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CHAPTER 8: NUTRITION RELEVANT POLICIES AND PROGRAMMES IN TANZANIA


Introduction
General policies to reduce economic inequalities
Household food security related policies and programmes
Public works for food security
Provision of Basic Social Services for All
Nutritional Interventions Through the Water and Sanitation Sector
Nutrition Education and Interventions Through the Educational System
Nutritional Interventions Through the Health Sector
Policies and programmes related to caring capacity
The Food and Nutrition Policy
Specific nutrition programmes of the eighties
Factors associated with success in the various programmes
Tanzania's Nutrition Goals for the 1990s

Introduction

Tanzania has been concerned with the welfare and nutritional status of its people since independence (1961) but more so after the Arusha Declaration which contained a policy of “Ujamaa” and self-reliance, with a heavy accent on development of people who would in turn develop things (TANU, 1967). Although no explicit nutrition policy emerged till the eighties, the following three policies had a direct bearing on nutrition: (1) reduction of inequalities (2) food security for all and (3) provision of free social services. We shall review each policy briefly, noting its nutrition related sectoral programmes which eventually led to the formulation of an explicit nutrition policy after the mid-eighties.

General policies to reduce economic inequalities

Equity was one of the key words in Tanzania's post-Arusha policy of “Ujamaa” and self-reliance. Four policy instruments were applied in an effort to create an egalitarian society, namely (1) fixing and regular revision of minimum wages; (2) a progressive tax system; (3) subsidization of production inputs and maize flour; (4) policies to effect redistribution of incomes in rural and urban areas.

Each of these policy instruments underwent significant changes in the course of time, partly due to limitations in the “carrying capacity” of Tanzania's economy and institutions, and partly because of pressures from external benefactors such as the IMF and the World Bank.

Regulating Wages

Minimum wages were first introduced in 1963 and were calculated to cover the basic need of an average household. They have increased (nominally) many times ever since 1969, 1972, 1974, 1975, 1980, 1984 and each year during 1987-92. The policy was that minimum wages would rise faster than those in the middle and higher salary brackets. For example, when public sector wages and salaries fell sharply in real terms after the mid-seventies, salaries of middle and top officials fell at a faster rate than those of the lower level. Whereas in 1979 the minimum wage was 58 percent of its 1969 value, top salaries were down to 11 percent of their 1969 value while middle wages were 16 percent. The policy on narrowing the gap in official earning was closely observed until mid-eighties, and the ratio between top salaries and the minimum wage which had been 69:1 in 1961, 30:1 in 1069, had been reduced to about 7:1 by 1984.

Despite the relatively big increases in nominal wages, real wages had declined all the time from 1963 to 1985, and continued the downward trend thereafter. Thus, as already discussed the purchasing power of the major staples had decreased several fold, badly affecting economic accessibility to food. High nominal wages had been awarded at the cost of inflationary budgets which were accompanied by rocketing consumer prices for the staples. In terms of maize flour equivalence, for example, minimum wages declined by 14.7 percent at official prices, or by 90.5 percent at open market prices, or by a weighted average of 2.2 percent (with weights of 0.9 and 0.1 for open and official markets, respectively) during the 1984-88 period (Amani et, 1989:34). The ERP policies were accompanied by a rapid overall rise in consumer prices: by over 30 percent during 1986-88 and 26 percent in 1989, affecting workers in all categories. This is what led to the 'struggle' for a general revision of wages and salaries during the 1980s.

On recommendations of a Presidential Commission, conditions of service were restructured in 1989, providing for greater salary differentials for senior officials and those with special skills. Parastatal bodies were also encouraged to formulate their own incentives and pay their staff whatever they could afford. Further wage increases and reduction of taxes in July 1990 improved situation somewhat, but the government admitted that nobody could live on official wages and salaries. For example, by 1990 minimum wage earners would spend about 55 percent of their pay on a diet of maize and beans only, for an average family of five person (URT UNICEF 1990:12) Clearly the remaining 45 percent could not cover other needs, including contributions to the essential services demanded by the cost-sharing policy.

The government found a solution in permitting all employees to engage in extra economic and professional activities after office hours. The implications of this policy await assessment, but one the negative effects has been the growing use of official time and premises to do private business, especially by professionals such as teachers and doctors. This makes essential services more expensive and less accessible to the poorer members of the community.

At present the data on income distribution based on official wages and salaries do not reveal the real situation. First, higher officials have other sources of income, legal and not-so-legal. Second, non-salary benefits extended to higher officials e.g. housing, transportation, travel and many other allowances - are usually undervalued (if not discounted) in official presentation of relative wage distribution. If to these benefits we add the many non-salary allowances extended to senior officials, it will be clear that the trend is towards bigger income differentials between the workers and higher officials. A rough estimate would put the ratio between 20:1 and 30:1 or, at any rate, very close to the 1967-69 situation. Moreover, the policy to permit workers to supplement their wages through non-salary activities can only benefit the few with capital or security to be credit worthy. The trend would suggest that the ujamaa policies of the earlier phase are being erode or abandoned.

Progressive Taxation System

Tanzania also uses a progressive taxation system as an instrument of reducing inequalities. However, as we saw in an earlier section, in practice taxation has not been as progressive as intended. We noted that dependence on indirect taxes (on consumption goods) rather than direct taxes (on income and property) tended to protect the rich while penalizing the poor.

Taxation has in practice been progressive only in official wages and salaries where evasion is not easy. Thus higher earners have paid a higher rate than lower earners, and from 1974 to 1984 minimum wage earners were exempted from taxes. Following the reintroduction of Local Authorities in 1984, however, minimum wagers had to pay the Development Levy stipulated by the authority in their areas. Paid by all workers, peasants, public officials and traders, the Development Levy initially introduced a regressive element in the taxation system, but was later made progressive. However, the tax further reduces the ever declining real income of the minimum earners and smallholder peasants, particularly because it applies to the employed and unemployed, rich and poor, men and women, married and unmarried. Struggles by women from poorer families led to a decision by government in 1991 to allow local authorities to determine whether or not to exempt women from paying the Levy, and some have already extended the exemption to specified categories of women.

Under the current reward structures in the public services, progressive taxation has become obsolete as an instrument of reducing income distribution. A great proportion of the earnings of higher officials is now given in the form of non-taxable allowances which are, in some cases, five times the size of the taxable income. Many public firms give non-taxable bonuses to all workers at the end of the year. Although this may have a motivational effect and increases worker's disposable income, it does not reduce income differentials, for in most cases the higher the salary, the higher the bonus awarded.

Subsidies to Producers and Consumers

After the food crisis of the mid-seventies, the government decided to increase production by providing good producer prices and subsidizing inputs such as improved seed, fertilizers, insecticides and herbicides. The rise of the so-called “Big Four” grain basket regions - Iringa, Ruvuma, Mbeya and Rukwa has often been quoted as evidence that the subsidization policy worked. However, the policy achieved only partial effectiveness because of three main problems. First, cheap fertilizers were misused in some areas. Second, demand greatly outstripped supply, with the result that recommended quantities were not applied, partly also because there was competition for fertilizers between cash and food crops. Third, input subsidies became a big burden on the government budget. Subsidies for fertilizers rose from shs.49.6 million in 1976/77 to shs.215 million in 1983/84 when they were abolished (table 51).

The drastic decline in the real value of minimum wages discussed earlier made the government to respond by subsidizing maize flour so as to maintain a stable relationship between the price of this staple food and the minimum wage. The subsidy was, however, removed in 1984 on three main arguments. First, in the absence of an effective system of enforcing official subsidized prices, only traders in the parallel market benefitted from the subsidy. Second, the subsidy was not targeted to disadvantaged groups, and therefore, could not achieve the equity concerns of the Party and Government. Third, maize flour subsidy had become a big burden on inflationary government budgets, having grown from shs.49.3 million in 1976/77 to shs.245.6 million in 1983/84 when it was abolished (table 50).

Table 50: Government subsidies for Fertilizer and Maize Flour, 1976/77 - 1983/84 (in Tshs. million)


Fertilizers

Maize Flour

1976/77

49,693

49,349

1977/78

100,000

84,263

1978/79

135,400

562,350

1979/80

134,692

419,080

1980/81

136,450

125,151

1981/82

202,800

405,290

1982/83

195,970

216,550

1983/84

215,000

245,630

Source: Ministry of Finance and Economic Planning, 1986, Government Report (mimeo), Dar es Salaam
Reducing Rural-Urban and Other Inequalities

Various Tanzanian social policies have addressed problems of rural-urban imbalances and other forms of socioeconomic inequalities. They have undoubtedly made an impact on income distribution and nutrition within and between rural and urban areas.

Available evidence shows that the rural-urban income gap has continued to be reduced since independence. Whereas the ratio of the income of urban wage earners over that of the rural peasant smallholder increased from 2.24 to 2.94 between 1969 and 1973/75, it decreased thereafter to 1.56 in 1978 and 1.39 in the early eighties. The decrease was largely due to the increased in producer prices after 1974/75 following the food crisis (ILO/JASPA 1982; URT-UNICEF 1985:448-449). The decrease accelerated in the 1984-86 period and even reversed the situation. Thus whereas real incomes of agricultural producers rose by three percent those of non-agriculturalists declined by 2-6 percent during the period. This was a result of higher producer prices (Amani et al, 1987: 97-98).

The apparent closure of the gap, however, has not reversed the relative attractiveness of the town over the country. Rural-urban migration has continued to increase at a rapid rate, and the number of the unemployed and underemployed is currently very high in the urban areas - especially in the city of Dar es Salaam. Families of the unemployed and underemployed are the most vulnerable to malnutrition, child abuse and various social vices. Government's (political) solution to this problem has been to allow the urban unemployed to engage in petty trade (mainly selling food, fruits, etc) along the streets at the expense of hygiene and environmental sanitation.

The household surveys carried out by the Bureau of Statistics in 1969 and 1976/77, as well as studies of ILO/JASPA (1982), revealed that income equality increased among both rural and urban households, at least until the early eighties. Such equality, however, was achieved at a very low level of existence. According to ILO/JASPA's definition of “poverty line” - i.e. the minimum income essential to meet the basic needs of food, clothing, shelter and household goods - about 25 percent of the population was considered to be living in poverty in 1981. This proportion may have increased substantially by 1993 as a result of the souring prices under the ERP policies. While poverty in the rural areas is difficult to measure, poverty in the urban areas is mainly a function of low cash incomes, as a Dar es Salaam survey has shown (Sembajwe 1980).

Household food security related policies and programmes

The Party and the Government have made several policy declarations and carried out a number of campaigns, programmes and reforms with the objective of attaining food security. Table 51 lists the major ones.

Table 51: List of the major food security campaigns, policies and programmes

Year

Campaign, policy or programme

1972

Siasa ni Kilimo (Politics is Agriculture)

1974-75

Kilimo cha Kufa na Kupona (Agriculture as a matter of life and death)

1975

The National Maize Programme

1978

Public Works for food security

1983

Nguvu Kazi (Human Resource Deployment)

1983

The National Agricultural Policy

1984

The National Food Strategy

1991

The National Food and Nutrition Policy

1991

The National Food Security Programme


Most of the food security related policies and programmes have been done through the Ministry of Agriculture and Livestock Development (MALD). A few of these are discussed below.

The National Agricultural Policy was prepared in 1982 and adopted in 1983 [URT, 1983] as a major response to the proposed Food and Nutrition Policy which had been prepared in 1980 [TFNC, 1981]. The Agricultural policy is geared towards an agriculturally led economic growth with the objective of achieving self food sufficiency and improving the nutrition situation through increased investment in agriculture, and improved efficiency in agricultural production, marketing and processing. The policy was strengthened by a National Food Strategy which was adopted in 1984 [URT/FAO, 1984].

Institutional changes within the Ministry responsible for Agriculture were carried out in order to be able to monitor and give policy guidelines for implementation. These changes included the formation of a Food Strategy Unit (FSU), an Early Warning System, a Food Security Unit (FSU) and the Marketing Development Bureau (MDB). The Ministry also reorganized its food and nutrition extension system so that it operates directly under the Ministry at district and regional levels. Regional Food and Nutrition Coordinators were appointed and the Nutrition Unit was transferred from the Research and Training Division to the Agricultural Division, Extension Services. The nutrition unit made an inventory of existing field staff training in food and nutrition and reoriented their activities towards nutrition in line with the new Agricultural Policy. Also, a task force headed by the Chief Agricultural Extension Officer was appointed to review/reorient diploma level training in food and nutrition of agricultural field staff.

Improvements in family food storage also need special attention to enhance family food security. Improper management of storage facilities and the continued existence of rodents, insects and fungi, continue to cause high post-harvest losses of food. The magnitude of loss has not been established. While estimates of these losses for grains are as high as 30 to 40 percent per annum, documented storage losses in the regions are typically in the 5-20 percent range. Reducing such losses can make a substantial input on aggregate household food supply. TFNC has developed a simple method to help families to plan how much cereal they will need to store until the next harvest - a simple food security card for cereals based on a “bag model”.

The implementation of the Agricultural policy and the strategy adopted have not made any significant impact on the food security situation. Pockets of food deficits continue to exist and some areas have been added due to environmental degradation, population pressure or both. Though monitoring mechanisms have been put in place the extent to which the information generated is analyzed and utilized by decision makers seems to be low. For example it is not clear what happens to the information collected by the Marketing Development Bureau (MDB) daily on the prices of the major food crops from sentinel markets country wide; the Food Security Unit (FSU) “Food Security Bulletin” issued regularly and the Early Warning System which gives warning against impending food shortages. A major problem appears to be the dissemination of the information generated to relevant institutions and the slow speed with which decision makers react to the signals coming out of these monitoring system. Food crisis situations are often first be reported in the lay press instead of the warnings coming from the monitoring mechanisms.

Since 1991 FAO has been supporting the development of a comprehensive food security programme. The preceding review identified eight major problems related to Agriculture around which the programme was developed. These were:- (1) food insecurity among the vulnerable and low income groups (2) inefficient marketing systems (3) poor transportation and communication network (4) high post-harvest losses (5) demand outstripping supply (6) inefficient food crisis management (7) lack of credit and (8) resource degradation. The programme envisaged three scenarios for action. The first is a comprehensive food security programme comprising of 47 specific interlinked and interdependent sub-projects, each related to a particular technical discipline or area of activity was recommended. The second scenario is the implementation of 18 core areas for action and the third is an enhanced programme consisting of 27 specific activities including the 18 core activities. It is hoped that adequate national and international resources will be mobilized for the implementation of even the core activity scenario programme.

Public works for food security

There have also been labour-intensive public works for food security in Tanzania [Von Braun et al 1991]. These are the Rural Roads Rehabilitation and Maintenance Program (RRRMP) and the Labour Intensive Public Works Program (UNDP/ILO/GOT). The RRRMP was formulated to improve roads connecting high production areas. Phase one of the programme was aimed at maintaining 6,000 km of essential roads in seven regions and to rehabilitate 1,400 km of priority agricultural roads to be followed by phase two covering up to 5,000 km. of maintenance in other regions and a further 2,000 km of rehabilitation. A key policy component of the programme is the promotion of labour intensive construction and rehabilitation, and maintenance.

The Labour Intensive Public Works Programme was launched in 1979 and was aimed at creating social and economic infrastructure, building of technical and institutional capacity, as well as employment and income for the rural people. The labour-intensive projects do not explicitly target the poor, but there are efforts to facilitate employment for women. The programme covers 10 irrigation, road and housing projects in five regions. Funding for these projects was provided by the Netherlands Government, UNDP and DANIDA. The World Food Programme (WFP) has been funding similar projects in the sisal estates in Tanga and dairy farms in Zanzibar.

Due to domestic fiscal constraints, Tanzania's public works projects have been largely donor driven. For example out of US$ 12.0 million expended by the largest project, the UNDP/URT/ILO project in the 1979-91 period only US$ 2.4 million (20 percent) was government contribution.

The impact of these public works projects on nutrition and poverty alleviation has not been evaluated. The projects suffer from lack of documentation and most of the available information from them is mainly descriptive without analysis as to progress, which would be useful in drawing lessons of experience. However, since the projects are generally regarded as transitory sources of income which is spent on food and basic consumer goods (Teklu and Maro 1993), they are expected to have some positive impact on household security. They can substantially stabilize intra-year employment fluctuations and increase economic access to food as long as they do not compete for labour during the peak food production period.

Given the low and variable incomes in rural Tanzania, and the severe underdevelopment of rural infrastructure, rising unemployment and falling of living standards in both the urban and rural poor, there is need for the labour intensive public works programme to deliberately focus on the poor, develop clearer goals which should include improvement of food security and develop policy and programmatic frameworks to integrate local and national issues. For example the projects could be concentrated in food insecure regions, those prone to periodic flood and drought or even in the urban areas as a means of providing short-term employment to unemployed people. It will also act as a temporary safety net of the negative effects of structural adjustment.

Provision of Basic Social Services for All

During the early 1970's Tanzania adopted an ambitious policy of providing the basic social services to all her people (TANU, 1973). By the end of the seventies, an impressive infrastructure was in place and service delivery (virtually free for all) was relatively smooth. For a long time, the ruling Party and Government resisted pressures for introduction of user-charges, but following a series of economic crises, IMF conditionalities, etc, user-charges were accepted reluctantly, and these were increased gradually during the early eighties, and substantially during the ERP years. Table 52 shows the tremendous growth in the capacity building of the three services - education, health and water from 1961 to 1987. As already noted service delivery is an intervention directed against the immediate causes, while capacity building is directed against the underlying causes of malnutrition. We shall provide a brief review of the policies and programmes in these three services which are very crucial in promoting nutrition.

Table 52: Expansion in Government Services, 1961-87 (Service level in 1961 = 100)

Service

1961

1971

1976

1981

1987

Water supply1

100

200

400

620

900

Primary school2

100

n.a

440

700

640

Health service3

100

125

n.a

167

n.a

Source: Semboja and Therkildsen (1991), p.7

Notes:

1. Based on percentage of rural population served
2. Based on total enrolment, millions
3. Based on total population/primary health units

Nutritional Interventions Through the Water and Sanitation Sector

The provision of clean water and hygienic sanitation can be equivalent to a significant increase of food supply and essential nutrients through two mechanisms:

a) reduction of the waste of food and nutrients consumed which occurs during diarrhoeal and other water-related diseases, by lowering their incidence; and

b) reduction of time and energy spent by women in fetching water, hence increasing time available for child care and more frequent child feeding.

However, in order to realize the full health benefits it is vital that water and sanitation system installations be accompanied by adequate education in hygiene for households, and that sufficient supplies of soap are available for families to follow correct hygiene practices. In Tanzania accompanying IEC activities are largely the responsibility of lower-level health workers, in particular the VHWs, but it is not clear how effective such efforts are at present. Until the time of the trade liberalization there were general, chronic shortages of soap, related to low production of oils and fats.

The situation in Tanzania with respect to water and sanitation is better than in most African countries, following strenuous efforts made as a part of the 1970s villagization programmes. In urban centres, around 50 to 70 percent of the population is served by improved water supplies, and in the rural areas around 45 percent (map 7); however in both cases problems of inadequate maintenance and rehabilitation reduce the percentage actually using the supplies by about a quarter.

The importance of sanitation has been emphasized in Tanzania since colonial times; urban centres are covered by sewerage systems (10-15 percent of the centre's population) or septic tanks, cess pits or pit latrines. About 80 percent of rural households have latrines of which about 60 percent are classified as suitable by the MOH. Actual utilization of latrine, is undoubtedly at lower levels, particularly by children.

Following the 1973 Party directive on rural water, health and education, considerable attention was paid to water and sanitation by government and the donor community. Water programmes went hand-in-hand with educational campaigns to change the peoples' attitudes towards water and sanitation. Water is valued for health, nutrition and development reasons. Studies have shown that in some parts of Tanzania water-related diseases constitute about 46 percent of all diseases recorded there (Stahl et al, 1978). Others have demonstrated that improved water and sanitation reduces diarrhoea morbidity and mortality in children (URT-UNICEF 1985). Availability of safe water within reasonable distances will also give the women more time to concentrate on child care and production of food.

Map 7: Rural population served with improved water supply, 1988

Source: United Republic of Tanzania, Ministry of Water, “Evaluation of IWSSD in Tanzania”, 1989
In 1971 a twenty-year water development programme was approved by the Parliament with the aim of providing piped water supply to the rural areas so that by 1991 all Tanzanians would have access to a public domestic water project. Owing to high costs, however, the 'piped' water emphasis was revised in 1978 in favour of cheaper but sanitary sources, and a distance of 400 metres from water source was considered reasonable. Shallow wells were considered cheaper to establish, operate and maintain at the community level. But when it came to implementation, community participation depended on the technology mix used, and choice of technology depended on donor interests.

Initially, Regional Master Plans and village water schemes were developed without adequate involvement of the people at the community level; and water schemes depended on external financing at a level of about 60-70 percent with choice of technology done mainly by external experts (Therkildsen 1988; URT-UNICEF 1990:70-71). This approach led to several problems: villagers did not identify with the water schemes and would or could not maintain them; fuel supplies to diesel - driven pumps were irregular and expensive; pumps broke down and were left unrepaired. Thus about 30-50 percent of the water schemes were out of operation at any time (Mushi 1988), and studies have shown cases were improved water supply had been installed without improving health or nutritional status of the targeted people (Ingvar Anderson, et al, 1984; Carolyn Hannan-Anderson, 1983). The situation did not improve in the eighties because expansion lagged behind population growth in both rural and urban areas; and the user charges may have forced some people to return to their traditional dirty ponds.

As we saw earlier government budgetary allocations to water during the ERP years has been less than two percent - too little to maintain existing schemes. Thus from the mid-eighties the Ministry sought to avert the danger of losing the water infrastructure already established by introducing a new strategy. This had five elements: (1) community participation in construction and contribution for maintenance and operation; (2) use of low-cost appropriate technology, with special emphasis on shallow wells and hand pumps wherever possible; (3) training of village water technicians (including women); (4) protection of water sources through appropriate water committees at village and higher levels; and (5) cost recovery from users through contributions to a village water fund or other methods.

Sanitation lacked a clear policy statement, but was guided by two instruments. First, there was a law controlling water pollution (URT, 1974). Second, there was a target that every household in rural Tanzania should have a hygienic latrine by 1991 (URT, 1982). Going by official statistics, reasonable progress has been achieved in the field of sanitation. Between 1968 and 1977, households with a private pit latrine increased from 33 to 56 percent and the Ministry of Health estimated 70 percent by 1989. The successes in adult education and UPE undoubtedly contributed to successes in sanitation. The use of the ventilated improved pit-latrines (VIP's) increased in CSD programme areas; but rising costs of cement slabs make them un-affordable to the poor.

Thus the policies and water development plans which were drawn up have been constrained by financing particularly of investment costs in the current bad economic environment, even if partial costs recovery could be instituted and successfully implemented. It was because of such constraints that the Government decided to postpone the target of water for all in the rural population from 1991 to 2000.

The Health through Sanitation and Water (HESAWA) Project

This is a programme run jointly by the Government of Tanzania and the Swedish International Development Authority (SIDA) for the purpose of supporting water and environmental sanitation in the three lake Victoria regions of Mara, Mwanza and Kagera. The programme was launched in 1984 with the objective of improving the health of the people through improved health education, environmental sanitation and water supply in the three regions. In order to ensure affordability, sustainability and credibility the programme involved the people in the formulation and planning of the water and sanitation schemes.

In seminar to discuss the impact of the programme held in December 1991 there were indications that the programme has succeeded in decreasing water borne diseases like bilharzia and diarrhoea and has also improved the nutritional status of children in the pilot regions. In addition it was also reported that the programme contributed to the improvement of social services in the programme villages through the reduction of women's workload by bringing water supply within easy reach. An editorial in the Daily News in 1992 noted that the approach is appropriate for Tanzania's efforts to solve the problem of water and sanitation in the rural areas and called for the approach to be extended to the rest of the country.

Nutrition Education and Interventions Through the Educational System

Nutrition education activities in Tanzania can be traced back into the early 1920s when campaigns in increased cash and food crop production included the establishment of gardens at government schools and lessons in child feeding practices for the mothers. Since then the development of nutrition education has grown over the years, but has always been treated separately in different sectors. In addition the persistence of the concept of the “four food groups” in nutrition education in some sectors (especially Agriculture) has resulted into some inconsistencies about the messages delivered. The main target of nutrition education has been women and the assumption has been that people are uninformed about what to eat and conservative in their dietary practices. This assumption overlooked the fact that nutrition education alone without other basic necessities such as availability of food, purchasing power, water, medical services, sanitary facilities, produce extremely limited results. This approach has been substantially changed following the establishment of TFNC and the development of the TFNC/UNICEF conceptual model. Thus, nutrition education is meant not only to change behaviour, through influencing knowledge and perceptions but as an empowering tool for sustained nutrition intervention.

Nutrition education has an important role to play in improving nutrition and more education efforts need to be directed to two groups - children (as future parents) and men. The effectiveness of IEC in changing attitudes has been poor world-wide, Tanzania being no marked exception. However, new techniques of IEC development have been unfolding in other parts of the world which appear to be more successful at identifying resistances to change and focusing on them for nutrition education. These new approaches to IEC have considerable potential for use in Tanzania.

The school network in Tanzania is very widespread, far more so than the health services network; there is at least one school in every village, with a total of more than 10,000 schools in the country. The school system, together with adult literacy programs, has great potential for education on food and nutrition, which is now beginning to be exploited. Pilot programs of school feeding have also been undertaken in Dodoma and Singida. A five year health and nutrition programme in primary schools has jointly been prepared by the Ministry of Education, Ministry of Health and TFNC and support for implementation is being sought by the Ministry of Education.

In Tanzania formal educational policy focuses mainly on community empowerment rather than elite creation, preferring the “mass approach” to the “elite approach”. As Nyerere (1984) put it: “We cannot protect the excellence of education for the few by neglecting education for the majority; in Tanzania it is a sin to do so”. According to the Constitution of the United Republic of Tanzania (1984), “every person has the right to education”. This mass approach targeted universal adult literacy for 1975 and universal primary education (UPE) for 1977. The education Act of 1978 stipulated compulsory primary education for all young people 7-14 years of age, and crash programmes of UPE teacher training were put into gear in all regions. The approach relied on active participation by the communities which built schools, teachers' houses, latrines and provided desks and other contributions on self-help basis.

The results are impressive for a poor country. Within two decades (1967-87) illiteracy had been reduced from 67 percent to less than 10 percent. Sexual inequality in literacy was also reduced: whereas in 1969 illiteracy was 55 percent among men and 81 percent among women, by 1988 it was 7 percent for men and 12 percent for women. Enrolment rate in primary school standard 1 increased from 54 percent in 1975 to 90 percent in 1984, then declined to 66 percent by 1990s, with both sexes represented equally. This was made possible by the fact that primary education claimed more than 50 percent of the total educational recurrent budget during the 1970/71 - 1983/84 period. The wide literacy base achieved is an important factor in the fight against malnutrition through the printed word.

Disadvantaged children - blind, mentally retarded, physically disabled - also benefitted from this policy of empowerment through education. Schools for the blind increased from one (established in 1950) to 19 by 1983, situated in 16 regions. Three to five blind students have been graduating at the University of Dar es Salaam each year during the past decade, with the first blind M.A. holder graduating in August 1989. Other handicapped children have received support through government, private and NGO institutions many of which receive state grants-in-aid.

The mass approach meant that the government could not expand secondary and tertiary education facilities to meet the growing demand. Thus private people and NGO's were permitted and encouraged to run secondary schools which, by mid eighties, admitted more students than government ones.

Provision of educational services now faces many problems, including (1) unsatisfactory pay and housing for teachers which have led to low morale; (2) shortage of teaching materials; (3) limited secondary school places relative to the huge number of primary school leaver; (4) failure by schools to instil skills for self-reliance as stipulated in official policy since 1967; (5) high dropout rates in recent times, especially among girls, due to decline in enforcement of attendance (legally and politically), and also a growing perception that education does not necessarily lead to higher incomes than, for example, engaging in petty business; and (6) inability by individual parents and communities to shoulder the burden of cost-sharing in education, a problem currently being addressed by the Government.

Social mobilization and Advocacy

Advocacy plays an important role in promoting nutritional and related social welfare programmes. It is the driving force or the heart of the triple A cycle. Programmes may be championed by private individuals, institutions or the people themselves. Working within the Party and State institutions, such key personalities like Nyerere, Mwinyi and others have been able to push through very successful programmes - e.g. the Universal Child Immunization (UCI) programme - and their role in the nutrition field has recently been publicly acknowledged and rewarded by UNICEF.

The effectiveness of the UNICEF-supported CSD programmes has depended a great deal on the advocacy of Regional and District Commissioners, key leaders in the District Councils, and the district party organization. These 'advocates' have to be “won over” (through seminars, posters, malnutrition films, etc) before programmes were 'sold' to the people. The “Mtwara Initiative” for CSPD launched by the regional administration is an excellent example of empowering advocacy. Campaigns by these dignitaries have, for example, been an important factor in launching District CSD programmes and Village Health Days. One observer has described the launching of a Village Health day as follows:

“It is a concentrated event: colourful, packed with virtually all top district and regional leaders and functionaries, some visiting the village or being seen by the villagers for the first time - indeed, a mixture of serious business with pleasure (lectures, immunization and child-feeding on the one hand, and poetry, “ngonjera” and songs on the other). The presence of so many important people in the village shows the importance attached to the activity by the leaders and this, if reinforced, will have a long-lasting impact on the villages and their nutrition programmes” (Mushi, 1988:25).
Private and NGO institutions have also played a useful role in nutrition-related advocacy work. Just to take one recent example, the Industrial Products Promotion (IPP) Company, under the influence of its 'populist' chairman, Reginald Mengi, has championed a tree-planting programme in Kilimanjaro Region; made financial contributions to the Family Life Education Programme (POFEP) which promotes self-help projects in the villages; and established a fund from which the urban poor can borrow to finance small projects. Unfortunately not many other businessmen have followed this example. Church-based NGO's have promoted social welfare programmes since the colonial days, and their advocacy role is still important and valuable in those rural areas where they have a strong presence. In Tanzania, the ruling Party has historically led all other institutions in advocating nutrition-related programmes, especially in mobilizing advocacy of the beneficiaries themselves. Health and Nutrition advocacy offer great opportunity for practising multi-party democracy as the need for their improvement offers a common platform for discussion. The improvement of the health and nutritional status of children and women can be made good politics and any honourable party should feel ashamed if they do not include these concerns in their political agenda.

Community mobilization and participation have been directed at three levels: families, groups, and village authorities (councils and their committees). All these levels have to fulfil their roles if nutrition programmes have to succeed. The family is the basic unit because it makes critical decisions on what to produce and how much; the amount of grain to be used for beer, to be sold for cash, and to be reserved for food; the allocation of the family earnings to various activities; whether to send a sick child or expectant mother to the dispensary or the witch doctor, etc. In most rural families this decision-making process is men-dominated, and therefore one aim of the social mobilization effort has been to enable the women to participate more in family and community decisions. A specific government action in this regard has been to decree that women should be represented equally in such bodies as the village health committee (VHC) which has a female and male village health worker (VHW); the social services committee of the village council; the village water committee, etc. On the production side, the Government - UNICEF CSD programme, and similar programmes supported by other donors, have a large component reserved for women groups engaged in income-generating activities (URT-UNICEF 1985 and 1991). It is believed-rightly or wrongly - that a large part of women-controlled earnings goes to the welfare of the family, especially the children (Mascarenhas, 1983).

By its very nature, nutrition must depend heavily on the involvement and contributions of the people themselves - as individuals, families and communities. It is one of those fields which cannot succeed with a non-participant community. A survey carried out in CSD areas (Mushi, 1988; Mbilinyi et al 1992) showed high levels of programme social mobilization by the people, and preparedness to make a contribution to the programme. Distribution of responses to the question what the villages were expected to do for themselves to improve the welfare of children and mothers (Mushi 1988) was as follows: 41 percent (N = 810) advocated solving problems on self-reliance basis; 33 percent emphasized measures to improve the village economy so as to ensure growing incomes and food security; and 17 percent found solution in educating the people on health, nutrition and family obligations. Similarly, responses to the question what the regions and districts were doing to ensure that the villages are able to sustain the CSD programme in the long run clustered around mass education, campaigns, mobilization and measures to promote the spirit of community self-reliance. Mass education in its various forms has been the main tool in tackling the problem of nutrition in Tanzania.

Indicators of the people's advocacy are the actions taken or contributions made towards various social programmes. We shall give a few examples. In most areas with CSPD programmes, child feeding posts have been organized by the communities themselves to provide additional feeding to young children, especially the severely malnourished ones. Villages have devised models which suit their particular circumstances. In some cases food for feeding children is contributed by households, in others special farms have been set aside for this purpose. In some cases child care takers are paid compensation in cash or in kind, in others women take turns to do the work, etc. Most villages have also accepted the burden of paying their two health workers, now ranging from Tshs. 500 to Tshs. 2,000 per month. In the education field, villagers have made contributions in both cash and labour to have schools, teachers houses and latrines built, and desks repaired or made. The same self-help spirit is shown in water schemes to which villagers contribute labour in digging trenches for pipes and money for operation and maintenance costs. The level of voluntary contributions differs from place to place, and the poorer villages are finding the burden too heavy (Mushi and Baregu 1991).

Prevention and control of diseases, in particular, demand high levels of peoples knowledge and advocacy. Malaria control, for example, would require a strategy that ensures various actions-by individuals, families and communities. Actions include clearing potential mosquito breeding sites and using bed-nets impregnated with permethrin to kill mosquitoes on contact. Experience with malaria control programmes in Dar es Salaam and Tanga has shown limitations of the bureaucratic approach which failed to mobilize advocacy of the people at all levels. Similarly, family planning or control of the HIV virus can only succeed by changing individual's, family's and community's behaviour through mass education programmes. The social mobilization animation of the CSPD programmes offers a fertile ground for learning from its success.

The Role of Information, Education and Communication (IEC)

IEC play an important role in promoting nutrition and related programmes. The main tools used in mass education in Tanzania include newspapers, the radio, posters, films, traditional theatres, non-formal media, people-generated information and institutionally-generated information (reports and research findings). We shall have a brief word on these.

The mass media in Tanzania is reasonably well developed. There are four government and party newspapers. In the past five years or so, over a dozen private papers, bulletins and pamphlets have emerged, published on a weekly, biweekly, monthly or quarterly basis. The official newspapers have been very effective in social mobilization work and in sensitizing public officials to various social problems. For example, they have regularly carried news and feature articles on women and children, and on development projects in the rural areas. The private newspapers have also begun to participate in this mass mobilization effort. For example, some private papers have sought to sensitize the public on the central role of women in family welfare and national development. These include “Sauti ya Siti”, published by the Tanzania Media Women Association (TAMWA), and the Newsletter published by the Women Research and Documentation Project (WRDP) at the University of Dar es Salaam; it summarizes women-related research.

Furthermore, all regions with CSD programmes have established newsletters with village correspondents. These have made it possible for villages to share experiences - thanks to the high levels of literacy. Every now and then 'sensitizing' seminars or workshops have been organized by TFNC for journalists to keep their advocacy high.

However, the full impact of the national news papers (all based in Dar es Salaam) is mainly felt in the urban and peri-urban areas. High cost of printing materials and distribution and transport problems have reduced their impact in the remote rural villages. This gap is filled by Radio Tanzania which has established a long tradition of mass communication and mobilization. Access to radio sets and listening habits have been judged good, with an estimated listenership of two million people at any time during the day, reaching five to seven million listeners at peak times (i.e. about 30-50 percent of the population 15 years and above).

Radio Tanzania has a Public Education Committee whose membership includes representatives from the Tanzania Food and Nutrition Centre (TFNC), Education Unit of the Ministry of Agriculture, Health Education Unit of the Ministry of Health, and the Ministry of Education's Department of Adult Education. A special committee on women and children issues was established in mid-1990. These committees - along with the staff of Radio Tanzania - have formulated and broadcast useful nutrition-relevant programmes. Some of them seek to promote health, for example, Mtu ni Afya (Health makes Man); food production, for example, Chakula ni Uhai (Food is Life), and Kilimo cha Kufa na Kupona (Life or Death Farming); afforestation, for example, Misitu ni Mali (Forests are Wealth); welfare of mothers and children, for example, Mama na Mtoro (Mother and Child), etc. These have been judged reasonably effective (Wakati, 1990). There are also specific food and nutrition programmes prepared by TFNC and the Ministry of Agriculture.

The use of non-formal and traditional media has also gained in importance. Changes in nutrition patterns depend on significant changes in behaviour at the individual and community level where normative reinforcements occur. Thus the use of non-formal and traditional media of communication may turn out to be effective. A conclusion from experiences with the CSD programmes in Tanzania during the 1985-90 period reads as follows:-

“In the same way that education systems have community roots, so too there are strong informal systems of information within communities. People provide each other daily information about the health of their families, the state of affairs at home, problems, hospitals visits, and so on. Greetings in Tanzania and especially in rural communities, are elaborate exchanges of information which can be helpful in planning access to neighbours if needed in emergencies, as well as building us social groups to provide mutually beneficial services, child care, for example “(URT-UNICEF 1990:92)”.
Specific actions have been the use of traditional and popular theatres, choir groups, dance groups, poetry and “ngonjera” groups in addressing specific social problems using locally understood idioms and expressions. Themes have included proper child-feeding, care for pregnant mothers, family planning, preservation of water sources, proper sanitary habits, environmental protection, land allocation, etc. In fact the signature tune of the TFNC radio programme is a recording of a song in one of the villages in Iringa during the launching of the Iringa Nutrition Programme. Research on the use of popular theatre to promote women participation and communication in these fields suggests positive results (Mlama 1989); and other findings have attributed success of such nutrition programmes as the Iringa JNSP to the mobilizational power of the various information networks used, both modern and traditional (Mngodo et al, 1987). The use of cultural events and ceremonies for this purpose has also proved useful in some areas. For example, in Mbinga District (Ruvuma Region) CSD promoters have introduced nutrition-related songs to such cultural events as “Mganda and Chioda” (for women), and district leaders have claimed that this has had some impact (Mushi, 1988:12-14).

People-generated information is judged the most effective at the community level. Up until recently, information for programme implementation was the sole responsibility of the experts, namely the extension staff who went to the villages to gather data on various socioeconomic issues. Lessons from the JNSP and CSD programmes (which operate under a different model) showed that advocacy by the people themselves was at its highest where nutrition information was gathered at the community level by the themselves. In this approach, the primary role of the extension staff is to train and sensitize such community-level functionaries as the health workers and committees, teachers, leaders of the village government, and other community actors. These then take up the challenge to mobilize and sensitize the rest of the community, and to ensure that nutrition-relevant information is gathered on a systematic basis. The community-generated information (e.g. on child growth, births and deaths) enabled the village to assess the situation and to take action where it could or request assistance from the higher levels where necessary (URT-WHO-UNICEF, 1988). This approach has been credited with the achievements of the Iringa JNSP: “The generation of information within the community and its use there had been one of the most important mobilizing forces of the programme and one of the most important reasons for its success” (URT-UNICEF 1990:92).

Institutional sources of information have also been tapped. Ministries have participated in public communication through the printed word, taking advantage of the high literacy achieved in the country. For example, the Ministry of Education's Department of Adult Education has established seven zonal newsletters on Mainland Tanzania, with each zone targeting 50,000 to 100,000 copies. Like the other newspapers, these, too, have faced problems in meeting costs of printing materials and distribution. The Ministry of Health and its technical arm TFNC, have also taken initiative in the same direction. TFNC has distributed over 21,000 easy to read booklets (readers) on the major nutrition problems and their solutions. In June 1990 President Mwinyi launched the Health Education Initiative in Tanzania, with the aim of making important life saving messages available to as many people as possible. In this connection, the Ministry of Health made a wide distribution of a Swahili version of the “Facts for Life” booklet (“Ukweli Kuhusu Maisha”) and embarked on a training programme for primary health care workers at all levels, including members of the village health committees. Supported by UNICEF, UNESCO and WHO, the programme had by November 1991 held health education meetings in seven regions, trained 1,981 ward primary health care committees, and covered 7,464 villages. Three other institutional actors have been the source of planning and implementation information, namely the extension service, the Bureau of Statistics, and institutions of higher learning.

Extension staff of different sectors are expected to collect data on a routine basis, mainly relating to implementation of their sectoral projects and programmes. This information is communicated to the higher authorities in the form of quarterly and annual reports in a format prescribed by each sector. In most cases this information has been inadequate for planning purposes, partly because it is inaccurate and partly because historically such information has been intended for control rather than for planning purposes. Moreover, this information is transmitted 'raw' to the district or higher levels, and most districts lack the capacity to process, store and retrieve information. Hence many districts plan with inaccurate information, and continue to perpetuate this inaccuracy from year to year in the absence of rigorous evaluation of performance. Moreover, the annual planning cycle gives the planners inadequate time to do meaningful evaluation of results. This is a major weakness which requires early attention to improve planning, monitoring, evaluation and intervention.

The Bureau of Statistics has been an important source of nutrition-relevant information. It has conducted two household surveys in 1969 and 1976/77, and another one was planned for 1991/92. It is collaborating with the Tanzania Food and Nutrition Centre (TFNC) to develop nutrition surveillance systems, and with the Economic Research Bureau of the University of Dar es Salaam to monitor the social dimensions of economic adjustment. Its Social Statistics Section compiled a National Socioeconomic Profile in 1989 which provide some social indicators for monitoring non-economic aspects of development. The section also compiled a gender pocket book called “women and men in Tanzania” in 1992 which gives the gender situation with regard to a number of social and economic sectors. Academic researchers in Tanzania escaped the attention of policy makers in the past, but now they are beginning to have an impact, as more and more are being called upon to undertake policy-oriented assignments and to participate in sectoral policy seminars and workshops. Research revelations from academic institutions have made a significant contribution to the evolution of a nutrition policy in Tanzania.

Nutritional Interventions Through the Health Sector

The role of the health services in nutrition is essential to the fight against malnutrition, particularly for mothers and children, through:-

a) prenatal care of pregnant women, to protect both maternal and infant health;

b) promotion and support of breast-feeding and good weaning and child feeding practices;

c) surveillance of child growth through periodic weighing and recordings on the growth chart, to alert health workers and mothers to nutrition problems as they develop;

d) immunization of children against infectious diseases such as measles that can interrupt good feeding and growth;

e) oral rehydration therapy, to minimize nutritional losses from diarrhoeal diseases;

f) nutritional rehabilitation, of severely malnourished children; and

g) family planning, to ensure adequate spacing of children and reduction of high-risk pregnancies which could result in the death or debility of a mother.

A “medical-curative” model of health delivery was inherited and typified the 1961-66 phase. Under this model, urban hospitals and curative services were emphasized. Rural health remained the responsibility of local authorities and church-based NGO's. After the Arusha Declaration the Party preferred a “community-preventive” approach. So while expanding curative services in the rural areas, emphasis shifted to preventive actions to be taken by the communities with the assistance of the government. Thus a number of community-oriented health programmes were initiated, and between mid-seventies and mid-eighties an elaborate health infrastructure was created extending from the ministerial level to the village level. We can only outline the leading features of the policies and programmes which have some bearing on nutrition.

In 1974 a Maternal and Child Health Programme (MCH) was launched with the aim of providing mothers and young children with immunization, nutrition education, antenatal and postnatal care, treatment of minor health problems and growth monitoring - all during one and the same visit to the MCH clinic. During the same year the Ministry of Health launched the first village Health Worker (VHW) programme - a community-based programme, with VHW recruited from the village he/she serves under guidance of a Village Health Committee (VHC), and technical supervision from the Rural Medical Aid (RMA) and Maternal and Child Health Assistant (MCHA) based at a dispensary or rural health centre (RHC).

These grassroots institutions expanded country-wide in the course of the seventies and eighties, making community - level preventive interventions possible. Preventive services were particularly emphasized during the Third Five Year Plan period (1976-81), with their shares in the health development expenditure rising from two percent in 1970/71 to nine percent in 1975/76 and 17 percent in 1980/81. The figures for recurrent expenditure were five, ten and 11 percent, respectively. The Plan had a target of one dispensary per village, with a rural health centre supervising six dispensaries. An expanded Programme of Immunization (EPI) framed in 1976 took off in 1981 with DANIDA, UNICEF and WHO assistance which led to the UCI programme described earlier. Primary Health Care (PHC) was strengthened during the 1980s, with emphasis on health education; promotion of food supply and basic sanitation; MCH services, including family planning, immunization, prevention and control of locally endemic diseases. An Essential Drug Programme (EDP) was also started. In addition to the VHW training programme, traditional birth attendants (TBA's) were also trained. During the last half of the 1980s, programmes against diarrhoea, malaria, and a health information system were started or strengthened. The Ministry of Health through TFNC has also successfully launched the Baby Friendly Hospital Initiative (BHFI) and advocacy for breastfeeding.

During the late seventies a twenty year (1981-2000) health plan was launched, emphasizing empowerment of the communities to handle their own health problems with the assistance of ministerial staff. The targets for the year 2000 were (1) to raise average life expectancy at birth from 45 to 60 years; (2) to reduce infant mortality from 137 per 1,000 births by then to 50/1000 (same target as that adopted by the World Summit for Children ten years latter); (3) to have a village health post in every village without a dispensary or a health centre, and (4) to involve all the people in implementation and management of community based health programmes. The outcomes of the health policy were until mid-eighties, better than those of most other comparable developing countries.

The urban bias of the health services had been corrected to some extent by the end of the seventies. Thus the rural population which represented 86 percent of the total accounted for 70 percent of all in-patient days, for 75 percent of all out-patient visits, benefitted from 65 percent of all health expenditure; 70 percent of the rural population lived less than five kilometres from nearest health institution, and 50 percent of all health workers served in the rural areas (URT, 1979; URT-UNICEF 1985:189). By the end of 1988 Tanzania become one of the leading countries in achieving the Universal Child Immunization (UCI) target of 80 percent by 1990 - i.e. two years ahead of the deadline. The figure had risen to 86 percent by October 1991.

Since 1989, the various policy statements and strategies and plans on Health started being compiled into a comprehensive National Health Policy for Tanzania which is yet to be declared. The policy consists of a number of sub-policies which have the objective of improving the physical, mental and environmental health of all people through reductions in morbidity and mortality with a special focus on those most at risk. It also has the objective of improving the quality of life and increasing life expectancy.

The policy is based on the Primary Health Care (PHC) approach as originally embodied in the Arusha Declaration of 1967 and by the 1978 Alma-Aba Declaration. The strategy emphasizes the active participation of people in their own health and multi-sectoral involvement through a decentralized management system. The PHC strategy gives emphasis to the following elements:-nutrition; health education; water and environmental sanitation; maternal and child health services including family planning; immunization; control and proper treatment of endemic and epidemic diseases; the provision of essential drugs; and the provision of mental, dental and ophthalmic services. Active and successful programmes have been started for all the elements. Individual policies for nutrition, drugs and acute respiratory tract infections (ARI) have already been prepared.

In the new PHC Strategy; community involvement is seen as a process by which partnership between the government and local communities is established in the planning, implementation, utilization and financing of health service together with mobilization for a national health culture. Other requirements are seen as intra-and inter-sectoral collaboration; strengthening of district health services; promotion of community based health care and the development and utilization of appropriate technology. Major support and strengthening is also indicated in the following areas:-leadership for PHC through development of group dynamics and team work; women and health through improving MCH/FP services and empowerment of women in decision making; improvement of the capacity for health planning and budgeting; development of a responsive basic and continuing education including for health staff development; improving capacity for supervision, resource mobilization, and research for health.

Policies and programmes related to caring capacity

A number of the health programmes like Maternal and Child Heath (MCH) and Family Planning are related to improvements in the caring capacity. Improved education for girls also leads to improvements in the caring capacity. The government has already formulated policies with regard to “women development” and “youth upbringing”. Presently the Ministry of Community Development, Women Affairs and Children is formulating a comprehensive policy on children. In addition the Ministry of Health has formulated a multi-sectoral Safe Motherhood Strategy for Tanzania as part of the global UNICEF coordinated Safe Motherhood Initiative. It remains to be seen how these policies some aspects of which will require fundamental changes in attitudes and entrenched traditions will be positively effected.

The Food and Nutrition Policy

Given the array of sectors, institutions and agencies both governmental and non-governmental involved in nutrition work the need for some guidelines to harmonize their activities becomes important. In addition, the many policies and programmes which directly or indirectly affect nutrition, need to be made and implemented in a direction that should improve the nutritional status of the people. A Food and Nutrition Policy is thus an important tool for bringing this harmony, both conceptually and practically.

What is a nutrition policy?

A Food and Nutrition Policy (FNP) is a guideline aimed at giving the general conceptual and practical directions of nutrition policies and programmes with the ultimate goal of eliminating malnutrition. The guideline addresses the immediate, underlying and basic causes of the malnutrition problem. The guideline should also address cross-cutting issues like inter-sectoral collaboration, community participation, including nutrition in developmental planning and the issue of resource allocation to nutrition related activities. Thus a FNP may be an explicitly elaborate document giving directions in dealing with the food and nutrition systems. It requires a systematic analysis of the current food and nutrition situation in terms of the immediate, underlying and basic determinants. Since the analytical process is dynamic requiring constant review in assessment, analysis and action to cope with changing conditions; a FNP cannot be a precise listing of projects and programmes in itself. However, it may provide a framework from which programmes and projects can be drawn up. Essentially, a FNP would provide a guide to the entire community on how to deal with food and nutrition problems whenever they arise. It should also be possible to provide early warning for an impending food insecurity and deteriorating nutritional status to enable those responsible to take early corrective action.

The formulation of the National Food and Nutrition Policy for Tanzania clearly shows the complexities of formulating such a policy. It took four years (1976-1980) to formulate a draft policy under the coordination of the Tanzania Food and Nutrition Centre and another eleven years (1980-1991) for the policy to be amended and declared. The process for the formulation of the policy is described in more detail below.

The process of policy formulation

The process of formulating and implementing a food and nutrition policy is complex and long as testified by an analysis of the Tanzania Food and Nutrition Policy [Jonsson, 1979; Maletnlema 1976, 1979; TFNC 1980a-b, 1981; URT 1991]. The process as it was done in Tanzania could be conceptually summarized as follows:-

i) political motivation
ii) defining the problem
iii) laying out alternatives
iv) designing a draft policy
v) discussing the policy
vi) Reviewing the policy
vii) Formulating a plan of action
viii) Making the choice (i.e. a decision)
Political motivation

The process was politically initiated, when in 1976 the Secretary General of the ruling Party, the Tanganyika African National Union (TANU) requested the Tanzania Food and Nutrition Centre (TFNC) to formulate a Food and Nutrition Policy for Tanzania. The political impetus for this seems to have stemmed from the same reasons that led to the formation of the TFNC by an act of Parliament in 1973 [URT, 1973] namely:-

a) as a strategy to implement the 1967 Arusha Declaration which recognized peoples development as the centre of all development and diseases including malnutrition as one of the big three enemies of the people (the other enemies were poverty and ignorance)

b) as a response to the high priority given to the social services sector by the 1973 TANU biennial conference to enable meeting the targets for raising life expectancy and improving the general health of the people

c) as a response to the food crisis brought by the drought of 1974-75.

Defining the nutrition problem

From 1976 until 1980, TFNC was building up its institutional capacity in defining the nutrition problem in order to formulate appropriate policy. At the same time discussions on the need for a nutrition policy were started by TFNC in order to mobilize the support of decision makers [Jonsson 1979; Maletnlema 1976 and 1979]. Various nutrition surveys were done and planning visits to the regions were made by TFNC staff. In addition zonal nutrition planning courses were carried out for all regional and some district planners [Jonsson 1978a].

The Iringa Nutrition Surveillance project [Jonsson 1978c] which was initiated by TFNC under WHO support in 1979-1982; the extensive nutrition surveys done by TFNC in all the districts in Iringa region [Ljungqvist 1977-79 and 1981] and the national goitre survey [Kavishe 1986b; Ljungqvist et al 1979] done by TFNC in 1979-81; apart form contributing greatly to the understanding of the problem and causes of malnutrition were also important inputs in the preparation of the Food and Nutrition Policy. These surveys also laid down a strong basis and were an important consideration in choosing Iringa as the site for the WHO/UNICEF JNSP [URT/UNICEF/WHO 1983]. It was during this time that the “food cycle model” school of thought in approaching the problem of malnutrition started to be questioned and the integrated explicit framework model gradually developed. In fact the very first significant field test of the integrated conceptual framework and triple A cycle was through the Iringa Nutrition Surveillance project; with the Iringa WHO/UNICEF JNSP being its first large scale extension. As for the Iringa JNSP, TFNC stationed a staff in Iringa during the implementation of the surveillance project and also during the whole period of the implementation of the JNSP.

Laying out alternatives

Towards the end of 1980 it was felt that there was enough information and expertise to discuss the variable strategies for a nutrition policy. Thus from 3-5th September 1980, the first multisectoral national conference on food and nutrition for decision makers was convened by TFNC. The site was Moshi a town at the foot of mount Kilimanjaro; Africa's highest peak, where at independence a torch was lit “to shine beyond our borders, to bring light where there was darkness; peace where there was war and hope where there was despair,” in the words of the father of the nation and first President of Tanzania “Mwalimu” Julius Kambarage Nyerere the architect of the Arusha declaration. The meeting which brought together high level decision makers from the sectoral ministries and regions was opened by the Prime Minister at that time the late Edward Moringe Sokoine.

At this meeting various alternatives proposed by TFNC were extensively discussed and an expert committee was nominated to draft a policy [TFNC 1980a&b and 1981].

Designing a draft Policy

The multisectoral national expert committee was convened by TFNC in Morogoro region in December 1980 under the chairmanship of the Ministry of Agriculture and secretariat of TFNC and designed a draft policy [TFNC 1980b & 1981]. The Board of TFNC in 1975 had approved a system whereby expert committees would be nominated to give technical advice to the Managing Director on specific issues on basis of individual expertise rather than institutional representation. The draft policy was later polished by TFNC and submitted to the Government through the Ministry of Health and to the Party as a proposed food and nutrition policy for Tanzania [TFNC 1981].

Discussing the draft policy

The proposed food and nutrition policy document was submitted to both the Government and the Party (CCM) in 1981. Between 1981 - 83, there were discussions on making adjustments before presentation to the Cabinet, and also during this time a new procedure for the development and declaration of specific national policies was adapted. The new procedure required that the relevant sectoral Ministry of Government submits proposed policies to the relevant secretariat of the ruling Party (CCM) which would give its views and comments to the sectoral Ministry before the policy is submitted to the cabinet. In case of the National Food and Nutrition Policy, the Ministry of Health sent the proposal to the secretariat of the social services of CCM and comments were sent back to the Ministry of Health. There is evidence that the policy was widely discussed in both the Government and CCM secretariat.

In 1983, three important events took place. The first was the adoption of an agricultural and Livestock Policy [URT 1982b]; followed a year later (1984) by the National Food Strategy [URT, 1984b]. The Second was the initiation of the Iringa Nutrition programme [URT/UNICEF/WHO 1983]. The third was the development of the Primary Health Care guidelines followed by a Primary Health Care Review in 1984. The developments were important as they were partly implementation of the policy both from a sectoral and multi-sectoral perspective and in addition provided further information and experience with regard to the extent and causes of the malnutrition problem. There was also a lesson: that the policy document development in 1980, needed to be revised.

Reviewing the draft Policy

In November 1983, TFNC requested a review to be undertaken, but was advised not to withdraw the document for review, but review it as part of the discussion process.

In 1985, the social services sector of CCM gave its comments to the Ministry and in anticipation of a declaration, TFNC prepared a National Conference in 1986. But the process was not yet completed and the conference was not held. In 1987, the policy was discussed by the Inter-Ministerial Technical Committee comprising of all Principal Secretaries. Many useful comments were given especially with regard to the more precise definition of the problem and the need to take into account the changes which had occurred since 1980. A national food and nutrition situational analysis which better quantified the problem had been done in 1985 [URT/UNICEF 1985] and 1987 [Kavishe, 1987]. The evaluation of the Iringa Nutrition Programme provided an extremely important experience [URT/WHO/UNICEF 1988]. With such an experience at hand the Ministry of Health/TFNC made the necessary changes and in 1988, the policy was discussed by the Cabinet. The Cabinet approved the policy and gave very useful comments which were incorporated into the document sent to the Party. The comments included the need to incorporate more explicitly the role of culture and beliefs, the Policy on Women in Development; the need to develop an implementation plan of action and the mobilizational role of the Party.

In the same year (1988), the TFNC called a multisectoral workshop which involved all relevant sectors including a representative from CCM. Opportunity was taken to include experiences from the Iringa JNSP and CSD programmes which had expanded from the JNSP in 1985 and the micronutrient malnutrition control programmes which had started to be formulated and implemented. The document was also reoriented from the food cycle model approach of 1980, to the integrated approach conceptual framework and the triple A cycle tested in the JNSP Iringa Nutrition programme. Eventually the fifth revised document was sent to the Party in 1989 by the Prime Minister.

Making the Choice

While the Party (CCM) was scrutinizing the policy document, TFNC called a multisectoral workshop in July-August, 1990; to review the country's food and nutrition situation and programmes and recommended the formulation of a Medium-Term Plan of Action (MTPA) for the implementation of the food and nutrition policy. The workshop was opened by the Minister of State in the President's Office and Vice-chairman of the Planning Commission. The MTPA was formulated by a multisectoral expert committee under the chairmanship of the Economic Research Bureau of the University of Dar-Es-Salaam and secretariat of TFNC in August 1990. The objectives for developing the MTPA were:-

i) to indicate possible programmatic direction for critical intervention areas in solving the problem of food and nutrition

ii) to articulate possible strategies for achieving sustained intervention

iii) to stress and indicate multisectoral collaboration and dialogue with emphasis on community participation and mobilization and

iv) to stress the need to incorporate actions into sectoral plans and providing the means for monitoring and evaluation of the implementation of the policy.

The outcome of the workshop and expert committee provided further experience in reviewing the policy document. After submission to the Party (CCM) the document was reviewed three times more jointly between the Party and TFNC. The eight revised document was distributed to all members of Parliament in June 1991 and was incorporated into the Minister for Health's Budget speech in the same month. At the ninth revision, it was possible to articulate the nutrition goals adopted by the World Summit for Children of 1990 with the National Plan of Action (NPA) being interpreted as an implementation of the policy. The ninth and final version was passed by the Central Committee (CC) of CCM on 18th December 1991. The CC comprises of 18 high level decision makers including the President of the United Republic who is also the Chairman of CCM; the Prime Minister and first Vice-President; the President of Zanzibar and Second Vice-President; the Vice-Chairman of the Party and the Secretary General of the Party. The choice was thus finally made.

Implementation

The division between the process and implementation is an arbitrary one. As already indicated, implementation of the policy was going hand in glove with the development of the policy itself. The process of assessment, analysis and action on the main areas of food security; caring capacity and essential services continued even in the absence of formal declaration of the policy. This stresses the fact that the elaboration of the document was not the main aim. The mobilizational effect of the process was perhaps more important. In retrospect, the delay in the declaration of the policy was a blessing in disguise. In the absence of a blue print for the formulation of such a policy the delay kept the policy on the agenda of many high level organs until a critical mass of awareness and opinion was mobilized.

What were the reasons for the delay in declaring the policy?

If there was political commitment, technical competence in developing the policy and that decision makers were supposed to have their values and priorities right with regard to nutrition relevant policies why then was its declaration delayed for so long?

We have had occasion to discuss this issue with a number of Government and Party officials. The conclusions which we can draw from these discussions are two. First is that the policy touched areas for example food security which required their own specific policies. A delay was required to give time to the sectoral Ministry to develop a policy in those areas. The Agriculture and Livestock policy was declared in 1983 followed by a Food Strategy in 1984. In other words sectoral priorities and values overrode the multisectoral approach of the policy. Secondly, there were initial fears that the aim of the policy was to create a super-structure to coordinate and oversee food and nutrition activities with too wide a definition of nutrition as interpreted by the TFNC/UNICEF integrated conceptual framework. It was feared that this super-structure would have been TFNC. These fears took some time to subside. Thirdly the policy was widely discussed by policy making forums and several revisions were required with a long time lag between the time of those forums and information to the technical implementors. The policy document declared in 1991 was the ninth revision. Perhaps there is no other policy which has been discussed for so long by decision makers as the food and nutrition policy. It is pertinent to add that all nutrition-relevant evaluations, appraisals, reviews recommended the “immediate” declaration of the policy.

There were also two other important reasons for the delay in declaration. The first was a low capacity in the Ministry of Health to process the declaration of the policy. Ministries of Health are generally known not to be efficient in policy matters. This was the first policy to be developed under the auspices of this ministry. A health policy is still under preparation [URT/MOH 1989]. The second reason was that the policy was being proposed at a time when the government was giving highest priority to economic policies related to structural adjustment and political pluralism. As it were, there was not “enough time” for the government and the ruling party to put the food and nutrition policy in their consultative competing agendas. It is significant to note that the policy was declared at a time when the social dimensions of adjustment were being formulated. In fact the coverage of the policy declaration in the government owned “Daily News” was written side-by side with information on food crisis in one of the regions. Thus, while the proposal to have a national food and nutrition policy in 1976 was a response to the food crisis of 1973-75, its declaration was a response to the negative social effects of structural adjustment. Thus both the initiation of its development and its declaration were “crisis” responses.

Specific nutrition programmes of the eighties


The Iringa Joint WHO/UNICEF Nutrition Support Programme (JNSP)
The Child Survival and Development (CSD) Programmes
Nutrition surveillance and the development of Nutrition Information Systems (NIS)
Programmes for the Control of Micronutrient Malnutrition

During the eighties there were three major types of specific nutrition programmes whose objective was to reduce the high rates of malnutrition and mortality. These programmes are the Iringa Joint Nutrition Support Programme (JNSP); the Child Survival and Development (CSD) Programmes, Nutrition Surveillance and the national micronutrient malnutrition control programmes (MMCP). In this section we shall briefly describe these programmes.

The Iringa Joint WHO/UNICEF Nutrition Support Programme (JNSP)

Background

The Iringa Joint WHO/UNICEF Nutrition Support Programme (JNSP) began in October 1982 with funds provided by the Government of Italy [URT/WHO/UNICEF, 1983]. Tanzania, one of the first countries considered for inclusion in the JNSP was informed of the plans and invited to prepare a country proposal in March 1982. The planning process was started in April 1982 through the formation of a National Ad Hoc Planning Group comprising of representatives from the Prime Minister's Office (Chair), the Ministries of Health, Education and Agriculture and the Tanzania Food and Nutrition Centre.

Iringa region was proposed to be the location of the proposed area-based community nutrition programme for three reasons:- First it was the only region where comprehensive nutrition surveys had been done and the prevalence of malnutrition had been found to be very high. Second the region has diverse agro-ecological zones to enable the region to develop a broad base of experience in different settings to facilitate replicability in other areas. Thirdly, the strong institutional infrastructure found in the region was deemed essential since the project was viewed as an experiment with a new approach to nutrition intervention and thus would give the experiment a fair trial.

The National Ad Hoc Planning Group prepared a proposal and submitted it to the WHO/UNICEF Global Steering Committee in October 1982 shortly after the official commencement of the programme. According to the procedures defined by the Global JNSP each country project was given a life of five years from the date on which funds were first received from the Government of Italy.

The proposal was approved and funds were allocated for five years. Funds were made available to Tanzania in March 1983. However, because adequate funds were available beyond the official termination date of April 1988, the Global JNSP granted a one year time extension in July 1987 to 1989. A mid-term review of the programme was conducted in 1986 and a final evaluation was done in 1988 [URT/WHO/UNICEF, 1988] as it was planned under the initial grant. Because of the success of the Iringa Nutrition Programme (INP) as it became known in Tanzania; the programme was slowly expanded to other regions as the UNICEF supported Child Survival and Development (CSD) programmes starting 1985 and to Zanzibar as the original Joint WHO/UNICEF Support Programme (JNSP) under funding from the Italian Government in 1989.

The objectives

The objective of the JNSP was the development of community based improvements in nutrition and health including amelioration of the situation of women through a fundamental change in process. This was in the recognition that the nutritional status of an individual is the outcome of a complicated biological and social process in the fabric of society, and therefore, sustained change in the nutritional status of a population can be brought about only by changing that process.

The design

The Iringa JNSP was the first large scale application of the TFNC/UNICEF conceptual framework described earlier. As already discussed, the framework provides the context within which a continuous search for ways to attack the causes of malnutrition is made through repeated cycles of Assessment, Analysis and Action; the so called Triple-A Cycle. Thus the evolution of the programme was shaped by lessons learned through the application of the Triple-A Cycle at all levels of the administrative and social hierarchy, starting from the household and village and reaching all the way to the central Government. Each level assessed and analyzed those problems which can be addressed at its own level and tackled with the resources available at that level.

Coverage and activities

The programme covered 168 villages in seven divisions. Since it was started as a pilot programme the initial plan included all conceived activities for experimentation. Thus the programme started with 14 projects divided into 42 sub-projects. The projects were 1) Health sector support (8 sub-projects); 2) Environmental Health Hazard Control (3 sub-project); 3) Education and training (2 sub-projects); 4) Child care and development (3 sub-projects); 5) Technology Development Support (8 sub-projects); 6) Household Food Security (5 sub-projects); 7) Food preparation (3 sub-projects); 8) Programme Support Communication (3 sub-projects); 9) Monitoring and Evaluation (3 sub-projects); 10) Support to Regional and District Infrastructure (1 sub-project); 11) Additional Research Support (1 sub-project); 12) Soliwayo Base Camp (1 sub-project); 13) Programme Staff and Management (1 sub-project); and 14) Contingency (1 sub-project). With the exception of a sub-project on Biogas which was dropped at an early stage after having been seen to be inappropriate technology for communities in Iringa the rest of the projects were wholly or partially implemented during the period 1984-86.

However at mid-term review in 1986 it was apparent that the number of projects were too many to be effectively managed. So the mid-term evaluation recommended reorganization into 8 programmes and 31 projects as follows:- Programme 1: Systems Development and Support (4 sub-projects); Programme 2: Maternal and Child Health (11 sub-projects); Programme 3: Water and Environmental Sanitation (1 sub-project); Programme 4: Household Food Security (7 sub-projects); Programme 5: Child Care and Development (4 sub-projects); Programme 6: Income Generating Actions (1 sub-project); Programme 7: Research (1 sub-project) and Programme 8: Management and Staff (1 sub-project). Eight Task Forces were formed and charged with the responsibility for each of the respective substantive areas of the programme.

Management and Implementation

The launching of the JNSP was lengthy, intensive and complex due to the need to develop methods and materials from scratch. A unique and important feature of the programme's organizational structure, made possible by Tanzania's extensive local government and political systems, is that no special organizational structure was created to promote community responsibility. Apart from the formation of a National Steering Committee, and a small Regional Management Team no new posts were created. However, six people including two expatriates, worked in the region for 4 years (1983-1986) to help with the promotion of surveys, discussions, orientation and training at all levels and on the launching of the activities. The deep knowledge of the region by one of the expatriates who had organized the initial nutrition surveys done by TFNC in 1979/80; his wide knowledge about nutrition issues and genuine concern for improving the nutrition situation coupled with his ability to creatively catalyse and mobilize flexibly a broad range of sectors was very important during the launching of the programme.

Management and implementation of the programme was done in such a way as to enable the expansion and strengthening of national capacity to address issues bearing on nutritional improvement at central, intermediate and local levels. This was explicitly expressed as an objective using the Triple-A Cycle approach. This approach gave way to programme flexibility. The 1988 Evaluation found that the JNSP enhanced national capacity in many ways [URT/WHO/UNICEF, 1988].

Research was one of the important activities which enhanced national capacity. The programme called upon a number of institutions to do needed research in the region. Similarly, a number of institutions were given the opportunity to capitalise on the infrastructure support afforded by the project to choose their research. The process of identifying research was done in two ways. One way was for the programme implementers to identify research needs which were then sold to potential researchers. The second way was for the researchers themselves to come up with the research proposals which were then scrutinized by a research coordinating committee (RCC) to see if they matched with the programme priorities. Through research seminars a number of research priorities for the programme were identified, funded by the programme and taken up by the researchers.

An important future of research in the programme is that it was different from the traditional role given to research. Participation in research was seen as part of the social mobilization process as well as a key to the successful application of the Triple-A-Cycle. Thus all research was done in the name of learning more about operational issues rather than for the sake of research alone. As a result studies cut across all administrative levels from the central, regional, district and local levels often involving non-academic individuals in practical operational research. This strengthened the ability of field workers to pose questions and seek answers and change the way research was viewed in the region. Research was no longer just a matter for universities and higher institutions of learning but a tool which led to better design and implementation of field activities. As a result, preliminary findings were utilized in the implementation process so that by the time the final results were out most of the findings had already been applied. A number of National Institutions also took advantage of the studies conducted to develop and improve on the curricula for their fields of specialization, keeping students and graduates up to date with field experiences.

Though the Iringa programme was area based the National Steering Committee convened quarterly meetings to assure that the project evolved in a way consistent with national policies and programmes. These meetings were held in villages in the project area so that participants could interact with villagers and get first hand opportunity to see the project. Apart from improving the guidance offered by the committee, the meetings in the villagers assured that National Institutions remained in touch with the programme. An important outcome of this approach was the vigorous involvement of the CCM the Political Party in Tanzania, for social mobilization, which was not originally foreseen as a part of the implementation strategy. The strategy for Party social services involvement in Iringa was eventually adapted by the Party at national level.

At the regional level a Regional Support Team (early on Management Team) opened up new possibilities for coordinated social services planning. This was reinforced by a Regional Implementation Committee which created a forum in which the nutrition related activities of each sector was reviewed by representatives of other sectors. This enhanced the capability and willingness of many sectoral workers to address issues outside their original field of competence and to support the work of their colleagues whenever opportunity presented itself.

Since the Iringa Nutrition Programme was initially conceived as a regional programme, management and implementation of the programme was transferred to the district level half way through the programme. This necessitated the development of integrated support and implementation mechanisms similar to that at the regional level. Though district level officials had been involved in the programme from the outset; TFNC conducted integrated training for the district officials and extension workers in order to enhance district capacity in planning and implementation. Training was also conducted for Village Health Workers and Traditional Birth Attendants (TBA). District capacity was further enhanced by periodic meetings of the district and regional implementation committees which greatly contributed to the exchange of experiences and ideas among sectors as well as districts. The result was a sustained involvement of many individuals at many levels of administration which was a unique feature of the programme.

At the local levels Village Health Committees were strengthened, and the concept of management resource by the objective of nutrition improvement was introduced. Villages organized and managed by themselves such schemes as day care centres and feeding seriously malnourished children using locally available resource. Perhaps the most important outcome of this approach was the ability of the programme to mobilize villagers around nutrition as a major social concern.

Management Information Systems (MIS)

A key element of the programme approach was the provision of information about children's nutritional status to critical decision makers at all levels through a system of community growth monitoring system by quarterly weighing. Child growth cards and village registers permitted the follow up of individual children who were severely malnourished in a community based nutrition rehabilitation approach developed by TFNC, for the first time in Tanzania. Parents were given advice on information regarding increasing the frequency of feeding and the use of germinated flour (power flour) and other child-feeding practices. They were also provided with information with regard to increasing household food security or referred to other service which they needed. The TFNC House hold Food Security Card based on the number of bags (bag model) a household would need to last it until the next harvest season was developed and tested.

An important feature of the MIS was its use at all levels for decision making [Pelletier, 1991]. It permitted Village Committees to identify and target actions to at risk house holds. Likewise district staff used the information generated to target extension services in villages with poor nutrition or those who do not report regularly, an indication that the village committee may not be functioning well. District and Regional Development Committees were provided with summary reports for discussion in their meetings so that all senior officials in the districts and regions could advice on further actions to improve the situation. This led to the incorporation of nutrition objectives in district and regional development plans.

Although the information system in the Iringa Nutrition Programme (INP) was designated primarily as a management and motivational tool to catalyse the triple-A-cycle at household, village, and higher levels it was also used to a limited level to assist in the evaluation of the impact of the programme on nutritional status. The technical limitations and threats to plausibility of the information system has been attributed to the constraints in quality control of the collected data due to problems of staff capacity and skills [Pelletier, 1991]. In order not to compromise the motivational and management uses of the information, it was suggested that users of the impact information should be made aware of its limitations [Pelletier, 1991].

Programme Impact and Outcomes

Programme impact was indicated by mainly the community based ongoing nutritional status monitoring systems; and the results of various studies done as part of the programme activities or for the purposes of evaluation. The results showed that the programme was highly successful.

At the time of evaluation in 1988 [URT/WHO/UNICEF, 1988] a marked decrease in both the severe and moderate rates of underweight were observed. Severe malnutrition was reduced by 71.4 percent from a high 6.3 to 1.8 percent and total underweight was reduced by 32.0 percent from 55.9 to 38.0 percent in a period of five years. The drop occurred progressively over a period of three years and in recent years the low levels have been maintained. The reductions in the malnutrition rates were attributed to the programme, as marked differentials in the rates of severe underweight existed between the original 168 project villages as compared to 442 villages in the Iringa non-JNSP areas when the project was expanded to these villages in August-October 1987; after three years of the programme.

A comparison of the prevalence of severe malnutrition in the Iringa JNSP at the beginning of the programme in 1984 and at the time of evaluation in 1988 showed that the impact was due to the programme as the rates of malnutrition in the non-programme areas remained high (fig 8).

Improvements in the nutritional situation occurred before other elements of the programme for example rehabilitation of the health services or water facilities had been put in place. In great part, the initial success in the reduction of malnutrition could be attributed to increased feeding frequency for children, partly as the result of extra attention paid to feeding; the establishment of child feeding posts for the severely underweight and partly to improved health care in families and communities. There is evidence to indicate that improved information and use of the information system itself was an important factor in leading to improvements in the areas related to success and thus the initial reduction in the rates of malnutrition.

Figure 8: Prevalence of severe malnutrition in JNSP and non-JNSP areas (1984-1988)

Another important outcome of the programme was an increase in the rates of immunization from a low 35 percent in 1984 to 93 percent in 1988. The experience of the Iringa immunization campaign was in fact used in the accelerated programme for immunization started in 1986 country wide and is widely acknowledged as one of the reasons which made Tanzania reach the target of immunization two years before the target period.

An analysis of other key outcome indicators like the possession of an MCH card; mother's knowledge about the growth chart; ability to recognize malnourished children; knowledge about “kimea” (power flour); personal knowledge about the Village Health Worker (VHW) indicated that the programme reached nearly 85 percent of the mother/child pairs in a positive way. Relating these outcomes to nutritional status as a measure of the intensity of participation in the programme showed that generally the programme had a positive impact on the nutritional status.

Costs and affordability.

A cost analysis of the Iringa JNSP [URT/WHO/UNICEF, 1988] showed that about $19 per child per year was spent as follows: - $10 for ongoing costs of which $8 were from external resources and $2 from all national resources; and $9 for start up and expansion activities in the programme area. The start up costs amounted to 18 percent of total spending while “expansion” and “ongoing” activities were each about 40 percent of the total costs. The greatest expenditure on programme activities was on programme management which was over 20 percent of the total. Infrastructure support and community-based health services and dispensary construction each received about 10 percent of expenditures. Over half (57 percent) of the external JNSP inputs were provided as foreign exchange in the form of dollars. About 25 percent of these were in the form of vehicles; 20 percent for expatriate personnel and about 15 percent each was for buildings and purchased services.

The costs for the programme are clearly higher than those normally spent on services for children. On face value these costs may not seem “affordable” economically. But it is important to note a number of points.

First is that the annual cost per child were based on the estimated 46,000 children in the 168 villages in the programme area. But it should be realized that many of the benefits of the JNSP-supported activities like health services, food security, income generating activities extended beyond the child to their mothers, and other family and community members. Thus the start up costs helped initiate national, regional, district and community level processes for a far broader base of activities to improve nutrition and health of children and women than was the case previously in Tanzania.

Secondly these costs were drastically reduced in the expansion of the programme. This was because of the experience gained which was used to refine programme approach to concentrate on those elements which are the most cost effective. As it has already been noted the original nutrition programme in Iringa contained projects and funding for activities which proved not to be very effective in reducing child malnutrition rates. These were dropped or modified as the programme evolved. Experience in the expansion areas of Iringa which took place in 1987 point to the continued success of the programme approach with significantly reduced cost. The rate of reduction in severe child malnutrition in the expansion programme (CSD) has been even sharper than in the original programme (JNSP).

Sustainability and replicability

Since its inception the JNSP in Iringa continuously grew changed, and modified itself in response to the application of the Triple-A-Cycle. Lessons learnt regarding the process of the intervention and infrastructure development were transferred to other geographical areas as Child Survival and Development (CSD) programmes. However, the process of implementation took into account the social economic, technical, physical and resource availability in those areas.

There is evidence which strongly indicates that the Iringa “model” of the process approach has been sustainable in the local contexts of the CSD areas as indicated by the sustained reductions in the rates of severe malnutrition. Though economic considerations are important they are not primary in the process of replication. Affordability is demonstrated first in the degree of participation that is seen in a broad spectrum of CSD activities. This participation is indicated by the level of financial human and material contributions which have been made to the JNSP and CSD programmes which considerably extended beyond the originally defined scope of the programmes. Most striking is the support given to the villagers workers day-care attendants by community which sometime average more than 20 percent of the village budgets.

The essential elements which were responsible for the replication of JNSP were the following [URT/WHO/UNICEF, 1988; Pelletier, 1991; UNICEF, 1989]:-

1) The use of the explicit integrated conceptual framework which helped to seek solutions in a multi-disciplinary way within the comprehensive approach provided by the framework. An important strength of the framework is its lack of clearly defined boundaries which leave room to develop different causal models of the problem of malnutrition in different circumstances. Thus though the framework is not predictive it allows its application in a variety of situations.

2) The Triple-A-Cycle approach of Assessment - Analysis - Action led to the improvement of the capabilities at many levels to assess and analyze nutrition problems and to design appropriate actions. It also led to a fundamental change in process as well as a development of support systems for advocacy, training and monitoring. This is important for empowerment and sustainability.

3) Social mobilisation led to a high degree of active popular involvement in the programme with a consequent allocation of resources by communities for the improvement of nutrition within households. It is likely that much of the additional time and care of parents for their children was provided by women but with an increase in the participation of men. Social mobilization elevated malnutrition from the level of an individual problem to that of a community social concern.

4) The permissive social and political context in Tanzania was an important condition for programme sustainability and replicability. Political commitment is essential for the success of nutrition intervention programmes. As often stated by the regional and district officials the programmes's emphasis on a process approach of social mobilization and the resulting inter-sectoral action, made the effects of the programme go beyond the scope of “nutrition” programmes per se, to contribute to the effectiveness of all other development activities which were aimed at improving the people's well-being.

The Child Survival and Development (CSD) Programmes

The approach embodied in the Iringa JNSP was first extended to all 600 villages in Iringa [URT/UNICEF/WHO/UNFPA, 1989] and secondly to a selection of villages in six other regions as the UNICEF supported Child Survival and Development (CSD) programmes. These regions were Morogoro, Shinyanga, Kagera, Ruvuma, and Kilimanjaro. It was also extended to Zanzibar in 1989 as JNSP. By 1991 nine out of twenty regions in mainland Tanzania were implementing CSD community based programmes. The additional regions are Mtwara, Singida and Mara. Map 8 shows the districts implementing CSD programmes in Tanzania by 1991. As can be seen in the map other donors like the World Bank and the EEC have adopted the UNICEF supported CSD approach.

The procedures for extension of the Iringa approach begins with an orientation in working groups of the administrative staff party secretaries and technical staff at each successive level of region district, division and ward [UNICEF, 1991]. At the regional and district levels, the chief administrator designate a coordinator who is usually the Planning Officer or occasionally the Community Development Officer. An implementation committee is then formed and visits are made to the regions with a long experience of CSD programmes taking Iringa the model.

The next step is the promotion of the activities in the villages by district and ward staff through social mobilization and discussion of whether the village wishes to participate followed by election of health committee including a stipulated number of female members; selection of a male and female village health worker and preparation of a village register; if the village decides to join. The practical activities are inaugurated by the showing of an information film and a campaign day during which all children are weighed and immunised where necessary. Subsequently, there is a health day once a month or once a quarter for child weighing, immunizations etc. Other activities may be added over time such as feeding posts, informal day care for children for mothers working in the fields, vegetable gardens, introduction of grain mills and other labour saving technology as more fuel efficient stoves.

In order to assist the regions and district in training of community implementors, a “CSD Training Package” was developed and trainers from all the CSD areas were taught how to use the package. The package has been extensively used in all ongoing CSD programmes both for consolidation of programme activities as well as expansion to other areas. Advocacy and social mobilization approaches involving community, Government and Party Leaders have influenced communities to accept more responsibilities for mobilization of local resources for nutrition improvement. Districts now have integrated most of the support to CSD actions into regular planning and monitoring systems. Communities in 1200 villages in 31 districts of mainland Tanzania have improved their own capacity to assess and analyze problems affecting children and women and have taken actions to improve their nutritional status. In 1990 over 250,000 children under-five were weighed on average during each quarter. In many places severe malnutrition is decreasing and has dropped to below two percent.

Map 8: Tanzania districts implementing CSD programmes, 1991

Source: Programmes for Women and Children
An interesting observation in the rates of reduction of severe malnutrition is that there is a tendency for the rates to level off more or less when a rate of about two percent is reached. It seems that more fundamental changes in the basic causes of malnutrition is needed if further decreases are to be made.

Phase II of the Iringa CSD programme contributed to the establishment of three major national trials. These were the Safe Motherhood Initiative, community financing for primary health care, and the control of critical common disease factors: malaria and respiratory infections. The safe motherhood initiative in Mufindi district has provided consolidated information and training materials for use both in Iringa and nationally. Advocacy and promotion efforts for the Safe Motherhood Initiative are now integrated into most district and regional development activities.

There is a growing interest in the JNSP/CSD programme approach due to the success which has been shown to be cost effective. The annual cost per child to finance such community based programmes has been now reduced to the equivalent of $ 2-3 in 1987 prices three quarters of the costs are for imported items like drugs for village health workers and transportation [URT/UNICEF, 1990]. An estimate for programme costs in 1990 for the whole country at about 3 US$ per child would be about US$ 15 million for all children in mainland Tanzania with $11 million for imports requiring foreign exchange.

Thus with financing of three dollars per year per child and additional contributions in terms of time of extension staff and support and supervision from district and regional level and particularly time of parents and members of the village health committee and community contributions for the compensation of village health workers and child-feeding post attendants it is possible to reduce significantly the rate of severe malnutrition.

Since many other regions have been seeking an extension of the CSD approach in their areas if external support for launching the project system can be found; UNICEF will extend its support to the core elements of the CSD approach to all the 20 regions of the Tanzanian mainland for the five year programme support 1992-1997. In 12 regions UNICEF will support improved management of social mobilization for nutrition at community level, ward and district levels as well as some crucial inputs for specific social services: health, water and sanitation, education and child development, and nutrition/household food security. Support will also be provided to disadvantaged women to undertake economic activities. The core elements which have been identified for support are i) community mobilization, participation and management ii) adequacy of food intake including micronutrients, for women and children iii) child development and education iv) health and water v) income generation in poor households and vi) district management systems.

For the remaining eight regions UNICEF's support will be confined to the community based management training package including the establishment of a nutrition information system. The World Bank, NORAD and SIDA are joining in these CSD approach efforts in a number of districts as already shown in map 10. Other agencies like the EEC, IFAD and UNFPA are exploring their roles in this process so that by 1997 it is expected that all regions of mainland Tanzania will be pursuing effective community based actions for the improvement of nutrition.

Coordination of the CSD programmes is done by the Planning Commission in the President's Office under the National Coordinating Committee for Child Survival and Development (NCC/CSD). This committee replaced the National Steering Committee for the Iringa JNSP. The NCC/CSD coordinates the planning and monitoring of CSD and CSD related programmes through regular meetings and biannual meetings. Programme implementors, national technical staff and relevant donors participate in the meetings.

Nutrition surveillance and the development of Nutrition Information Systems (NIS)

Efforts to develop a nutrition surveillance system in Tanzania started as far back as the early 1970s. During that period a number of institutions started nutrition related data collection systems in order to meet specific sectoral data needs. For example the Ministry of Agriculture started an Early Warning System (EWS) for crop production and the Marketing Development Bureau (MDB) monitors closely the daily food prices in selected local markets. The Ministry of Health has a component of growth monitoring both during pregnancy and for all under-fives through the Maternal and Child Health (MCH) system; and collects information on diseases through the Health Information System (HIS). The Bureau of Statistics also collect vital statistics and morbidity and mortality data through censuses, demographic surveys and birth and death registration systems. In addition the monitoring systems of the JNSP and CSD programmes has collected serial nutrition specific data since 1984. What has been missing is a coordinative mechanism to ensure inter-sectoral analysis and utility of the collected information outside the specific sectors and a common interpretive framework.

It was because of this that since 1989 TFNC [TFNC, 1991] under the support of UNICEF through funding from the Netherlands Government and the Global Inter-agency Food and Nutrition Surveillance is implementing a three level nutrition surveillance systems (NSS) programme: - national, district and community based.

i) National nutrition surveillance

The national component is intended to systematize and communicate nutrition related data for use by national leaders for planning and decision making. Data on selected variables are organized at TFNC to form the National Nutrition Surveillance Database. The data systems from which information is collected come from the CSD programmes districts; the Marketing Development Bureau; the Bureau of Statistics; the Health information System (HIS) and the Ministry of Education. It has been difficult to obtain data from the Early Warning System because the data is perceived as confidential. The variables are analyzed to give indicators on child nutritional status; birth weight; health; food production and availability; changes in food prices; female education and various social and economic indicators that influence nutritional status.

As part of the national component of the nutrition surveillance programme, TFNC in collaboration with the Bureau of Statistic's house hold survey (HBS), has included a nutrition module into the programme which is based on a statistically obtained national master sample survey (NMSS) to be administered on a regular basis [Nyang'ali and Kaganda, 1991]. A module of questions was pilot tested and then included in the HBS. Assessment of nutritional status was done through anthropometric measurements of weight and length/height and questions about critical indicators and immediate determinants of nutritional status like feeding frequency, weaning practices and morbidity data (fever, diarrhoea, ARI and measles) were also included. The first round of survey was planned to have been conducted in December 1990 along with the Labour Force Survey conducted by the Bureau of Statistics but it was postponed and Started to be conducted in October-November 1991 because the nutrition module had not been institutionalized by then. The anthropometric results for the October 1991 to April 1992 has already been presented. Since it is planned to continue data collection throughout the year annual nationally representative indicators of the nutrition situation can now be available. The major problem facing the availability of this information is low capacity for analysis at TFNC due to shortage of staff.

ii) District nutrition surveillance

The district surveillance systems are based on the fact that Tanzania's Local Government system give a considerable amount of autonomy over resources and development decisions to districts. This makes districts a strong resource base for nutrition related actions and thus a good information system at this level will facilitate the tapping of the district resources for the improvement in nutrition. Since most of the nutrition related information is handled sectorally at the district level, the objective of the district surveillance project is to improve the district capability to organize, analyze and communicate nutrition data generated from the community based information systems. Five districts namely Kilosa (Morogoro region); Makete and Njombe (Iringa region); Hai (Kilimanjaro region) and Masasi (Mtwara region) all implementing CSD activities are participating on a pilot basis.

District staff responsible for information collection and use in planning and decision makers were trained in 1990 [TFNC, 1991]. However, until February 1992 only Hai and Njombe districts had established computer based data-banks. In addition to computer training of a staff from each of these two districts support with communication supplies like typewriters, filling cabinets, stationery and overhead projectors has also been given. As a result Njombe district has started compiling important data into a booklet called “Njombe District Statistical Abstract” which is updated annually. The booklet is distributed to the district decision makers like the District Commissioner (DC), the District Executive Director (DED) and to the various departments. Kilosa, Makete and Masasi districts have also started to systemize information from the various sectors in the districts.

iii) Community based nutrition surveillance

The community based surveillance systems (CBSS) presently cover about 42,000 children under-fives in 14 villages in Serengeti and Tarime districts (Mara region) and several villages in Iramba and Manyoni districts (Singida regions). In addition nutrition surveillance through child growth monitoring community based systems is currently operating in 31 districts of the UNICEF supported JNSP and CSD programmes in both mainland and Zanzibar. The provision of transport facilities (bicycles) to village health workers (VHW), ward level coordinators and district coordinating teams have greatly improved communication between the community and support groups.

Already a considerable amount of nutrition data has been generated through the three level nutrition surveillance systems (NSS) and computerized data bases established at TFNC and two districts. At TFNC Programme staff have been recruited and trained in database management and covered Harvard graphics, Atlas Graphics, Lotus 1-2-3, Informix and Word Perfect 5 packages. Even with limited data base management capabilities at both the level of districts and TFNC itself, the first national nutrition surveillance report was produced by TFNC in late 1990. The second report was produced in 1992.

All these developments have resulted into the development of a national data base since 1992 when the first national representative nutrition data became available. As already discussed the data from the nutrition module of the Household budget survey (HBS) is similar to that obtained from the Demographic and Health survey (DHS).

Two problems face the nutrition surveillance programme, the first is human resource capacity at both TFNC and in the respective districts. This problem has been addressed through training but more people need to be trained. The problem has resulted into delays in the compilation of reports and thus untimely availability and use of the information generated. The second is that even if the information is available there is still a tendency for decision makers in government to rely on their experience in taking decisions rather than using objective data. Thus there is need for the surveillance information to be summarized in an easier form to be readily understood by busy decision makers.

Programmes for the Control of Micronutrient Malnutrition

The development and implementation of national micronutrient deficiency control programs has been under the coordination of TFNC. The programmes are based on the causes of the problem as analyzed using the TFNC/UNICEF conceptual framework and the technical methods available.

The initial efforts were mainly limited to patchy surveys, but it was the Iringa regional nutrition surveys of 1979/80 [Ljungqvist, 1981]; the national endemic goitre surveys started in 1980 [Kavishe et al, 1983]; and the xerophthalmia surveillance system started in 1982 [Foster et al 1986] and the vitamin A community based surveys [Pepping et al, 1988] which made an assessment and analysis of the situation and provided community based data on prevalence, severity and causes of the problem of micronutrient malnutrition.

Under the coordination of TFNC various high level multi-sectoral and multidisciplinary workshops and expert committee meetings on the various micronutrients were convened to discuss the results of these and any other assessments done and proposed relevant actions.

In all cases both national and international experts and potential supporters participated. It was on the basis of the recommendations from these workshops and their vigorous media coverage that the need for urgent action was crystallized and five year national control programmes separately for IDD, vitamin A deficiency and nutritional anaemia were formulated and funded. Details about the micronutrient malnutrition control programmes are discussed elsewhere [Kavishe, 1991]. Here we shall only give a summary for each of them. A summary of the programme situation for each of the micronutrients is given in table 53.

i) Programme for the control of IDD

The national IDD control programme for IDD in Tanzania consists of the targeted distribution of iodinated oil capsules on a short term stop-gap measure and the universal iodation of salt (fortification of salt with iodine) meant for human and animal consumption as the long term sustainable measure. Tanzania chose to use iodinated oil in areas of severe IDD because the salt iodation programme has taken a long time to implement. The objective of the IDD control programme is to eliminate severe IDD areas by 1993 and eliminate IDD as a publish health problem by the year 2,000. The Swedish International Development Authority (SIDA) has been funding the iodinated oil capsule distribution; while the Royal Netherlands Government has funded the salt iodation component through UNICEF.

Table 53: A summary of the micronutrient malnutrition programmes in Tanzania


IDD

VITAMIN A

NUTRITIONAL ANAEMIA

Year programme started

1979: initial development
1985: comprehensive partly funded national programme in place

1981: initial development
1985: comprehensive partly funded programme in place

1982: initial development
1991: comprehensive funded national programme in place

Goal by 2,000

eliminate

eliminate

reduce by one third in women of reproductive age

% population affected

25

6

32

% children under five affected

13

30

45

% pregnant and lactating women affected

52

0.7

80

Programme components:-
1) Dietary diversification

advocacy for sea fish and weeds. Not much emphasis has been put on this option.

Horticulture, Red palm oil, yellow fruits e.g. papaya, mangoes, guava; dark green leafy vegetables. Animal products whenever possible

Dark green leafy vegetables; vitamin C containing fruits; avoiding tea and coffee immediately after meals; animal products whenever feasible

2) Supplementation

Iodinated oil capsules distributed in severely endemic areas to ail people 1-45 years of age. Already covered more than 5.0 million people. Cost estimated at 0.30 Us $ per person for two years

Targeted capsule distribution through EDP to those with clinical signs, measles, severely malnourished, diarrhoea lasting for more than seven days, PTB, bronchiolitis ARI.

Targeted iron and folate to pregnant women attending ante-natal clinic. Cost is 1.54 US$ for a full coarse in pregnancy starting at 20 weeks.

3) Fortification

Universal iodation of salt meant for human consumption. About 40% of salt now being iodated.

Feasibility studies for suitable vehicle under way.

Feasibility studies for suitable vehicle underway.

4) Public Health measures.

Legal regulation for iodation of imported and produced salt being finalized

Control of relevant diseases e.g. measles, ARI, diarrhoea, PEM, being undertaken

Control of relevant diseases e.g. malaria, intestinal worms, bilharzia being accelerated

Management Structure

NCCIDD
Chair: Health
Secretariat: TFNC
Membership: Multisectoral

NVACG
Chair: Agriculture
Secretariat: TFNC
Membership: Multisectoral

NNACG
Chair: Health
Secretariat: TFNC
Members: Multisectoral

Training

TFNC, PEG (Brussels), IAC (Wageningen), PAMM (Emory University), Lubeck (Germany)

TFNC, IAC, PAMM,

TFNC, PAMM

Source of funds

Government, SIDA, Netherlands Government, UNICEF, WHO, ICCIDD.

Government, World Bank, SIDA, UNICEF, WHO, FAO, DANIDA, IAC Netherlands

Government, World Bank, UNICEF, WHO, DANIDA, SIDA, IPICS, SAREC.

Monitoring and evaluation

Severely affected areas almost being eliminated. Impact data show substantial improvement in indicators.

Process and impact evaluations show considerable improvement in the situation.

Process monitoring indicate good progress in programme development.


Salt iodation

The main stay strategy for the elimination of IDD is salt iodation. After years of effort three salt iodation machinery imported from India were installed at three different sites in May of 1991; two in Bagamoyo in the Coast region and one at Uvinza, in Kigoma region. Capacity of the three machinery is estimated at about 37,000 metric tones of iodated salt per annum, which is only about 40 percent of the requirements. Due to various operational problems only about 14-20% of the salt is being iodated at the present time. Five more machinery have been ordered for phase two of the project, but it may be difficult to achieve universal iodation in the short run since there are numerous small salt works along the 900 km coast line. The important thing, however, is that the major salt production works which produce more than 90 percent of the salt will be covered, and legislation enacted for salt iodation whether imported or produced in the country.

An iodated salt marketing network comprising of 196 wholesalers was established in all 20 regions of the Mainland in 1992 and all known salt producers were made aware of the IDD problem through workshops.

A study on salt production, importation, distribution pattern and marketing in Tanzania was done in 1992 by the Tanzania Industrial Studies and Consulting Organization (TISCO) for NCCIDD. The major problems identified were:-

a) Under-capacity utilization of production potential - the total installed capacity was 266,924 MT, per annum out of which 45,784 was thermal salt, 161,140 was solar and 60,000 was PVD salt. The installed capacity for iodated salt was 189,000 MT per annum of which 60,000 MT was PVD salt from Nyanza Salt Mines at Uvinza Kigoma, and the three iodation plants with a combined installed capacity of 129,000 MT per annum assuming 300 working days. However, the actual production at the time of the study was 87,567 MT per annum out of which 13,682 (12 percent) was iodated. The iodated salt represented 18.6 percent of the demand of 73,500 MT for edible salt. In order to solve the problem of under-capacity utilization there is need to assist the producers to alleviate their problems related to purchase of chemicals, spare parts, packaging materials, mechanization of their production facilities etc. There is also the need to ensure continuous operation of the iodation plants.

b) Marked price differentials and poor distribution systems - Consonant with the liberalization policy salt is marketed freely at competitive prices with imported ones. While Tanzania exported to Burundi, Malawi, Rwanda, Uganda and Zaire 9,997 MT mostly iodated form Nyanza Salt Mines in 1991; it imported about 10,000 tons in the same year. The countries from which Tanzania imports significant amounts of salt include India, U.K., United Arab Emirates, Kenya, Italy, Yemen, Aden, Ethiopia, U.S.A., Canada, Belgium, Sweden, China, and Bulgaria. Some of the imported salt is iodated while some is not. For locally produced salt, the ex-factory price of salt ranges between Tshs. 16,000-30,000/MT for solar salt, 20,000-50,000/MT for thermal salt and for iodate salt the price is Tshs. 55,000/MT. Iodated salt from Kenya is sold at Tshs. 100,000-160,000/MT which is roughly two to three times the price of the locally iodated. Generally, the price of the imported salt is higher than that locally produced but due to the aggressive marketing done by the importers the local salt becomes less competitive. The generally higher price of iodated salt is not because of increased production costs, but due to demand which outstrips supply. The salt iodation regulation drafted in 1992 is expected to control the production and importation of un-iodated salt meant for human and animal consumption.

c) Long transit period due to the slow sea and surface (road and rail) distribution systems which may take up to a month to reach the lake Victoria regions indicating the potential long period for iodine loss during transportation. This loss can be substantially reduced if priority given to the development of infrastructure including transport facilities in the Economic Recovery Programme (ERP) is satisfactorily implemented.

A quality control and monitoring mechanism is being set up and a series of training workshops of health workers, salt traders and government officials on IDD and Quality Control and monitoring of iodated salt were started since May of 1992. The targeted workers are expected to be involved in the monitoring of iodine in salt at field level and salt traders at district and regional levels. So far 450 out of an expected 600 trainees were trained from Mbeya, Iringa, Kilimanjaro and Arusha regions in three courses. These comprised of 300 health workers, 100 salt traders and 50 government key officials. There were also two Health Inspectors from Zimbabwe who participated. At the end of the training each participant was provided with a test kit. The kits available in Tanzania are the MBI Field Test kit and Iodine Detection Paper. Participants felt that the training was very good as indicated by a post training follow up. During the workshops it was felt that a training manual on monitoring was desirable and the draft of such a manual has already been developed. This is important as monitoring is the weakest component of the IDD programme in Tanzania. In 1992 collaboration with ICH (Uppsala) started in the areas of the development of epidemiological samples and indicators for monitoring the elimination of IDD which is important for the verification of IDD elimination.

In order to establish the level of iodation, TFNC in 1992 carried out a study on Human Salt Consumption in Tanzania. The objective of the study was to find the average per capita salt consumption of salt and the factors influencing the distribution and consumption of salt at individual house holds and the local level in order to determine the appropriate level of salt iodation. The study revealed that salt consumption ranged from 6.6 to 9.4 g with an average of 8.1 g per person per day which is above the WHO recommendation of 5-7 g per person per day. Based on the average daily salt consumption and assuming a 50 percent loss of iodine from production to retail and a further 50 percent loss from retail to household a level of 75 to 100 ppm were recommended at the production level. The study also gave information on the importance of the radio as a communication media for salt iodation; salt preference by consumers at household; pricing and packaging, salt acquisition, utilization, storage etc. The study areas included high (Mbeya, Ulanga); moderate (Mpwapwa) and non- (Dar-Es-Salaam) IDD endemic areas. The salt consumption in the urban areas of 9 g/person/day was higher than that of the rural areas of 7.0 g/person/day.

Iodinated oil capsules

Although iodinated oil injections were given in some areas during the early 1980's, the iodinated oil program in Tanzania has been based on the distribution of iodinated oil capsules. The major difference between the injectable and oral iodinated oil is the duration of action. While because of its depot intramuscular storage and slow release the injectable form acts for 3 - 5 years; the oral form acts for a shorter duration of one to two years which is roughly half the duration of the injectable form. The advantage with the oral preparation is that it can be delivered by even non-medical personnel and avoids the use of needles which have a potential and real risk in spreading diseases like AIDS and Hepatitis B.

The target group for the iodinated oil capsule distribution is everybody aged 1-45 years in districts severely affected by IDD. The younger age group was excluded hoping that since there is near universal breast-feeding for children under one year of age they will get their iodine from breast milk. For the older age group above 45 years their requirements for iodine are low and are more prone than the younger age groups to the effects of excessive iodine which the program wanted to avoid. The dose given is about 400 mg of iodine (two capsules) for the target population once every two years.

The criteria for choosing the severely affected districts was initially based on a visible goitre rate of 10 percent or more but due to political and public pressure, this was lowered to a prevalence of combined grade 1b and visible goitre rate of 10 percent or more. The last criteria categorized 30 districts as having severe IDD. On average the 30 districts have a visible goitre rate (VGR) of 11.0 percent; a VGR + 1b of 31.3 percent and a total goitre rate (TGR) of 57.1 percent. The population involved is about 5.0 million.

The iodinated oil capsules are distributed through the Primary Health Care (PHC) system or in a campaign form using the Primary schools and the Government and CCM Party infrastructure for mobilization and compliance. By the end of 1991 about 5.0 million people were covered in both round one and two.

An evaluation of the impact of the iodinated oil capsule distribution in three districts [UNICEF/WHO/ICCIDD/TFNC, 1991 and Bunga, 1991] using goitre rates has shown significant decreases in both the visible goitre rates (VGR) and total goitre rates (TGR). Table 54 below gives a summary of impact evaluation studies using goitre rate as the criterion in primary school children aged 7-18 years. In a period of at least two years after capsule distribution overall the visible goitre rates were decreased by over a half, while the total goitre rates were decreased by over a quarter. Repeat distribution of the capsules in these areas is likely to eliminate all areas of severe IDD endemicity provided as planned iodated salt is phased in a sustainable manner.

Table 54: The impact of iodinated oil capsules on goitre rates in primary school children aged 7-18 years in some districts in Tanzania before and after capsules

District

Goitre prevalence rates (percent)

Percent reduction of goitre rates

Before capsules

After two capsules, 400 mg Iodine

n

VGR

TGR

n

VGR

TGR

VGR

TGR

Mahenge

904

26.9

74.9

1,334

7.6

51.9

71.7

30.7

Sumbawanga

2,717

44.1

78.7

1,064

26.5

56.3

39.9

28.5

Rungwe

2,603

38.6

61.7

1,141

14.9

46.4

61.4

24.8

Average

6,224

36.5

71.8

3,535

16.3

51.5

57.7

28.0

Source: TFNC reports nos. 818; 1370; and 1429
Specific studies have also shown a normalization of urinary iodine excretion and thyroid hormone levels in those given the capsule within a period of 56 days sustained over a period of one year and also confirmed that the reduction in the rates of the visible goitres is greater than that for total goitres (Jeeninga et al, in press). One explanation is that the visible goitres do not completely disappear, but become non-visible. The other is the subjectivity in the classification of the non-visible goitres especially palpable grade 1A. To improve on this kind of evaluation a thyroid ultrasound capable of measuring the actual volume of the thyroid gland has been procured and a trainer of trainers trained under UNICEF/ICCIDD support.

Apart from iodinated oil and salt iodation the only other effort to address the problem is the provision of Lugol's iodine by individual medical practitioners, though this does not form part of the national program. The iodinated oil capsule and salt iodation strategies are backed up by social mobilization, technical training and development of monitoring and evaluation capacity.

ii) Program for the control of vitamin A deficiency (VAD)

The programme has a national coverage, and consists of:-

a) the targeted supplementation of vitamin A capsules through the Essential Drug Program (EDP) as the short term intervention,

b) the stimulation of demand for foods containing vitamin A especially the less expensive dark green leafy vegetables (DGLV) and fruits and red palm oil as a long term measure,

c) supportive activities including the promotion of agricultural and horticultural practices and extension; nutrition education through the various media and curriculum change and advocacy for the overall improvement in the quantity and quality of the diet as a component of community based strategies for achieving household food security.

d) additional activities include public health measures leading to the immediate and prolonged breastfeeding and to ensure the conservation of vitamin A through the control of diseases like measles, diarrhoea, ARI etc. Presently margarine is fortified with vitamin A, but due to being expensive does not reach the at risk population.

The target group for the vitamin A capsule distribution is estimated to be 1.04 million children 6 months to six years of age who have either developed signs of deficiency or are at risk of doing so. The at risk group has been defined as those children with measles, severe PEM, diarrhoea lasting more than seven days and those with acute or chronic respiratory infections presenting to a health unit. In a national workshop held in December, 1990 mothers who have just delivered have been added as another target group. Universal distribution to all children in the at risk age bracket has been done only in those areas where community vitamin A surveys have been conducted like in Wanging'ombe division (Iringa), Kishapu and Negezi divisions (Shinyanga), and in Nzega and Lusso wards (in Tabora).

The vitamin A capsules (VAC) being used in Tanzania contain 50,000 IU of vitamin A per capsule rather than the normal high potency 200,000 IU capsules. The low dose capsules were introduced instead of the normal high potency capsules because when the VAC were added to the EDP, there was concern on the part of some physicians that toxicity might result if the 200,000 IU capsules were prescribed incorrectly. Thus a compromise was reached in which only the 50,000 IU capsules are included in the EDP, though four capsules at a time are used to achieve the WHO recommended dosages. The fear was based on the fact that in most of the health units vitamin tablets may be prescribed as a placebo to patients usually at a dose of one tablet three times a day for five days. If this were to be the 50,000 IU VAC, this would mean 150,000 IU per day or 750,000 IU per five days which would be within very safe limits. If this were to be the 200,000 IU the daily dose would be 600,000 IU a day or 3,000,000 IU for a five day course which would still be within safe limits. With continued training of health personnel and the exclusion of pregnant women in the target group; the worry about toxicity is unwarranted and it has been recommended by the 1991 TFNC evaluation that the present stand on the capsules be revised [Latham et al 1991].

The doses given are a slight modification of the WHO/UNICEF/IVACG 1988 recommendations and were agreed in a TFNC training workshop on “Vitamin A deficiency, vitamin A capsule distribution and xerophthalmia surveillance” held in December 1990 for regional level ophthalmologists who would in turn train district level health workers. The modifications were made to define more precisely terms like “chronic diarrhoea” since it was felt that diarrhoea lasting for more than 14 days was infrequent and if it occurred it was likely to be food intolerance or to some other condition for which vitamin A may not be important. Also instead of the term “acute lower respiratory infections” the actual names of the common diseases are mentioned to make it easier to understand. The “universal distribution prevention schedule” with the exception for lactating women has been omitted since it was felt that it cannot be affordable nor sustainable in Tanzania.

There have been discussions on the possibility of distributing the capsules through the Expanded Program for Immunization (EPI) but this would mean covering children who are mainly under nine months, who do not seem to be at great risk, because of the high rate of breast-feeding in this age group. The present policy still remains to target distribution at the risk groups mentioned above through the EDP and avoid universal distribution, but strengthen the more sustainable dietary and public health approaches. If a decision to use the EPI for vitamin A capsules distribution will be made in the near future, it will probably be at the time of measles vaccination which is nine months.

More than 25.0 million capsules have been distributed through the EDP system since February 1987. Because of pile up of the capsules due to the lack of knowledge by health workers about their use, TFNC under World Bank support funds conducted training workshops for Rural Medical Aids (RMAs), Medical Assistants (MAs) and Paediatrician at regional, district, health centre and dispensary levels in all twenty regions of mainland Tanzania in order to increase their knowledge on the use of those capsules. Reports indicate that there is no more pile up, and the capsules in the EDP kit are no longer adequate to meet the needs.

Long term measures are also being undertaken. The dietary approach being implemented include an information, education, and communication component aimed at creating public awareness of the problem and stimulating the production and consumption of affordable vitamin A rich foods. The mass media particularly the radio and the news papers have been used and journalist have been sensitized through seminars aimed at them. TFNC has got a 15 minute radio air time allocated twice a week for food and nutrition broadcasting since 1983 and a considerable number of these have discussed the problem of micronutrient malnutrition.

There have been particular efforts aimed at promoting the production of red palm oil particularly in Kigoma and Mbeya regions and improving horticulture practices. Feasibility studies on the production and marketing of red palm oil from the southern region of Mbeya has been done and indicate good prospects. There has also been training of relevant staff through national and district workshops. Formal training for clinical and laboratory assessment of vitamin A deficiency including the setting up of the needed equipment and methods has also been done. Review of the curricula for primary health workers (Maternal and child Health Aids, Medical Assistants, and Rural Medical Aids) with a view to incorporating nutrition including the micronutrient deficiencies has been done. To improve the human resource development with regard to vitamin A control in the regions, the Ministry of Health has given priority to posting eye personnel in areas where there were few or did not exist.

Another important approach which has been used is a public health one which has emphasized on measles immunization as one important component of the vitamin A control program. This has led to a very substantial increase in the vaccination coverage which now stands at 83 percent, and has already drastically reduced the number of measles cases seen. The challenge facing the programme is whether or not this high rate of vaccination coverage can be maintained. Emphasis has also been placed on early breast-feeding particularly on the use of colostrum which is thrown away by some ethnic groups believing that it is bad for the child. This is also been done through the national child feeding program whose evaluation in one hospital, the Muhimbili Medical Centre, has shown that the has been an improvement in the use of colostrum.

An analysis of impact using the xerophthalmia surveillance sentinel system from hospitals which have been reporting since the system was started in 1982 show that the prevalence of active xerophthalmia has declined very slightly as shown in table 55.

Table 55: Prevalence of active xerophthalmia in reporting hospitals (1982-1989)

Reporting Hospitals

Reductions (Percent) of active xerophthalmia (XB+X2+X3) over time.

August 1982-July 1983

August 1983-July 1984

1985-1989

Percent reduction, 1982-1989

n

%

n

%

n

%

Arusha

1,425

2.0

1,163

1.9

1,626

1.2

40.0

Bariadi

833

1.8

1,112

1.2

323

2.5

-38.8

Iringa

407

4.7

148

5.4

111

2.7

42.6

Average

2,665

2.8

2,423

2.8

2,060

2.1

25.0

Source: Kisanga; Wagara; Jeje et al [1991] TFNC report no 1378
It should be noted, however, that the population from which the xerophthalmia data comes from is a highly selective one, consisting of children 0 - 10 years reporting to the eye clinics in the respective hospitals for various reasons. In using the xerophthalmia system as an evaluation tool the assumption was that a successful vitamin A deficiency control program should lead to fewer children with the problem reporting to eye clinics.

It should be noted that overall there was a reduction in the proportion of children with active xerophthalmia reporting in the sentinel clinics in the three districts. The apparent increase after an initial decline in Bariadi needs to be followed up.

A follow up study of the universal distribution of vitamin A capsules in Shinyanga, Negezi and Kishapu divisions, where more than 207,000 children under six years were covered, showed an improvement in the serum levels of vitamin A as shown in table 56. The important thing to note is the dramatic decrease in the prevalence rates of deficient serum levels in both divisions; and a general shift towards more adequate levels.

Table 56: Prevalence percent of various serum retinol levels before (1988) and after (1990) vitamin A capsule distribution in Negezi and Kishapu divisions, Shinyanga region.

Serum Retinol levels (mg/dl)

Negezi

Kishapu

Average for Negezi and Kishapu

1988

1990

Reduction

1988

1990

Reduction

1988

1990

Reduction

Number

142

209

-

158

150

-

301

359

-

<10

25.2

2.3

90.9

17.6

1.3

92.6

21.4

1.8

91.6

10-20

20.7

28.7

-38.6

21.5

22.0

-2.3

21.1

25.4

-20.4

>20

54.0

68.8

-27.4

60.9

76.0

-25.0

57.5

72.4

-25.9

Source: TFNC report no. 1402 [107]
iii) Program for the control on nutritional anaemia

The program for the prevention and control of nutritional anaemia in Tanzania has a national coverage but targeted mainly to pregnant women and children under-five years of age. The program aims at addressing the major causes of anaemia in a fashion which ensures sustainability. The dietary approach against iron and folic acid deficiency anaemia (IFADA) consists of the promotion of the production and consumption of iron and folic acid rich foods particularly green leafy vegetables and vitamin C rich foods like fruits which enhance iron absorption. Animal and dairy products are also encouraged whenever possible. A pharmaceutical approach through the supplementation of iron-folate tablets targeted to the most vulnerable group, pregnant women through the Essential Drug program (EDP) and the Maternal and Child Health (MCH) system has also been implemented for a number of years.

General public health measures aimed at the strengthening of control measures against malaria, schistosomiasis, and intestinal parasites like hookworm forms an important component of the program. The integration of these measures with the vitamin A program and in particular with other existing and health and nutrition programs coupled with adequate research, information, communication and education and management information systems ensures community participation and program sustainability.

The target group for supplementation has been pregnant women attending antenatal clinics country wide, who have been given both preventive and prophylactic supplementation. Children under five years and other adults who have been found with anaemia have also been given treatment. As will be indicated later the target group has been proposed to be expanded to include children under-fives and school children.

Monitoring of the program was incorporated into the MCH reporting system but the data has not been analyzed on a monitoring basis. It is planned to analyze this data and disseminate it through a planned micronutrient deficiency newsletter. Although the supplementation program has been going on for more than a decade now a glance at the information from the MCH and hospital reporting systems does not indicate any significant improvement in the problem of anaemia.

In fact there is a general feeling that the problem seems to be increasing rather than decreasing. The reasons for this vary. Low compliance by women due to the side effects of nausea and constipation caused by ferrous sulphate is one reason. Another is that even when there is no problem of compliance the supplies are inadequate. Perhaps a bigger reason is the increasing role of malaria in causing anaemia and the effect of intestinal parasites especially hookworm which has not been effectively controlled. Although no figures for coverage are available mothers book late and attend irregularly in-spite of a quite high (95 percent) service utilization. In Dar-Es-Salaam where mothers are known to report earliest to the antenatal clinic, only 35 - 63 percent booked before 20 weeks in 1990.

The problem of malaria which seems to be increasing is another major hindrance and AIDS is slowly getting into the picture. In order to rectify these problems, it is planned to make a follow up of the route of supply and delivery of the haematinics in order to lay open any inadequacies and take appropriate corrective measures. Also a national surveillance system will be started and studies on compliance and alternative drugs and vitamin C supplementation would be conducted.

Promotion of horticulture to increase the production and consumption of iron, folic acid and vitamin C containing vegetables and fruits has been included in the five year program. Other efforts include strengthening of public health measures against anaemia related disease like malaria, hookworm and bilharzia.

iv) Management of the micronutrient malnutrition programmes

At the national level the management of the micronutrient malnutrition control programs is vested in TFNC through national multisectoral coordinating committees which are responsible for policy steering and implementation. The national committees have been structured as national units of the corresponding international bodies. The respective committees are the National Council for the Control of Iodine Deficiency Disorders (NCCIDD) as a national unit of the International Council for the Control of Iodine Deficiency Disorders (ICCIDD); the National vitamin A Consultative Group (NVACG) as a national unit of the International Vitamin A Consultative Group (IVACG) and the National Nutritional Anaemia Consultative Group (NNACG) as a national unit of the International Nutritional Anaemia Consultative Group (INACG). The national coordinating bodies have formed technical committees through which technical matters are discussed more in detail before they are discussed in the main committees.

At the sub-national level the programs are managed under the primary health care (PHC) committees which are supposed to be at the regional, district, and village levels. The PHC committees are multisectoral and discuss and allocate responsibilities for implementation to the relevant sector for any health problem under discussion. They are chaired by the chief executive of the region, district or village and the secretary is the functional health manager at the particular level of operation. The success of these committees is mainly seen in the universal immunisation campaign and the control of cholera. The introduction of nutrition in the agendas of these committees has only been successful in areas implementing the CSPD programmes.

Some lessons can be drawn from the micronutrient malnutrition control programmes. One regards management. Management means to get things done. A good manager would do this mainly through other people. At the same time a good manager should provide leadership. It is possible to manage very well the wrong kind of things. Leadership provides direction so that management manages the right kind of things. This is particularly important for the micronutrient malnutrition control programs, because low professional and public understanding of the problems is common even where advocacy has been done. Moreover, there would also be professional colleagues who might view specific action on micronutrient malnutrition as too narrow an approach to nutritional intervention and a management capability of program integration may be needed. The TFNC/UNICEF conceptual approach which explicitly analyses the causes of mortality and malnutrition has been found to be very useful in facilitating dialogue, multisectoral and integrated approach to these issues. In other words it has been used as a management tool as well.

The critical management issues for program managers, therefore, is to have a fairly good assessment and analysis of the problem based on an explicit framework and be able to mobilize human, organizational and financial support for action. In doing this it is important to recruit strategic allies and win the support of political and decision makers through a vigorous process of information dissemination and advocacy. It is imperative that managers should exercise patience in judging the response received and should not be easily discouraged by what may appear as a negative response. That is the reason for doing advocacy in the first place.

It is also important for managers to build a management and technical capacity which should be spread so that the program should not depend upon a only a few individuals, but upon a permanent structure with a wide technical and managerial base. Human resource development should, therefore, be of particular concern to program managers. In addition an institutional base is critical.

There is great similarity in the process of the development of the micronutrient malnutrition programmes. The process goals could be summarized as: - (a) defining the problem (b) building consensus across sectors and (c) support in the development of a plan for intervention; monitoring and evaluation and operational research.

In defining the problem direct and indirect indicators should be looked for from both high and low yield data sources. The process of building a consensus consists of essentially five steps:-identification of a lead agency (TFNC in our case); an initial planning meeting; collection of “focused” data; the convening of “an inter-sectoral situational assessment workshop” where a plan for a broad based data collection may be hatched in the form of small research projects; and finally a broad based data collection inter-sectoral plan where other nutrition problems may be included, focusing on the vulnerable groups with geographical representation. Information on the feasibility of various strategies could also be collected.

At this point the lead agency could convene another inter-sectoral workshop where a plan is developed. The plan should contain intervention, monitoring and applied research plans.

During the implementation phase, broad and specific policies should be developed; mechanisms for inter-sectoral/inter-programme coordination should be developed preferably using existing institutional framework. The intervention strategies should take into account various factors like historical precedence; targeting; supplementation; fortification; dietary diversification; IEC/Advocacy; affordability and sustainability.

Monitoring and evaluation should be incorporated in the programme from the start; goals should be established; so should procedures and routine and specific indicators. Although realism should prevail everything monitored should be seen as leading to an increase in the intake of the particular micronutrient under consideration.

It should, however, be observed that the interventions required for vitamin A and anaemia programs are more complex than the IDD program. In countries where all three problems exist it would be probably advisable to start and learn from an IDD program first before starting the other two programs. The convenient order may be IDD - Vitamin A - Anaemia in order to gain experience and build confidence when moving from a less complicated to a more complicated problem.

A question which may be asked is how much prepared should one be before a program is started? Our experience is that there is always a trade off between wanting to be completely prepared and getting things done. Often you learn about certain problems or successes by doing the programme than to try and study every possible aspect first as some things may not be generalizable. The bottom line is that the program should be needed and is technically sound. In fact the start of a program may have a very large advocacy effect especially in countries which do not have TV transmission like in mainland Tanzania.

There is also the question of targeting. The question is how much targeting should be done? It is important to understand the kind of pressures that program managers face sometimes because of too strict a targeting. For example in the IDD program we had to expand the target areas for capsule distribution to include goitre grade Ib due to political pressure. Targeting is more cost-effective but the more the targeting the more probability there is to get less community acceptance. It is therefore, important to try to achieve a good balance when deciding on the level of targeting that should be done.

A major lesson to learn in communication is the identification of the target group. It is all too common to concentrate efforts at advocating programs to the already converted because there is no dissenting voice. Communication should be directed more at those who have not been reached yet and those showing resistance to the programs than those already on your side. As the word stands, communication should be a two way process and should be repetitive if it will have the effect desired.

Factors associated with success in the various programmes

There are various dimensions of success in a nutrition related programme. It may be success in getting a programme started; success in sustaining interventions cost-effectively; or success in alleviating malnutrition. A programme that is effective in getting services out to the community is more likely to have an impact on the nutritional status than one which does not involve the community. Unless people participate regularly and frequently delivery of nutrition related services alone will not automatically reduce malnutrition.

The JNSP/CSD and micronutrient programmes have been successful on all dimensions. Programmes were started and a replicable process of starting nutrition programmes was established; programmes have been cost-effectively sustained; and the very high rates of malnutrition especially of the severe forms have been substantially reduced. This success has been recognized widely. For example in recognition of people's own efforts to contain malnutrition and hunger, the Regional Medical Officers Conference in Tanzania of 1990 commended the people of Iringa for their exemplary work in alleviating malnutrition and Brown University's World Hunger Programme gave the 1991 World Hunger Award to the people of Iringa. It is of interest and importance to policy and decision makers to sieve out specific factors which have contributed to this success.

The factors which have been responsible for replication and sustainability of the Iringa JNSP have already been mentioned. Experience from all the areas which have implemented JNSP/CSD programmes and from the micronutrient programmes show the following major factors to be associated with success:-

a) a favourable socio-political context with a people centred developmental goal, which resulted in Government commitment strongly advocating social action with a community orientation and backed up by a decentralized administrative structure conducive to social mobilization from both a bottom-up and top-down system; a result of the 1967 Arusha Declaration. Since the 1960s Tanzania had already focused on the nutrition problem through an aggressive community based approach. The use of existing structures was possible because adequate structures had already been put in place. In fact one of the reasons advanced for the choice of Iringa for the JNSP was based on the existence of a well developed infrastructure. The favourable socio-economic context may have also been responsible for the favourable and flexible donor response;

b) the use of a flexible and contextual conceptual framework approach which facilitated dialogue among and between sectors and sharply focused the problem of malnutrition to that of society and not of a few individuals or sectors. As a result it was possible to enlist multi-level participation from various Government sectors, NGOs and the Private sector;

c) the emphasis given to the process of programme development where an advocacy social cyclic process of problem assessment, analysis and action (Triple-A-Cycle) was used at all levels (community, ward, district, regional and national) to raise nutrition-related awareness of the people, politicians and decision makers at the various levels; and build confidence in programme implementors; which led to the development of a “nutrition movement”.

d) a strong active community participation orientation of the programmes led to a significant allocation and reallocation of community resources towards the alleviation of malnutrition, and to local nutrition intervention initiatives. For example many Village Health Workers (VHWs) and Day Care Attendants (DCAs) are paid in kind or in cash from village budgets. At the time of the 1988 evaluation of the Iringa JNSP 80 percent of villages paid their VHWs while 70 percent paid their DCAs. The “Mtwara Initiative” which spread to Zanzibar and other regions like Kagera, Morogoro and Shinyanga served as a very important trial local initiative in strengthening programme approach through mobilization, training and participation. Community participation here does not mean active participation of the local community only but goes beyond the village to embrace awareness and commitment of the leadership at higher levels of Government, Donor Organizations or NGOs who support the programme in one way or another. Active community participation led to a feeling of owning the programme an important empowerment motive;

e) the strengthening and modification of existing multisectoral management and supervisory mechanisms based on the experience of the Primary Health Care (PHC) committees which had been established by regulation throughout Tanzania in the 1970s;

f) field oriented continuous training of all categories of programme staff at all levels mainly through improved supervision, seminars, workshops, involvement in operational research, study tours to other areas, or through formal training packages. Training was done to improve skills, widen scope in the multifaceted nature and intervention of the nutrition problem and was mostly concentrated on staff functions e.g. TBA, VHW, or programme managers. Curricula were developed from experience gained in implementing the programme and was thus very much field oriented.

g) the presence of a strong institutional base in nutrition related activities like TFNC which has a wide multidisciplinary and multisectoral community based experience in nutrition intervention was an important factor in success;

h) the use of a combination of strategies which reflected the multiple causes of the nutrition problems addressing at various intensities the immediate, underlying and basic causes of malnutrition. For example simultaneous actions where taken to address the causes related to food intake, diseases, food security, caring capacity, health education, water and sanitation, income and cultural habits and believes;

i) the presence of technically competent and interested nationals and expatriates with planning managerial and communication skills who were able to mobilise national and international expertise and finance for the development and implementation of the programmes. In many cases there were a few enthusiastic people who were able to cross bureaucratic lines and made many things work. These were among the good managers who with appropriate supportive services carried out the programme operations. Discussions with people in the field indicate the flexible approach and field competence of UNICEF as one of the major reasons for success especially in the stages of process development and implementation;

j) the establishment of a monitoring and information system using nutritional status as an indicator through growth monitoring. This was backed up by frequent internal and sometimes external process and impact evaluations by technical missions which was important in reviewing and guiding the course of action.

Tanzania's Nutrition Goals for the 1990s

An important element of a nutrition programme, and in fact of any successful undertaking is goal setting. In the past most nutrition programmes lacked the incorporation of clear and explicit goals and therefore what needed to be done became rather diffuse. The development of the Joint Nutrition Programmes with clear and explicit goals, led to the setting of global nutrition goals for the 1990s firstly by the World Summit for Children and later adopted by the International Conference on Nutrition. The adaptation and adoption of these goals by Tanzania and other countries and their inclusion in the National Plans of Action has for the first time focused and obtained consensus of what need to be achieved in nutrition.

The summary of the specific goals as adapted in the National Plan for Action (NPA) for Tanzania is shown in table 57. There are indications that these goals can be substantially attained if the scope of the commitment is appreciated by a larger section of policy and decision makers than at present in order to ensure increased political commitment which should be matched by increased resource allocation.

Table 57: Summary of Nutritional Goals for Tanzania (1992-2002)

Type of Malnutrition

Situation in 1990

Goal for the year 2,000

Annual reductions required to achieve goal

Protein Energy Malnutrition:





Severe (< -3SD)

5

2

0.3

Moderate (between -3SD and -2SD)

47

23

2.3

Total (below -2SD)

52

25

2.7

Low birth weight (LBW). Birth weight less than 2,500 grams

14

less than 10

0.4

Anaemia

Pregnant/lactating women

80

50

3.0

Children underfive years

45

30

1.5

Iodine Deficiency Disorders (IDD): in general population

25

eliminate

2.5

Vitamin A deficiency: in children underfive years

30

eliminate

3.0


The specific nutrition goals for Tanzania shown in table 57 are based on the experiences learnt from the nutrition related policies and programmes during the 1980s. The nutrition goals adopted by the World Summit for Children (WSC, 1990) and the International Conference on Nutrition (ICN, 1992) include:-

a) Reduction in the prevalence of severe as well as moderate malnutrition among underfive children by half of 1990 levels;

b) Reduction of the prevalence of low birth weight (LBW) (2.5 kg or less) to less than 10%;

c) Reduction of the prevalence of iron deficiency anaemia in women by one third of the 1990 levels;

d) Virtual elimination of iodine deficiency disorders;

e) Virtual elimination of vitamin A deficiency and its consequences including blindness;

f) Growth promotion and monitoring to be action oriented in all MCH clinics;

g) Dissemination of knowledge and supporting services to increase food production to ensure household food security.

The conclusions and recommendations from this review discussed in chapter nine indicate that Tanzania's vast experience in nutrition related policies and programmes have generated a swell ground work on which further actions can be based to increase the scope and depth of actions in order to achieve the above goals.


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