the responsibility for child malnutrition to the community itself - so they better deal with it. That may not have been Shekar et al’s intention, but it sure reads like that.
DONORS (AND WE OURSELVES) TOUCH SOME PROJECTS MORE THAN OTHERS
What are the reasons for a lack of commensurate donor support for IDA and for the reduction of child malnutrition? Does it have something to do with donor fatigue or with targets for these two problems having been set at unreasonable levels? Remember at this point that UNICEF dropped monitoring the underweight goal from its mid-decade review.
Are we responsible for having set ourselves up for failure? I tend to think not. In the eyes of donors (...and many amongst us) IDA and chronic malnutrition are more messy to deal with than IDD and VADD. There is all this bottom-up, community action, poverty alleviation and equity involved, as well as longer time horizons. Hence, donors pay plenty of lip service to these instead of embarking head-on towards working out solutions. That is not fatigue. It is not lack of will. It is a political choice. Internal and external resources allocated to IDA and child malnutrition have thus remained a pittance, unmatched to the challenge. There is nothing in sight that tells me this will change soon.
Again, it is in the process of selecting the strategies and the steps to progressively achieve them where donors and many amongst us have been and continue to be undemocratic and where we have failed those whose nutrition rights are being violated. As long as we consider the strategies needed to tackle the basic causes of malnutrition to be outside the realm of our professional scope of work, we should consider ourselves part of the problem and not the solution.
THE POVERTY ALLEVIATION CONNECTION
Will the new global shift towards poverty alleviation strategies happen and will it change what has been said so far?
The reduction of child malnutrition is now a key outcome indicator to measure progress in poverty alleviation. But, alas, this does not automatically translate into greater advocacy, action and donor resources for the prevention of child malnutrition. Being an indicator does not translate into being the object of concerted new efforts directed at halving malnutrition. We have a lot more to do here. Improved socio-economic status will improve nutrition, but we know that is only part of the story - although quite a big part.
The take-home message is that there is probably no such thing as across-the-board realistic targets. At most, they can be proposed on some technical grounds. But consensus must be painstakingly built for them in many, many places with both bottom-up and top-down inputs. There simply are no short-cuts. Goals or no goals, for people to gain control over the resources they need to overcome all aspects of malnutrition remains the key. Keep in mind the conceptual framework and the Triple A process.
Claudio Schuftan is a freelance consultant in public health and nutrition, based in Hanoi Contact: aviva@netnam.vn
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LET US KNOW WHAT YOU THINK! WE WELCOME YOUR COMMENTS. WRITE TO US AT: ACCSCN@WHO.INT |
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Is the use of growth charts an application of (growth) goals? Growth charts have been at the core of family level nutrition projects for 40 years. The growth chart - essentially a set of internationally determined weight-for-age references - has been used to monitor health and nutrition goals. These goals are taught to mothers and care givers around the world - literate and not. In a way, the chart sets monthly goals for child growth (or the direction and slope of the curve). Mothers are told that the achievement of these relate directly to their children’s health and development. Carts have provided mothers with a means of visualizing regular progress by “seeing” the current and longer term growth goals as shown on the chart. The power of this goal-based system is now being enhanced by new studies coordinated by WHO that will provide new growth curves for full-term, normal birth weight, healthy, breastfed infants. This work should provide new monthly goals for infant and young child growth that can be used to reinforce, expand and revitalize community based growth monitoring worldwide. New emphasis will hopefully be placed on younger infants aged 6-24 months and will include stronger interventions to assure adequate micronutrient nutrition for this group. Commune level (or equivalent) growth monitoring uses the growth charts to set a goal for a monthly weight gain of an age-cohort of children. This is then directly linked to community level decision making. A commune level children’s growth monitoring activity greatly reinforces community-based growth monitoring by extending the measurements into aggregates that lead to planning. Too little work has been done systematically in this area that has major community development potential and that adds a new dynamic to community level participatory planning and social development. Overall, nutrition related goals do serve to maintain nutrition in community level planning and development decision-making. They help set the indicators to be used in social planning, and help to measure progress in community programmes, especially in child development and in the protection of children’s rights. In addition to growth monitoring, areas in which goals are useful to measure progress at community level include, among other, exclusive breastfeeding, the Baby Friendly Hospital Initiative, iron deficiency and anaemia reduction, access to iodized salt and access to water and environmental sanitation. Gary Gleason grgleason@mediaone.net |
VOICES FROM THE FIELD
SUMMARY OF RESPONSES TO AN INFORMAL SURVEY EXPLORING FIELD WORKERS’ OPINION ON NUTRITION GOALS AND TARGETS
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Questionnaires were sent by Email to 25 field workers
- eight in the Americas, ten in Asia and seven in Africa. Of these, ten
responded: seven from Asia, two from Africa and one from Latin
America. |
THE SUMMIT FOR CHILDREN CALLED BY UNICEF IN 1990, THE INTERNATIONAL CONFERENCE ON NUTRITION IN 1992 AND THE WORLD FOOD SUMMIT IN 1996 SET SOME IMPORTANT NUTRITION GOALS FOR THE 90S AND BEYOND. GIVE US YOUR EXPERIENCE-BASED OPINION ON THE FOLLOWING:
1. IN YOUR COUNTRY, HAVE NUTRITION GOALS AND TARGETS HELPED US ACCELERATE ACTIONS OR IN ANY OTHER WAY?
Eight of the respondents answered yes and commented:
· Targets became part of national plans of actionOne respondent answered no and added nutrition remains everyone’s business, but no one’s responsibility; setting targets on paper with little follow-up and accountability breeds scepticism.· Yes, particularly the nutrition goals of the World Summit for Children
· Yes, but few translated into country-specific benchmarks
· They helped to focus and to accelerate actions
· They found their way into several other development plans
· They served to remind the governments about commitments they had made in summits
· They gave breastfeeding and micronutrient interventions a major boost
· Yes, from them we set our own national goals
· Targets sensitised top level planners
· Yes, they created awareness among professionals, but not much at policy level, and government ownership is needed for sustainability
· Yes, but nutrition has remained within the health sector
· Yes, we need something to aspire to and to aim for, setting sub-goals has helped countries carry out reality checks of where they are when
· They also affected NGO plans.
2. OR HAVE GOALS AND TARGETS HINDERED PROGRESS BY CONCENTRATING OUR EFFORTS MORE ON OUTCOMES THAN ON SUSTAINABLE PROCESSES? IN YOUR SITUATION, ARE NUTRITION GOALS AND TARGETS GUILTY OF PROMOTING VERTICAL THINKING AND HAVE THEY RATHER FOSTERED SILVER BULLET, TECHNICAL FIXES?
Four respondents answered no and commented:
· Internationally set targets are a good starting pointFive respondents said that it is possible that targets may have fostered verticality and commented:· They helped primarily in setting up inter-sectoral development plans and, as partners became aware of the roles they were called to play, this ensured horizontal rather than vertical thinking
· No, but I have to admit that low birth weight, child malnutrition and anaemia turned out to be more complex than what we thought originally and our interventions turned out to be too simplistic
· Integration has often diluted the success made by vertical programmes, diluting ownership and accountability.
· The response for different goals has been different as regards vertical thinking; for instance, in IDD a focus on outcomes and a sustainable process complemented each other, in VADD and IDA, verticality damaged dietary diversification approachesOne respondent definitely thinks targets have fostered verticality and added that there is a clear tendency to seek quick fixes, and such an approach is least likely to succeed and produce long-lasting changes.· To tackle immediate, severe problems, vertical programmes are needed, but not otherwise
· Implementation may have been vertical, but was successful showing that real progress is possible; at least some problems were solved; it is not wise to wait for general development to happen to see advances in human nutrition
· Although not intended, targets sometimes lead to vertical thinking, as well as to only one ministry being made to take action
· Focusing on achieving quick outcomes is detrimental in the long run, for example, sustaining the full baby-friendly status of hospitals where personnel was initially trained has turned out to be quite difficult
· We have concentrated too much on the curative and easily doable preventive aspects; we spent millions of dollars and we often have little to show for it.
3. THESE GOALS AND TARGETS WERE THERE, BUT I (WE) NEVER BOTHERED TOO MUCH WITH THEM. (TRUE OR FALSE)
Seven respondents thought this was false and commented:
· They did become an integral part of tracking progressOne respondent thought this was partially true and added many people care about goals, but their voices are not heard and do not get translated into fully implemented actions; caring is not enough to move things forward so people tend to lose faith.· They have been central to our work on micronutrients
· Focusing on general economic improvements hinders simple actions towards progress in human nutrition.
One respondent thought it was true and added not many implementers are bothered. Focusing on targets results in too many players without clearly identified responsibilities.
4. HAVE NUTRITION GOALS AND TARGETS BEEN GOOD FOR YOU TO USE AS ADVOCACY/SOCIAL MOBILISATION TOOLS FOR NATIONAL DECISION - MAKERS? HAVE THEY BEEN GOOD TO MOBILISE COMMUNITIES?, DID USING THEM MAKE AN EXTRA DIFFERENCE? DID THEY FOSTER QUANTUM LEAP IMPROVEMENTS IN NUTRITION WORK IN YOUR COUNTRY?
Seven respondents said yes to all questions and commented:
· These goals do carry weight; our job is to help put into place review processes so that they are treated as serious commitments· They moved nutrition work forward in our country
· They helped sensitise policy makers and programme implementers, as well as to mobilise thousands of volunteers for the VADD programme; but goals need to be interpreted locally if the community is to be mobilised; otherwise, people feel these targets are imposed from outside
· To know that some actions are part of a global effort carried out in many other countries as well helped for advocacy.
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...goals do carry weight; our job is to help put into
place review processes so that they are treated as serious commitments...but
goals need to be mobilised; otherwise people feel these targets are imposed from
outside. |
· Yes for the decision-makers, but not for communities; quantum leaps were only seen in iodised salt and vitamin A coverageOne person said ‘not so far’ to all questions and added there has been political and economic turmoil in his country so that it has been difficult, if not impossible, to make a strong case for nutrition programmes.· Yes, they helped strengthen certain components in government programmes, but no, they have not worked to mobilise communities; it is difficult for communities to understand the long-term implications and no one is explaining these to them; There have not been any quantum leaps in our country.
5. DO WE NEED UPDATED NUTRITION GOALS AND TARGETS FOR 2015? WOULD A NEW SET OF NUTRITION GOALS AND TARGETS FOR 2015 MOBILISE LEADERS, THE MEDIA AND CIVIL SOCIETY MORE UNDER CURRENT CIRCUMSTANCES IN 20001? IS IT WORTH SPENDING TIME AND MONEY IN SETTING THESE NEW GOALS? OR SHOULD WE DEEMPHASISE THE USE OF GOALS AND TARGETS IN NUTRITION WORK OVERALL? WHY?
Seven respondents said they were needed and commented:
· Updated goals are key to monitor performance; we should compare success and failure experiences so far to learn how goals helped or notTwo respondents said they are not needed and commented:· The new set of goals has to get a broader commitment at country level; our job is to keep them in the agenda
· Yes, but we have to make them more relevant to the current circumstances, look at emerging issues and think of innovative ways of addressing them; do not de-emphasise the use of goals, they are important also in getting various countries to address common issues across countries
· Updated goals need to be realistic if they are going to keep out interest
· Yes, but it is essential this time to support all new goals with resources to implement the activities called for
· Yes, but beware, summits are not followed by making available the needed resources; summits are forgotten except for the few of us who have to do the follow up; many countries do not keep their promises; also, governments change; how do we make sure that the next government will keep the promise?; we should look for more innovative ways of getting people on board again
· Yes, but new goals should not be arrived at by a few bureaucrats, academics and senior programme staff, but should include people with practical field experience and grassroots representatives.
· Setting new goals will cost money and precious time; just admit our inability to reach the goals on schedule; give broader time frames that are country-specific6. WOULD GOALS BE NEEDED ON INDICATORS OTHER THAN THE ONES SUGGESTED BY THE THREE IMPORTANT MEETINGS ABOVE, I.E. ON INFANT AND UNDER FIVE MORTALITY, MATERNAL MORTALITY, STUNTING, UNDERWEIGHT, LOW BIRTHWEIGHT, HYGIENIC WATER AND SANITATION, EXCLUSIVE BREASTFEEDING, CONTINUATION OF BREASTFEEDING TO UP TO TWO YEARS, ADEQUATE COMPLEMENTARY FEEDING, VACCINATION COVERAGE, IODINE, IRON AND VITAMIN A DEFICIENCY RATES?· Although noble, goals mean little; they encourage grossly inaccurate data to be used as barometers; better focus on processes to achieve change; targets must always go together with an enunciation of the actions needed to achieve them.
Five respondents were of the opinion we need new ones and suggested indicators for access, availability, acceptability, affordability, for diabetes, cardiovascular diseases, obesity and gout, and for gender and maternal health other than during pregnancy.
One respondent was non-committal and added that we may extend the list to one or two more micronutrients, to physical activity, smoking and healthy diet indicators.
One respondent thought other goals are not needed and thought we already have enough goals to worry about.
7. DID THE USE OF THE SUMMIT GOALS AND TARGETS INCREASE VISIBILITY AND/OR COMMITMENT OF GOVERNMENT FUNDS TO NUTRITION ACTIVITIES?
Four respondents said yes and commented and one added that there was a relative increase in government funding. Two respondents said yes, but to a limited extent only.
Three respondents did not think visibility and government funding increased and commented:
· Goals by themselves do not; committed actors do8. DO YOU FEEL THAT LOCAL/NATIONAL STAFF INTERNALISED THE GOALS (MADE THEM THEIR OWN) TO GUIDE THEIR WORK?· Now, it is time governments pick up the costs of these successful interventions;
· As is, governments have meagre resources; they can and often do show commitment if and after funding is provided by donors.
Three respondents were of the opinion that the goals had been internalised and commented:
· Staff have been instrumental in adapting goals to the country situationFour respondents had mixed responses and commented:
· Yes, but the issue of ownership of the activities has not been achieved yet
· This is the key issue in making goals work; we need to avoid national staff feel that these goals are imposed, and that some external agency comes in and admonishes them for not achieving themTwo respondents answered no and gave no comments.· National staff has internalised the goals, but local staff has had difficulty
· Yes, but only certain staff
· Technical levels more than decision makers; the turnover rate of the latter is a problem.
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Articulating goals and targets by themselves is not
enough; a group of committed people needs to translate them into strategies and
interventions which they will then pursue forcefully. |
Two respondents thought that goals were unattainable and added that it is important to work with countries so they can modify the goals to correspond to their specific national context..
Four respondents were non-committal in their view and commented:
· Those for micronutrients were realistic; those for child malnutrition were notThree respondents did not agree that targets had been unattainable and added that the constraints lie in the lack of adequate finances and technical manpower, as well as weak multisectoral efforts.· Goals were to be used mainly as a yard-stick to measure performance in nutrition
· Assessment and measurement of progress has been a main constraint
· Whether the goals should be achieved seems less important than trying to get there; we thus would need more process indicators to ensure that those countries that really try hard, but cannot reach the goals, are provided with more resources.
10. IS THE QUALITY OF THE AVAILABLE DATA IN THE NATIONAL/LOCAL CONTEXT GOOD ENOUGH TO WARRANT MEASURING AND REPORTING PROGRESS AGAINST THE GOALS?
Three respondents think the quality of data is good enough and added that the data were getting better, but still not representative of the whole country; there is enough information in the country now, though, to say that nutritional problems have worsened over time.
One respondent was non-committal and offered no comments.
Five respondents think data is not reliable and commented:
· Governments have not been able to bear the costs of regular national surveys; the MOH statistics are not reliable; community-level monitoring does not provide correct data either due to poor training and poor understanding of the meaning of the indicators· Quality of data being a limiting element, this is an area that requires more international support
· Surveys are mostly contracted out by international agencies; the training of interviewers is short and often inadequate; the quality of the data is questionable
· Much of the data is from small-scale surveys; there are hardly any representative data.
11. DID THE EXISTENCE OF THE GOALS MEAN THAT YOU RECEIVED PRESSURES TO REPORT IMPROVEMENTS ON THEM?
Two respondents say there have been pressures and offered no comments. Five respondents say they never received pressure and one added that some gentle pressure is needed to bring about a competitive spirit.
12. IN YOUR ENVIRONMENT, HAVE SOME NUTRITION GOALS AND TARGETS SUCCEEDED BETTER THAN OTHERS? WHY?
All ten respondents answered yes to this question and commented:
· IDD, VADD and the Baby Friendly Hospital Initiative have had more success13. WHICH GOALS DO YOU THINK FAILED (AGAIN, IN YOUR ENVIRONMENT)? WHY?· Goals associated with supplementation (e.g. vitamin A capsules) are soft options and more likely to succeed
· Government commitments, international agencies and private sector inputs have been key contributory factors
· Only if and when support of international agencies was received, goals have succeeded
· Long term commitments and significant coverage of the national population, as well as their participation are crucial for success
· ‘Showcasing’ these successful programmes has brought more resources and further success
· Overall development and secular trends rather than any concerted programme explain some progress in decreasing rates of severe malnutrition.
Five respondents said the IDA and child malnutrition goals failed and one added exclusive breastfeeding and appropriate complementary feeding as failures. Reasons given for this are: no community ownership and empowerment, insufficient leadership and coordination, low visibility/low priority given, these are more ‘complex’ issues, experts could not come to a consensus on what exactly to do, a lesser role for the private sector in these goals, inadequate behavioural change promotion for these goals, and no work on gender equity even attempted.
14. DOES NON-ACHIEVEMENT OF NUTRITION GOALS AND TARGETS MEAN WE (THE NUTRITION COMMUNITY) FAILED TO ARTICULATE AND POSITION THEM IN A CONVINCING MANNER? OR IS IT RATHER THAT WE FAILED TO TRANSLATE THEM INTO CONCRETE STRATEGIES AND INTERVENTIONS?
Two respondents answered yes to both questions and added that the yes is more so for the second question, adding that advocacy is wonderful, but if it is not backed up by concrete proposals for what to do, one loses one’s audience and one’s credibility.
One respondent replied yes to the first and no to the second question and added that more efforts are required to convince policy makers and the community at large. We do not do that well yet.
Four respondents replied no to the first and yes to the second question and one commented saying that the strategies remained unclear and not integrated into a life-cycle approach.
Three respondents said no to both questions and commented:
· Articulating goals and targets by themselves is not enough; a group of committed people needs to translate them into strategies and interventions which they will then pursue forcefully15. CAN WE MAKE NUTRITION GOALS AND TARGETS IMPOSSIBLE NOT TO PURSUE, I.E. A POLITICAL IMPERATIVE? HOW?· The failure has rather been in proving our success to others and in eliciting more community participation
· Success is not always to be measured as full attainment of set goals and targets.
Four respondents think we can and commented:
· Those in positions of power have to be made uncomfortableOne respondent answered ‘hopefully’ and added that he was not sure how, but thought that linking nutrition goals to human rights and poverty alleviation would be good starting points.· Making all nutrition issues human rights issues
· Including nutrition goals as prime national development goals; this requires community mobilisation with an emphasis on basic rights.
Four respondents were non-committal and added that it would depend on the person who holds the seat of power and that what is needed is for the public to pressure the decision makers.
One respondent answered no and added that countries need to modify and adapt goals according to their own political environment.
16. DID NUTRITION GOALS AND TARGETS TACITLY CALL FOR UNREALISTIC MEASURES UNAFFORDABLE TO DEVELOPING COUNTRIES’ STATE COFFERS?
Three respondents were of the opinion goals did call for unaffordable measures and commented:
· Yes, but countries also cannot afford not to embark in reaching these goalsOne respondent said it depends on what goals and targets. Four respondents answered no and commented:
· Yes, because of other conflicting government priorities.
· Measures are affordable if the leadership so decides17. IS IT VERY DIFFERENT TO HAVE GOALS AND TARGETS FOR MICRONUTRIENT DEFICIENCIES AS OPPOSED TO HAVING THE SAME FOR STUNTING AND/OR UNDERWEIGHT?
· It is a matter of allocation priorities, not of lack of resources
· Many developing countries spend more on defence so there is definitely room.
Six respondents think it is very different and added that stunting and wasting require more complex interventions and are very influenced by external factors, and that focusing the prevention of stunting in the under 2 years of age group can make things cheaper and more focused.
Three respondents answered no to this question and one added that micronutrient deficiencies cannot be totally controlled with vertical programmes; they require overall nutrition and public health approaches.
18. WOULD IT BE ANY BETTER TO EXPRESS NUTRITION GOALS AND TARGETS IN TERMS OF DECREASING THE NUMBERS OF THOSE WHOSE NUTRITION-RELATED HUMAN RIGHTS ARE BEING VIOLATED?
Three respondents think it would be better and one added that by doing so, Human Rights institutions can become ‘watch-dogs’ challenging implementing agencies and making them accountable.
One respondent recognises she does not understand enough about this issue and the response of another is non-committal. One respondent was of the opinion that it would be difficult to express the goals in terms of Human Rights and had no comments. Two respondent said it would be a bad idea.
SCN News sincerely thanks Chandrakant Pandav, Shawn Baker, Rosanna Agble, Ram Shresta, Indira Chakravarty, Johnny Kyaw-Mynt, Rukhsana Haider, Nguyen Khan, Zulfikar Bhutta and Omar Dary for having taken the time to respond to this questionnaire.
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Women comprise 70% of the world’s poorest In the last decade, the importance of women’s and adolescent girls’ economic participation and empowerment has increasingly been recognized. While policies and programmes to increase women’s economic opportunities have been laid down, they have yet to be translated into action. How can women and adolescent girls benefit from current economic trends that offer room for growth and access to economic resources and rights? How do we get from here to there? Women are key economic contributors, with their income directly benefiting their children and households. Yet, women and girls continue to constitute the majority of those living in poverty. Why? The reality is that many women in developing countries work long hours, earn low wages, have insecure jobs and continue to lack access to key economic resources such as ownership of land and property. The strain of these factors weighs heavier on the poorer families. Presently, nearly 120 million young people around the world work full-time - 61% of all adolescents in Asia, 32% in Africa and 7% in Latin America - to support themselves and their families. The need for action to economically empower women and girls is all the more pressing today, because the current cohort of adolescent girls is the largest ever in the world’s history. In many poor families, adolescent girls do the housework so that their mothers can earn income elsewhere - they take care of siblings, tend the home, prepare food. In times of great economic need, girls, like their mothers, play the dual role of caretaker and wage earner, putting in long hours working both in and outside the home. But they earn little income. In order to fulfil these roles, girls from poor households are the first to drop out of school and miss out on the education and training that could enable them to have better lives. ICRW/UNICEF msims@icrw.org (You can order The International
Center for Research on Women’s Biannual Report 1999/2000 from the same
address). |
