SECTION D
TOWARDS A SUCCESSFUL COMMUNITY-BASED
NUTRITION PROGRAMME

The success of a programme lies on the one hand in its ability to achieve its objectives, which for a nutrition programme must mean improved nutritional status, and on the other hand, its ability to sustain these achievements. These issues, and their implicit complexities, have been discussed previously, amply illustrated by the experiences of the case studies and desk reviews. We turn now to the practical implications of these findings to a community-based nutrition programme. Simply put, how is success to be achieved ?

• Creating a supportive macroenvironment: In many countries this already exists but, even where it exists, the support and good will may need re-orientation. Often the supportive environment translates into a welfare approach, or there is a lack of understanding of the causes of malnutrition, leading to a curative approach or endless supplementary feeding programmes. Many countries would claim a supportive environment because they are signatories to a number of nutrition or nutrition-related declarations. These declarations are helpful but will not of themselves achieve the kind of support needed.

Creating a supportive environment, or re-orienting an existing one, needs to be achieved through a strong political and public awareness-raising campaign. The campaign needs to highlight at least the following:

• nutrition as an outcome indicator of national development, and improving nutrition as an essential part of the development process;
• nutrition and food security as a basic human right for all;
• a conceptual framework to show the multisectoral pathway to improving nutritional status, and hence the need for intersectoral collaboration;
• the role of the various sectors in providing good quality basic services (health, agriculture, education) to the whole population, and how this contributes to improving nutrition;
• the role and contribution of the community and the nature of community participation;
• how decentralization can contribute to linking a top down approach to a grassroots approach (if this is appropriate in the country).

Implementing a high-visibility and persuasive campaign of this nature needs time and resources, and perhaps the support of an important political figure. An alternative approach is to secure substantial donor support for a major programme, and make the campaign the initial activity of the programme. This, intentionally or otherwise, is what Madagascar has achieved. Yet another approach is to undertake a pilot project and produce a success story: a high impact, high profile project that can be held up as an example of what can be done. Whichever approach is selected, a good macropolicy environment must be created if improving nutrition in a sustainable fashion is to be achieved.

• Achieving community participation:
  There are no short-cuts to achieving true participation. As mentioned in Section A, there are now numerous published guidelines for the methodology of community participation. These should be consulted. Achieving real participation is a slow process of moving from one step to the next, and occasionally having to take a step back. A pragmatic approach is probably best: starting with what there is, build on it and seek to shape it gradually so as to move from one level to the next. There will be successes in one community and failures in another, reflecting sometimes the initial level of development of a community, sometimes its diversity or homogeneity, the resources at its disposal, its geographical isolation or otherwise, the quality and motivation of its leadership and, finally, of the staff used to mobilize the community and its volunteers.
• Community mobilizers (or facilitators or supervisors):
  Unless the programme is to start in a small area and expand with time, which is a real option to consider, the community mobilizer will often be the first ‘face’ of the programme that most communities will meet. The mobilizer may be a community health worker, an agricultural extension worker, a community development worker, or someone employed by the programme itself. Whatever the background of the mobilizer, investment in good training is essential. Poor training will lead to repeated failures and disappointments. Training needs to focus first and foremost on community development and organization, participatory techniques and group dynamics, management and planning. While some technical training needs also to be provided, perhaps a more important aspect of the training is learning when and where to seek technical assistance. Learning to supervise and motivate community volunteers must also be an important component of the training programme
• Community volunteers (or workers):
  Community volunteers will be members of the community, selected by the community to support their efforts on a daily basis. Experience indicates that a volunteer should be asked to work with no more than ten families. Volunteers may or may not be paid (by the programme or by the community) but many also receive contributions in kind from the families they work with. As with mobilizers, good training is crucial.

Important aspects of achieving participation are motivation and good staff management (including management of volunteers). Motivation is assisted by a system of regular feedback, to staff and to communities, and by a recognition of achievements. A participatory monitoring system will itself provide some feedback to the community, but feedback that allows the community to see its progress and efforts as part of a whole (in relation to other communities in the district, say) is equally important. Good staff management includes motivation, but also includes the recognition of aspirations. A mistake made by many programmes is to assume a static situation; inevitably, many volunteers and mobilizers will aspire to higher positions, and this needs to be accommodated within the programme by means of a career structure and the facility to train new staff and volunteers as need arises. Programmes therefore need an in-built flexibility.

• Improving nutritional status:
  As stated repeatedly in this report, improving nutrition demands an integrated approach. Providing nutrition education if food access is so inadequate that families cannot follow the advice they receive is a pointless endeavour. Similarly, if there is excessive nutrient loss through diarrhoea or parasitism, then providing food supplements becomes at best a wasteful exercise. Traditionally, nutrition education and other activities related to child care are targeted to the mother, but in many cases decisions in a family are taken by the father or a grandmother, so other family members must be included in the process of achieving behaviour change. These examples highlight again the importance of a conceptual framework²³. Efforts to improve nutritional status must emphasize both the quantity and the quality of the diet: a diet that is adequate in energy and protein as well as in micronutrients.

Nutrition research is an ongoing activity. New findings are published daily. A problem common to many nutrition programmes, especially those that have been in existence for many years, is that they are out-dated in their scientific premises and approaches. An example is the promotion of the production and consumption of green leafy vegetables; as part of a diversified diet this is fully justified, but as a strategy to combat vitamin A or iron deficiency it probably is not: research suggests that a weaning-age child cannot possibly consume sufficient green leafy vegetables to meet his or her iron and vitamin A requirements. A key role of a programme’s senior management is thus to remain up-to-date with scientific findings, to translate these into modified programme strategies when necessary, and to keep programme staff informed so they can provide the best possible advice to communities. This emphasizes again the importance of in-built programme flexibility.

Measuring improvements in nutritional status is another issue that needs to be considered. If recent research is correct and the causes of stunting and wasting are indeed different²⁴, then programmes need evaluation systems that measure both of these conditions, so that appropriate targeting and strategies can be used. The Mexican programme, recognizing that the main nutritional status concern in Mexico (as in most Latin American countries) is stunting and not wasting, correctly used improvements in height to assess its impact on nutritional status. Another important role of a programme’s senior management is interpreting data from the evaluation system and recognizing when errors have been made if data are clearly unrealistic. This cannot be left to a statistician. A statistician will not appreciate when a finding is biologically or epidemiologically impossible or unlikely.

• Meeting resource needs:
  Adequate human, physical and financial resources will be needed for a successful community-based nutrition programme. Qualified and well trained human resources are essential at all levels, as stated implicitly and explicitly at various points in this report. If they do not exist in the country, then the programme must seek to create them, through capacity-building and scholarships, if necessary. If international staff must be employed, then this must be viewed as a short-term measure, with a clear strategy to replace them by nationals as quickly as possible. This will entail a combination of formal training (within the programme or at national or regional training institutions) and on-the-job training. Indeed the latter, as well as a clear procedure for handover, must be part of the job description for all international staff. Physical resource demands for nutrition programmes are generally not great, and can often be met by sharing resources of other sectors (health, agriculture). For poor countries, financial resources present a major constraint, and most have no alternative but to turn to external donors. If this is so, then there must also be a mutually acceptable schedule for gradual handover of financial responsibility, with targets and time frames.

Partnerships, including those with non-traditional partners such as the private sector, can contribute substantially to meeting resource needs of all kinds. Contributions can include physical facilities, human and financial resources, as well as training programmes. Virtually all the programmes examined for this report have taken advantage of the opportunities offered by partnerships, especially with NGOs. The somewhat unusual partnership of the Catholic Church in the Brazil programme (indeed the Church is the prime mover and the operating agency of the programme) has brought to the programme a level of dedication and commitment on the part of community workers that is probably unmatched by any other programme. The private sector has much to contribute, in terms of business management experience, to microenterprises and credit schemes. National NGOs have technical resources, sometimes not of adequate quality, but generally rely on the programme for funding. International NGOs, however, can provide financial contributions. Many of the in-depth case studies have indicated the value of partnerships with academic institutions, for training, small research projects to provide answers to guide strategy and for monitoring and evaluation. The challenge with all partnerships is retain control of the programme, avoid inordinate compromise with programme strategy and ensure adequate supervision, quality control and the timeliness of inputs; in other words, successful partnerships demand strong programme management.

• Time frames:
  A national nutrition programme, such as that of Thailand, has no time frame²⁵. It should (indeed must) set targets and goals and time frames for achieving these, and flexibility is needed to accommodate changes in social, cultural and economic conditions and a changing profile of nutrition. Essentially it must be viewed as an integral component of a country’s development strategy, in much the same way as health, education and agriculture are. One of the nine themes of the 1992 International Conference on Nutrition (FAO/ICN, 1992) was “Incorporating nutritional objectives, considerations and components into development policies and programmes”, and this can be fairly easily achieved by considering nutritional improvement as a key outcome of development plans (in the same way that it would fit in a poverty alleviation strategy).

The programme should also be prepared to accommodate changes as and when decentralization proceeds, recognizing the administrative implications of the process and the need to provide good nutrition expertise at middle and local levels, and not just at the national level. Targets and goals need to be realistic and take into account the magnitude and nature of the nutrition problem, the current state of community development and organization, levels of literacy, resource availability and the national economy. Gender biases, culture, geographic and ethnic diversity are also important factors to consider when setting targets.

Programmes with external funding support will inevitably have a specified time frame, often too short to enable a programme to become sustainable, although donors are increasingly recognizing the need for long-term support. A programme such as the Bangladesh Integrated Nutrition Programme is essentially a pilot, although on a large scale, with plans for transformation into a national nutrition programme. Information is not available on the degree of support it will continue to receive from its current major donor, the World Bank. The future of the Madagascar programme is bleak at the moment, since it seems that there are no plans for continuation of the programme or its activities beyond the current termination date of 2003. Most of the other in-depth case studies enjoy financial support from national governments, have no specified time frame, and seemingly could survive were external funding to cease, as has the Zimbabwe programme, although perhaps with some reduction in activity.

²³ A number of generic conceptual frameworks exist. What is actually needed is closer to a “problem tree” that is a concrete description of the local situation. Arguably, different problem trees are needed for different locations e.g. rural vs urban, for different ethnic groups, or for different agro-ecological zones.
²⁴ A meta-analysis of food and nutrition surveys worldwide (Victora, 1992) suggests that stunting is more likely to occur when energy intake is adequate but the diet lacks diversity (specific micronutrient deficiencies are proposed: zinc, calcium, vitamin A). Wasting on the other hand is linked to a diet that is inadequate in both macro and micronutrients. Thus providing a high-energy supplement to a stunted child (who is not also wasted) may not be appropriate.
²⁵ It is important to note, however, that the programme is subjected to a re-evaluation and “renewal” every five years through a national food and nutrition plan.