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Identification of problem, analysis of causes,resources constraints, selection of interventions, setting a strategy, implementations and evaluation of the programme

Rapid improvements in health and nutrition in developing countries may be ascribed to specific, deliberate, health- and nutrition-related interventions and to changes in the underlying social, economic, and health environments. This chapter is concerned with the contribution of specific interventions, while recognizing that improved living standards in the long run provide the essential basis for improved health. Consideration of the environment as the context for interventions is crucial in determining their initiation and in modifying their effect, and it must be taken into account when assessing this effect.

The WHO asserts that the global food price crisis threatens public health and jeopardizes the health of the most disadvantaged groups such as women, children, the elderly and low-income families. Economic factors play a crucial role and could affect personal nutrition status and health. Economic decision factors such as food price and income do influence people’s food choices. Moreover, food costs are a barrier for low income-families to healthier food choices. Several studies indicate that diet costs are associated with dietary quality and also food safety. Food prices have surged over the past couple of years (2007-9) and raised serious concerns about food security around the world. Rising food prices are having severe impacts on population health and nutritional status. Therefore, people who change their diet pattern for economic reasons may develop a range of nutritionally-related disorders and diseases, from so-called over-nutrition to or with under-nutrition even within the one household. This is likely to increase with growing food insecurity. Presently, economics is not integrated with mainstream nutrition science or practice, other than in “home economics”, but it can enable greater understanding of how socioeconomic status may interplay with human nutritional status and health and how these situations might be resolved. Collaborative, cross-disciplinary nutritional economics research should play a greater role in the prevention and management of food crises.

WHOs response

Nutrition

Nutrition is a critical part of health and development. Better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of non-communicable diseases (such as diabetes and cardiovascular disease), and longevity.

Healthy children learn better. People with adequate nutrition are more productive and can create opportunities to gradually break the cycles of poverty and hunger.

Malnutrition, in every form, presents significant threats to human health. Today the world faces a double burden of malnutrition that includes both undernutrition and overweight, especially in low- and middle-income countries.

WHO is providing scientific advice and decision-making tools that can help countries take action to address all forms of malnutrition to support health and wellbeing for all, at all ages.

This fact file explores the risks posed by all forms of malnutrition, starting from the earliest stages of development, and the responses that the health system can give directly and through its influence on other sectors, particularly the food system.

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Defining success in nutritional programmes

Before considering the range, combination, and relative weighting of factors contributing to successful community based nutrition programmes (CBNPs), it seems pertinent to question the term “success.” What is a successful programme? The simple, almost facetious answer is “A successful programme is one that achieves its objectives!”There are three issues here concerning attainment of objectives:» Objectives (when they are stated) for CBNPs almost always include “outcome” objectives ranging from narrow nutritional outcomes, e.g., the eradication of grade III malnutrition (Costa Rica), to broader contributions, e.g., the reduction of malnutrition and high mortality rates of children under three (Tamil Nadu) .» Objectives sometimes include “process” objective sranging from narrow nutrition-related processes, e.g.,to enhance mothers’ capability for nutrition surveil-lance (ICDS India), to broader social objectives such as increasing community participation and expanding coverage (UPGK, Indonesia).» Stated objectives frequently do not explicitly include process objectives, yet certain processes may be facilitated or even initiated, either as a result of the programme design, or, in some cases, as an unexpected by-product of the programme, e.g., Zimbabwe child supplementary feeding programmes (CSFP)(strengthened self-organization of village people). In addition to certain processes being facilitated by the development of programmes (e.g., community participation), intended or sometimes unforeseen effects may occur, such as the influencing of policy by successful nutrition programmes, e.g., Zimbabwe’s CSFP/SFPP (supplementary food production programme)influenced agricultural policy). Another important, yet often neglected, measure of success is sustainability. The sustainability of a programme without significant external funding should be one ultimate goal of any community-based programme But financial sustainability is only one, al-beit crucial, aspect of sustainability. The other criticala spect is functional sustainability.

Factors influencing success

Success in CBNPs is a function of sociopolitical, technical, and financial factors. Although each of these factors—or rather group of factors—is essential, the strength and relative weight of each differs from pro-gramme to programme.Sociopolitical factors are those which describe powerarrangements and social relations affecting nutrition programmes and which influence the decision takenin a society to initiate or support such programmes.Technical factors include two broad components,which may be termed programme hardware, which includes the buildings, equipment, transport, and other materials necessary for implementation; and programme software, which has to do with the technical capacity of programme personnel to design, initiate, manage,and evaluate nutrition programmes .Financial factors are both external and internal. Al-though nutrition programmes are often initially funded externally, their sustainability is significantly dependent on internal financial capacity and its reliability.The above groups of factors are explored in more depth below and are illustrated by reference to four well known and successful large-scale nutrition pro-grammes.Sociopolitical factors Community participation In their review of successful nutrition programmes ,Gillespie et al. identify “genuine community involvement [as] a key feature of those programmes that work.”Kavishe, invoking UNICEF’s “triple-A” programm in gcycle, insists that community participation includes a full role in assessment, analysis, and action. Shrimpton has detailed further numerous components of programme development in which communities can successfully engage. Jennings et al. have summarized the pros and cons of community participation in nutrition programmes. According to Jennings et al., the perceived benefits of community participation in nutrition programmes include the following:

i)It increases a sense of ownership of the project by the community, thus leading to sustain ability of the project;

ii) it decreases resistance to project innovations, assists the dissemination of nutrition education messages, and promotes regular and ongoing attendance at programme activities;

iii) it decreases dependence on external assistance and promotes self-help in tackling community problems through the strengthening of community structures and leadership; and

iv) projects which stress community participation tend to be interventions which are more appropriate for the community, in the goals and objectives defined and in the technology employed.One limiting factor of community participation in a project is an increased administrative complexity…. Logistical constraints are also increased due to the frequent location of needy communities in isolated areas with weak infrastructure. The benefits would appear to outweigh these negative aspects.

It should be recognized, however, that the real ways is the potential for local elite groups to use‘community participation’ in a project as a means of extending their own patronage network within the community…. Yet if targets are well defined and the programme is closely monitored to deter-mine coverage and beneficiaries, this should bedetected early in the implementation phase.When community participation is promoted in the planning phase, there can be conflicts between programme goals and community goals. Based ona review of community participation in the health planning process in several health programmes in South east Asia, it was considered that in some cases‘community members did not see health as a priority’…. In recalling the historical developments of nutrition programmes in Tanzania… it is shown that poorly considered attempts to involve community participation in the planning process can possibly hinder efforts to reach programme goals.

“Community participation” is a central principle of the Primary Health Care Approach (PHCA) and a feature distinguishing it from previous approaches to healthcare. Genuine community participation in programme development implies participatory democracy and ameasure of popular democratic control more generally in a society”.

Community- and Facility-based Programs

Protecting and improving health, especially in poor communities, requires a combination of community- and facility-based activities, with support from central levels of organization, as well as some centrally run programs (for example, food fortification). The place of these activities in a strategy is likely to vary, depending on level of development (of infrastructure, health services, and socioeconomic status) and on many local factors. For the poorest societies, the first priorities are basic preventive services, notably immunization, access to basic drugs, and management of the most serious threats to health, such as some access to emergency care. Moving up the development scale, starting community-based activities may soon become cost effective for prevention, referral, and management of some diseases (notably diarrhea) when coverage of health services is poor. Community-based programs continue to play a key role until health services, education, income, and communications have improved to the point that maternal and child mortality has fallen substantially and malnutrition is much reduced; at this intermediate development level, the needs are less felt, and health services again take on a more prominent role. In this scheme, the widely felt need for better access to emergency obstetric services is problematic, requiring a well-developed human and physical infrastructure, yet arguably being one of the highest priorities.

Facility-based programs can be seen either as linking with the community program (referrals, home visits from clinics, and so forth) or as actually being part of the same enterprise. A distinction is that community-based activities take place outside the health facility, in the home or at a community central point, even if they may be supported by health personnel based in health facilities. The local workers in community-based programs may be drawn from the community itself, may be home visitors from a health center or clinic, or may sometimes be volunteers supervised by these home visitors. Many community-based programs come under the health sector, whatever the exact arrangements with local health services. Regarding specific program components, we return to the relative role of community programs and facilities later.

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