tial Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition
to be complementary1 foods for young children – is quite common in these programmes, nearly always targeted to children identified as at risk through growth monitoring or other assessments.
Growth monitoring is not itself expected to improve nutrition, but has been found to be a regular activity in most programmes. The outcome used, underweight, may not be affected by the micronutrient components. The relation between programmes with common but not standardized features and a general nutrition outcome can be examined. The relative effects of individual components cannot be assessed in the present data.
7.2 Specific implications for designing future programmes and sustaining existing ones
When assessed in successful programmes, it appears that the initial improvement in underweight prevalence in participants is quite rapid, reducing by up to 10 ppt in the first year or so. At the same time, severe malnutrition also falls rapidly to low levels (e.g. 10% to 2%). This pattern was seen in, for example, Bangladesh (early BNIP), Ethiopia, Senegal, Tanzania (Iringa), Thailand and other places. The reasons for this initial response are not known, and are likely to be in part from treatment of diseases and immunization.
The sustained rate, over a number of years, is what presumably makes a long-term difference.
An expected dose-response is seen roughly in the sustained rate (Figure II-1), measuring the resources as CHNWs/1000 households (or children). The results suggest that a level of around 30 CHNWs/1000 (1 CHNW:33 children, estimated as part time, 0.1 FTEs) is needed for an improvement rate of 1 ppt/year or higher in underweight.
The most important implication is that community-based nutrition programmes can be effective, and that adequate resources – for example, enough CHNWs, trained and supported – must be put into these, and sustained over years, for them to provide a substantial impact on child nutrition. For example, a with-programme improvement rate of 1.5 ppt/year is typical; current sub- regional child underweight prevalences are 13%–23% in Africa, with change rates of 0.1 to -0.2 ppt/year; in Asia these figures are 18%–33%, with change rates of -0.3 to -1.0 ppt/year. A rate of 1.5 ppt/year over 10 years reduces these prevalences by 15 ppt, i.e. to 0%–7% in Africa and 3%–18% in Asia (57). Thus, sustaining these activities at the required intensity for 10 years or so would substantially reduce child malnutrition, as has been seen in several countries with national programmes (e.g. Thailand, Vietnam).2
The resources needed show no such relation (Figure II-2), partly because of difficulties in estimating financial resources. This finding may also reflect that it is how funds are used that counts: investing in local organizations, and especially appropriate training, support, and incentives for community workers, are key.
The precise details of the interventions (counselling, referral, micronutrients, etc.) may not be the most essential factor, although of course they must be relevant and appropriate to the context.
The extent of contact between trained, familiar community workers and mothers with children may be more crucial. It could be argued that the impact comes not primarily from delivering services, but from fostering the collective efficacy of communities: mothers obtain more control over their families’ health and survival, and increase their own effective efforts.3 This is catalysed and supported by the community-based programme structure.
The question of interfacing with vertical programmes – child health days or weeks – was not explicitly studied here. Experience in six African countries (58, 59) indicates that there are opportunity costs to child health days/weeks for community-based programmes (e.g. personnel
1 “Complementary foods” refers to those given from six months on to complement breastfeeding; it may in practice refer to children’s foods in the period between 6 and 23 months of age. Supplementary foods refer here to foods provided from outside of the household.
2 Countries that have experienced transitions at these rates are illustrated in (57), Figure 9 – some of which may be attributable to nutrition programmes (but the data are insufficient to estimate how much).
3 This argument is elaborated on p. 1067 in (22). The huge commitments of their own scarce resources that poor families make to children’s education attest to the strong will to foster children’s welfare, when people know better how to do so.
and resources are temporarily reassigned). While these can be mutually supportive, only a few interventions are effective on the six-monthly periodicity typical of child health days/weeks (notably immunization). Transition to continuing community-based activities as soon as outreach is adequate is implied.
In sum, community-based nutrition programmes would seem to be reasonably established as an effective route for bringing about significant reductions in child malnutrition. To do this they need to be supported and sustained for long enough to bring about lasting change. In principle, if they continue for sufficient time for intergenerational impact – fewer small girls growing up to be small mothers having small babies – to take effect, they can contribute to bringing about a permanent transition in populations’ nutritional status. Indeed, these transitions are completed or underway in many countries (60), and the policy should be to accelerate these in many more.
tial Nutrition Actions: improving maternal, newborn, infant and young child health and nutrition