PHA-Exchange> Food for a sceptic's thought

[Claudio Schuftan]

AIMING AT THE TARGET: WHAT'S LEFT FOR THE DEVIL TO ADVOCATE?
Some thoughts on the setting of goals and targets in nutrition:Have they
helped progress or not?

The big hype:
There is a big difference between the excitement and  the expectations
generated while preparing for a big international gathering to set or to
monitor the status of time-bound, monitorable global goals and targets, and
saying that the same will be or are being really useful. Keep in mind that
setting these goals is the result of a process in which public admission of
dissent is difficult. Therefore, countries pledge, but do not really embark
and comply.

The real challenge, therefore, comes after the (usually expensive)
international gathering. It comes during the process of preparing, finding
the funding and executing down-to-earth action plans. Unfortunately, this
process is rarely participatory. And for this process, the international
conference, more often than not, is not too helpful, because the respective
strategies to achieve the targets are left a bit in the air (or in the
paper).

The outcome-process riddle:
Getting to where we want to go requires not so much knowing and quantifying
where we want to be at a given time, but more so the process(es) through
which we are going to get there.  Goals and targets address the former.
Processes are left to the planners and implementers to
decide/execute --often excluding community representation. But it is the
process that carries in it the seed of sustainability. Unfortunately, as
nutrition professionals, we fear prescribing processes (or denouncing
processes we know do not work or are not working). We also have not spent
the time to arrive at universally acceptable indicators that can measure
sustainable progress in processes such as participation, mobilisation and
empowerment. Instead, we have spend time and money choosing and monitoring
outcome goals and targets that have unduly overmedicalised the nutrition
problem. Think about it.

Being realistic:
With a pinch of self-criticism, some goals and targets set in the 90s called
for a number of pretty unrealistic measures, unaffordable to most developing
countries' state coffers. With low resources, one cannot but get low
coverages --and this is by definition, not only ineffective, but also
wasteful.  The danger I see is that we may be doing it again for goals to
2015. At the moment, we have no assurances that the new set of goals will
mobilise leaders, the media and members of civil society any more than
before. Business as usual will not get us there for anaemia, stunting and
underweight: at present rates, it will take us decades to halve the
prevalence of child malnutrition.

Moreover, three serious concerns arise here.
One is on who the judges should be of what is realistic. Certainly not only
us the technicians. And certainly, realism can no longer be based on global,
across-the-board targets.
Another related concern is that being realistic also has to do with the
quality of the data we use to monitor progress towards achieving the
respective goals. If the latter is poor, the intrinsic value of the number
reflecting how far one is from achieving the target can certainly be
misleading. This comes out clearly in the responses we received to the
questionnaire sent out to field workers which you can find in the next
section.
The third concern is that I still find colleagues saying that this or that
goal may be ambitious. I think the time has passed for 'maybe' positions. [I
am reminded of a small poster hanging on the wall of my office which reads
"I said maybe, and that's final!"]. The facts are out. After democratic
consultation, we are expected to endorse concrete advice on directions and
finish lines.

On convergence:
An issue not often touched is the convergence of some of the goals and
targets set in the 90s.
Even if they branch out to achieve different primary outcomes, actions to
overcome more specific aspects of malnutrition can be additive.
For example, improvements in vitamin A status positively affect nutritional
anaemia; improvements in iron status can positively affect the appetite of a
child. Quite a few other examples can be found. Our actions to address
micronutrient deficiencies and chronic malnutrition are thus complementary
and impact on the overall well-being of individuals.
But these individuals live in imperfect societies that cause them to suffer
from the different forms of malnutrition.
I guess what I want to highlight is the centrality of the individual with
her/his multifaceted problems. With a goals and targets mindset, we tend to
forget and depersonlise the individual, especially the fact the s/he lives
in an adverse environment. Yes, we can get the retinol levels of a child up
to normal, but the child goes on to die very anaemic from malaria. So, to
what avail our efforts? We simply cannot afford to miss the big picture.

When it comes to processes, it behoves us to jointly embark on the processes
needed to make change sustainable. The processes still in need of much more
convergence are those related to tackling the underlying and basic causes of
malnutrition. Much more needs to be done on this, perhaps starting with the
demedicalisation of our goals, as well as with focusing more on these
processes than mostly on outcomes. And this applies to all of us.

The Human Rights twist:
As members of institutions and/or as individuals, many of us are moving
towards a change in the paradigm giving direction to our work. What we may
not have thought enough about is that goals and targets --many of them
intermediate in nature-- are, in a way, antithetical to the Human Rights
paradigm. This, because it rests on the principle that we cannot rest until
the rights of all are restored or instated, i.e. a target of 100% ...not ten
years down the road, but the soonest possible. Consequently --and being
realistic-- we should be talking of steps to be achieved in the process of
fulfilling the Human Rights of all claim holders. In our case, the issue is
nutrition rights and food as a right. And, for most of us, this is a whole
new approach.

A complementary compromise position could be to start working on goals and
targets in reverse. We could express targets as an expected decrease in the
number of malnourished (or what it will still take to close the gap and
uphold the right of 100% of them).

The equity factor:
Reaching targets (usually followed by a congratulatory stage) can be
misleading.  Applying all prescribed interventions primarily to the
easier-to-reach near poor --say the second lowest income quintile-- can,
eventually, get us to achieve national targets on schedule. I do not need to
tell you what this means to equity.  Here, I just want to bring to your
attention what some are calling the distributional concerns of (sometimes
short-cut) actions (imposed) to achieve goals.

On accusations of dependency and top-down implementation:
The achievement of micronutrient goals has created dependency. How? Not only
are many iodine deficiency disorders (IDD) and vitamin A deficiency
disorders (VADD) schemes top-down --with an element of dependency there--
but supplies and other resources are, more often than not, donor provided.
In the long run, in terms of sustainability, what worries some of us is the
'ownership-donorship' interplay. At the end of the day, it is a zero sum
game.

On this issue of top-down, I do disagree with what some colleagues imply
when they tell us that solutions lie in a continuum from vertical
micronutrient interventions to those addressing stunting and underweight so
that the former call for vertical goals which need little action at
community level and only the latter need active community involvement; I
disagree with them when they say that it is only when goals need action at
community level that actionable levels must be consulted with community
representatives.
To me, the idea of 'some amount of community action' is non-sensical.
Implying that for child chronic malnutrition most actions are to be devised
and carried out by the community implies shifting the responsibility for
having so many malnourished children among them to the community itself --so
they better deal with it.

Donors (and we ourselves) touch some projects more than others:  What are
the reasons for a lack of commensurate donor support for iron deficiency
anaemia (IDA) and for the reduction of child malnutrition?  Does it have
something to do with donor fatigue or with targets for these two having been
set at unreasonable levels? (Remember that, justifiably or not, UNICEF
dropped the monitoring of the underweight goal from its mid-decade review).
Are we then in part responsible for having set ourselves up for failure? I
tend to think that the response to the latter two questions is no. In the
eyes of donors (.and many amongst us) IDA and chronic malnutrition are more
messy to deal with than IDD and VADD. There is all this bottom-up, community
action, poverty alleviation, equity and other such involved in them, as well
as longer time horizons. Donors pay plenty of lip service to these more
than, so far, embarking head-on on working on solutions for them. That is
not fatigue; it is not a lack of will, it is a political choice. Internal
and external resources allocated to IDA and under five malnutrition have
thus remained a pittance, unmatched to the challenge. And there is nothing
in sight that tells me that this is changing soon.

Again, it is in the process of selecting the strategies and the steps to
progressively achieve them where donors and many amongst us have been and
continue to be undemocratic and where we have failed those whose nutrition
rights are being violated. As long as we consider the strategies needed to
tackle the basic causes of malnutrition to be outside the realm of our
professional scope of work, we should consider ourselves part of the problem
and not the solution.

The poverty alleviation connection:
Will the new global shift of all donor agencies towards poverty alleviation
strategies happen?  and will it change what has been said above? The
reduction of child malnutrition has now been selected as a key outcome
indicator to measure progress in poverty alleviation. But, alas, this does
not automatically translate into greater advocacy, more actions and more
donor resources going for the prevention of malnutrition. Being an indicator
does not translate into being the object of concerted new efforts and
investments directed at halving malnutrition. We have a lot more to do here.
Improved socio-economic status will improve nutrition, but we know that is
only part of the story --although quite a big one.

To sum up, the take-home message perhaps is that there is probably no such
thing as across-the-board realistic targets. At most, they can be proposed
by us on some technical grounds. But consensus must be painstakingly built
for them in many, many places with both bottom-up and top-down inputs. There
simply are no short-cuts.  Goals or no goals, for people to gain control
over the resources they need to overcome all aspects of malnutrition remains
the key. Remember UNICEF's conceptual framework of the causes of
malnutrition and the bottom-centred (top-down and bottom-up) AAA
(assessment-analysis and action) process.

Claudio Schuftan, Hanoi
aviva at netnam.vn