SECTION E
CONCLUSIONS

This report has brought together and presented the findings of in-depth case studies of nine community-based nutrition programmes and three desk reviews, and the implications of these findings for programme design and strategy. Inevitably, many of the conclusions are based on judgement and assessment. It cannot pretend to be a statistically valid exercise. The challenge for nutrition planners is to take from this report what is appropriate in their country context and to use it to improve their existing programmes or to design better programmes. To help in this process, FAO has produced a companion volume: “Improving Nutrition Programmes – An Assessment Tool for Action” (FAO, 2002).

The future of nutrition programming holds its own challenges, some of which are beyond the control of nutritionists or their programmes, but all of which demand a flexibility in approach and a willingness and ability to accept new situations, innovative technologies and changes in administrative and institutional structures. We briefly highlight here some of these challenges:

• The nutrition transition:
  Many countries are experiencing, or have experienced, a change in the profile of nutrition problems. Undernutrition has generally been reduced but with it has come a rise in obesity and obesity-related disorders. Most developing countries now carry a double burden of disease and their related nutrition problems. The prevalence of, and deaths from, non-communicable diseases, such as cardiovascular disorders and cancers have risen sharply. Infectious disease prevalence has declined but many countries face the challenge of AIDS, often of epidemic proportions.
• Meeting the needs of older people:
  With increasing life expectancy has come an increase in the proportion of the population that is elderly. Most countries are ill-prepared for this, few have even considered the need for a shift in emphasis of their health and nutrition programmes, most of which are still targeted almost exclusively to infants, young children and pregnant women. Recent studies (Ismail and Manandhar, 1999) have shown a high level of malnutrition in elderly people – 35 percent in poor communities of urban India as well as in rural Malawi. Social security programmes are mostly inadequate and the traditional support of the extended family is substantially reduced in the wake of urban to rural migration, the AIDS epidemic and the trend towards smaller families.
• Urbanization:
  Most of the programmes (excluding those of Brazil and Mexico) examined for this report address problems of rural communities. Increasingly, all regions of the world are faced with massive urbanization, and the complexities of problems that this brings with it. There is an urgent need for the development of effective strategies for urban communities.
• Decentralization:
  Most countries have embarked on a serious process of decentralization, and nutrition programmes are having to accommodate new administrative structures. In some cases decentralization is little more than a cosmetic exercise, which in itself presents problems, especially in relation to the availability of (and control over) funding at the local level. In many ways decentralization helps and supports a grassroots approach, and community participation can be easier to achieve. However, it raises other problems, especially that of the availability of good nutrition (and other) expertise at the level where decisions need to be taken.
• Scientific advances and new technologies:
  In the context of the history of science, nutritional science is an infant. There is much still to be understood and discovered and advances are being made every day. The challenge for the nutrition planner is to keep abreast of these advances, to be able to evaluate their scientific validity, and to adjust programmes accordingly. In the field of agriculture, new technologies are being developed. Some, such as the Quesungual method, have been developed locally, but many, such as genetically modified foods, are the subject of serious financial investment in research, development and promotion by powerful multinational companies. These are likely to have enormous implications for the future of food availability and nutrition.
• New partnerships:
  Increasingly, there is a trend in many developed and developing countries towards privatization of what traditionally was viewed as the domain of the public sector. Many aspects of health care are contracted out to private firms, provision of free medical care is giving way to care funded through self-payment or through private medical insurance. NGOs too are acquiring the characteristics of small businesses rather than charitable ventures. Our case studies have shown that national nutrition programmes are not immune to this process. All have formed partnerships, mostly with NGOs, but some also with the private sector. Academic partnerships are also formed increasingly as universities and research institutions discard their traditional exclusivity and move into the development arena.

Malnutrition is an impediment to development and its presence indicates that basic physiological needs have not been met. What is observed as malnutrition is not only the result of insufficient or inappropriate food but also a consequence of other conditions, such as poor water supply and sanitation and a high prevalence of disease. Thus, reversing the procedure is complex, because many issues need to be addressed more or less simultaneously, and every situation is different, so that there is no single solution for all. There can only be general guidance on directions to pursue. Experience from lessons learned shows that considerable time is needed to redress a situation (ten years and more), and that a strong supportive political and policy environment remains crucial throughout the period. There is no “quick-fix” to this problem. Once achieved, however, the effect is likely to become permanent, offering a substantial return on investment.