SECTION B
SUMMARIES OF IN-DEPTH CASE STUDIES

The programmes for the in-depth case studies were selected during the course of a technical consultation (FAO Rome, October, 2001 ²). The three regional consultants were asked to bring details of candidate programmes with them, based on ten selection criteria:

Countries

1. One detailed case study per country, three countries per region (Africa, Asia, and Latin America and the Caribbean).
2. Countries with a relatively high incidence of poverty, food insecurity and high prevalence of child malnutrition.

Programmes

3. Programmes with explicit or implicit food security and/or nutrition objectives. Implicit food security and/or nutrition objectives means that the actions undertaken and/or supported by the programme can reasonably be expected to have an impact on food security and/or nutrition conditions of the target population.
4. Programmes that have been functioning a minimum number of five years or more, and thus have accumulated significant programme experiences, and either are still functioning or ceased functioning only a short while back.
5. Programmes that have or had participation by at least two sectors, e.g. agricultural and health sectors, or health and education sectors, etc.
6. Programmes that support actions, activities, and/or projects at community-level, with some degree of community participation.
7. Programmes that have large-scale coverage with respect to their target population. Normally this means national or province or department-level programmes that reach a significant share of the target population, such as, for instance, under-five children who suffer from malnutrition. Small-scale community projects will not be included.
8. Programmes that can provide insights into processes related to interinstitutional coordination and collaboration, either horizontally (among government agencies, government and civil society institutions), and/or vertically (community-based and grassroots organizations, municipal, provincial or departmental and national levels).
9. Programmes should have achieved a significant and demonstrable improvement in the nutritional status of their target population.
10. Programme experiences should be selected that will provide substantial insights into different macro and community level contextual factors, implementation processes and programme impacts and their interactions, as well as providing important generalized lessons learned with respect to these aspects.

The candidate cases were presented by the regional consultants. No programme met all ten criteria, and detailed information on the programmes was not always available. The cases were ‘rated’ and discussed at length, and the final selection of three programmes per region was made. Further details of the selection procedure are provided in the report of the Technical Consultation³.

The in-depth case studies are of the following programmes:

In addition to the in-depth case studies, it was decided to include three desk reviews of programmes two of which had received FAO support to be prepared by FAO staff who were familiar with the programmes. The desk reviews⁴ are of the following programmes:

Thailand:	Nutrition and Poverty Alleviation
Viet Nam:	Household Food Security for Nutrition Improvement
Zambia:	Improvement of Household Food Security and Nutrition in the Luapula Valley

We present here brief summaries of the key features of the nine in-depth case studies. Further details are provided in Tables 1 and 2.

1. Africa

i) Kenya: Applied Nutrition Project – Makueni District (1983 to present)

Longstanding and well managed, the Applied Nutrition Project is implemented in three food-insecure divisions that comprise arid and semi-arid land. The project has mainly food production or food-related objectives, but has no specific nutrition improvement targets, nor do the objectives mention community participation. Funding was primarily from bilateral agencies and non-governmental organizations (NGOs) but also from the communities and the government. While external funding may end some day, sustainability is likely to be ensured by the fact that many activities have become, or are becoming, institutionalized within the communities. This is at least partly an outcome of the long duration of the project. Initially the project provided health and nutrition services through mobile teams but subsequently some communities built permanent health posts. The Government provided health supplies and staff but funding is provided by the communities themselves. Other activities focus on increasing food production and generating income (introduction of drought-tolerant crops, group seed banks, small livestock, credit, and improved water supply and sanitation). Existing traditional community structures are employed as entry points: women’s groups (Mwethya), village councils and the community decision-making forum (Baraza). Despite the lack of specific mention of community participation in the objectives, the project has clearly used this as its mode of implementation. The project has not gathered systematically any information on nutrition impact, but some community surveys and other data suggest that at least there has been no decline, despite a worsening drought situation. The macroenvironment for nutrition in Kenya is not particularly supportive nor have Kenya’s technical institutions contributed much nutrition expertise to the project, and there is very little expertise available at the district level. Perhaps this is why the nutrition component of the project (education) is its weakest. The success of the project lies primarily with its emphasis on local-level food production, its use of existing community structures and its willingness to allow time to institutionalize the activities.

ii) Madagascar: Expanded School and Community Food and Nutrition Surveillance and Education Programme – SEECALINE (Phase I: 1993-97; Phase II: 1998 to present)

This programme, heavily funded by the World Bank, expanded recently (1998) to the national level. The budget includes a contribution of food for supplementary feeding from the World Food Programme (WFP), an in-kind contribution from the government (3.7 percent of total) and a contribution of labour from the beneficiaries. The programme has specific nutrition objectives (these are quantified, which is commendable) and community involvement objectives. It has four main components: community nutrition, school nutrition, natural disaster preparedness and information, education, communication (IEC). Community participation is weak and passive and sustainability doubtful, with little thought or effort devoted to institutionalization of the activities. It has a top-down, short-term approach, and its major achievements lie in the area of sensitization and drawing in a wide cross-section of agencies and institutions. There are, however, difficulties with collaboration and adequacy of supervision, leading to poor quality control of the activities. Programme data from growth monitoring suggest a substantial improvement in nutrition, but in the light of poor attendance and the low level of community based activity, these data are questionable. Programme documentation is good, and the SEECALINE has benefited from a number of evaluations and reviews. However, there is little evidence that any of the recommendations of these exercises have been used to modify the programme. The programme has benefited from political support and the macroenvironment is good. The latter has indeed been improved by the sensitization and advocacy component of the programme itself. There is, however, no thought or planning for the future of the programme activities after funding ends (scheduled for 2003).

iii) Zimbabwe: Community Food and Nutrition Programme – CFNP (1987 to present)

This is a longstanding national programme, focusing heavily on improving food production and access at the local level. It has its roots in a predecessor programme, the Supplementary Feeding Programme, established soon after independence as an emergency programme to cope with food shortages following drought. The Government has always provided some funding, but has increased this now that external funding has stopped. The programme has benefited from a supportive macroenvironment, and from the decentralized nature of nutrition expertise in the country (at least to the provincial level). Multisectoral collaboration functioned largely at the district level but more recently this has extended up to the central level with the formation of the national Food and Nutrition Council. While there is no real evidence of community-initiated actions, the programme has made use of a cultural tradition (Zunde raMambo⁵ – the chief’s granary), which has generally been a positive experience but does not necessarily imply active community decision-making. The main objective of the programme focuses on community participation and the improvement of food and nutrition security but there are no specific nutrition targets. The programme has gathered no data to demonstrate nutrition impact, but national surveys suggest an improvement until recent years, corresponding to the trends in the country’s economy.

2. Asia

i) Bangladesh: Integrated Nutrition Programme – BINP (1995 to present)

BINP is a large programme that has both nutrition and participation objectives, is heavily funded by the World Bank, and claims to have made a very significant, positive impact on nutritional status and the incidence of low birth weight. It is an interesting example of NGO-government collaboration. Initially the programme employed two modalities: activities in some thanas (subdistricts) were government-led with assistance from an NGO⁶, and activities in other thanas were led by the NGO that was contracted to provide all programme services and management. More recently, activities in all thanas have been contracted out to NGOs. On the whole, the programme has benefited from a supportive macroenvironment (policies, commitment, national institutions); however sustainability is questionable since it is so heavily dependent upon massive external funding which the Government of Bangladesh cannot hope to take over. The programme includes three components: firstly, national-level nutrition activities (institution building, IEC, strengthening of existing nutrition activities and programme monitoring and evaluation, of which only the IEC subcomponent has received serious attention); secondly, intersectoral nutrition programme development to include nutrition aspects in other sectoral development plans (with limited success); and thirdly, community-based nutrition interventions (growth monitoring and supplementary feeding). The third component receives the greatest attention and share of the budget. At the microlevel, the situation is not encouraging. It would seem that all activities have been preselected and designed at the top, with community participation limited to passive participation for material incentives. They are beneficiaries of health and nutrition services but do not make decisions by choosing and planning their own specific activities, based on their assessment of their own needs. However, the programme has helped to ‘organize’ communities, and these organized communities (specifically those who have been in the programme longest) are now beginning to assert themselves and have started to make decisions. Whether intended or not, the programme is empowering the communities, and this may improve the programme’s likelihood of sustainability.

ii) Philippines: Programme on Good Nutrition for Health – LAKASS (1989 to present)

LAKASS is a programme funded by the government (national and local), with assistance from Japanese development aid. It targets nutritionally depressed municipalities throughout the Philippines. Its objectives include the improvement of the nutrition situation (not quantified) and promoting community involvement. The programme functions through a complex array of multisectoral committees and meetings at all levels, from national to barangay (village) level. Primary responsibility for the programme rests with the National Nutrition Council Government Board. Nutrition in the Philippines has long enjoyed high-level support, and the programme thus benefits from a supportive macroenvironment. The programme claims significant improvements in the nutritional status of young children, but data supporting this claim are unsubstantiated. It provides nutrition services (growth monitoring and promotion, micronutrient supplementation, supplementary feeding, IEC and weaning food production, community, school and home food production), and enables the planning and implementation of development projects at the community level (literacy projects, infrastructural development, poverty alleviation and economic interventions which mostly take the form of small income-generating projects). Capacity-building at many levels is an important component of the programme. In addition to government funding, development projects receive support from the communities and from NGOs. Nutrition expertise and training capabilities are available to the programme from the strong research and training institutions of the Philippines. Some counterpart funding for salaries and incentives for programme overseers are provided from the municipal budget. Community participation in development project planning is generally good, and the programme has a high likelihood of being sustainable.

iii) Sri Lanka: National Programme for Poverty Alleviation – Samurdhi (1994 to present)

The Samurdhi (= Prosperity) Programme is a national poverty alleviation programme funded entirely by the government, managed by the Samurdhi Ministry established specifically for the programme. The programme objectives do not specifically mention nutrition but enhancement of health and nutrition is implicit. Community participation is clearly a programme strategy, with a particular focus on youth, women and other disadvantaged groups. The programme combines a welfare approach (income support to the poorest families) with development activities that include voluntary and compulsory savings, the provision of credit for income-generating activities, skills training and a number of infrastructural and social development activities. In these areas, the programme appears to have made good progress. There are no data however to assess the programme’s impact on health and nutrition. Success with achieving community participation is variable, ranging from passive to interactive participation, depending on the strength of the village-based organization established by the programme. Multisectoral collaboration, while considered important, is currently weak, and at the moment there are no links with other programmes or activities (for example, in the area of health or nutrition). The programme enjoys strong political support and a strong macropolicy environment. The welfare approach may not be the best in the long run, it creates dependency and an unwillingness to develop and build on indigenous coping strategies. It may however be needed for the ultra poor, to help them achieve basic subsistence requirements. Sri Lanka has a long history of welfare programmes and it may be that omission of this programme component would be viewed as politically unacceptable. It should be mentioned also that Samurdhi is intended to replace existing welfare programmes and is viewed as a transition programme, to encourage the move away from welfare towards self-reliance. A Samurdhi Ministry, Task Force and a number of Samurdhi Banks have been established, indicating a high level of commitment and likelihood of sustainability.

3. Latin America

i) Brazil: Child Pastorate Programme (1982 to present)

The Child Pastorate programme is a large programme run by the Catholic Church, with primary funding from the Ministry of Health. The broad objective is the promotion of social justice and greater equality, based on the principles of the Christian faith. Specific objectives include the reduction of infant and maternal mortality, better access to health and nutrition services and the promotion of community organization. It claims remarkable achievements, especially in the area of infant and child mortality reduction. The programme relies heavily on the commitment of community leaders who, with the support of the Ministry of Health, could continue the programme if the Church withdrew. The health and nutrition package of activities is top-down, chosen without consultation with the community. On the other hand, the community leaders can and do initiate income-generating projects but only if these receive the approval of programme management. However, it is not clear if the leaders have selected the projects by themselves or in consultation with the community. In fact, true community participation with decision-making by the community seems to be generally absent – community people participate only to the extent that they benefit from the package of health and nutrition activities that is offered to them. There are also some community ‘welfare’ activities led by the Church, for example the collection and distribution of food to the poorest families. The income-generating projects seem to have faced some problems, primarily the lack of markets for the products, suggesting poor planning and an absence of feasibility studies. It appears to be a ‘politically’ popular and visible programme, with strong support at a high level and with some interesting partnerships: the Church, the Government, international agencies, NGOs and the private sector.

ii) Honduras: Rural Development Project for Southern Lempira Department – PROLESUR (1988 to present)

The project PROLESUR began in 1988 as an emergency project in response to severe drought and food insecurity in the southern municipalities of the Department of Lempira in Honduras. It is funded jointly by the Honduran Government (22 percent) through the Secretariat of Agriculture and Livestock and the Netherlands Government (78 percent) through FAO. It is primarily a rural development programme with the objective of improving the quality of life of households through new soil conservation and agricultural techniques, and employment opportunities. Specific objectives do not include nutrition but do mention the participation of the communities. The programme appears to have had a major impact on food production (maize and beans) and food storage capacity, such that the region was able to withstand the devastating impact of hurricane Mitch, and actually export food to other areas of Honduras after the hurricane. Two main aspects of the programme are thought to be responsible for these successes, namely the introduction of the Quesungual⁷ system of production (that replaces the ‘slash and burn’ system) and the construction of metal silos. The Quesungual system is credited with increasing maize yield from 10 to 24 quintals per ‘manzana’, while the use of metal silos ensures food security during the dry summer months of food scarcity. The programme is also said to have had a positive impact on the environment and on the soil’s water content and fertility. There are no data available to indicate whether there has been any impact on nutritional status. Other programme strategies that have been well received are the conversion of five high schools into agricultural training institutes, by the Education Secretariat, and the introduction of improved kitchens. The programme has benefited from good technical support. The socio-economic component of the programme has received little attention to date. The assumption is that now that communities have observed the success of the agricultural aspects of the programme, they are more likely to participate in the socio-economic aspects. The programme enjoys strong government support, which has been maintained through a number of changes in government, suggesting sustainability, at least as long as funding is available. It is not clear if the government will be able to maintain the existing level of funding when external funding ends. However, the changes introduced in conservation and agricultural practices are likely to be maintained by the communities themselves. There has also been some sharing of knowledge and experiences among communities. Intersectoral coordination is variable: quite good at central, departmental and community levels, but less satisfactory at the municipal level. Initially at least community participation was poor, with decisions being taken centrally and communities acting only as recipients of technology transfer. More recently, however, some community groups established under PROLESUR have begun their own planning processes, suggesting a development and consolidation of the process of community empowerment.

iii) Mexico: Education, Health and Nutrition Programme – PROGRESA (1997 to present)

The PROGRESA programme is a large, nationally funded programme that is intended to break the cycle of poverty and deprivation. It targets low income families in poor localities in both urban and rural areas. The broad objective is to improve the well-being and quality of life of families living in extreme poverty. Specific objectives include the improvement of educational coverage, health care and nutrition (these are not quantified) and the promotion of the participation of families in the process and in community initiatives. The programme benefits from an elaborate and well-implemented monitoring and evaluation system, largely because of the involvement of research institutions (national and international). Hence it is able to provide detailed information on coverage of its various components and on some impact indicators. The programme has substantially improved school registration and attendance at all levels, health care usage, and growth in height of children receiving food supplements. There are also improvements reported in haemoglobin and Vitamin A status. The programme has a complex system of selection of participating localities and then of participating households within these localities. Participating households are able to access educational grants (with a special incentive for girls) to encourage school attendance and compensate families for lost child wages. They can also receive free food supplements (fortified with micronutrients) from health centres, and an income supplement to improve the quantity and quality of the household food supply. However, all of these benefits (educational grants, food and income supplements) are only given on condition that the family participate fully in all aspects of the programme, namely school attendance, clinic attendance, and health education. It would seem that this conditionality is monitored rigorously. The community participation component is very weak, represented only by the appointment of a community promoter whose primary responsibility is to promote PROGRESA, motivate families and ensure compliance, in other words to act as a local representative of PROGRESA. However, some promoters have taken the initiative of starting some income-generating projects, but these are not well supported by PROGRESA. PROGRESA enjoys vigorous political support at the highest level, and the involvement of a number of strong national institutions. At this stage, its sustainability cannot be predicted since it has not functioned for long enough. Perhaps its sustainability lies in its philosophy: that by breaking the cycle of poverty and deprivation, we can rapidly reduce the number of households in extreme poverty, and hence the need for a programme such as PROGRESA. At the moment it is a costly, welfare-type programme, and a criticism levelled against it is that the administrative and monitoring costs are very high. It is not at all clear that gains in school attendance and usage of health and nutrition services would continue were the food and monetary incentives to stop.

Table 1: Summary details of the nine in-depth case studies

Table 2: Assessment of main characteristics of the nine in-depth case studies

² Technical Consultation on Criteria for Successful Nutrition Improvement. Food and Nutrition Division, FAO, Rome, 16-19 October, 2001.
³ Preparatory documents for this activity can be found in the report of the Technical Consultation on Criteria for Successful Nutrition Improvement as follows: (i) Annex 3: Methodological framework for review and analysis of community-based food and nutrition programmes, and (ii) Annex 9: Reporting format for in-depth case studies. These documents are available at: www.fao.org/es/ESN/nutrition/national_sustainable_en.stm
⁴ This report also makes occasional reference to a Central American project which was not included as a case study or desk review because it did not fit the criteria for these studies. However, it provides additional interesting findings that are mentioned in this report. The project was a pilot project operated by the Institute of Nutrition for Central America and Panama (INCAP), funded by the United Kingdom government for five years. It employed a participatory approach to improving local level food and nutrition security in a small number of communities in El Salvador, Guatemala, Honduras and Nicaragua. The report of the final evaluation of the project is referenced at the end of this report (Ismail, 1999).
⁵ Editor’s note: Zunde raMambo is a custom whereby a plot of land is planted, tended and harvested by the community. Produce from this plot is stored and used by the community when food is short or to supplement the food supply of poor, vulnerable households.
⁶ BRAC (Bangladesh Rural Advancement Committee) was the NGO in question; another NGO, PROSHIKA, joined the programme later.
⁷ The Quesungual agroforestry farming system was developed in a village of the same name in Lempira Sur and validated by FAO. It is used on plots at altitudes of 200-900 metres. Maize, beans and sorghum are grown between trees, and the trees themselves as well as shrubs are pruned to heights of 1.5-2.0 metres to allow light to reach the crops below. The system reduces soil erosion, maintains soil moisture and enhances fertility, thereby increasing yield.