Eight useful lessons
What have these success stories shown? While there is no single prescription, these eight points bear noting.
1. Solutions must involve those most directly affected.
Malnutrition has many causes and manifests itself in several ways. There is no single, globally applicable solution to the overall problem, and there is no substitute for assessment and analysis done with the full and active participation of the families most threatened by nutritional problems and most familiar with their impact and causes. People who suffer or whose children suffer from malnutrition cannot be passive recipients of programmes. If they are not the main players in problem assessment and analysis, then actions to reduce malnutrition are likely to be inappropriate or unsustainable.
2. A balance of approaches is necessary.
A central challenge for nutrition programmes, as well as other development efforts, is finding a balance of approaches that work. Processes involving assessment, analysis and action -- the triple A approach -- are essential for formulating appropriate 'bottom-up' solutions, particularly with respect to the ways in which programmes are organized, managed and monitored. But there are some aspects of resolving malnutrition that can be appropriately formulated at higher levels, using wide and more 'top-down' application of appropriate strategies and technologies, based on the best scientific knowledge and the most effective technologies available.
UNICEF experience indicates that for many problems, a combination of top-down and bottom-up actions may be best. BFHI was formulated as a global strategy, but its success has taken many forms, depending on the engagement of national and local institutions and groups.
Vitamin A supplementation was suggested by the mortality reduction it enabled in many places and endorsed globally as a strategy, but its application has depended greatly on ex isting health measures and the involvement of community-based institutions.
Salt iodization has been enhanced by consumer advocacy and legislative change at the local and national levels and by the fact that communities previously affected by IDD can see and feel a difference.
The essence of a triple A approach is not necessarily to establish new cycles but, as much as possible, to build upon existing ones. Assessment-analysis-action cycles are the logical steps everyone tries to follow in order to cope with their problems better. By understanding how nutritionally useful mechanisms work and where the weaknesses are, a nutrition programme can build upon and improve existing good practices, rather than estab lishing new systems and procedures that may be difficult to accept and adopt, and are therefore difficult to sustain.
In the case of the Tanzanian CSD Programme, there were many components but the main focus was to improve people's capacity to assess the problem -- through growth monitoring -- and thereby help them make better use of their resources.
3. Nutrition components work better in combination.
Because malnutrition is the result of so many factors, it is not surprising that it has been attacked most effectively in situations in which several sectors and strategies have been brought to bear.
Combining improved infant feeding, better household access to food overall and improved and more accessible health services and sanitation is clearly more effective in reducing mal nutrition where food, health and care are a problem than any of these measures taken alone. In support of these various approaches that work, relevant social services -- health, education, communication and social mobilization -- must be more clearly focused on nutrition. This is not done by creating new 'nutrition projects' in these areas, but rather by incorporating nutrition components in ongoing community-based activities. Exper ience shows the usefulness of building such nutrition components into all programmes, wherever possible.
The impact on nutrition of health, education and other social services should also be monitored, with the results used both for a better understanding of nutrition problems and as a means to motivate policy makers, programme staff and communities themselves to increase their efforts to reduce malnutrition. Based on the mon itoring of nutrition impact, viable and successful programmes should be redesigned so as to have the best effect.
Communication plays a special role in nutrition programmes in arming parents, educators and other caregivers not only with basic nutrition information but also with the ability to make informed decisions and the skills and knowledge needed to take action to support improved nutrition in their communities.
Communication should be carried out simultaneously at various levels to include parents, other family members, teachers, volunteers and community leaders who can in turn teach and support good practices. In addition, personnel of provincial and district health offices, staff in agriculture, rural development and education itself, media representatives, researchers and persons in positions of power of any kind must be reached and their help enlisted.
Photo: Governments, communities and families need to work together to fulfil their children's rights to good nutrition. In Cambodia, a girl carries her baby sibling.
4. Progress hinges on continuing research.
All of these gains against malnutrition have depended upon programmatically relevant research, but more is needed. Both motivated researchers and processes to support such research are needed. For example, it took the urging of United Nations agencies and financing from the Government of Canada to ensure an analysis of the mor tality impact of vitamin A deficiency.
There is a need for more research to improve programmes that affect the hardest-to-reach people, and for determining the effectiveness of feasible interventions -- for example, how to encourage increased consumption of green leafy vegetables. Research institutions, both industry-based and academic, need to include the poor and their day-to-day nutrition problems on the research agenda.
5. Food production is important but not enough.
As was demonstrated in the Tan zanian programmes of Iringa and Mbeya, nutrition can be improved even in rather poor communities without increasing overall food availability. Increasing food production is often necessary, but it is never enough to ensure improvement in nutrition.
Programmes that aim to increase food production countrywide or in parts of countries should not claim that nutrition will be improved in young children and women unless other specific and focused measures are implemented to better their situation.
6. Everyone has an obligation to child rights.
Children have a valid claim to good nutrition. The government has an obligation and many other members of society and the community, including parents, have duties to realize the child's right to good nutrition. All of these groups need to become aware of the nutrition problem, its causes and consequences, the possibilities of solutions, and their obligation to respect, protect, facilitate and fulfil child rights. They need to know what to do and how to do it. Advo cacy, information, education and training are all important strategies to create or increase this necessary awareness.
7. Community and family-based involvement is vital.
Children's rights give them valid claims on society. In order for poor people to carry out their duties towards children, the poor must be recognized as key actors rather than as passive beneficiaries.
All available resources, even those controlled outside the community, should be used to support processes within households and the community that contribute to improved nutrition. Such processes involve decisions about the use of resources and the monitoring of the impact of these decisions.
As described above, households and communities learn how to search for better solutions through the process of assessing the existing situation, analysing the causes and acting as available resources permit. Community-based monitoring is important in the repeated assessment of the evolving situation. Analyses by the community and by all supporters outside the community are facilitated by an improved understanding of the causes of the nutrition problem.
Outside support includes advocacy, information, education, training and direct service delivery. Gov ern ment and NGO staff may work outside the community, but should be in frequent contact with the community, functioning as facilitators. They should focus their support and dialogue on community mobilizers: people who are a part of the community and enjoy its trust and respect.
There is no pre-defined package of inputs or services that can work. Instead, the community is constantly learning about the best mix of interventions, a mix that can change significantly over time. Community de velopment means that desirable outcomes, such as good nutrition, are achieved through participatory and sustainable processes. A combination of top-down advocacy and mobilization and a bottom-up demand for support will ensure that both community and government feel ownership of successful changes.
8. Government policies must reflect the right to nutrition.
Some national policies affect nutrition directly, such as salt iodization or immunization programmes, for example. Others, like income and price policies, affect nutrition indirectly.
With the ratification of the Convention on the Rights of the Child, governments have the obligation to respect, protect, facilitate and fulfil the rights enshrined in the Con ven tion. All policies should therefore be analysed in terms of their real and potential impact on the right to good nutrition.
The most important strategies for nutrition include those for food, health, breastfeeding, education, and water and sanitation, and national nutrition information systems should be established to provide valid data about their impact. Policies should be based on knowledge from relevant research and be constantly evaluated for their real impact on nutrition in communities. Nutrition information systems should be as decentralized as the existing administrative systems, starting with community-based monitoring.
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