PHA-Exchange> Health, Nutrition and Development

[Claudio Schuftan]

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THE ROLE OF HEALTH AND NUTRITION IN DEVELOPMENT

Abstract: Nutrition la not only a problem of health. It is necessary to
consider it as the biological translation of a number of socio-economic
factors afflicting a given society. The .author identifies six principle
causes and examines the; capacity of actual systems to reduce them. He
describes the elements of an overall strategy as veil as the specific role
of the health sector. He concludes that any solution requires taking into
account both the national and international perspectives and context.

LE RÔLE DE LA SANTÉ ET DE LA NUTRITION DANS LE DÉVELOPPEMENT

Résumé: La malnutrition n'est pas seulement un problème de santé. Il faut y
voir la traduction biologique d'un ensemble de facteurs socio-économiques
agissant dans une société donnée. L'auteur identifie six causes principales
et examine la capacité des systèmes actuels à Les réduire. Il décrit les
éléments d'une stratégie d'ensemble ainsi que le rôle spécifique du secteur
de la santé. Il conclut que toute solution requiert la prise en compte des
perspectives nationales et internationales.

EL PAPEL DE LA SALUD Y LA NUTRICIÓN EN EL DESARROLLO

Resumen: La malnutrición no es sólo un problema de salud. Debe considerarse
la interpretación biológica de un conjunto de factores socioeconómicos que
actúan dentro de una sociedad dada. El autor identificó seis causas
principales y examina la capacidad de los sistemas actuales para atenuarlas.
Describe los elementos de una estrategia de conjunto y el papel específico
del sector de la salud. Finalmente llega a la conclusión que toda solución
exige tomar en cuenta las perspectivas nacionales e internacionales.

THE ROLE OF HEALTH AND NUTRITION IN DEVELOPMENT

The solving of problems of malnutrition was for many years considered
primarily a health activity and prerogative.

The modern approach to the problem - after having witnessed the failure of
many attempts to solve malnutrition through health interventions alone - is
to rather consider malnutrition as the biological translation of a variety
of socio-economic problems afflicting a given society. Therefore, we now
approach the problem as a "food and nutrition" problem to avoid the above
bias. This moans looking at the root causes of malnutrition and at their
resolution along the Food Chain, defined as the paths food follows from its
production (or import) to its consumption and utilization by individuals in
the population:

Storage----production---Transport---Processing---Marketing---Consumption---U
tilization---Digestion---absorption ---Metabolization.

At each step of the chain one finds bottle-necks that directly or indirectly
contribute to malnutrition. It is the task of the food and nutrition
planning process to identify these multiple constraints and to propose
viable solutions for as many of them as possible to allow for a smooth
left-to-right flow of the different foods in the chain. In so doing, the aim
is to minimize the negative impacts of each constraint, in maintaining
malnutrition as a national problem.

It should come as no surprise that key elements of a host of economic,
infrastructural, manpower, agricultural, educational, environmental, health
and other constraints need to be considered in any diagnostic analysis of
the problem and that solutions often far-removed from strict "nutritional"
interventions are proposed as indispensable to achieve success in the battle
against malnutrition. Special mention should be made of the immense
potential of integrating two of the classical development programs at the
crux of the malnutrition problem. We refer to the integration of primary
health care with agricultural and rural development activities. Both require
a food and nutrition input that needs to be coordinated.

A number of major constraints to better health and nutrition are probably
common to most Third World countries.

Food and nutrition problems are strongly linked to the problem of urban
migration. Every urban-migrating young adult male represents at the same
time two less arms to produce food and one more mouth to feed in the city
through the efforts of those who stayed behind (mostly women, children and
elderly men). For this reason, increases foreseen in food supplies are
probably going to be only moderate in the future. Therefore, cities will
continue to deteriorate if the countryside does not prosper. On the other
hand, the "traditional" agricultural sector will continue to be, for years
to come, the number one moving force of the country, producing more than 80%
of the food eaten in most countries. Availability of productive employment,
revenue and food (basically staples) is often seasonal in rural areas thus
compounding the problems of health and nutrition during the. hungry season.

In most of these countries a sizeable proportion of the population (those of
low income or subsistence status) get less than the FAO recommended averages
daily calorie ration of 2200 calories. Although urban average often surpass
the above recommendation, it is in the cities, also, whore we find the
largest income disparities. We can, therefore, safely assume that 30-40% of
urban dwellers are also below the norm.

Moreover, the cost of a minimum cost diet for an average family of five or
six members is often above the minimum wages of most unskilled workers in
urban centers. Calorie deficiencies and malnutrition should come as no
surprise under such circumstances.

The overall purchasing power of the population (mostly poor) will improve
only very slowly, causing the effective demand for food to grow only very
slowly as well. The demand for food is not equal for the different
socio-economic groups and for the different types of food (especially those
of animal origin).

Averages hide disparities of the economic behaviour of different sectors of
the population. This heterogeneity in the possibility of acquiring food
(secondary to income distribution disparities) can in the future generate
social tensions.

Finally, mother factor hampering well-being that needs to be tackled is, the
negative impact of the environment and infectous and parasitic diseases on
the nutritional status of the low income groups. Environmental sanitation,
potable water, immunizations, as well as overall preventive medical services
and child spacing will become increasingly import ant in combatting
malnutrition in vulnerable groups as defined earlier.

The causes of malnutrition can arbitrarily be classified into six
categories, namely:

1. Socio-economic causes;
2. Political causes (related to government policies);
3. Agricultural causes;
4. Health and environmental causes;
5. Educational causes (includes cultural determinants);
6. Administrative, managerial and infrastructural causes.

The ordering of the above causes in the sequence shown probably reflects
their order of magnitude in perpetuating the problem. A deliberate effort to
identify these causes should be made to put the problem of malnutrition, and
the chances of doing something about it, in the proper perspective for each
particular country. This exercise will also help to better design
appropriate nutrition/health interventions with special reference to Primary
Health Care.

CAPACITY OF THE CURRENT SYSTEM TO ALLEVIATE HUNGER AND MALNUTRITION.

As the list of determinants of malnutrition is so extensive, intricated and
interrelated and as the scope of our efforts focuses more on health,
interventions, let us first briefly analyze the set of overall policies and
interventions needed to decidedly move towards erradicating the problem of
malnutrition to then focus our attention on the special role of health
interventions in this process.

Overall strategy

The capacity of the system to alleviate hunger and malnutrition in the
long-run depends on the concerted efforts the government is making to tackle
the root causes of malnutrition. This is in turn related to whether the
government is really committed to this task. Equity oriented policies are at
the center of this commitment since adequate food consumption due to poverty
is the main underlying problem.

Commitment in this respect might be reflected, among other, by
labour-intensive agricultural production, by high priority placed on
production of crops for domestic consumption, by a reasonable equitable food
distribution system and by a broad-based participatory system of health
services. Based on past experience, the above capacity of the system to do
something significant about malnutrition should be judged as poor unless a
significant number of some of the following actions are foreseen and carried
out in the national development plan:

- measures to slow down urban migration by increasing rural employment
opportunities, making agriculture more profitable and providing a minimum of
infrastructural services in rural communities. This entails a change in
investment priorities towards overall rural development;
- measures to curb urban unemployment;
- major staples in the country roust be made profitable to producers;
- incorporation of women into the development process explicitly, i.e.
making them eligible for bank loans and credit;
- government marketing boards to pay fair market prices to producers of cash
crops in the traditional sector;
- agricultural banks to strike a fairer balance between cash-crop and
food-crop credit allocation: favouring the latter;
- minimum wage policies to be based on minimum cost diet studies;
- higher import duties to be levied on luxury items, especially luxury foods
and beverages;
- the volume of subsidies for selected durable inputs (i.e. tools and small
machines) for small farmers to be increased;
- installation or expansion of rural cooperative systems;
- subsidization of fertilizers and pesticides imports and proper balance to
be stricken between the proportion of these inputs going to food production
as opposed to cash-crop production;
- logistical support for agricultural extension workers and community
development workers;
- priority to home and school gardening programs and small dry-season
irrigation projects;
- measures to improve farm-level food storage practices to significantly
decrease food losses;
- primary school enrollment as percentage of eligible school-age children to
be increased. Includes the opening of more schools and the progressive
teaching of more work-related skills in the same (especially in
agriculture);
- adult literacy campaign with emphasis on women to be intensified;
- strong drive for community development and organization to foster citizens
participation in development activities at all levels;
- organization of a network of daycare centers and nurseries in the country.

This list of interventions is by no means complete, but probably reflects
most of the more equity-oriented actions committed governments would embark
on. The collection of some of the data related to the causes of malnutrition
as depicted in the proceeding pages should help to objectivate the degree of
commitment a given government has.

Although improving the nutritional status of vulnerable groups in the
population remains closely related to the alleviation of poverty, it also
requires specific intervention from many sectors. Some determinants of
malnutrition ion are, for instance, amenable to partial or total correction
through explicit health interventions.

Special role of the health sector in the battle against malnutrition

It is now quite universally accepted that primary health care (PHC) is the
most viable, logical and best possible approach to eventually reach the goal
of health for all by the year 2000. Whenever PHC gets a commitment beyond
lip service in the allocation of resources in a country it actually has the
potential, because of, among others, its appropriateness in design and
choice of technology pointing towards higher degrees of self-sufficiency and
its need for active community participation and involvement. As such, PHC
both addresses the host of local health problems as felt by the beneficiarie
s and has the added potential to go beyond traditional health care concerns
in organizing the people around some activities that eventually have an
added potential to address some of the root causes of malnutrition and
poverty. In short, PHC carries in it the seed for an important mobilization
of the rural communities to change some of the determinants of their
condition.

As can be suspected, a genuine PHC emphasis requires some painful
re-shifting of priorities in health, often away from urban-biased,
big-hospital and doctor-centered traditional approaches.

In general, the range of health interventions that point towards PHC goals
(although not always strictly PHC activities) would be among the following:

- construction, staffing, equipping and opening to use of more primary
health clinics. Includes training of necessary paramedical personnel,
village health workers and traditional birth attendants;
- a higher percentage of the national health budget to be shifted to
preventive services;
- expansion of national vaccination programs;
- expansion and extention of coverage of overall maternal-child health
services including child-spacing and family planning services;
- emphasis to be given to preventive and curative approaches to intestinal
parasites, malaria and diarrheal diseases including home-based oral
re-hydration therapy (ORT);
- promotion activities to Increase the number of deliveries properly
attended by trained personnel and expansion of the pre-natal control of
mothers (includes monitoring maternal nutrition during pregnancy and
lactation and provision of iron and folate supplements plus tetanus
vaccination and malaria prevention during pregnancy);
- promotion and expansion of latrine construction programs through
self-help;
- the number of households with access to safe and sufficient drinking water
to be increased through self-help projects;
- introduction and use of growth charts in all clinics including the
training of the personnel to use them properly and periodic reporting of
growth retardation trends found;
- retraining of field health personnel with emphasis on nutrition and
preventive health activities;
- development of nutrition protocols for the treatment of malnourished
children to standardize the therapeutique approach at the national level;
- mechanisms to record and periodically report birth weight data to be set
up;
- review and improvement of the nutrition curriculum in all university
health related schools;
- introduction of health and nutrition education through the radio;
- introduction of health and nutrition modules in the science carricula of
primary, secondary and technical schools;
- import controls of baby formulas and, baby weaning foods assuring
reasonable margins of profit for wholesalers and retailers; promotion of
these products through the media to be stopped.
Again, this list is not necessarily complete and, as said, includes some not
strictly PHC policy options. Directly or indirectly, all of them are related
to the problem of malnutrition and the ways and means to ameliorate it.
Therefore, an assessment of whether national health plans incorporate these
activities at all and to what degree will help to determine the capacity of
the health sector to tackle some of the determinants of malnutrition in its
realm. We all know that the implementation of all these interventions is
very expensive - especially the expansion of all sorts of health coverages
and the training efforts needed to achieve the same - and is, therefore,
beyond the capacity of any average Third World country in the short run.
Nevertheless, health policies can clearly point in the right direction (with
PHC) as a distinct priority) without major increases in economic resources
allocated, or they can stay the course, relegating PHC to a token program
within the health strategy.

The capacity of the health sector to affect changes, of course, does not
only depend on the policy options chosen (the political instance) and the
qualitative considerations about each intervention proposed (the technical
instance) but very importantly on the budgetary, material and human
resources available to carry out those plans (the infrastructure's
capacity).

If we go back to the incorporation of nutrition components in the design and
operation of PHC projects, this latter question is crucial. Can whatever we
are going to ask to be done be really done with the existing infrastructure
in primary health care in the country? If the answer is no, then the
strengthening of that PHC structure is (or will become) the first priority
of our effort, to incorporate nutrition considerations. Too often this has
been overlooked and well conceived components of PHC programs have stayed
unapplied.

Of primary importance, then, is that planners spend some time in inventoring
available resources in PHC and nutrition as they exist at present in the
country. Once this is done, the missing resources can be inventoried and the
needs and areas for improvements can be identified, both for health and
nutrition components, and both in infrastructure and in actual programme
components, disaggregated by region or province and in budgetary, material
and human resource terms.

In summary, food and nutrition interventions have to be looked upon, both in
a national and an international perspective and context. Foreign aid,
intended to alleviate hunger and malnutrition, has created dependency, the
foreign debt it generates being a constant reminder of neo-colonial
relationships between the countries of the North and the South. Part of the
borrowed money has been used to maintain consumption levels (mostly urban)
at a time when the prices of Third World countries' exports commodities are
falling. Little of that borrowed money contributed to economic 'growth and
food self-sufficiency has tended to fall.'

So, do we need to invest more heavily in better health and nutrition
programs? The answer is, obviously, YES. But we are told that governments
cannot tolerate empowerment and autonomy of communities and primary health
care should do exactly that. This is the challenge committed health workers
face: to revert this grim picture, since the final, more profound solutions
will depend on the resolution of the MACRO determinants we started to
enumerate earlier.

We ought to be advocates of the poor. But, are we?... Is putting nutrition
into PHC programs enough? There has been a general failure to tackle the
profound underlying causes, such as land distribution, land shortages, low
farm gate prices, lack of investment in the peasant sector, i.e. in health,
education and water and an unwillingness to leave the control of food
production in the hands of its producers; the peasants also are under
pressure by their governments (who are pressured from outside themselves) to
favour technically advanced, large-scale farms; agribusiness will not
reverse the Third World's food shortages!

The main problem remains: POVERTY. Emphasis on production fails to address
the problem of WHY people in rural areas are poor, in poor health and
malnourished. They are not self-destructive or short-sighted, but oppressed.
We must become better advocates towards a politization of the health sector.
Our first goal is to universalize PHC so that it can acquire the capacity to
carry a nutrition component.


Claudio, Hanoi
aviva at netnam.vn

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