Integrated Multisectoral Nutrition Interventions at the Village Level

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In considering integrated and multisectoral nutrition interventions at the village level, two general propositions should be emphasized at the outset. First, we need to recognize that in the low-income developing countries where nutritional and related health problems are most serious and intractable, the great majority of the population still lives in rural villages. Hence, as we consider the issues related to the design and implementation of policies and programs capable of having an impact at the village level, we must not lose sight of the fact that this target population represents some 70–80% of the total population and is located in thousands of villages—indeed, in something over 500 thousand villages in the case of India alone. Second, I believe that we must face up to the fact that the actual progress to date in reducing malnutrition in most of the developing countries has not measured up to the high expectations expressed at the 1971 MIT Conference on Nutrition, National Development, and Planning (1) and at other international forums.

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The widespread and serious problems of malnutrition in developing countries are unquestionably the result of multiple causal factors. The fact that malnutrition, especially in developing countries, is to such a large extent a manifestation of poverty is sufficient to underscore the importance of multiple causation. In addition, I will be arguing that for the groups that are nutritionally most vulnerable—infants and small children and pregnant and lactating women—factors in addition to poverty are also of great importance.
Commoditization of food systems, defined as the use of agricultural goods for sale rather than for home consumption, affects nutrition of rural families via economic, social and ecological mechanisms in addition to direct dietary effects. Broad-scale mechanisms include alterations in land tenure, increased stratification of wealth, widespread labor migration, urban bias, food price changes, disruption of traditional reciprocal social relations, and ecological changes accompanying commercial agriculture that may limit long-term food production. At the family level, the replacement of food with cash is often problematic as regards nutrition, due to low prices to producers, increased cash needs, the 'lumpiness' of earnings during the year, reduced decision-making power of women, and often decreased dietary diversity. Three case studies in Latin america and the Carribean, from Peru, Jamaica, and Mexico, illustrate that commoditization tends to have a negative impact on nutrition in poor rural households. Although commoditization is theoretically advantageous on a national level by allowing the use of 'comparative advantage', in actuality its potential benefits are eroded by inequitable uses of foreign exchange. Commoditization is in essence a more efficient means by which to extract surplus value from small agricultural procedures. While commoditization is a necessary component of economic growth, policies to safeguard health and nutrition and improve the status of women in development programs must be implemented within an overall strategy to meet basic needs of the population.
Rapid population growth in developing countries is expected to continue in many areas. Although sustained fertility decline has begun among the majority of populations in the developing world, many smaller nations show little or no decline. This review of population trends illustrates the importance of socioeconomic, cultural, and environmental factors in explaining fertility differences both between and within countries in the major regions of the developing world. Conclusions from a review of current trends differ in several ways from what might have been found five years ago: (1) expectations about the future of mortality decline in most developing countries are considerably reduced; (2) family planning programs can effectively accelerate fertility decline under favorable conditions; (3) development programs outside the population field can affect desired family size and thus fertility levels.
Why have growth and development in poor countries failed to improve the welfare of the poorest people? This question was raised by Michael Lipton in 1977. He then argued that poverty persists mainly because development was designed by and for people in urban areas. Most poor people lived in rural areas, but the towns and cities got a far larger share of national resources. This, he argued, was not only unjust but also inefficient. In this book, Lipton presents the theory of ‘urban bias’ arguing that the development of urban areas and industrialisation in poor countries has been at the expense of rural areas. During this time usual theory and practice saw development as a process of transformation from the rural and agricultural towards the urban and industrial, through fast and artificially stimulated resource transfers from village to city. Rural areas were not normally seen as a potential source of economic progress. The book shows that public spending in poor countries has been concentrated on the development of urban areas and on industrial growth. Governments tend to favour allocating resources to towns and cities as opposed to villages. This is mainly because people in urban areas have more political power to convince governments to make taxation and spending choices that favour their interests. Key findings include: The 60 to 80 percent of people in poor countries who depend on agriculture for their livelihoods are typically allocated less than 20 percent of development spending. Urban areas get a disproportionately and inefficiently high share of public spending, particularly in health and education. Poor people in rural areas are disadvantaged in terms of nutrition, education, health, technology and access to financial services. Government policies keep goods and services from rural areas (for example, food) under-priced and those from urban areas over-priced. Urban bias has resulted in a rural skills drain as educated younger workers leave to work in towns and cities. Urban bias has prevented the formation of valuable rural-urban links. Lipton argues that comparisons being made with the economic history of the industrialised countries were misleading: the gap between urban and rural wealth and power was much bigger in poor countries than it had been in rich countries during the early stages of their development. Successful pro-poor development would require a much larger share of resources for rural areas and farming. Key recommendations include: Development normally requires industrialisation but both are impeded when countries seek to industrialise too early, too quickly or by artificial resource extraction from rural areas. Resources should be initially directed towards developing the agricultural sector: growing farm productivity has almost invariably been a pre-condition of successful development in other sectors. Investment in small-scale agriculture would be the best way to raise incomes quickly in poor countries, with high ratios of labour to capital, because it is labour-intensive farming, especially on a small scale, and rural activity in general, uses less capital (directly and for infrastructure) per unit of labour than does urban industry. Rural and agricultural enterprises need better – but not normally subsidised – access to loans and investment. Incentives are needed to encourage public sector workers, particularly in education and healthcare, to work in rural areas. Governments should set and monitor targets for the share of public spending on farming and rural areas.
Describes various research projects pertaining to the permanence of intellectual retardation brought on by malnutrition in young children. Concludes that there is strong encouragement for complete intellectual rehabilitation of the malnourished child if intellectually rich environmental settings are available to the child. (SL)
The notion that, given sufficient ingenuity and resources, any social problem can be solved, in a manner consistent with the announced policy objectives and with the accepted institutional framework, has been a major source of failures and frustrations. This paper suggests that policy analysis should concentrate on the investigation of the conditions of feasibility of public programs. Feasibility is defined in terms of all the relevant constraints: social, political, administrative, and institutional, as well as technical and economic. The emphasis on the pure logic of choice and optimal decision rules, so characteristic of normative theorizing in decision theory, management science, and welfare economics, has tended to obscure the fact that in the field of social policies, the range of feasible choices is severely limited by a variety of constraints. Most bad decisions are not just suboptimal; on closer examination, it usually turns out that they were not even feasible at the time they were made. Only by understanding the reasons why, under certain circumstances, a given goal cannot be achieved, can we hope to gain better knowledge about the working of social institutions. Just as the essence of the scientific method is the critical analysis and refutation of proposed theories, rather than the accumulation of evidence in favor of pet solutions, so the most important task of policy analysis consists in submitting plans and objectives to the most stringent tests of feasibility. Also in analytic case studies, the search for constraints that were ignored by the decisionmakers has considerable heuristic value, as I try to demonstrate with a critical discussion of some aspects of the British National Health Service.
This paper analyzes income distribution data for a single brigade of a commune in Fukien Province, after the 1962 movement down to the production team as the basic agricultural unit. The primary result is that returns to nonlabor resources owned by the production teams cause significant income differences between team income levels even within the same production brigade. Inequality based in ownership patterns seems incompatible with Chinese Communist ideological principles so its continued existence reflects the extent to which pragmatism has dominated ideology in the People's Republic of China.
At a time of fertiliser scarcity and high prices it is important to know more about the poorly understood relationships between fertiliser and food production. Fertiliser price increases are reflected in increased prices for food which poses a dilemma for governments attempting to increase food production and minimise rising prices. Through the use of a simple macro-model these relationships are discussed and the policy insights they offer. Impact of price receives special attention because of its frequent use as a policy instrument.
The generation of extended plots for melodramatic fiction is an interesting task for Artificial Intelligence research, one that requires the application of generalization techniques to carry out fully. UNIVERSE is a story-telling program that uses plan-like units, ‘plot fragments’, to generate plot outlines. By using a rich library of plot fragments and a well-developed set of characters, UNIVERSE can create a wide range of plot outlines. In this paper we illustrate how UNIVERSE's plot fragment library is used to create plot outlines and how it might be automatically extended using explanation-based generalization methods. Our methods are based on analysis of a television melodrama, including comparisons of similar stories.
Nutrition planning features a ‘rational choice’ bias that often characterises applied knowledge. John O. Field questions this bias by exploring the softer side of success in nutrition planning efforts. He contrasts the scope of nutrition planning as understood by the international community of experts and by administrators in low income countries. He examines the politics of planning and programme implementation. Consideration of nutrition planning in an ideological and historical perspective reveals both the ambivalence of nutrition planners as agents of change and the tenuous, untested nature of nutrition planning as an approach to ameliorating malnutrition.
Printed and electronic ed. In PDF, 7 MB. Includes bibliographies diagrs., tables
The complex interrelationships of price policy and income distribution are analyzed, beginning with the simple effects of changes in food prices as they are reflected in consumer-budget data and consumption patterns and the effects on producers of different income levels. The analysis progresses to a more complex study of the effect on agricultural technology and production and on employment in non-agricultural areas. The impact is shown to be greatest on low-income groups, whose economic condition also has the greatest impact on food demand. Secondary impacts on employment and income of low-income groups also result from changes in the real income of high-income consumers as prices change. On the basis of this analysis, the author suggests food-pricing policies that will encourage technological change in agriculture and employment growth in industry.
PIP: Remarks on the importance of developing integrated processes and strategies for national development which aim at rural, low-income populations as main targets. Citing data which underline the disproportionate distribution of income, food and health services, the article demands a reconsideration of priorities in the social planning and economic development programs which are traditionally designed. Increased attention to agricultural programs and family planning programs is suggested, since these 2 areas are indeed the most crucial in scope for the rural community. Realistically recognizing financial limitations, the proposal favors the development of integrated programs which would stress popular participation in the development of better nutritional, health and family planning design. The interrelationship between many of the problems of the rural poor are presented as interdependent, often self perpetuating. Integrated programs would more efficiently make use of scarce human resources, as well as maximizing positive interactions and their results between these diverse yet highly interrelated needs in nutrition, health and family planning areas.
Beginning at different ages in their preschool years, groups of chronically undernourished children from Colombian families of low socioeconomic status participated in a program of treatment combining nutritional, health care, and educational features. By school age the gap in cognitive ability between the treated children and a group of privileged children in the same city had narrowed, the effect being greater the younger the children were when they entered the treatment program. The gains were still evident at the end of the first grade in primary school, a year after the experiment had ended.
Interactions between malnutrition and infection contribute directly to the health of individuals and communities. The relevance of this concept to the practice of clinical medicine, dentistry, and public health is supported by an imposing collection of evidence from the clinic, laboratory, and field. Malnutrition can interfere with any body mechanism that acts as a barrier to the multiplication or progress of infectious agents. This includes formation of specific antibodies, number and activity of phagocytes, integrity of skin, mucous membranes, and other tissues. Some of the less definite, nonspecific protective substances in body fluids are also affected by malnutrition. Infectious disease adversely influences the nutritional state in several indirect ways. Loss of appetite and intolerance for food result in metabolic changes. Cultural factors lead to substitution of less nutritious diets as a presumed therapeutic measure and to administration of purgatives, antibiotics, and other medicines that reduce digestion or absorption of specific nutrients. All of these may help to precipitate kwashiorkor in children subsisting on protein-deficient diets. Classical nutritional deficiencies precipitated by infection in individuals with borderline nutrient depletion include: keratomalacia due to avitaminosis-A; scurvy from lack of ascorbic acid; beriberi as a consequence of inadequate thiamin; pellagra resulting from insufficient niacin; macrocytic anemia due to folic acid or vitamin B12 deficiency; and microcytic anemia resulting from a shortage of iron. In well nourished individuals, body reserves and normal dietary intake assure that malnutrition will not result unless infection is prolonged.
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