Atténuer la malnutrition dans les communautés
Mitigar la malnutrición en las comunidades
FAO's evolving strategies
E. Muehlhoff, F. Simmersbach, P. Baron and F. Egal
Ellen Muehlhoff, Franz Simmersbach, Pierre Baron and Florence Egal are Nutrition Officers in the Nutrition Programmes Service, FAO Food and Nutrition Division.
Since FAO was founded 50 years ago, the basic goals of its community nutrition programmes have remained the same: to raise levels of nutrition and improve the living standards of the rural poor. While the specific objectives of current projects are similar to many of those of the 1950s and 1960s, many of the strategies and approaches employed for solving nutrition problems are different today. They reflect the experience FAO has acquired overtime and the knowledge FAO is constantly incorporating into its community-based nutrition programmes.
During the early years of FAO, community programmes to alleviate malnutrition were supported independently by FAO and the World Health Organization (WHO). By the mid-1950s, both agencies realized that their nutrition activities in developing countries, mainly nutrition education and supplementary feeding programmes, had not brought the expected improvements.
APPLIED NUTRITION PROGRAMME
From the late 1950s through the early 1970s FAO, along with WHO and the United Nations Children's Fund (UNICEF), embarked on a new approach to combat the diverse causes of malnutrition. The Applied Nutrition Programme (ANP) aimed to educate rural families to grow and use the foods needed to improve their diets, especially the diets of mothers and children, ANP projects were launched simultaneously in different regions; by 1961, 26 ANP projects had been established, and within five years 56 country projects were fully operational (McNaughton, 1975).
The ANP projects sought to improve nutrition through a three-pronged approach of community action in agriculture, health and education. The main activities involved agricultural training to increase food production through community and school gardening; raising fish, poultry and other small animals; and providing materials and inputs such as tools, seeds and fertilizer. Nutrition education to teach better use of foods and healthy eating habits was provided to women's groups, schools, health centres and youth groups. Supplementary feeding of schoolchildren and preschool children often formed an integral part of the programme.
The integrated approach of ANP required cooperation among the health, agriculture, education and community development sectors; however, each project focused on one sector. When a country chose to give primary emphasis to agriculture for its project activities, FAO became the leading United Nations agency implementing the project. For example, in the Republic of Korea, village-level food production and utilization were prominent elements of ANP, so FAO provided technical assistance to the Ministry of Agriculture. In countries where health was the focus of project activities, as was the case in Indonesia, WHO led the programme.
Assessment of the Applied Nutrition Programme
The experiences of ANP projects varied from country to country, and after 20 years the results of the programme appeared to be mixed. While some projects were successful in terms of the adoption of nutrition gardens or small animal raising, it was sometimes difficult to identify any tangible improvement in the nutritional status of the beneficiary communities. Progress was confined to a limited area, as ANP was designed to foster pilot projects. The programme could not go beyond this phase owing to lack of sufficient funds. For example, in the Republic of Korea the project promoted hew practices which the target farmers adopted readily; however, only 1 percent of the villages participated in the project.
In 1966, FAO trained Lesotho nutritionists to demonstrate food preparation to village women - En 1966, la FAO a formé des nutritionnistes au Lesotho pour qu'ils montrent aux villageoises comment préparer les aliments - En 1966, la FAO capacitó a nutricionistas de Lesotho para que hicieran demostraciones ante mujeres aldeanas sobre cómo preparar alimentos
In retrospect, a major weakness of the programme was the failure to ensure the integration of ANP activities into national and local development plans from the time of their inception. This flaw, together with insufficient local and international financing, led to difficulties in expanding ANP pilot activities to full-scale projects. Coordination among the United Nations organizations as well as among government ministries was difficult and less effective than anticipated. Insufficient priority was given to agricultural extension, and at times the advice of nutrition educators was impractical or inappropriate.
In spite of these limitations, ANP did have many lasting beneficial effects: it stimulated governments' interest in nutrition; national staff became committed to the concept of applied nutrition; and nutrition improvement came to be seen as an important component of rural development.
Senegalese schoolchildren learned to produce vegetables as part of the FAO/UNICEF Applied Nutrition Programme in 1968 - Des écoliers sénégalais apprennent à produire des légumes dans le cadre du Programme de nutrition appliquée FAO/UNICEF en 1968 - Los niños de las escuelas senegalesas aprendieron a producir hortalizas como parte del Programa de nutrición aplicada de FAO/UNICEF en 1968
NUTRITION AND DEVELOPMENT STRATEGIES
Throughout the 1960s and 1970s, developing countries made determined efforts to increase their food supplies, and attaining national food self-sufficiency was given top priority. Unfortunately, in many countries production gains were insufficient to meet rising demands for food. Despite enormous production increases as a result of the green revolution, in many countries the benefits were not distributed equally and many people remained food insecure. The FAO Committee on Agriculture noted that increased food production, while often necessary, did not guarantee a decrease in the number of malnourished people (FAO, 1979).
In the 1970s, FAO, along with other development agencies, emphasized that malnutrition affecting economically marginalized and socially disadvantaged people could only be lastingly solved through increased food production, national economic growth, poverty alleviation, social development and education. The accepted wisdom of the time was that isolated nutrition programmes could not work and that nutrition activities should be integrated into agricultural and rural development programmes. Discussions and analysis of nutrition improvement focused increasingly on the underlying causes of global malnutrition, and it was hoped that this problem could be tackled through national food and nutrition policy and multisectoral nutrition planning.
PROGRAMMES DURING THE 1980S
By the early 1980s, it had become abundantly clear that the national strategies were often overly ambitious and that nutrition concerns had been placed in competition with other aspects of socio-economic development. Access to nutritionally adequate diets and improvements in nutritional status were not seen, and poverty continued to be a major determinant of food insecurity at the household level. Poor families were still unable to produce enough food or to earn sufficient income to purchase the food they needed.
Despite continuing debates over development strategies and nutrition, it was widely agreed that those nutrition problems that can be solved with simple technology (for example, deficiencies of vitamin A, iron or iodine) should be tackled immediately at community level. During the past ten years, FAO has strengthened its advocacy of interventions to solve specific problems as rapid and direct ways to improve nutrition within a community. Such interventions offer a means of channelling resources quickly and effectively to nutritionally needy groups.
Vitamin A Programme
Vitamin A deficiency was the first nutrition problem to be addressed by this new strategy. In 1985, the UN ten-year-action programme to control and prevent vitamin A deficiency, xerophthalmia and nutritional blindness was launched at WHO headquarters. In this programme the main technical agencies FAO, WHO, UNICEF, the United Nations Educational, Scientific and Cultural Organization (Unesco) and the United Nations Development Programme (UNDP) collaborated closely and provided technical as well as financial support according to their mandate to governments. While WHO and UNICEF assisted in addressing the immediate health-related problems of children and Unesco gave support to education, FAO emphasized and promoted food-based approaches to ensure sustainability of programmes and gave priority to prevention of vitamin A deficiency, FAO's major contribution to this programme has been to increase the production of vitamin A - and carotene-rich foods and to ensure their increased consumption. International non-governmental organizations (NGOs) also participated actively in this UN programme.
REDUCING VITAMIN A DEFICIENCY AND DIVERSIFYING DIETS IN THE NIGER AND VIET NAM
Through the FAO Vitamin A Programme, the production and consumption of foods rich in this micronutrient began to be promoted in the Niger in 1992 (FAO, 1995a). The two-year pilot project was implemented by the Ministry of Agriculture in collaboration with the Ministries of Health and Education in six villages with a total estimated population of 2 100 households or 10 700 individuals. In the project, women were the principal producers and agents of behavioural change. The primary beneficiaries were the members of nine women's groups (ranging in size from 30 to 70 women) and their families, neighbouring households and the village at large.
When the project villages were compared with others, an increase in the proportion of healthy children was noted in the project areas. The successful ingredients of this project appear to be a strong emphasis on nutrition education to promote available, underutilized foods such as green leaves and liver; the cultivation of traditional wild sources of vitamin A-rich foods; and the use of food preservation and solar drying to address the problem of seasonal shortages.
In Viet Nam, a programme to improve nutrition and reduce vitamin A deficiency was implemented in four pilot communes from 1991 to 1994 (FAO, 1995a). The major interventions were nutrition education, particularly for pregnant women and mothers of children under five years of age; and the promotion of home gardening, especially for the production of vitamin A-rich foods. A network of community volunteer educators ensured delivery of services at the grassroots level.
Over two years, mothers' knowledge about nutrition increased, with an associated increase in the use of vegetables in weaning foods. Home production increased, and consumption of vegetables rose, especially among children under five years of age. Overall food intake, average daily intake of energy per caput and protein and fat intakes increased as well. The prevalence of xerophthalmia decreased overall from 1.01 to 0.09 percent (night blindness from 0.55 percent to 0, Bitot spots from 0.40 to 0.09 percent, and corneal scarring from 0.06 percent to 0). The project had a positive impact on health, nutrition and household food security in the target communes. It is believed that this model can be self-sustaining and can be expanded within the limits of the existing resources of the country.
Education materials developed by vitamin A projects in the Niger and Viet Nam - Matériel d'éducation développé par le projet vitamine A, au Niger et au Viet Nam - Materiales educativos elaborados por proyectos de vitamina A en Níger y Viet Nam
FAO greatly increased its active support for community nutrition projects through its work on vitamin A-rich foods. In assisting governments, FAO emphasizes food-based actions since only they can promote prevention, sustainability and self-reliance. Foods that are rich in vitamin A and carotenes are widely distributed in the animal and plant world. Furthermore, the focus on foods gave attention to all the macro- and micronutrients they contain rather than vitamin A alone.
The Vitamin A Programme was very similar to the comprehensive Applied Nutrition Programme in that it called for support of community action. It involved home, school and community gardens; small animal raising; aquaculture; home and community food processing, preservation and storage; nutrition education; recipe development and cooking demonstrations; income generation for women; and training of field workers. Community action for micronutrient deficiency prevention and nutrition improvement required cooperation among different key ministries (agriculture, health, education, social affairs and rural development), various United Nations agencies, international and national NGOs and the participating communities. The Vitamin A Programme differs from ANP in that its projects were fully integrated in governments' nutrition and development plans and programmes.
While the UN ten-year action programme will be completed by the end of 1995, FAO will continue to work to eliminate vitamin A deficiency by the year 2000, a goal set by the World Summit of Children in 1990 and reiterated and confirmed by the International Conference on Nutrition (ICN) in 1992. FAO is adopting a broader approach; efforts to prevent vitamin A deficiency are being implemented in the context of food-based programmes to alleviate micronutrient deficiencies and to improve overall nutrition.
Promotion of traditional food crops
Another strategy to maintain adequate diets among the poor that gained attention in the 1980s was the promotion of traditional food crops such as vegetables, fruits, pulses and certain cereals and tubers that are habitually consumed in rural areas. With the strong emphasis on the production of staple cereals in earlier years, the so-called "minor crops" had been neglected. Encouraging production of these traditional foods is now recognized as a way to broaden the food base and ensure a minimum supply of food prior to the harvest. These foods add diversity to diets and help to prevent micronutrient deficiencies. They are especially important in poor households and for women, who tend to be the main producers and consumers of traditional food crops.
In 1985, the FAO Committee on Agriculture requested that assistance to governments be given for programmes to promote traditional food plants (FAO, 1985a). An expert consultation on broadening the food base with traditional food plants, held in November 1985 in Harare, Zimbabwe, made recommendations for the development of a programme to promote underexploited food plants (FAO, 1985b). Subsequently, FAO published a policy brief and several resource books on traditional foods.
It is now recognized that the promotion of underexploited foods should not be restricted to food crops, but that consideration should be given to animals and wild foods as well. To increase the consumption of these foods an intersectoral and interinstitutional approach is required to address constraints at all stages of the food chain (particularly at the stages of processing and consumer information). The promotion of underexploited foods should be considered systematically in most development projects and programmes rather than only in specific projects on the subject.
Currently, FAO gives priority to raising awareness among development institutions about the present and potential contribution of underexploited foods to household food security and nutrition, so that these foods can be considered in the design and implementation of development policies, programmes and activities. FAO encourages exchange of information among institutions and experts concerned with underexploited foods. In particular, a methodology was developed to promote a coordinated approach among all institutions operating at local level. It was tested at an interinstitutional planning and formulation workshop organized jointly with the International Fund for Agricultural Development (IFAD) in August 1992 in Luapula Province, Zambia.
RECENT APPROACHES AND STRATEGIES
FAO is concerned with improving households' access to nutritionally adequate and safe food. However, ensuring the nutritional well-being of individuals requires additional measures, including improvements in health and sanitation, the provision of adequate supplies of safe water, nutrition education and appropriate care of vulnerable individuals in the household.
Collaboration among sectors (including agriculture, health, education, community development, industry and organizations) to achieve nutritional well-being has been given impetus especially by the ICN and the subsequent development of National Plans of Action for Nutrition. The participation of various public- and private-sector organizations that have a stake in improving nutrition will contribute significantly to sharing of responsibilities for projects and programmes, which will enhance national commitment and the chance that programmes will be sustainable in the long term.
Participatory nutrition approach
Malnutrition can be found in many places, for instance urban slums, densely populated rural areas or heavily degraded ecological zones. Because of the diversity of conditions, universally valid answers to nutrition problems are extremely rare. Existing technological solutions to food problems often need to be adapted to fit specific agro-ecological and socio-economic conditions (for example, poor smallholdings and women-headed households), and this requires people's participation.
The early 1990s saw a shift in FAO's approach to planning and implementing community nutrition programmes. New approaches involve a process of learning and dialogue among the farming community and international and local development agents such as experts, researchers and field staff. The participatory approach has become a prominent characteristic in nutrition improvement programmes. In this approach a partnership is formed between project personnel and the people in the community to ensure that nutrition interventions and activities respond to the community's needs and resources and can be sustained long after project funds and technical experts are gone.
FAO is assisting member countries in developing participatory nutrition approaches and projects. The Organization has published guidelines to help development staff working at the community level to facilitate the appraisal of local food and nutrition problems, the selection of feasible activities to address the constraints identified and the monitoring and evaluation of activities by the staff and members of the community (FAO, 1993). The Organization is developing an in-service training programme at district level for government and NGO staff involved in community development (for example, agriculture, health and education programmes) to introduce this approach.
The participatory nutrition approach has been effective in the identification of the poorest households in a community and the formulation of specific activities to address the food and nutrition problems they face. It encourages women to state their particular constraints and needs more actively, which is an important consideration in view of their special role in food production, processing, preparation and distribution (FAO, 1993).
In early nutrition projects, attention was given to the role of women in domestic activities such as selection and preparation of food and feeding of children, rather than to their role as agricultural producers and providers of food for family consumption. In the late 1970s and early 1980s quantitative data began to show the magnitude of women's involvement in food production, and the implications of their work for household food and nutrition security were fully recognized.
Today, FAO projects give full recognition to women as important partners in development, not only as mothers and home managers but also as agricultural producers and income earners. FAO projects stress enhanced access to credit, extension services and nutrition education for male and female farmers to improve their ability to produce a greater variety of foods for healthy diets and to generate income for their families. Although careful analysis is needed to ensure that projects do not overburden women, activities can be designed and technologies developed and adapted so that the condition of women and the welfare of their families can improve.
Women are active participants in community projects to grow food - Les femmes participent activement aux projets communautaires de production alimentaire - Las mujeres participan activamente en los proyectos comunitarios de producción de alimentos
The results, resolutions and recommendations of recent international conferences will determine the support that FAO will give to community nutrition programmes in the future. The implementation of the National Plans of Action for Nutrition that countries are developing following the ICN will provide a strong orientation for the design and implementation of community nutrition programmes. By 1995, FAO has assisted more than 95 countries in their preparation of these national plans, most of which include strategies to be carried out at the community level (FAO, 1995b).
As a contribution to the implementation of Agenda 21 of the United Nations Conference on Environment and Development (UNCED). FAO will promote traditional foods from animals and plants and will carry out environmentally sustainable, multidisciplinary strategies to alleviate food insecurity and to improve nutrition.
In light of the issues raised at the International Conference on Population and Development held in Cairo in 1994, FAO training programmes for field workers will continue to include discussions on the consequences of demographic changes (population growth, the AIDS epidemic, refugee movements) for natural resources, food production and household nutrition.
Other forth coming international events, especially the Fourth World Conference on Women in Beijing in September 1995 and the World Food Summit to be hosted by FAO in Rome in November 1996, will undoubtedly influence the design of FAO community nutrition programmes in coming years.
FAO. 1979. Nutrition in agricultural and rural development. In Report of the fifth session of the Committee on Agriculture. 18-27 April. Rome.
FAO. 1985a: The role of minor crops in nutrition and food security. In Report of the eighth session of the Committee on Agriculture. 18-27 March. Rome.
FAO. 1985b. Broadening the food base with traditional food plants. Report of the Expert Consultation, Harare, Zimbabwe, 16-23 November. Rome.
FAO. 1993. Guidelines for participatory nutrition projects. Rome.
FAO. 1995a. The vitamin A programme. Fifth summary progress report, 1993-1994. Rome.
FAO. 1995b. Follow-up to the International Conference on Nutrition (ICN) Plan of Action. In Report of the 13th session of the Committee on Agriculture. 27-31 March. Rome.
McNaughton, J. 1975. Applied nutrition programmes - the past as a guide for the future. Food Nutr., 1(3): 17-23.
Depuis les années 50, la FAO s'emploie, par ses programmes de nutrition centrés sur la communauté, à améliorer l'état nutritionnel des familles rurales en les éduquant et en appuyant les efforts qu'elles font pour cultiver et utiliser les produits nécessaires à l'amélioration de leur régime alimentaire. Si les objectifs fondamentaux des programmes actuels sont analogues à ceux des initiatives antérieures, les stratégies et les démarches diffèrent cependant.
Le Programme de nutrition appliquée (PNA), mis en uvre de la fin des années 50 jusqu'au milieu des années 70, était exécuté par la FAO, l'OMS et l'UNICEF. Les projets réalisés dans ce cadre favorisaient la création de potagers familiaux et le petit élevage domestique tout en dispensant une éducation nutritionnelle et en fournissant une alimentation complémentaire. L'approche intégrée retenue pour le Programme nécessitait une coopération entre différents ministères clés - agriculture, santé, éducation, affaires sociales, développement rural - et entre les organismes des Nations Unies. En dépit d'un bilan mitigé, le Programme amena toutefois les responsables a s'intéresser à la nutrition appliquée et l'on en vint à considérer l'amélioration de la nutrition comme un aspect important du développement rural.
Le Programme «Vitamine A», qui représente la contribution de la FAO au Programme d'action décennal des Nations Unies pour le contrôle et la prévention de la carence en vitamine A, de la xérophtalmie et de la cécité nutritionnelle (1985-1995), visait à inciter les communautés rurales à produire et consommer davantage de produits riches en vitamine A et en carotène. A la différence du PNA, ce programme entendait améliorer directement la nutrition au sein d'une collectivité en mettant l'accent sur un problème spécifique. Les projets pilotes étaient par ailleurs pleinement intégrés aux plans élaborés par les gouvernements en matière de nutrition et de développement. Actuellement, la FAO adopte une démarche fondée sur des considérations alimentaires plus larges pour atténuer les carences en plusieurs micronutriments et améliorer la nutrition globale.
A la fin des années 70, on a pris conscience du rôle spécial que jouent les femmes dans la production, la transformation, la préparation et la distribution des aliments: dans ses projets, la FAO a donc commencé à mettre l'accent sur les moyens d'assurer aux femmes un meilleur accès au crédit et aux services de vulgarisation agricole pour leur permettre de produire une plus grande diversité d'aliments et d'augmenter leurs revenus. L'importance que revêtent les aliments traditionnels comme moyen d'élargir la base alimentaire, et de garantir un niveau minimum de disponibilités alimentaires, a suscité un intérêt à partir des années 80 et cette question bénéficie maintenant d'une attention accrue.
Aujourd'hui, la FAO plaide pour la participation active de l'ensemble des membres de la communauté aux projets de nutrition et pour l'intégration des programmes de nutrition communautaire dans les initiatives nationales. Les plans d'action nationaux pour la nutrition, élaborés par chaque pays après la Conférence internationale sur la nutrition en 1992, orienteront la conception et l'exécution des programmes de nutrition communautaire que la FAO mettra en oeuvre à l'avenir.
Desde los años cincuenta, los programas de la FAO para la nutrición de comunidades han tratado de mejorar el estado nutricional mediante la educación de las familias rurales y apoyando sus esfuerzos encaminados a producir y consumir los alimentos necesarios para mejorar su alimentación. Aunque los objetivos básicos de los programas actuales son semejantes a los de las iniciativas anteriores, las estrategias y los enfoques son diferentes.
A partir de finales de los años cincuenta y hasta mediados de los años setenta la FAO, la OMS y el UNICEF llevaron a cabo el programa de nutrición aplicada (PNA). Los proyectos del PNA promovieron los huertos familiares y la cría de pequeños animales y facilitaron la educación nutricional y la alimentación suplementaria. El PNA adopta un enfoque integral que requería la colaboración entre algunos ministerios clave como los de agricultura, salud, educación asuntos sociales y desarrollo rural, así como de organismos de las Naciones Unidas. Si bien las repercusiones del PNA fueron variadas, el programa mismo despertó el interés de las autoridades responsables por la nutrición aplicada y la mejora de la nutrición llegó a considerarse un componente importante del desarrollo rural.
El Programa de la Vitamina A se ejecutó como una contribución de la FAO al Programa decenal de apoyo a países en el sector de la prevención y control de la carencia de vitamina A y de la ceguera de origen nutricional (1985-1995) para promover el aumento de la producción y asegurar un consumo mayor de vitamina A y de alimentos ricos en caroteno en las comunidades rurales. A diferencia del PNA, este programa se concentró en un problema concreto como forma directa de mejorar la nutrición en una comunidad, y los proyectos experimentales se integraron plenamente en los planes gubernamentales de nutrición y desarrollo. Actualmente, la FAO está adoptando un enfoque más amplio basado en la alimentación para aliviar algunas deficiencias de micronutrientes y mejorar la nutrición general.
Al final de los años setenta se reconoció la función especial de la mujer en la producción, elaboración, preparación y distribución de los alimentos, y los proyectos de la FAO empezaron a hacer hincapié en mejorar el acceso a los créditos y prestar servicios de extensión a las mujeres para que mejoraran la variedad de los alimentos que producían y aumentaran los ingresos. El interés por los alimentos tradicionales como un medio para ampliar la base alimentaria y asegurar un nivel mínimo de suministros alimentarios comenzó en los años ochenta y crece cada vez más.
Actualmente la FAO propicia la plena participación de los miembros de las comunidades en los proyectos nutricionales y la inclusión en las actividades nacionales de los programas de nutrición para comunidades. Los planes nacionales de acción para la nutrición, elaborados en cada país después de la Conferencia Internacional sobre Nutrición de 1992, servirán de orientación para el diseño y la ejecución de los programas de la FAO para la nutrición de comunidades en el futuro.