Section II: Assessing the Micro-Environment

In addition to the macro-environment, a community-based nutrition programme will be strongly influenced by factors and conditions that prevail at sub-national levels. There is no clear line that can be drawn between the macro-level and the micro-level. Arguably, the community represents the micro-level, but communities are part of higher administrative demarcations such as districts or municipalities which in turn are part of yet higher demarcations, regional or provincial^[12]. Events and policies at the national levels will influence situations at the micro-level, but their impact will be modified by conditions that prevail at the micro-level.

Here are some examples of how the micro-environment can affect programme performance:

• A country launches a policy of universal literacy. Resource constraints and geographical access limit policy implementation in remote regions;

• A country decides to promote equality for women. Culture and tradition may affect the degree to which all communities are willing to participate;

• The Ministry of Agriculture encourages household food production. Achievements are influenced by a range of local conditions: access to fertile land, access to irrigation in drought-prone areas, resource poverty.

• The Nutrition Unit launches a clinic-based child growth promotion programme. Women from the poorest families are too busy to attend clinic sessions.

These examples illustrate the dangers of adopting a uniquely top-down approach. What is needed rather is an approach that makes available good quality services (health, nutrition, agriculture), but at the same time accommodates local conditions and priorities. This linking of top to bottom is crucial to the ultimate success of a community-based nutrition programme.

This section shows you how to assess the micro-environment by assessing:

• The extent of diversity in the programme area^[13];

• The local food economy;

• Levels of community development;

• Access to basic services and technical expertise;

• Adequacy of local development structures;

1) Assessing the extent of diversity

Almost all countries exhibit diversity within their boundaries. Diversity can take the form of:

• geographical diversity: agro-ecological and climatic zones, rural vs. urban populations, and degree of isolation of communities;

• socio-economic diversity: countries have richer and poorer regions, depending on the location of natural resources, industries, arable land;

• diversity in health conditions (e.g. malaria, HIV)

• ethnic and cultural diversity.

Such diversity can lead to differences in the nature and extent of nutrition problems, and a nutrition programme must recognize and accommodate such differences. A programme that is top-down in approach is unlikely to have such in-built flexibility. What is needed rather is a programme that on the one hand ensures good access to basic nutrition services, but on the other hand also functions at the sub-national (regional, provincial or municipal) level so that local causes of malnutrition are addressed. To achieve this, a programme must firstly establish the nature of diversity in the programme area, then develop conceptual frameworks and activities accordingly (see Section III: Assessing Programme Design).

To assess diversity and the extent to which the programme accommodates diversity, you need to ask the following questions:

• What are the main forms of diversity that influence the programme?

• Has the programme made any effort to recognize diversity?

• Has the programme made any effort to identify the causes of malnutrition associated with diverse areas or populations?

2) Assessing the local food economy

Closely linked to geographic and socio-economic diversity, are differences in the local food economy. Agro-ecological conditions, climate, availability of, and access to, natural resources, land conditions (including access), economic activities (agriculture, industry, services) and other aspects associated with location, determine household economic activities and thus household access to food. An important distinction is between urban and rural food economies, with usually much greater market-dependence of household income and of food access in urban areas. Diversity in livelihood strategies and activities by households are normally found within regions or areas, as well as in household food security outcomes and in the degree of vulnerability that households face with respect to food insecurity. This is a broad topic, and the assessment team must carefully analyse what aspects are the most relevant to the programme. For an integrated programme that has a food production component, the local food economy is highly relevant. It has less relevance for a programme with a strong primary health component, for example.

Another important aspect to consider is the local occurrence of phenomena (“shocks”) that negatively impact on household food security and nutrition. The extent of the impact will depend on the households’ capacities to withstand the effects of these phenomena, such as floods, droughts, sudden increases in market prices, or population displacement due to civil strife or armed conflict. Such phenomena can offset any positive programme impact on food security and nutrition. The main components of the local food economy are:

• household food production (crops, livestock, hunting, fishing, wild foods collection);

• food and cash transfers (gifts, remittances, food and non-food relief);

• market sales of agricultural and non-agricultural products;

• labour in exchange for cash and/or food;

• food processing;

• household savings (cash), assets (livestock, consumer durables) and stocks (food);

• food consumption patterns (including seasonal variations).

In urban settings, household food production is of little relevance (although urban agriculture is currently being actively explored), while food marketing (market prices, availability of different foods) and employment (income) are. All components may be relevant in rural areas, but with different relative importance. In relation to programme target households, obtain answers to the following questions:

· What household production patterns can be identified?

How do poor and vulnerable households normally acquire food? What sources of food and non-food income do they rely upon? Do food acquisition patterns vary from season to season, and if so, how? If poor households are faced with a food emergency, what coping mechanisms do they employ?

· Are subsidized foods made available to some groups or the population as a whole?

Are there programmes to facilitate access of the poor to foods, such as a price support programme for staple foods, a food stamp programme, food-for-work schemes, subsidized complementary feeding programmes for young children, school lunch programmes, etc?

· In rural programme areas, how are food stocks stored?

How long do household food stocks normally last after harvesting? Are food crops sold before, during or after harvesting? Are the same foods purchased in the market later in the year?

· How well are local food markets developed?

How good is seasonal market access? Which foods are subject to seasonal variation in availability?

· What foods do households normally consume?

Are consumption patterns seasonal, and if so, how do they differ? What are the intra-household food distribution patterns? Are there specific food taboos, and to whom do they apply? What food knowledge do households have?

· Have “shocks” occurred recently in the programme area?

If so, what impact did they have on the local food economy, and who was most affected? Is it possible they will recur soon? And if so, what measures are in place to mitigate their impact and/or to strengthen households’ capacity to withstand the effects?

Information about local food economies is increasingly becoming available in many developing countries, often in the form of disaggregated food economy maps and local food economy analyses^[14]. Good sources of information are food security departments in the Ministry of Agriculture, emergency management offices in the Planning Office/Ministry, in-country offices of Save the Children Fund, FEWSNet, CARE, and/or the VAM Unit of WFP.

3) Assessing levels of community development

Many internal factors influence the rate at which community development occurs and the success of community development efforts. Some are beyond the scope of a nutrition programme, but must be taken into account when assessing likely success. Here are some that may influence the rate of achieving full community development and empowerment:

• Level of literacy;

• Gender issues;

• Economic condition of the community;

• Pre-existence of strong, representative community groups (formal and informal);

• A culture of working together, rather than as individuals;

• The degree of homogeneity within the community.

There may be other important factors that are characteristic of your programme area. You should identify these and add them to the above list. Then, using the list of factors to guide you, carry out a series of focus group discussions with key informants so as to gain an understanding of the nature of communities in your programme’s catchment area.

4) Assessing access to basic services and technical expertise

We have stated repeatedly that linking top to bottom is an important element of success for the programme. However successful the programme is in achieving self-reliance and empowerment within communities, communities will continue to need access to good basic services and technical expertise. Indeed, if the programme is successful, demand for improved services and expertise may, and should, increase (see Section IV: Assessing Sustainability). Failure to respond to such demands can lead to alienation and disillusionment on the part of communities. Even in countries where the process of decentralization is far advanced, basic services are often provided by central government. Under decentralization, management of the services may be more localized, and the specific nature of the services offered may vary from one region of the country to another.

· Do communities have easy access to good quality basic health, nutrition and agricultural services?

Many countries have conducted reviews or evaluations of their basic services. If these are sufficiently recent, they should be examined in the first instance. Then, through discussions with key informants from the relevant ministries at national and sub-national levels, seek the following basic information for health and agricultural services^[15]:

For health:

• What is the effective coverage of primary health care?

• Does coverage vary substantially from region to region? If so, why?

• Are basic health services offered at primary health care clinics adequate?

For agriculture:

• Do sufficient numbers of extension workers cover rural programme areas effectively? Do they have adequate logistic support?

• What is the primary focus of the expertise and advice that they provide? Is it on cash crops or on home food production?

• Are extension workers trained to address the specific agricultural problems of the regions they work in?

• Is the nutrition knowledge of extension workers adequate?

For nutrition, we suggest that you undertake a more extensive assessment. You should also undertake field visits to a number of clinics to observe activities, examine records and have discussions with clinic staff.

As a minimum, the basic nutrition services that should be provided are:

• Growth monitoring and promotion (GMP)^[16];

• Promotion of exclusive breast-feeding;

• Complementary feeding, preferably with recipes based on local foods;

• Management of malnutrition;

• Prevention and treatment of micronutrient deficiencies (especially Vitamin A, iron and iodine deficiencies);

• Nutrition care for pregnant women, to include dietary advice to promote adequate weight gain, and iron and folate supplementation, and nutrition care for lactating women;

• Nutrition support for HIV+ individuals.

To assess the adequacy of basic nutrition services, assess both coverage (which is linked to access) and quality. Answers to the following questions can be found in clinic records and by observation of clinic sessions. If there are any other nutrition activities conducted by the clinics, assess these as well.

• Is attendance at GMP sessions good?

• Is there an age bias in attendance at GMP sessions^[17]?

• Do mothers understand problems of growth faltering and receive dietary advice^[18]? If so, is it appropriate? Is communication between the health staff and mother good?

• Is weight measured, plotted and interpreted correctly? Is weighing equipment available, and in good condition?

• Is there an adequate method for the management of malnourished children? Is there a system of referral for severely malnourished children?

• What micronutrient supplements are available? Do national supplementation guidelines exist, and are they followed?

• Is attendance at antenatal clinics good? In which trimester do women begin antenatal care?

• Do pregnant women receive iron and folate supplements, appropriate dietary advice, and advice on breast-feeding?

• Do mothers receive help in establishing and continuing breast-feeding?

• Are there recipes and complementary foods available and utilized?

· Is good technical expertise available at the local level?

In most countries, the best technical expertise is available at the national level only. Countries that are decentralizing are struggling with providing technical expertise at sub-national levels, since this is where many decisions on basic services will be taken. Moreover, if community participation is successful, communities too will need help in choosing and designing activities. Sadly, access to such expertise at the level it is most needed has proved a weakness of many community-based nutrition programmes. It has led to inappropriate and ill-conceived food production and nutrition^[19] activities, and income generating activities that fail because no marketing or feasibility studies have been conducted, or no training in accounting and management was provided.

You may have obtained the answer to this question, namely the availability of good technical expertise at the local level, when assessing question 5 of Section 1. Even if you have, you need now to look at it from the perspective of meeting local needs, including community needs. Making the assumption that programme-funded expertise will not be available once the programme ends, you need to answer the following questions:

• Do established government positions exist for regional, provincial, municipal or district nutritionists?

• Are all these positions filled? If so, have these nutritionists received adequate training? If not, what additional training is needed? Is there any mechanism to ensure that these nutritionists have access to recent scientific knowledge?

• Have the nutritionists received any training in community participation? If yes, was it adequate? What additional training should be provided?

• Do communities have good access to other expertise that is relevant for nutrition-related activities, expertise in areas such as home food production, storage and preservation, health, water and sanitation?

• Are there NGOs working in programme catchment areas that can provide the needed expertise, in nutrition and nutrition-related topics, especially if government staff are not available? Or are there any other sources of expertise, such as a nearby nutrition (or nutrition - related) programme?

• Is expertise available to help communities conduct marketing and feasibility studies for income generating activities?

• Is there a system of community volunteers to help households access basic technical advice^[20]? Has adequate training been provided to these volunteers, or are there unmet training needs? If so, what are they?

The answers should help you to decide not only the adequacy of expertise today, but to what extent it is likely to be available in the future. These answers will thus help you in your assessment of sustainability (Section IV: Assessing Sustainability).

5) Assessing the adequacy of local development structures

You will probably have gathered by now most of the information you need to assess the adequacy of local development structures or authorities^[21]. If your programme is really community-based, it should be working in close collaboration with, or through, local development structures, using a participatory approach. If it is not, or if the role of these structures is minimal within your programme, then you need to strengthen their involvement. Ultimately, it is likely to be these structures that could ‘institutionalize’ the community base of your programme. Here are the questions you need to answer:

· What development committees exist at sub-national levels? Which are closest to community development?

· How active are they? What is their membership? Do they have an adequate budget? How autonomous are they?

· How do communities identify and communicate their needs?

· Do they attend to community needs?

· If there are no development committees, what other formal or informal committees or systems exist to support the programme?

6) Summarizing the assessment of the micro-environment and action

You should now have gathered the information you need to make an assessment of the micro-environment in which your programme is situated. Turn now to the Summary Report (Annex 1), and answer the questions in Section II. Then carry out a SWOC analysis.

Not all aspects of the micro-environment can be addressed within the nutrition programme. In some cases you must advocate for change at the national or sub-national levels. Any changes to the programme must be in the direction of increased flexibility to accommodate local conditions, a reduced emphasis on a top-down approach through increased consultation, and a strengthening of community participation.

Here are some actions you can take to reduce the constraints imposed by factors in the micro-environment:

i) Re-design programme components to accommodate local diversity and varying levels of development. For example:

• If the advice given to mothers at clinics as part of the GMP programme is not appropriate in relation to the foods available locally, or food preparation facilities available locally, re-design these components;

• Strengthen community involvement: provide additional training to community groups to enable them to organize better; make use of local cultural practices whenever possible; encourage the inclusion of women^[22] in decision making; lobby the Ministry of Education to establish and implement an adult literacy programme;

• Build in social recognition programmes to encourage and support individual and community initiatives;

• Vary time frames, for achievement of goals, within the programme to allow for local diversity and levels of development;

• Re-design credit schemes and other components of the programme to ensure that poorest families and communities are able to participate. In some cases, establishing closer links with a poverty alleviation programme may be helpful. You may need also to seek additional funding for this, and also in order to reach remote, isolated communities and households.

ii) If basic services and access to technical expertise are inadequate:

• Improve basic services in nutrition (this must be a top priority if they are found to be inadequate), and lobby for improvements and greater relevance in health and agricultural services. If necessary, seek external funding to implement a programme of re-training. Consider also moving the GMP programme out of the clinic and into the community: experience has illustrated the advantages of this, as GMP is then viewed as preventive, rather than curative, because the link to other health activities is removed. Work with communities to improve health (and nutrition) seeking behaviour;

• Lobby government to provide more and better technical expertise at sub-national levels. As a short term measure, the programme itself should provide the expertise. Provide (additional) training in community participation. Establish partnerships with relevant NGOs and other programmes.

iii) If local development structures are inadequate (or non-existent), either strengthen these through programme activities or work with a single-sector committee at the lowest level possible (likely district), preferably health or agriculture. Then lobby at the local level for multisectoral committees. As a last resort, the programme could establish such committees itself, but for the sake of sustainability it is better for local authorities to do so.

Here are some of the findings of the SWOC analyses performed as part of FAO’s in-depth study of nine programmes (2002):

Strengths:

• Good basic and support services provided by the government (health care, nutrition services);

• Successful linking of top-down and bottom-up approaches;

• Addresses extreme poverty.

Weaknesses:

• Inadequate nutrition services provided by government;

• Inadequate local technical expertise;

• Poorest families not reached;

• Programme staff technically weak, inadequate access to technical support.

Opportunities:

• Planned government re-vitalization of village health worker programme;

• Planned expansion of basic service provision to remote areas;

• Organized and trained communities can undertake other development activities;

• Planned increase of nutrition expertise at district level will improve quality and appropriateness of community activities.

Constraints (and threats):

• Poor infrastructure in some areas limiting access to remote communities;

• Socio-economic, religious, cultural constraints (e.g. gender bias, poverty);

• Incomplete or absence of decentralization;

• Failure of planned government improvements: trained district nutritionists, village health worker scheme;

• Extreme poverty, leading to lack of time to devote to development activities, and to exclusion from credit schemes.