IMPROVING NUTRITION PROGRAMMES

AN ASSESSMENT TOOL FOR ACTION

(REVISED EDITION)

Suraiya Ismail
Maarten Immink
Guy Nantel

For further information, contact Guy Nantel
Nutrition Planning, Assessment and Evaluation Service
Food and Nutrition Division
FAO, Viale delle Terme di Caracalla, 00100 Rome, Italy
Tel: (39) 06 5705 2028; Fax: (39) 06 5705 4593
E-mail: guy.nantel@fao.org.

Food and Agriculture Organization of the United Nations
Rome, Italy, 2005

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E-ISBN: 978-92-5-108504-2 (MOBI)

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© FAO 2005

TABLE OF CONTENTS

ACKNOWLEDGEMENT

FOREWORD

INTRODUCTION

BACKGROUND

METHODOLOGICAL GUIDE

Section    I: Assessing Programme Design

1.Assessing programme relevance

2.Assessing programme targeting

3.Assessing programme interventions

4.Assessing community activities

5.Assessing the effectiveness of community mobilizers

6.Assessing programme management

7.Assessing programme monitoring and evaluation

8.Assessing programme linkages

9.Summarizing the assessment of programme design and action

Section  II: Assessing the Macroenvironment

1.Assessing the macropolicy environment

2.Assessing the degree of intersectoral collaboration

3.Assessing the level of Government’s resource commitment to nutrition

4.Assessing the role and contribution of the international community

5.Assessing the adequacy of national technical expertise

6.Summarizing the assessment of the macroenvironment and action

Section III: Assessing the Microenvironment

1.Assessing the extent of diversity in the programme area

2.Assessing the local food economy

3.Assessing levels of community development

4.Assessing access to basic services and technical expertise

5.Assessing the adequacy of local development structures

6.Summarizing the assessment of the microenvironment and action

Section IV: Assessing Sustainability

1.Assessing programme resources

2.Assessing programme ownership

3.Assessing the programme’s ability to respond to future felt needs

4.Summarizing the assessment of sustainability and action

Conclusion

Annex 1:Summary report

Annex 2:Further reading and how to get help

Annex 3:An example of a conceptual framework

Annex 4:Methods

ACKNOWLEDGEMENT

FAO gratefully acknowledges permission to reproduce material used in Annex 4 of this document.

Reproduced by permission of Macmillan, Oxford

“Partners in Planning. Information, Participation and Empowerment”
Susan B. Rifkin and Pat Pridmore, Macmillan Education Ltd., 2001
© Copyright text Susan B. Rifkin and Pat Pridmore, 2001

FOREWORD

This Assessment Tool (AT) represents a milestone in the continuous involvement and experience of FAO in assisting Member Countries in developing community-based food and nutrition programmes. There is an increasing recognition of the need to engage target communities in the process of nutrition programme planning and implementation. FAO believes that it is important to strengthen these programmes on the understanding that nutritional status is the most important outcome indicator to measure progress against poverty and undernutrition.

In this context, FAO started the process that has led to the development of this AT with the preparation of a methodological framework to guide the review and analysis of existing programmes as in-depth case studies. Nine case studies were selected and the reporting process defined at a technical consultation held in Rome in October 2001. The field work was carried out and subsequently analysed to prepare an integrated report. The methodology for the AT was developed based on the lessons learned from these case studies.

The purpose of this AT is to contribute to strengthening community-based food and nutrition programmes. The ultimate objective of the AT is to help the users launch and develop a process to strengthen their country’s ability to address the causes of malnutrition. It is generally agreed that we need to address not only the immediate causes of malnutrition, but also their underlying factors if we are to achieve nutritional well-being and reach functional and productive capacity of a population.

The methodology is divided into four sections covering programme design, the macroenvironment, the microenvironment, and sustainability. The AT is used for making suggestions for action following the assessment. Anticipated users are normally food and nutrition programme planners, but any number of individuals with planning and programmatic responsibility who are concerned about poverty alleviation and overall development can, and should be, part of the Assessment Team.

The AT includes those important aspects of programme design having a significant impact on programme performance. Ultimately all nutrition programmes must aim to improve nutritional status. This improvement must be the primary objective of any comprehensive, national food and nutrition programme and it must also be measurable using accepted indicators. Thus, all objectives need to be specific, measurable, achievable, relevant and time-bound (SMART). Assessing the extent of community participation is essential because it is a key prerequisite for empowerment and sustainability. Participation ranges from passive to self-mobilization. A useful method for assessing it is to measure participation in five key areas: needs assessment, leadership, organization, resource mobilization and management. An interesting methodology exists for this, making use of a ‘spidergram’, and instructions on its use are included in Annex 4.

The term macroenvironment refers to those specific factors which indicate the degree of commitment of a country to a particular issue. It is recognized that a supportive and enabling macroenvironment is essential to the success of a programme and guidance is provided on how to assess the characteristics of a country’s environment.

In assessing the microenvironment, examples are shown to illustrate the risks of adopting a uniquely top-down approach. It is stressed that what is needed is an approach that makes available good-quality services but, at the same time, accommodates local conditions and priorities, since this linking or interfacing of top to bottom is crucial to the ultimate success of a community-based nutrition programme.

Many of the factors assessed in Sections I, II and III have implications for sustainability. This is an important albeit complex issue which can be defined as the ability to maintain the momentum of those programme activities with a positive impact, once that programme has achieved its objectives. Issues that need to be addressed include programme resources, ownership and the programme’s ability to respond to future needs.

After having completed the detailed assessment of a programme, it is suggested that users list most urgent actions, then group, rationalize and prioritize them. Major groups of actions are likely to relate to improving political commitment and public awareness, implementing a programme of human resource development and capacity building, raising the level of community participation and improving programme design.

It is hoped that the use of the AT will stimulate the development of a mindset to continuously seek to improve the effectiveness of support for community-based activities that reduce hunger and malnutrition and alleviate poverty. Hopefully it will not be used for a one-time exercise only. The AT should lead to the strengthening of the process which results in community-based activities characterized by a significant degree of self-reliance with household and community empowerment. This process, once it is in place, can also be used for furthering economic development. The time and resources invested in a process of this nature is an essential first step in building a solid foundation upon which a healthy and equitable economic growth can take place.

Kraisid Tontisirin
Director
Food and Nutrition Division

INTRODUCTION

A strong recommendation of the 1992 FAO/WHO International Conference on Nutrition was that each country should develop and implement a national plan of action on nutrition. Most countries now undertake a range of nutrition activities to tackle their nutrition problems. In some cases, these activities form a cohesive national nutrition programme. In other cases, nutrition problems are tackled through a number of focused nutrition projects or programmes, addressing one or more specific nutrition problems, geographic areas or vulnerable groups. Many countries also have externally-funded programmes of varying dimensions and scope.

The nutritional well-being of a population is both an outcome and an indicator of national development. The achievement of national goals depends upon it.

Reducing food insecurity and improving nutrition have recently acquired importance within the context of poverty reduction strategies. We are seeing now an increased scrutiny by donors (and national governments) on the progressive realization of access to food and good nutrition as a human right. Such an environment makes it imperative that food and nutrition programmes succeed and that success is sustained. This is why countries need to undertake assessments of their programmes, to improve outcomes, cost-effectiveness, efficiency and sustainability.

The purpose of this assessment tool is to contribute to strengthening community-based food and nutrition programmes. It is based on a clear, step-by-step analysis of the programme’s design and its macro and microenvironments, bearing in mind the programme’s likely sustainability.

Use of the tool for nutrition programme assessment is expected to contribute to strengthening macro-micro linkages for the purpose of policy formulation and resource allocation, to forging partnerships and alliances between government, civil society and the private commercial sector and to encourage participatory development within the context of decentralized administrative structures.

The assessment tool is perhaps best suited for longer programmes, of at least two years’ duration. It is ideal for continuous national nutrition programmes which allow time for regular assessments and programme revisions.

The tool makes suggestions for action following assessment.

The suggestions are necessarily limited in scope and specificity because any remedial action must be considered in the national context and will vary from one situation to the next. The assessment itself will suggest ways in which the programme’s effectiveness can be improved and, hence, its impact on the nutritional status of its target population.

Assessments can be undertaken at different points in the life of a programme. After completing the first assessment, we recommend that you set a date for the next assessment, allowing time for the actions suggested by the first assessment to be implemented and to be effective. Situations and conditions change, and by undertaking regular assessments, you will ensure that the programme accommodates and responds to these changes.

If you are beginning the process of designing a new programme, we urge you to read the assessment tool so as to ensure that the programme’s design incorporates the essential elements needed for it to have a positive impact.

The tool is intended for use by nutrition programme planners, but in collaboration with a number of key people: it is not intended for use by an individual, but rather by an Assessment Team.

A point that needs to be clear also is that it is not a tool for programme evaluation. While there may be some overlap with evaluation, in the area of programme design features, assessment is much broader than evaluation: it examines also the macro and microenvironment within which the programme functions and assesses likely sustainability.

The tool makes every effort to present the methodology of programme assessment in a straightforward and concise way, and in as user-friendly a fashion as possible.

Programme assessment is a complex procedure and over-simplification can lead to errors in conclusions reached and omission of key information. Assessment is not a rapid exercise: it entails numerous discussions and meetings, examination of documents, field visits and observation. But the process itself, as well the ultimate findings, should prove illuminating and will not only serve to improve the nutritional impact of the programme under consideration, but will also lead to better programme planning in the future. Programme assessment should be seen as a continuous and participatory process: it is not a one-off event. But having completed the first assessment, subsequent assessments will prove much easier.

The nature and causes of nutrition problems differ from country to country, as do political, economic and sociocultural environments. Moreover, within a country there may be regional differences. No single assessment tool can accommodate all these differences. Not all the questions this assessment tool asks you to answer will be appropriate for your programme and your country and there may be some other questions that should be asked. We urge you to add or remove questions where necessary. You may also want to prioritize the questions to reflect the particular circumstances of your country or programme. This process of “customizing” the tool is an important part of the assessment process.

The ultimate objective of the tool is to help you launch and develop a process to strengthen your country’s ability to address the causes of malnutrition, a complex process that encompasses the promotion of communities’ capacity for self-reliance on the one hand, and real political commitment and support on the other. Nutrition serves as an entry point and nutritional status as the chief indicator that is able to show insufficient or inadequate progress in meeting basic physiological needs, as the first step towards development. To achieve nutritional well-being and full functional and productive capacity in a population, we need to address not simply the immediate causes of malnutrition, namely an inadequate diet and high morbidity, but also their underlying and basic factors. This is illustrated in the conceptual framework provided in Annex 3.

BACKGROUND

Community-based food and nutrition programmes have been implemented in many countries. They have in common nutrition or nutrition-related objectives, be it the broad objectives of reducing the prevalence of malnutrition or improving household food security, or more specific objectives related to a single micronutrient or a single nutrition activity such as the promotion of breastfeeding. There are now a number of successful programmes, and a close examination and analysis of these can help us to understand the process of achieving success.

There have been a number of studies (ACC/SCN, 1996; Iannotti and Gillespie, 2002; Mason et al, 2001) of national and subnational nutrition programmes. These have examined how macrolevel economic growth and social investment factors contribute to downward trends in the prevalence of child undernutrition. Key factors that were identified based on these country studies include poverty-alleviating and equitable growth strategies and increasing levels of investment in health and education. The information from these studies does not permit a detailed assessment of community-level factors though, in general, community involvement, participation, ownership and empowerment seem strongly related to effective community-based food and nutrition programmes.

In recent years, there has been an increasing recognition of the need to engage target communities in the process of nutrition programme planning and implementation. Almost by definition, most nutrition programmes are ‘community-based’, but the community participation approach, in its true anthropological sense, is not necessarily implicit in this label. There appears to be a mixed understanding of the term community participation: interpretations range from informing people what is to be done in their communities, through requiring their participation in pre-defined activities, to involving communities in their own situation analysis, decision-making and planning.

Equally important is the macroenvironment within which the programme finds itself. Although external to the programme, it is acknowledged that it has a major impact on the programme’s functioning, level of achievement and sustainability. Of primary importance is the recognition, at the highest national level, of nutritional well-being as both an outcome and an indicator of national development, and the acceptance of nutritional status to monitor the extent to which the basic needs of a population are being met. The term sustainability is frequently used, often with little appreciation of its meaning, or its implications for programme design.

It is against this background that FAO initiated the process that has led to the development of this Nutrition Programme Assessment Tool. The process began with the preparation of a methodological framework to guide the review and analysis of programmes as in-depth case studies. At a workshop held in Rome in October, 2001, the framework was reviewed and revised, the case studies selected, and the process defined and agreed upon. Following the workshop, the in-depth case studies were undertaken and subsequently analysed together to form the basis of the companion volume to this Assessment Tool: “Community based food and nutrition programmes: what makes them successful. A review and analysis of experience” (FAO, 2003). This integrated report of the nine in-depth case studies (and three desk reviews) provides key background reading for users of the Assessment Tool. Much of the methodology developed for the Assessment Tool is based on the lessons learned, strengths and weaknesses of nutrition programmes as illustrated in the case studies and which are brought together and analysed in FAO’s integrated report.

The draft version of the Nutrition Programme Assessment Tool was discussed at a user’s workshop held in June 2002 in Cape Town, South Africa, and modifications were made in line with the recommendations of the workshop. The modified version was piloted prior to finalization and publication as this final version. FAO would appreciate receiving your comments and suggestions for improving the Tool, based on your practical experience of using it. Such input would be invaluable in the preparation of further revised editions. Comments can be sent to the address provided in Annex 2 (see “Some Useful Information”), which can also be used if you seek assistance.

METHODOLOGICAL GUIDE

The assessment methodology should be viewed as a continuous and participatory process. It is based on seeking answers to questions through discussions with key informants, an examination of documents, as well as field visits and observation. There will be many questions that you cannot answer; this must not prevent you from undertaking the assessment.

Take a pragmatic approach: do the best you can with the resources you have. The key point is that you have started the process.

The following step-by-step guide will help you to carry out the assessment.

Step 1: Preparing for the assessment

a) Essential reading

To begin, you need firstly to undertake some essential background reading: this Tool itself should be read thoroughly, as well as its companion volume “Community-based food and nutrition: what makes them successful. A review and analysis of experience” (FAO, 2003)[1]. A list of recommended reading is provided in Annex 2 which also gives details of how you can obtain the essential texts. If you are unfamiliar with the methodology of community participation, we urge you to read at least “Partners in Planning” by S. Rifkin and P. Pridmore (2001).

FAO, in collaboration with the University of the Western Cape’s School of Public Health, Cape Town, South Africa, has prepared a Users’ Training Manual to assist in the preparation of the Assessment Team members. This is an important consideration since they may not all be familiar with some of the nutrition concepts being used in this tool. Furthermore, it is in the interest of an effective assessment to be able to draw upon individual team members who do not have formal nutrition training. This can make an important contribution towards the building of an effective intersectoral process for nutrition improvement. The training can be adapted to varying levels of knowledge and to the amount of time available. The Users’ Training Manual, together with the Assessment Tool, will constitute valuable resources for all those involved in programme assessment.

b) Forming the Assessment Team

You need to form an Assessment Team. Ideally, the Team should comprise the following 10 to 15 people, as appropriate to your programme:

- A senior government nutritionist;

- Senior representatives of relevant sectors: essential sectors are Agriculture and Health, but other recommended sectors are Education, Rural Development or Community Development, and Planning. Representatives should come from their sectoral planning departments or from whichever department has collaborative links with the country’s nutrition unit and/or the programme you are assessing;

- A representative from an international agency with an interest in nutrition;

- A representative from a leading non-governmental organization that is engaged in nutrition activities;

- A representative from the nutrition department of a research and training institution (e.g. university), if this exists;

- A social scientist;

- The director or manager of the programme to be assessed;

- One or more representatives of provincial, municipal or district development communities that are in the geographical catchment area of the programme;

- One or more representatives of communities participating in the programme (community mobilizers and/or community leaders).

Remember that this is the ideal team. If you cannot form such an extensive, high-calibre team, then settle for a more modest one, with a minimum of two people.

If your first assessment has been successful, you may be able to expand the team for future assessments. The specific composition of your Assessment Team should be guided by the size, resources and nature of the programme you are assessing. We recognize that it may not be easy to bring together such a complete team and to ask many individuals to devote considerable time and energy to the assessment. It will be especially hard to achieve if nutrition is not well recognized in the country as a part of national development, or if good intersectoral collaboration for nutritional improvement has not yet been achieved.

c) Identifying key informants and essential documentation

The Assessment Team, however complete, will not be able to answer all the questions for the assessment. Working with your Team, go through the four sections of the Assessment Tool to identify the key individuals who can give you the answers. You need such key informants from all levels: national, subnational, programme and community levels. Community leaders and field programme staff can be especially helpful: they can provide a perspective that cannot be provided by national-level personnel.

Necessary documentation should be gathered: as a minimum you will need the programme document and any reports or evaluations that the programme has produced. You should seek evidence that supportive national policies have not simply been signed but have also been implemented. To assess the nature of the nutrition problems, and hence whether the programme has addressed these, you should look for surveys and other reports that cover the programme area. Also important is evidence of programme-led community-based activities, such as community action plans.

d) Developing a plan of work

The Assessment Team needs to agree on a schedule of meetings, a time frame for the assessment, responsibilities, and a plan of work. The Assessment Tool asks you to read many documents, hold many discussions and focus group meetings and to conduct many field visits. To rationalize these, you need to study the Assessment Tool carefully to determine all the information you can gather during the course of any one exercise, so as to avoid having, for example, to return repeatedly to communities or consult the same key informants again and again. A well-planned schedule and plan of work will simplify the methodology and save considerably on time and effort.

Step 2: Assessing the nutrition programme

a) Getting started

An excellent way to start the process of assessment is to draw up a problem tree[2]. The Assessment Team should do this as a participatory exercise: it will help focus the thoughts and ideas of the Team members and help everyone to understand the nature of the nutritional problems in the programme area and the constraints to improvements in nutritional status. If your programme covers different agro-ecological zones with different food security and nutritional profiles, you will need to develop more than one problem tree.

b) Working through the assessment sections

The methodology is divided into four sections:

Section I:

Assessing programme design

Section II:

Assessing the macroenvironment

Section III:

Assessing the microenvironment

Section IV:

Assessing sustainability

Overlap between sections in the information you are asked to gather is inevitable, but it is also useful as you will be looking at the information from different perspectives. After constructing the problem tree(s), start working through each section, attempting to answer the questions in each section. Save a copy of your problem tree so that you may go back to it as often as necessary in order not to lose the view of the bigger picture of the issues that you are trying to address. Not all questions will necessarily be relevant to your programme. You may also like to add questions specific to your programme. Use your key informants, documents and field visits to answer the questions.

c) Completing the summary report

Once you have completed a section, you need to summarize the information you have gathered. A summary helps you to organize your findings and pinpoint weaknesses that need to be addressed, but any summary necessarily tends to simplify what is in reality a complex situation. You have gathered a wealth of information which will be useful to guide action. Through discussions, the Assessment Team should agree on the three most important issues that have emerged within each subcomponent of that section. Use the Summary Report form provided in Annex 1 to guide your discussions, then complete the form. This procedure should be repeated after each of the four sections.

d) Conducting SWOC analyses[3]

Using your Summary Report as a guide, undertake a SWOC analysis for each section of the assessment: list the main strengths, weaknesses, opportunities and constraints identified. Decisions should be based on reaching consensus within the Assessment Team. Keep the lists you have compiled: they are essential for guiding action.

e) Preparing the assessment report

Once you have worked through all four sections, completed the Summary Report and SWOC analyses, prepare the Assessment Team’s report. The issues identified in the summary will form an excellent basis for the report’s executive summary.

Step 3: Planning action

It is time now to move to action. Each section ends with some suggestions for actions related to that section. Use these suggestions and the SWOC analyses to decide:

- Which ‘strengths’ you want to ensure are retained;

- Which ‘weaknesses’ need attention;

- What opportunities you have identified to strengthen the programme and other nutrition activities in the country and how you can seize these opportunities;

- How you can minimize constraints and threats;

- Appropriate actions to address the above issues. If there are many, you might need to compile a priority list or to group actions.

Prepare a plan of action (with targets and deadlines) to improve the community-based nutrition programme. Attach this plan to the Assessment Report and circulate the report to relevant government ministries and departments, programme management staff and other key actors in programme implementation. Then begin to implement the plan.

The Assessment Team needs also to decide when it will re-assess the programme. The Assessment Team’s report, the completed checklist, the SWOC analyses and the plan of action are all important as baseline documents for the re-assessment.

A final note

You have started an important process and it is important to remember that it is a process, not a one-off event or a checklist to complete. It is a process of reflection and investigation that will give you a deeper understanding of how your programme functions and how its impact could be enhanced. Be practical; do the best you can with the resources you have. The first assessment may well be incomplete and less than perfect. This should not deter you. What is important is that you have started the process.

SECTION I: ASSESSING PROGRAMME DESIGN

Assessing ……

- Programme design

- The macro-environment

- The micro-environment

- Sustainability

We begin with an examination of the programme itself. This section focuses on those important aspects of programme design that have been found to have a significant impact on programme performance. You are asked to examine the programme design to assess the following:

- programme relevance;

- programme targeting;

- programme interventions;

- community activities;

- community mobilizers;

- programme management;

- programme monitoring and evaluation;

- programme linkages.

1)Assessing programme relevance

Assessing Programme Design

- Programme relevance

- Programme targeting

- Programme interventions

- Community activities

- Community mobilizers

- Programme management

- Monitoring and evaluation

- Programme linkages

To assess programme relevance, you need to discover whether:

a)causes of malnutrition were investigated, and

b)whether the programme’s objectives address the identified causes.

Ideally you need to talk to the persons who formulated the programme, or at least to senior programme staff, and examine the programme document and relevant files.

Broad causes of malnutrition such as ‘poor diet’ are not especially helpful: you need to know in what way the diet is poor. You also need to know why the diet is poor. Answers to these questions should have guided the nature of the interventions undertaken by the programme.

Planning the programme (problem analysis, selection and design of interventions) should have taken place in a participatory fashion, working closely with the programme’s target communities. If it did not, not only are errors in analysis and design more probable, but also the target communities are unlikely to have any sense of ownership or involvement.

Ultimately all nutrition programmes must aim to improve nutritional status (reduce wasting, stunting, obesity or micronutrient deficiencies, as appropriate) and this improvement must be measurable using accepted indicators, such as anthropometric status and/or biochemical indicators of micronutrient status. Improving nutritional status must be the primary goal or objective of any comprehensive, national nutrition programme. All objectives need to be relevant, specific, measurable, realistic and time-bound[4]. It is against its objectives that a programme’s success or failure is evaluated.

Many smaller or focused programmes set objectives that relate only to one or a few of the impediments to improving nutritional status. For example, a programme may aim to improve nutritional knowledge. This is an intermediate objective, addressing one impediment to improving nutritional status. Improving nutrition knowledge will only lead to better nutritional status[5] if it is accompanied by, for example, improved child feeding practices, better access to food, and activities to reduce morbidity, as appropriate. The primary objective of improving nutritional status must therefore be accompanied by a set of intermediate objectives that address the specific causes of malnutrition in the programme’s catchment area.

A nutrition programme will benefit by setting also objectives relating to community participation, improving the macro and microenvironment, and building capacity. Setting such objectives will ensure that these important issues are not forgotten during the implementation of the programme.

Here are the questions you need to answer to assess the programme’s relevance:

•Was any form of problem analysis undertaken before the programme was designed? If so, is there evidence that a participatory approach was used for the problem analysis? How specific are the causes of malnutrition identified by the problem analysis?

•Does the programme have clear, realistic, relevant, measurable and time-bound objectives? Are there objectives relating to:

-Nutrition? If so, do they address the causes of malnutrition identified in the problem analysis?

-Community participation?

-Improving the macro and microenvironment?

-Capacity building?

2)Assessing programme targeting

Assessing Programme Design

- Programme relevance

- Programme targeting

- Programme interventions

- Community activities

- Community mobilizers

- Programme management

- Monitoring and evaluation

- Programme linkages

Targeting is a mechanism to ensure that the programme reaches only those beneficiaries for whom it is intended. Good targeting can reduce costs because resources are not wasted on beneficiaries who do not need the programme interventions.

Targeting can take the form of geographical targeting (to depressed areas, or areas with particular agricultural or climatic problems), of socio-economic targeting (to low income areas of cities, or to households that fall below a specified poverty line, poor elderly people or landless households), or of vulnerable group targeting (to weaning-aged children, single mothers or elderly people for example).

If the programme is targeted to specific beneficiaries, you need to find out if the programme is failing to reach the intended beneficiaries (undercoverage), or if it is including beneficiaries who do not meet the selection criteria (leakage):

•Are programme activities targeted to specific households, communities or areas? If so, what are the criteria for inclusion in the programme?

•If the programme is targeted, is the system working? Is the programme reaching all the intended beneficiaries? Are beneficiaries included who do not meet the selection criteria?

On targeting

“Targeting can take various forms: geographic targeting, such as found in the Kenya project (arid and semi-arid lands) or the Honduras project (focus on an area with a specific environmental problem); vulnerable area targeting (targeting to areas where the density of poor communities is high); or socioeconomic targeting (selection of households below a poverty line, such as found in the Samurdhi programme). In the Mexico programme a more elaborate dual form of targeting was employed: vulnerable area targeting to select programme localities, then socio-economic targeting to select participating households.

Good targeting can save resources, on the other hand elaborate screening procedures entail unnecessary bureaucracy and high administrative costs (for example, the case of Mexico). They are also open to political manipulation ......... and corruption.”

Quote from FAO’s in-depth study of nine programmes (2003).

3)Assessing programme interventions

Assessing Programme Design

- Programme relevance

- Programme targeting

- Programme interventions

- Community activities

- Community mobilizers

- Programme management

- Monitoring and evaluation

- Programme linkages

Programme interventions must address the causes of malnutrition identified by the problem analysis. They need to meet the objectives of the programme, within the specified time-frame, and be as cost-effective as possible, bearing in mind issues of equity. Costs borne by the communities, in terms of both material resources and time, must be considered. You should consider too that the most cost-effective programme is not necessarily the most sustainable, nor is a programme that is cost-effective in the short-term, necessarily cost-effective in the longer term. Consider a clinic-based vitamin A supplementation programme, for example, in comparison with a food-based approach that attempts to improve consumption of vitamin A rich foods. The supplementation programme will be more cost-effective in the short term, but the food-based approach will not only be more sustainable, but in the long run may prove less costly[6].

There is now a considerable body of literature on experiences of nutrition interventions worldwide. This presents an excellent resource and should be consulted at the programme formulation stage, to help select the most appropriate and cost-effective programme design. Interventions must not only address the causes of malnutrition in the programme area, they must also be based on the most up-to-date scientific knowledge (see footnote 30), they must engage all appropriate sectors and they must take into account local resources, conditions, food availability and cultural practices.

You should check that the interventions undertaken by the programme do not contradict the services that are offered to the communities. An example of this would be a programme that distributed infant formula, while the local health center attempts to promote breastfeeding. The programme should reinforce rather than undermine the activities of the local health and agricultural authorities, provided these are indeed appropriate.

No programme will meet its objectives if the quantity and intensity of resources allocated are inadequate. Here are some examples:

-A one-off short course to improve nutrition knowledge is unlikely to be sufficient to change behaviour: it needs re-enforcement.

-Community mobilizers or health workers with too many families to cover cannot provide the intensive support needed to achieve change.

-Micronutrient supplementation or food supplementation needs to be provided at a sufficiently high level to achieve the intended improvement in nutritional status.

-Agricultural extension workers need to visit farmers frequently to improve food production.

To assess the appropriateness and adequacy of programme interventions, obtain answers to the following questions:

•Were appropriate interventions selected and implemented?

•Are the interventions in line with the basic nutrition services offered in the programme area?

•Are the programme’s resources sufficient to achieve its objectives?

4)Assessing community activities

Assessing Programme Design

- Programme relevance

- Programme targeting

- Programme interventions

- Community activities

- Community mobilizers

- Programme management

- Monitoring and evaluation

- Programme linkages

This subcomponent asks you to assess the extent of community participation, whether staff have been adequately trained in the participatory approach and how it has been used and supported in the implementation of community activities.

Community participation in nutrition programmes is now accepted as a key prerequisite for success and sustainability. The aim of the participatory approach is to assist communities to become more self-reliant, with the capacity to analyse their own food and nutrition situation, identify their needs, plan activities to address these needs, secure funding and technical expertise, and implement and manage the activities. Achieving a fully participatory approach, whereby communities have a true sense of ownership of the programme, demands considerable investment of time and resources. However, once achieved, it can be maintained at little cost to the programme, provided that communities continue to have access to adequate basic services (health, nutrition, agricultural extension services, for example), technical expertise to help in their selection and design of activities, and funding support for their activities.

On community participation

“A community-based nutrition programme is not necessarily one that employs a participatory approach. Most people-oriented programmes today will naturally mention community involvement in some form ..... However, few community-based nutrition programmes are truly participatory in nature, engaging communities in decision-making and the selection of activities to answer their felt needs.”

Quoted in FAO’s in-depth study of nine programmes (2003).

Participation ranges from passive participation to full community mobilization. To assess the degree to which the programme has achieved a participatory approach, you are asked firstly to assess where in this range the target communities of your programme fall. Secondly, you are asked to assess whether programme staff are adequately trained in the participatory approach.

Harnessing local cultural practices and knowledge

FAO’s in-depth study of nine programmes (2003) found that:

Communities possess a wealth of knowledge and experiences that can be harnessed to become a part of the programme. In Honduras, the project was in fact built around a soil conservation technique developed in the village of Quesungual. Communities that have lived with food insecurity have developed a number of coping strategies to improve their chances of survival. Many of these can be retained and supported. Local cultural practices, such as Zunde raMambo in Zimbabwe, offer entry points and strategies that are more acceptable to communities than unfamiliar, externally-imposed strategies. In Kenya the tradition of women’s groups and regular community meetings was used by the project to encourage participation.

Visit a representative range of communities, observe community meetings in progress and have discussions with community leaders and community members. Make sure you meet the most vulnerable members of the community, to assess the extent of input they have had in decision-making.

Ask the following questions:

- Does the programme work with active, representative community action groups? Community groups should meet regularly, have well-defined plans, priorities and activities. They should include representation from all sections of the community and women must be active members.

- Is the programme-building capacity in the community? What training has been provided and what skills have been acquired (e.g. management, conducting meetings, planning)? What additional training needs are there?

- Do communities have access to funding and technical advice for their identified projects/activities?

- Has the programme made use of appropriate cultural practices?

Then situate the communities within the following range:

Another method of assessing the extent of community participation is to measure participation in five key areas: needs assessment, leadership, organization, resource mobilization, and management. To do this we suggest you use the ‘spidergram’ approach described in S. Rifkin and P. Pridmore: “Partners in Planning” (see Annex 2 for full reference). Details of how to use this method are reproduced in Annex 4.

Now organize a few focus group discussions with programme staff from different levels and different regions covered by the programme, to ask the following questions:

- Do you think communities can identify their own needs, and plan and implement activities to meet their needs? If not, why not?

- What training have you received in the participatory approach?

- What additional training do you feel you need?

Based on your observations and discussions, you should begin to have a good idea of the programme staff’s perceptions of community participation. This information will help you decide whether additional training is needed.

You should now be able to answer the following questions:

•What is the level of participation achieved by the programme?

•How adequate was the training in community participation received by programme staff and their understanding of the approach?

•Has the programme encouraged community organization, self-reliance and empowerment?

5)Assessing the effectiveness of community mobilizers

Assessing Programme Design

- Programme relevance

- Programme targeting

- Programme interventions

- Community activities

- Community mobilizers

- Programme management

- Monitoring and evaluation

- Programme linkages

Community mobilizers[7] are an essential part of any project that employs a participatory approach. Some are paid by the programme, by local authorities or by the communities themselves. Others are volunteers, generally serving their own community only. Paid mobilizers are often responsible for a number of communities. Some programmes also have supervisors who monitor the work of a number of mobilizers or volunteers. Whatever the system, community workers, whether paid or unpaid, play a crucial role in community development and programme delivery. The success or failure of the programme relies heavily on their performance. Unfortunately, their selection, training and supervision are often given scant attention. Broadly, mobilizers must have strong technical support and supervision, but must also be accountable to the community they serve.

Another aspect that needs attention is the career aspirations and expectations of community workers. We tend to assume that having identified and recruited the workers, they will be willing to undertake the same work for the same pay for an indefinite period of time. Inevitably, dissatisfaction sets in and work performance falls off.

A method to identify community mobilizers

“[In Thailand] ...... mobilizers are identified and recruited as a result of a sociogram process, where the individual members of a cluster or neighbourhood in a community are asked whom, among their neighbours, they find trustworthy, someone that they tend to consult when they need advice about a particular problem. These individuals can be recruited to act as “resource” persons for their 10 or so households*. These volunteers have a relationship of trust with the households, so that their involvement in addressing problems of nutrition is an extension of their natural disposition.

Quote from G. Nantel and K. Tontisirin (2002).

*The optimum ratio of households to mobilizer will vary according to local conditions.

There are ways around this: a basic career and salary structure, training opportunities, regular feedback to highlight achievements, public recognition and awards[8], and additional responsibilities. Field visits for observation are essential to assess their role and effectiveness, as well as focus group discussions with a sample of community groups and discussions with mobilizers and with supervisors, if these exist. Here are the questions that need to be answered:

•Have mobilizers received any training in community participatory methods? In leadership and group dynamics? Are they effective in the communities?

•Is there a system of accountability? If so, to whom are mobilizers accountable and does the system work?

•Can they help communities secure funding for their selected activities? Do they know when and where to seek technical expertise[9]?

•Is their workload manageable? Are they well supervised? Do they receive any feedback on their performance?

•How are they rewarded? Are they paid? If so, by whom[10]? Is there any system of social recognition or motivation?

•Are there opportunities for advancement? Is there a programme of workshops or further training opportunities, when they can also interact with other mobilizers?

“A key constraint in the project’s performance towards attaining its objectives has been the great shortage of community support staff with appropriate training and skills and the lack of institutions able to facilitate and sustain the development processes required…. This has meant that not only the community action planning process, but also project-supported activities in the agriculture and health/nutrition sectors, have been poorly conducted….”

Quoted in FAO’s case study of Zambia’s project (Muehlhoff, 2001).

6)Assessing programme management

Assessing Programme Design

- Programme relevance

- Programme targeting

- Programme interventions

- Community activities

- Community mobilizers

- Programme management

- Monitoring and evaluation

- Programme linkages

Management problems beset a surprising number of programmes. FAO’s in-depth study of nine programmes (2003) highlights the following:

- poor supervision and quality control;

- poor staff motivation;

- excessive control over community leadership;

- absence of feasibility studies for income-generating activities, leading to failure and disappointment;

- failure to fund community activities;

- operational difficulties with credit schemes;

- delays in the release of funding and resources;

- no feedback to communities or programme staff;

- political interference in selection of programme staff and beneficiaries;

- overly elaborate management structures leading to excessive bureaucracy.

The challenge with good management is to establish a structure that promotes transparency, that defines roles and responsibilities clearly, that permits quick response and limits bureaucratic formalities but that at the same time is able to check misuse of programme resources. Perhaps one of the most important features of good management is the ability to maintain a committed and motivated staff. For this, frequent feedback is needed and a recognition of achievement and good performance.

Through an examination of programme reports and discussions with programme staff at all levels, answer the following questions:

•Is there an adequate management system? Is support and supervision adequate?

•Is the staff committed and motivated? Are there well-defined roles, job descriptions and lines of responsibility?

•Does the programme demonstrate financial transparency? Are programme resources well-utilized and monitored?

•Has management training been provided at all levels?

7)Assessing programme monitoring and evaluation

Assessing Programme Design

- Programme relevance

- Programme targeting

- Programme interventions

- Community activities

- Community mobilizers

- Programme management

- Monitoring and evaluation

- Programme linkages

All programme planners agree that monitoring and evaluation is an essential component of good programme design. Yet few programmes make provision for adequate monitoring and evaluation. Monitoring and evaluation should be viewed as an integral part of the programme design. Monitoring and evaluation should therefore be:

- included in the programme design;

- designed at the start of the programme with advice from a statistician and epidemiologist;

- funded within the programme budget.

Monitoring and evaluation can be divided into three parts:

a)monitoring (a process management tool);

b)evaluation (to measure programme performance and impact);

c)participatory monitoring (community-based, for the community’s use).

The literature on monitoring and evaluation is extensive. Two such publications are included in the reference list in Annex 2 (IADB 1997, ACC/SCN 2001).

a) Monitoring

Monitoring is the periodic and routine collection of information throughout the life of the programme to determine whether programme delivery is proceeding smoothly. It is first and foremost a management tool for programme staff, but also provides essential information to understand and explain the results of programme evaluation. As a management tool, it answers questions such as:

- Are programme inputs delivered on time, inputs such as equipment, supplements, funds and training exercises? If not, why not?

- Is coverage of intended programme participants good? This includes, for example, attendance at antenatal clinics or growth monitoring and promotion (GMP) sessions. If not, why not?

- Are community mobilization activities proceeding on schedule? Have community groups been established, do they meet regularly, have they developed action plans, are they implementing activities? If not, why not?

Information should also be recorded on external events that can affect programme impact. This includes events such as drought or floods, civil disorder, the state of roads and bridges. As a management tool, there are two other important aspects of programme monitoring:

- There must be a system of rapid response to identified problems;

- There must be a system of information flow.

b) Evaluation

Evaluation attempts to determine and document, as systematically and as objectively as possible, the relevance, effectiveness and impact of a programme in the light of its objectives. Appropriate indicators[11] must be identified, an epidemiologist must contribute to evaluation design and a statistician to data analysis. Both qualitative and quantitative information are important components of a good evaluation system.

c) Participatory monitoring

The information provided by a programme’s monitoring and evaluation system is largely of little interest to communities. What they need is a system to monitor their own progress towards achieving their own specific developmental goals. For this, it is recommended that community groups be encouraged to establish a simple system of participatory monitoring that relates closely to their own identified priorities and activities. Examples of simple community monitoring tools include:

- a chart showing the growth of community children;

- a community map showing, for example, which households have built latrines, established kitchen gardens or participated in credit schemes;

- the community action plan indicating the status of activities.

To decide if the programme has an adequate monitoring and evaluation system, answer the following questions:

•Does the programme have an adequately-funded monitoring and evaluation system?

•Are monitoring reports scrutinized? Is feedback provided to programme staff?

•Is there evidence of timely response to monitoring information on bottlenecks and other operational problems?

•Has statistical and epidemiological advice been sought in the design of the evaluation system?

•Are the indicators in line with the programme’s objectives? Has evaluation been implemented as scheduled?

•Does the evaluation data allow assessment of programme impact?

•Have the communities designed and implemented a participatory monitoring system that relates to their specific development priorities[12]?

•Do community members understand and use the information it provides?

8)Assessing programme linkages

Assessing Programme Design

- Programme relevance

- Programme targeting

- Programme interventions

- Community activities

- Community mobilizers

- Programme management

- Monitoring and evaluation

- Programme linkages

No programme can function well in isolation. Linkages with subnational authorities are essential to its eventual institutionalization. Linkages with other programmes and the establishment of useful partnerships can enrich a programme substantially and make it more cost-effective. You are asked here to seek information in order to answer the following questions:

•Has the programme established good working relations with subnational authorities, bodies or committees?

•Does the programme have collaborative linkages with other relevant programmes?

•Has the programme established useful partnerships? Partnerships[13] with nongovernmental organizations, the private sector and with research and training institutions are important to access technical expertise and supplementary funding, especially funding for community activities.

9)Summarizing the assessment of programme design and action

You now have the information you need to make an assessment of the programme design. Turn now to the Summary Report provided in Annex 1, and answer the questions in Section I. Then carry out a SWOC analysis.

Programme effectiveness or the extent to which your programme is able to improve nutritional status in the area covered by the programme will be seriously undermined if your programme design is flawed. If you judge the programme design to be poor, then you need to consider whether the programme is worth continuing, and whether you should not rather formulate a new programme. In any event, you will need to discuss your options with the programme funders, especially if the programme is externally funded.

If you have identified some weaknesses, you can take any or all of the following actions, as appropriate:

i)

Re-formulate programme objectives to make them relevant, achievable and measurable;

ii)

Develop the necessary conceptual frameworks to ensure that your programme addresses the causes of malnutrition in the different areas covered by the programme;

iii)

Consider targeting, or improve the system for targeting, as appropriate;

iv)

Examine alternative programme designs to see if any are more cost-effective and appropriate for your situation;

v)

Strengthen community participation by providing additional training to all staff and by addressing ways and means of enhancing the effectiveness of community mobilizers;

vi)

Find ways to motivate community mobilizers. Discuss with them how you can improve their job satisfaction: the problems they face in their jobs, their career aspirations, their response to the ideas of social recognition schemes and additional training opportunities;

vii)

Establish clear guidelines for community-level activities, covering the following aspects: identifying suitable community action groups, building community capacity, helping communities access technical expertise and funding sources, encouraging inter-community collaboration and the use of appropriate cultural practices;

viii)

Introduce a system of monitoring and evaluation, and secure funding for it, or re-design the existing one. Establish a system of information flows and use the information for programme management;

ix)

Address identified weaknesses in programme management: simplify if necessary; discuss job descriptions, responsibilities, career structures and recognition of achievements with staff and modify as needed; provide (additional) training in management to supervisors;

x)

Improve relations with local authorities; establish or strengthen links and partnerships with other programmes, non-governmental organizations, the private sector and research and training institutions, as appropriate.

FAO’s in-depth study found a number of strengths, weaknesses, opportunities and constraints in the nine programmes it examined:

Strengths:

high level of community involvement;

well-trained and committed community workers;

effective and appropriate community activities;

appropriate use of local tradition and culture;

well targeted (socio-economic or geographic targeting);

good programme management;

good monitoring and evaluation system;

feedback to communities, recognition of achievements, motivation of communities and community workers;

Weaknesses:

political interference in targeting of programme activities;

operational problems and delays;

limited community participation;

poor community capacity development, or some leaders not used to full potential;

some inadequate or inappropriate community activities;

lack of conceptual framework, leading to root causes of malnutrition not being addressed, short-term interventions and curative rather than preventive approach;

no clear objectives;

weak monitoring and evaluation system;

poor management.

Opportunities:

planned strengthening of community involvement and capacity building;

planned change of programme offers opportunities for improvement.

Constraints (and threats):

political interference in programme operations (targeting; staff selection);

delays due to government bureaucracy, leading to operational problems;

programme expansion leading to inadequate supervision and poor quality control;

failure to secure funding for community activities leading to disillusionment;

excessive programme control over community leadership; limited flexibility.

SECTION II: ASSESSING THE MACROENVIRONMENT

Assessing ……

- Programme design

- The macro-environment

- The micro-environment

- Sustainability

No programme exists in a vacuum. It is rooted in a country where conditions prevail that will affect the functioning and achievements of that programme. Such conditions include the socio-economic situation, the distribution of wealth and level of development (including the level of literacy and the condition of women), political ideology, culture, degree of diversity in terms of agro-ecological zones, climatic conditions and ethnicity. These provide the background within which the programme must function and which it must take into account if it is to be successful.

We use the term “macroenvironment” to refer to those specific factors which indicate the degree of commitment of that country to a particular issue, in this case to the improvement of the nutritional well-being of its people.

The macroenvironment: some lessons learned

FAO’s in-depth study of nine programmes (2003) indicated that the following are important elements of a supportive macroenvironment:

- A strong policy environment that recognizes, at the highest level, nutritional well-being as an essential indicator of national development;

- Active intersectoral collaboration, involving all relevant sectors;

- A significant financial commitment to nutrition by the government;

- Strong partnerships with international agencies, non-governmental organizations, and the private sector;

- High-quality research and training institutions and technical expertise.

A supportive and enabling macroenvironment is essential to the success of a programme. A government and a population that recognizes the importance of food security and good nutrition and accepts nutritional well-being as a key indicator of national development provides such an environment. The reality, however, is that few countries can boast of a fully supportive macroenvironment. Working towards creating it thus becomes a responsibility of the programme itself. To decide what you need to do to achieve a supportive macroenvironment, you need first to identify and assess the strengths and deficiencies of the environment in your country. This includes assessing the following:

- macropolicy environment;

- degree of intersectoral collaboration;

- level of government’s resource commitment to nutrition;

- role and contribution of the international community;

- adequacy of national technical expertise.

1)Assessing the macropolicy environment

Assessing the Macroenvironment

- Macropolicy

- Intersectoral collaboration

- Resource commitment

- International community

- Technical expertise

A number of supportive national policies are needed to ensure that nutrition issues are adequately addressed. As a minimum, the country should have a well-formulated food and nutrition policy (and a national plan of action for nutrition), a poverty alleviation strategy and a rural (and/or urban, as appropriate) development strategy.

Furthermore, over the last few decades there have been a number of international position statements, often linked to international conferences and signed by most countries. Among those relevant to nutrition, the following are important:

- International Declaration on the Rights of the Child (from 1959)

- Alma Ata Declaration on Health for All by the Year 2000 (1978)

- Code of Marketing of Breast Milk Substitutes (1981)

- Nutrition Goals of the World Summit for Children (1990)

- Baby-Friendly Hospital Initiative (1991)

- World Declaration and Plan of Action for Nutrition, International Conference on Nutrition, (1992)

- Rome Declaration on World Food Security and World Food Summit Plan of Action (1996 and 2002)

“Thailand’s experience has indicated that policy decisions which bring about deliberate actions are often in response to political concerns, public opinion and awareness.”

Quoted from: Winichagoon et al (1992).

By signing international declarations and by formulating relevant policies, the country has taken the first step towards political commitment to improving nutrition. You need to assess the extent to which the government has acted to implement its stated commitment:

- Has improving access to food been explicitly recognized as a government priority within a poverty alleviation strategy?

- Has a national food and nutrition policy been endorsed by government? Is there a national plan of action for nutrition with targets and to what extent are these targets being met?

- Does legislation exist that limits the advertising of breast milk substitutes and how is it enforced?

- Have any public hospitals achieved ‘baby-friendly’ status? Is there a programme to make all public hospitals ‘baby-friendly’?

What you are asked to do here is to find tangible evidence of progress towards achieving stated goals. Such ‘evidence-based’ assessment is crucial. Good intentions and political rhetoric are not enough.

You need to determine who has ultimate responsibility for the political commitments implicit in the international declarations and initiatives which the government has signed. Ask the question: who oversees progress towards achieving stated goals? If no high-level government official or ministry has this task, then the likelihood is high that political commitment to improving nutrition is inadequate.

To assess the macropolicy environment, answer the following questions through discussions with key informants, observation and by examining documents.

•What supportive policies, strategies and initiatives are in existence to address, directly or indirectly, food security and nutrition issues?

•Is your country a signatory to major relevant international declarations, initiatives and codes?

•To what extent are these political ‘commitments’ actively implemented?

•At what level are the commitments implemented and monitored? At the Ministerial level, the Head of State level, or by a senior ministry such as the Ministry of Planning?

2)Assessing the degree of intersectoral collaboration

Assessing the Macroenvironment

- Macropolicy

- Intersectoral collaboration

- Resource commitment

- International community

- Technical expertise

Nutrition is a cross-cutting issue. To achieve nutrition improvement, active collaboration is needed from a range of sectors, such as health, agriculture, education, trade, as well as within sectors. For such action to take place, there needs to be an effective mechanism for collaboration and a recognition of nutrition as an essential indicator of national development reflected in sectoral priorities. Collaboration with the civil society, non-governmental organizations, international agencies and research institutions is also important. Food and nutrition councils or committees exist in many countries, but few are effective or active. If participation is insufficiently broad, or if sectoral representation is insufficiently high, then nutrition is not viewed as a priority.

There is an assumption on the part of some sectors that nutrition will somehow improve as a result of their plans and programmes and that no specific attention to nutrition is needed. Agriculture, for example, may assume that by increasing national food production, household food security will improve and, hence, nutritional status. Experience has shown that explicitly stated nutrition outcomes are needed in order to ensure a positive impact on nutritional status. This is true also of other sectors. As a minimum, you should assess the health and agriculture sectors.

Answers to the following questions will help to assess the extent of intersectoral collaboration at the national level:

•Is there a mechanism (a food and nutrition committee or council, for example) for intersectoral collaboration in nutrition? If yes:

- What is its mandate?

- Which ministries participate and at what level (minister, permanent secretary, head of department, other)?

- Is the non-governmental sector represented?

- Does it meet regularly and is attendance good?

- Does it have a permanent secretariat? And a budget?

- Has the committee influenced national decision-making?

•Are nutrition outcomes included in sectoral policies and programmes?

Achieving intersectoral collaboration

Effective intersectoral collaboration is difficult to achieve. Two essential preconditions are the acceptance at the highest level of nutritional well-being as an indicator of national development, and the recognition of the need for an integrated approach to tackling nutrition problems.

- Thailand achieved intersectoral collaboration by means of a long and aggressive public and political awareness campaign: it harnessed public opinion and lobbied key government officials to achieve recognition of the importance of good nutrition.

- Zimbabwe took a different approach: through its Community Food and Nutrition Programme, intersectoral collaboration was achieved at the district level first. Recognition of achievements in nutrition then enabled it to extend collaboration upwards, with the creation of the National Food and Nutrition Council.

- Mexico has achieved a measure of collaboration through its poverty alleviation programme, PROGRESA, which brings together the health, nutrition and education sectors.

3)Assessing the level of government’s resource commitment to nutrition

Assessing the Macroenvironment

- Macropolicy

- Intersectoral collaboration

- Resource commitment

- International community

- Technical expertise

If the nutritional well-being of its population is indeed considered a key goal and indicator of a country’s development, then there should be evidence of this in the form of a budget devoted to nutrition activities.

Most countries provide some funding to nutrition activities, to support a few staff positions and a very limited number of activities. What is important is not the absolute amount of government funding for nutrition, but the proportion this represents of the national budget, or at least of the sectoral budget of which it is a part, and how this proportion compares with the proportion devoted to other key activities. These figures can be obtained from the Ministry of Finance or from the ministry that houses the nutrition unit[14]. You need to consider also whether funding for nutrition is included in budgets of other sectors or units e.g. agriculture may fund relevant food-based activities, clinic-based nutrition services may be provided by the maternal and child health unit, and information, education and communication (IEC) activities by the health promotion unit.

Is national funding important, or should we rely on external support?

Some quotes from FAO’s in-depth study of nine programmes (2003):

“The Governments of the Philippines and Zimbabwe and, to a large extent, Brazil have shown a clear commitment in this regard, and national funding has been made available and sustained for many years. In these countries, the supportive macropolicy environment is translated into a tangible investment in nutrition.”

“There is a danger in such reliance [on external funding]: …political events can lead to the withdrawal of donor support. There is also the danger of donor-fatigue: simply put, the donor’s decision that it is time to move on to something else or somewhere else.”

You should try to answer the following question:

•Does the government provide adequate funding for the provision of basic nutrition services?

4)Assessing the role and contribution of the international community

Assessing the Macroenvironment

- Macropolicy

- Intersectoral collaboration

- Resource commitment

- International community

- Technical expertise

International, bilateral and non-governmental agencies can make important contributions to improving nutrition in a country: by raising the profile of nutrition, lobbying national governments, by demonstrating their own commitment to nutrition through investment in nutrition programmes and by making available technical expertise.

In some cases, however, there is a tendency for the international community to impose its own priorities and to support only those activities which fall within such priorities. In some cases too there is a lack of coordination among the agencies, leading to both overlaps and gaps in the range of nutrition issues addressed and the absence of an integrated approach to tackling nutrition problems. In recent years, there has been an attempt to resolve these difficulties by creating a coordinating committee that brings together all agencies with an interest in nutrition.

Look at your programme to see how and why it came into being. Through discussions and an examination of documents, you should find out who made the decisions, who chose the specific nutrition activities and why these were selected. You should also seek to determine whether priority national nutrition problems are being addressed, and if not, why not.

To assess the role and contribution of the international community, answer the following questions:

•Is there a coordinating committee[15] and, if so, what is its membership, how regularly does it meet and what decisions does it take?

•Are nationals (nutritionists and other) members of the coordinating committee and, if so, what positions do they hold in government?

•What is the real contribution of nationals to decision-making?

•If no active committee exists, how does the international community decide what nutrition activities to support? Is there evidence of donor-driven decision-making? Can nationals influence decision-making and secure support for activities that they have assessed as priorities?

5)Assessing the adequacy of national technical expertise

Assessing the Macroenvironment

- Macropolicy

- Intersectoral collaboration

- Resource commitment

- International community

- Technical expertise

A precondition for the success of a nutrition programme is the availability of high-quality technical expertise. If such national expertise does not exist, funders provide international experts but, unless there is a serious effort to build capacity, the programme’s sustainability will be in doubt and the country will consistently fail to achieve self-reliance. The country’s ability to successfully negotiate for support for its own priorities will also be severely constrained.

To create (and replenish) a body of national technical expertise to run its programmes, a country needs at least one of the following:

- a high-quality national research and training institution capable of providing training to the postgraduate level; or,

- access to such an institution within the region[16]; or,

- a funded programme of human resource development and in-service training to upgrade staff. Such programmes often exist within World Bank loan agreements.

Ultimately a country should seek to establish a national institution, or participate fully in a regional one. In addition to training, such institutions provide excellent support to nutrition programmes: they can undertake small research studies within programmes to answer specific questions and can also assume responsibility for its monitoring and evaluation. They can also assume some responsibility for maintaining a focus and momentum for action on nutrition issues.

The importance of national research and training institutions

FAO’s in-depth study of nine programmes (2003) revealed that those of Mexico, Thailand and the Philippines benefited from close collaboration with strong national research and training institutions. These institutions provided programme staff, training inputs and technical advice, as well as undertaking small research activities within the programmes. In the case of Mexico, programme evaluation was contracted out to a research institution, with the result that this programme can provide strong evidence of its positive impact on nutritional status.

You can assess the adequacy of national technical expertise by answering the following questions:

•If there has been a recent human resource needs assessment for nutrition, what were its findings and is there any effort to fill identified gaps?

•Is there any intention to replace international experts with nationals and, to this end, is training (both external and on-the-job) foreseen within the programme?

•Are well-trained nutritionists employed at national and subnational levels[17]?

•Is there a national research and training institute (or does the country have access to one in the region)? Does the institution provide training in nutrition to the postgraduate level? Does it have an active programme of research?

•Is there a funded programme of human resource development for nutrition? If so, does this programme encompass training at all levels? Is it being actively implemented and are suitable positions available to employ returning graduates?

6)Summarizing the assessment of the macroenvironment and action

You should now have the information you need to make an assessment of the macroenvironment within which the nutrition programme functions. Turn to the Summary Report (Annex 1) and answer the questions in Section II. Then carry out a SWOC analysis.

Your programme will be most effective in a fully supportive macroenvironment. If you assess the macroenvironment in your country to be insufficiently supportive (in any or all of the key subcomponents), then you need to take one or more of the following actions:

i)Design and implement a high-profile campaign to create public and political awareness, using all means at your disposal. The emphasis of the campaign should be on food security and nutritional well-being as outcome indicators of national development and of access to an adequate diet as a human right[18].
Here are some ideas for the campaign:

- Use the media (radio, television and newspapers) to highlight the importance of good nutrition, the negative consequences of malnutrition and the weaknesses identified in your assessment;

- Lobby key politicians, spokespersons and public opinion leaders to gain political support and a voice in government;

- Secure the support of the international community to lobby for nutrition and to invest in nutrition;

- Publicize figures on the prevalence of malnutrition, nationally and in depressed areas and for vulnerable groups[19];

- Lobby for action on declarations, codes and initiatives which the government has signed; if appropriate, publicize the government’s failure to follow through on the promises implicit in their acceptance of such commitments;

- Establish strategic partnerships with the private sector and universities.

ii)

Include specific activities (such as components of the campaign described above) within the nutrition programme you are assessing. This is possible if you have judged your overall environment to be supportive, but have identified a few weaknesses that can be addressed within the nutrition programme.

iii)

If intersectoral collaboration is poor, you can seek to establish such collaboration first at the district or community level. This is often easier to achieve than collaboration at the national level. If you then implement the campaign described above, it may be possible to extend intersectoral collaboration upwards to the national level in the future.

iv)

If the adequacy of suitably-trained human resources is a constraint, then you need either to address this within the nutrition programme[20] or secure funding[21] for a programme of human resource development. You should also establish strong working relations with national or regional research and training institutions. Such links are of mutual benefit, since they serve also to strengthen the institutions. Finally, draw up a schedule to replace international staff with trained nationals in your programme.

FAO’s in-depth study of nine programmes (2003) highlighted the following strengths, weaknesses, opportunities and constraints in relation to the macroenvironment:

Strengths:

has achieved good advocacy, sensitization, awareness-raising;

benefits from a supportive policy environment and/or funding commitment from government;

employs integrated and multisectoral approach, has achieved intersectoral collaboration;

strong partnerships with national training and research institutions leading to good technical support.

Weaknesses:

weak advocacy component of programme;

weak intersectoral collaboration and links with other development activities or programmes;

top-down approach;

welfare rather than development approach.

Opportunities:

increased national awareness and recognition of nutrition problems can lead to more and improved nutrition actions;

positive experience with collaboration and partnerships can lead to better intersectoral collaboration, new partnerships.

Constraints (and threats):

political instability, civil disorder;

economic decline;

climatic problems.

SECTION III: ASSESSING THE MICROENVIRONMENT

Assessing ……

- Programme design

- The macro-environment

- The micro-environment

- Sustainability

In addition to the macroenvironment, a community-based nutrition programme will be strongly influenced by factors and conditions that prevail at subnational levels. There is no clear line that can be drawn between the macrolevel and the microlevel. Arguably, the community represents the microlevel, 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[22]. Events and policies at the national levels will influence situations at the microlevel, but their impact will be modified by conditions that prevail at the microlevel.

Is the microenvironment important?

Multisectoral strategies are needed [to combat malnutrition], but developing such a strategy to address all sources of the problem in traditional top-down fashion is almost impossible because of its complexity. The alternative is to bring in the beneficiaries to participate by helping them devise their own solutions, while making use of their resources to the largest extent possible.

From: G. Nantel and K.Tontisirin (2002).

“Progress has been made where community-based programs are linked operationally to service delivery structures.”

“Community-government partnerships need to be forged through broad-based social mobilization and communication strategies.”

Quotes from: K.Tontisirin and S. Gillespie (1999).

Here are some examples of how the microenvironment 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 microenvironment by assessing:

- the extent of diversity in the programme area[23];

- 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 in the programme area

Assessing the Microenvironment

- Diversity

- Local food economy

- Community development

- Access to basic services and expertise

- Local development structures

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 subnational (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 I: 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?

On diversity

“Some of the constraints faced [by Thailand’s programme] include …... lack of accessibility to basic services in remote/border areas, migration of minority hill tribes, drought in some areas of northeast Thailand and limited accessibility of mass media to the rural communities.”

Quoted in: Community-based nutrition programmes – Thailand Case Study by L. Battacharjee (FAO, 2001).

2)Assessing the local food economy

Assessing the Microenvironment

- Diversity

- Local food economy

- Community development

- Access to basic services and expertise

- Local development structures

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) are all factors that determine household economic activities and thus a household’s access to food. An important distinction is between urban and rural food economies, with usually much greater market-dependence of household income and food access in urban areas. Diversity in livelihood strategies by households are found within regions or areas, as well as in household food security outcomes and in the degree of vulnerability to food insecurity that households face. 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 have a negative 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 differing importance.

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[24]. 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, Famine Early Warning Systems Network of the US Agency for International Development, Cooperative for Assistance and Relief Everywhere, and/or the Vulnerability Analysis and Mapping Unit of the World Food Programme.

In relation to programme target households, answer 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 available to some groups or the whole population?

- 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 intrahousehold 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?

3)Assessing levels of community development

Assessing the Microenvironment

- Diversity

- Local food economy

- Community development

- Access to basic services and expertise

- Local development structures

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.

By means of key informant interviews and focus group discussions, gain an understanding of the nature of communities in your programme’s catchment area. Specifically, answer the following questions:

•What conditions exist in programme communities that may limit the success of programme interventions?

•How has the programme sought to accommodate these conditions?

4)Assessing access to basic services and technical expertise

Assessing the Microenvironment

- Diversity

- Local food economy

- Community development

- Access to basic services and expertise

- Local development structures

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-quality 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.

“Community participation should not be viewed as a way out of unsuccessful nutrition programmes. Communities will continue to need access to services provided by government, non-governmental organizations, the private sector or other agencies and institutions ...... As the example of Thailand has shown us, we must link the top with the bottom.”

Quoted in FAO’s in-depth study of nine programmes (2003).

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 subnational levels, obtain the following basic information for health and agricultural services[25]:

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[26] that should be provided are:

- growth monitoring and promotion (GMP)[27];

- 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, 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[28]?

- Do mothers understand problems of growth faltering and receive dietary advice[29]? 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 recipes and complementary foods available and utilized?

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 subnational 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. Access to such expertise at the level it is most needed, however, has proved a weakness of many community-based nutrition programmes. It has led to inappropriate and ill-conceived food production and nutrition[30] 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.

Making the assumption that programme-funded expertise will not be available once the programme ends, you need to obtain the following information:

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

- Are all these positions filled? If so, are these nutritionists adequately trained? If not, what additional training is needed? Is there a mechanism to ensure that these nutritionists can access 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 non-governmental organizations 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?[31] Has adequate training been provided to these volunteers, or are there unmet training needs? If so, what are they?

The information you have gathered should help you to decide not only the adequacy of expertise today, but to what extent it is likely to be adequate in the future. This will thus help you in your assessment of sustainability (Section IV: Assessing Sustainability). Your findings will also help you answer the two key questions:

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

•Is good technical expertise available at the local level?

5)Assessing the adequacy of local development structures

Assessing the Microenvironment

- Diversity

- Local food economy

- Community development

- Access to basic services and expertise

- 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[32]. 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 subnational levels? Which are closest to community development?

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

•How do communities identify and communicate their needs?

•Does the programme work in collaboration with any local development committees?

•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 microenvironment and action

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

Not all aspects of the microenvironment can be addressed within the nutrition programme. In some cases you must advocate for change at the national or subnational 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 microenvironment:

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

- If 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[33] 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 subnational levels. As a short term measure, the programme should provide the expertise. Provide training in community participation. Establish partnerships with relevant non-governmental organizations 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, preferably health or agriculture, at the lowest level. 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 (2003):

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.

SECTION IV: ASSESSING SUSTAINABILITY

Assessing ……

- Programme design

- The macro-environment

- The micro-environment

- Sustainability

Sustainability is a complex issue. Are we concerned about the sustainability of the programme or of its achievements? In broad terms, sustainability can be defined as the ability to maintain the positive impact of a programme, once that programme has achieved its objectives. But maintenance of the positive impact may not be all that you want to do. If, for example, your programme has achieved its objective of reducing malnutrition by 20 percent, you may want to achieve a further 20 percent reduction in the future. Maintenance of the positive impact of a programme, or making further improvements, can be achieved in a variety of ways:

- Continue the programme: a national nutrition programme, for example, is not a one-off activity, but should be a continuing commitment.

- Institutionalize components of the programme in sectoral activities.

- Design, fund and implement a new programme: if the programme you are assessing is focused on a specific nutrition problem, you might want to take a broader, more holistic approach in a new programme.

We suggest the Assessment Team devote a session to discussing the issue of sustainability, not simply in programme terms, but also in terms of maintaining and further improving the nutritional well-being of the population, namely setting the foundations for good nutrition in generations to come.

Achieving sustainability: some alternatives

FAO’s in-depth study of nine programmes (2003) gives these examples:

“Mexico’s PROGRESA programme aims to break the cycle of poverty, .... [to] .... allow development to take place. If.......the programme achieves its aim, arguably then the sustainability of the programme itself is not an issue. It will have served its purpose of ‘jumpstarting’ the development process, and support to this process would then need a different approach. Along similar lines, Sri Lanka’s Samurdhi programme sees itself as a transition from a welfare approach to a development approach. If the transition is successful, the programme will have done its job. Honduras’ PROLESUR programme, on the other hand, focuses on a transfer of technology..... It has clearly succeeded in transferring the technologies, and these appear now to be institutionalized and hence sustainable.....”

A key element of success, perhaps the most important one, is real political commitment to achieving the nutritional well-being of the population, and a recognition of nutrition as both an input to and an outcome indicator of national development. Political instability or a new government can threaten the sustainability of this commitment, but if public opinion has been harnessed, then the chances of maintaining commitment are enhanced.

Many of the factors you have been assessing in Sections I, II and III have implications for sustainability. A supportive macroenvironment, the availability of good technical expertise, communities’ access to adequate basic services and a high level of participation are all examples of factors that will promote sustainability. In this section, we bring together some outstanding issues that you need to address. These are:

- assessing programme resources;

- assessing programme ownership;

- assessing the programme’s ability to respond to future felt needs.

1)Assessing programme resources

Assessing Sustainability

- Programme resources

- Programme ownership

- Ability to respond to future felt needs

A programme draws upon a number of resources: financial and human resources as well as logistic support. Funding itself is a vexed issue. Few national nutrition budgets are adequate to cover the real needs of nutrition activities in the country. Even if they represent a respectable proportion of the national budget, the actual amount may be too small, especially in a poor country where the prevalence of malnutrition is likely to be highest. Securing external funding therefore becomes an essential part of funding arrangements. In some very poor countries, reliance on external funding is high and will continue so for the foreseeable future. But whatever the need for external funding, you need to be sure that there is in place a schedule for progressive handing over of the funding to the national government, however long-term this may be. Adequate human resources are often scarce in poor countries. If this is not addressed through an adequate programme of human resource development, then the programme will become unsustainable when external technical expertise is withdrawn.

As a part of its discussion on sustainability, the Assessment Team should address the following questions:

•Are funding arrangements sufficient to ensure sustainability of the programme and/or its achievements?

•If the programme receives external funding, is there a planned schedule of handing over of funding responsibility, and has it been adhered to? Or have other funding arrangements been made?

•Is funding provided by non-governmental organizations and by the communities? Do you assess that this is likely to continue?

•Is there a clear understanding, on the part of the donor(s) and government, that nutrition improvement programmes require long-term investment, most likely beyond one political mandate? If this was understood at the outset of the programme, then funding should have been secured for a long period (ten years or more is often recommended).

•Has the programme adequately addressed the issue of continued technical and logistic support?

2)Assessing programme ownership

Assessing Sustainability

- Programme resources

- Programme ownership

- Ability to respond to future felt needs

If your programme has taken an intersectoral approach as recommended, it may be possible to secure the sustainability of some components at least through the assumption of responsibility of these components by other sectors[34]. There will however be a continuing need for specific nutrition activities which must remain the responsibility of a nutrition unit in whichever ministry it is located. The programme, either as a whole or as its component parts, must become an accepted part of routine sectoral activities: it must seek to become ‘institutionalized’. Furthermore, its community base must become institutionalized within communities: if the participatory approach has been successful, communities should have a sense of ownership of the programme.

Based on all assessments thus far, the Assessment Team should discuss the following questions:

•Has the programme become institutionalized? If so, in which Ministry or organization?

•Have components been ‘adopted’ by relevant sectors? If so, are mechanisms in place to oversee implementation? Are these adequate?

•Do communities have a sense of ownership of the programme, such that they can insist on its continuation?

3)Assessing the programme’s ability to respond to future felt needs

Assessing Sustainability

- Programme resources

- Programme ownership

- Ability to respond to future felt needs

Future needs are often unpredictable. They may relate to emergencies, such as drought or civil unrest or to emerging disease conditions. A good nutrition programme should be able to respond to these needs, with or without external assistance: it should be seen as part of a country’s disaster preparedness plan. Other future needs relate to an increase in demand for basic services, as communities improve their health-seeking behaviour for example, or to a changing profile of nutrition in the country[35]. Programme flexibility is needed too, to accommodate events as diverse as increasing decentralization and new scientific knowledge and new technologies.

Responding to emergencies

“The [Honduras] project PROLESUR began in 1988 as an emergency programme in response to severe drought and food insecurity in the southern municipalities of the Department of Lempira.......... It is [now] 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...... 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.”

Quote from FAO’s in-depth study of nine programmes (2003).

Based on information gathered throughout the assessment exercise, the Assessment Team should discuss and answer the following questions:

•Are good basic services available, responsive to community needs?

•Can you be reasonably sure that future needs for basic services and technical expertise, in nutrition and related areas, can be met?

•Is the programme flexible enough to accommodate future events and changes in nutrition problems and priorities?

•Are plans in place to undertake future assessments?

“…if community participation is successful, demand for such services will rise and the insistence upon quality will also rise: better access to good health care and nutrition services, education, access to markets, safe water supply and good sanitation..… Community participation will fail if community demands and needs consistently remain unmet. The programmes of Brazil and Mexico mention the threat of increasingly unmet demand for services.”

Quoted in FAO’s in-depth study of nine programmes (2003).

4)Summarizing the assessment of sustainability and action

You now have gathered the information you need to make an assessment of sustainability. Turn now to the Summary Report provided in Annex 1, and answer the questions in Section IV. Then carry out a SWOC analysis.

Sustainability is an important issue: many accounts exist of programmes and projects whose achievements disappear once the programme ends. At best, they will have had an impact on one generation of the country’s children and at worst they represent wasted resources, external or national. You should now list all identified actions and see if there are any outstanding in view of the assessment of sustainability you have undertaken. One important action is setting a date for the next assessment.

Here are the strengths, weaknesses, opportunities and constraints in relation to sustainability, identified by FAO’s in-depth study of nine programmes (2003):

Strengths:

institutionalization of the programme (through demonstrated funding commitment, or ownership, or successful technology transfer);

programme’s long time-frame allows it to reach even the poorest communities.

Weaknesses:

excessive dependence on non-governmental organizations and/or external funding.

Opportunities:

integration of activities into sectoral plans and other development programmes;

planned government action to decentralize and improve land distribution;

development of new technologies can provide answers to community problems.

Constraints (and threats):

cessation of external funding;

change in political orientation;

successful community empowerment leading to unmet demand for services.

CONCLUSION

“Malnutrition is an impediment to development and its presence indicates that basic physiological needs have not been met. What is observed as malnutrition is not only the result of insufficient or inappropriate food, but also a consequence of other conditions, such as poor water supply and sanitation and a high prevalence of disease. Thus reversing the procedure is complex, because many issues need to be addressed more or less simultaneously, and every situation is different, so that there is no single solution for all. There can only be general guidance on directions to pursue. Experience from lessons learned shows that considerable time is needed to redress a situation (ten years and more), and that a strong supportive political and policy environment remains crucial throughout the period. There is no “quick-fix” to this problem. Once achieved, however, the effect is likely to become permanent, offering a substantial return on investment.”

Quote from FAO’s in-depth study of nine programmes (2003).

You have now completed the assessment of your programme. In the process, we have asked you to assess many factors outside the programme but which can have an impact on the success and sustainability of the programme. You should have been considering and deciding on the actions you need to take to correct the weaknesses you have identified, as you worked through each section. We suggest now that you list, prioritize, rationalize and group the actions. Major action groups are likely to relate to:

- improving political commitment and public awareness;

- implementing a programme of human resource development and capacity building;

- raising the level of community participation;

- programme design modifications.

Now prepare and implement a plan of action to improve the community-based nutrition programme. Finally, set a date to conduct a re-assessment. Re-assessment will be much easier: you will have already gathered much of the needed information and you will have this assessment’s report, the completed Summary Report, the results of the SWOC analyses and your plan of action as baseline documents.

ANNEX 1

SUMMARY REPORT

SUMMARY REPORT

You are asked to identify the THREE most important issues that relate to each of the questions or statements below. Each question relates to a subcomponent of one of the four sections (the numbering system is identical to that used in the text of the Assessment Tool). The Assessment Team should discuss the questions and agree on which are the three most important issues or responses by reaching a consensus within the Team.

SECTION I: ASSESSING PROGRAMME DESIGN

1)Assessing programme relevance

Describe the three most important issues with regard to the adequacy and relevance of the programme’s objectives.

a)

b)

c)

2)Assessing programme targeting

If your programme is targeted, identify three ways by which you could improve the targeting system. If the programme is not targeted, identify three forms of targeting that could be used and state how these could reduce programme costs.

a)

b)

c)

3)Assessing programme interventions

Identify three ways to improve the appropriateness and effectiveness of programme interventions.

a)

b)

c)

4)Assessing community activities

Has the programme achieved, or is it working towards achieving, real community participation? If yes, list the programme’s three main strengths in relation to community participation. If not, identify the programme’s three main constraints to implementation of the participatory approach.

a)

b)

c)

5)Assessing the effectiveness of community mobilizers

Identify three ways by which the performance of community mobilizers could be improved in the programme area.

a)

b)

c)

6)Assessing programme management

Describe the three most important management issues that have confronted the programme.

a)

b)

c)

7)Assessing programme monitoring and evaluation

Identify the three most important issues relating to the quality of the programme’s monitoring (including participatory monitoring) and evaluation system.

a)

b)

c)

8)Assessing programme linkages

Identify the three most supportive and useful partnerships that the programme has established, and describe briefly how they have influenced programme performance and impact.

a)

b)

c)

SECTION II: ASSESSING THE MACROENVIRONMENT

1)Assessing the macropolicy environment

You have identified which policies and strategies relevant to nutrition exist in your country, which of these are actively implemented and whether monitoring is adequate. Now identify which three would most strengthen the macropolicy environment if better implemented, or if better implemented, as appropriate. You should state briefly also how these policies could help your programme.

a)

b)

c)

2)Assessing the degree of intersectoral collaboration

Identify either the three greatest barriers to effective intersectoral collaboration in your country, or if you judge that such collaboration is effective, identify the three most important contributors to this success.

a)

b)

c)

3)Assessing the level of government’s resource commitment to nutrition

Identify the three most important constraints to increasing the resources for nutrition from the government.

a)

b)

c)

4)Assessing the role and contribution of the international community

Identify three ways by which the international community could improve its support to nutrition in your country.

a)

b)

c)

5)Assessing the adequacy of national technical expertise

Identify the three most important issues related to the adequacy of national technical expertise in nutrition, in your country.

a)

b)

c)

SECTION III: ASSESSING THE MICROENVIRONMENT

1)Assessing the extent of diversity in the programme area

Identify the three most important issues relating to diversity that the programme has not taken into account.

a)

b)

c)

2)Assessing the local food economy

Identify three ways in which the programme has accommodated or supported the local food economy.

a)

b)

c)

3)Assessing levels of community development

Describe briefly how the programme can address the three most significant constraints to community development in the programme area.

a)

b)

c)

4)Assessing access to basic services and technical expertise

Describe three ways in which the programme can improve, within its area, the quality of basic nutrition services and communities’ access to technical advice.

a)

b)

c)

5)Assessing the adequacy of local development structures

What local development structures exist in the programme area? Identify three important issues with regard to their involvement in the community base of the programme.

a)

b)

c)

SECTION IV: ASSESSING SUSTAINABILITY

1)Assessing programme resources

Which are the three most important resource constraints which may limit the programme’s sustainability?

a)

b)

c)

2)Assessing programme ownership

Has programme institutionalization been achieved? If yes, identify three reasons why this has occurred. If no, identify three reasons why it has not occurred.

a)

b)

c)

3)Assessing the programme’s ability to respond to future felt needs

How has the programme considered future needs and changing priorities?

a)

b)

c)

ANNEX 2

FURTHER READING AND HOW TO GET HELP

FURTHER READING AND HOW TO GET HELP

Essential

FAO. 2003. Community-based Food and Nutrition Programmes: what Makes Them Successful. A Review and Analysis of Experience. FAO, Rome.

FAO. 2004. Improving Nutrition Programmes: an Assessment Tool for Action. Users’ Training Manual. FAO, Rome.

Rifkin, S.B. and Pridmore, P. 2001. Partners in Planning. Macmillan, London.

Recommended

ACC/SCN. 1996. How Nutrition Improves. Nutrition Policy Paper no.15, Geneva.

ACC/SCN. 2001. What works? A Review of the Efficacy and Effectiveness of Nutrition Interventions by L. Allen and S. Gillespie. Nutrition Policy Paper no.19, Geneva.

Battacharjee, L. Community-based Nutrition Programmes: Thailand Case Study. Desk study. FAO, Rome, October 2001 (unpublished document).

Feuerstein, M. 1986. Partners in Evaluation. TALC, London.

IADB. 1997. Evaluation: A Management Tool for Improving Project Performance. Inter-American Development Bank, Evaluation Office (IADB/EVO), Washington, DC, USA.

Iannotti, L and Gillespie, S. 2002. Successful Community Nutrition Programming: Lessons Learned from Kenya, Tanzania and Uganda. The LINKAGES Project, Regional Center for Quality and Health Care and UNICEF, June, 2002.

Jewkes, R and Murcott, A. Meanings of Community. Soc. Sci. Med. 43(4): 555-563 (1996).

Mason, J, Hunt, J., Parker, D. and Jonsson, U. Improving Child Nutrition in Asia. Food and Nutrition Bulletin, 22(3):supplement (2001).

Muehlhoff, E. 2001. Improving Household Food Security and Nutrition in the Luapula Valley, Zambia. A case study based on the experiences of project GCP/ZAM/052/BEL – Improving Household Food Security and Nutrition in the Luapula Valley. FAO, Rome, December 2001 (unpublished document).

Nantel, G and Tontisirin, K. Policy and Sustainability Issues. Journal of Nutrition 132: 839S-844S (2002).

Rifkin, S., Muller, F. and Bichmann, W. Primary health care: On measuring participation. Soc. Sci. Med. 26(9): 931-940 (1988).

Sanghvi, T and Murray, J. 1997. Improving child health through nutrition: The nutrition Minimum Package. Arlington, Va.: BASICS Project, for the USAID.

Seaman J, Clarke, P, Boudreau, T and Holt, J. 2000. The Household Economy Approach. A Resource Manual for Practitioners (SCF Development Manual No. 6). London, United Kingdom.

Tontisirin, K and Gillespie, S. Linking community-based programs and service delivery for improving maternal and child nutrition. Asian Development Review, 1: 1-33 (1999).

Winichagoon, P., Y. Kachondam, G. Attig, & K. Tontisirin, 1992. Integrating Food and Nutrition into Development. Thailand’s Experiences and Future Visions. UNICEF/EAPRO and Institute of Nutrition, Mahidol University, Thailand, 1992.

Some useful information:

- If you need help, or there is a section of the methodology that you do not understand, please contact:

Dr Guy Nantel
Food and Nutrition Division (from January 2006: Nutrition and Consumer Protection Division)
Food and Agriculture Organization
Viale delle Terme di Caracalla
00153 Rome
Italy
Email: guy.nantel@fao.org

- If you would like to send comments on your experience of using this Assessment Tool, please send them to the above address.

- The companion volume to this Assessment Tool, “Community-based Food and Nutrition Programmes: what Makes Them Successful. A Review and Analysis of Experience” (FAO, 2003) can also be obtained from the above address.

- The recommended text for the participatory methodology is:

Partners in Planning by S. Rifkin and P. Pridmore. ISBN 0-333-79266-1

It can be obtained from:

a)Publishers: Macmillan Education Ltd
London and Oxford, with representatives throughout the world.
www.macmillan-africa.com

b)TALC
P.O. Box 49
St Albans
Hertfordshire AL1 5TX
United Kingdom
Tel: +44 (0) 1727 853 869
Fax: +44 (0) 1727 846 852
Email: talc@talcuk.org
www.talcuk.org

ANNEX 3

AN EXAMPLE OF A CONCEPTUAL FRAMEWORK

AN EXAMPLE OF A CONCEPTUAL FRAMEWORK

ANNEX 4

METHODS

METHODS

1) SWOC ANALYSIS METHODOLOGY

The purpose of a SWOC analysis is to identify the main Strengths, Weaknesses, Opportunities and Constraints that characterize a particular situation or entity, such as a programme or an institution. SWOC analysis is often used as a management tool.

In this Assessment Tool you are asked to undertake a SWOC analysis at the end of each of the four main assessment sections[36]. This will enable you to organize, summarize and even prioritize the wealth of information you have gathered during the process of working through the questions in each section.

Step 1

Each SWOC analysis should be undertaken by the Assessment Team as a whole. If the Team includes more than seven members, create groups of team members. Groups should contain a minimum of two and a maximum of four persons per group. If you need to divide a large assessment team into groups, try to end up with four to seven groups comprised of two to four persons each.

Step 2

On a large board or wall, draw the following blank table:

On a flip chart, write the words Strengths, Weaknesses, Opportunities and Constraints at the top of four pages (one on each page).

Step 3

Starting with Strengths, ask each member or group[37] to identify the strengths of the assessment section under discussion e.g. What are the main strengths of the macroenvironment? You should allow a minimum of 30 minutes for this part of the process. Allow more time if you observe that individuals/groups are still adding items to their list.

Step 4

Working with the whole Assessment Team, list all identified strengths on the relevant page of the flip chart. Through discussion, narrow down the list by crossing out repeated items, dropping those that the Team decides are inappropriate, and combining others that are similar. Try to make sure that all members of the Team contribute to the discussion. When the list is final, transfer the agreed items to the blank table prepared in Step 2.

Step 5

Repeat the process in order to identify weaknesses, opportunities and constraints. When discussing opportunities, you should consider circumstances or potential factors that could be exploited so as to improve the impact or sustainability or cost-effectiveness of the programme you are assessing. Here are some examples of opportunities:

- Planned decentralization or the establishment of municipal development committees can be exploited to strengthen community-based activities;

- A new agricultural production programme could be used to improve food security in your programme’s catchment area, or to provide technical expertise to community-based activities;

- Your government is revising its human resource development programme. Seize the opportunity to upgrade technical skills in nutrition.

The results of the SWOC analyses (as well as the completed Summary Report in Annex 1) will form an excellent basis for decisions on what actions are needed to improve your programme. As with the Problem Tree Analysis, the process of undertaking the analysis is as important as its results.

2) PROBLEM TREE ANALYSIS METHODOLOGY

Supplies needed

Note cards or sheets of paper, felt pens or markers, adhesive material to hold cards on a large surface area (a wall, for example, and preferably one where the problem tree could remain for some days).

Step 1: Definition of the problem statement

Problem tree analysis is carried out to help identify the causes and consequences of a particular problem that the group feels needs to be urgently addressed. If more than one high priority problem is identified, there has to be consensus building on which problem the group (i.e. the Assessment Team) will analyse. Everyone should also clearly understand what is meant by a consequence and by a cause of the problem. At the outset, the process of developing a problem tree starts with a statement about the main problem to be investigated, i.e. the core or the focal problem. For example, in the case of this Assessment Tool, the problem statement could be something like “There is a high incidence of undernutrition and malnutrition which needs to be permanently corrected”, or “The programme [that you are assessing] is not achieving improved nutrition or is not sustainable”, or “Increasing agricultural production has not achieved better access to food by the poorest communities/households”. The statement needs to be written out and put on a board or wall. This will constitute the surface on which the problem tree will be developed.

Step 2: Identifying the consequences of the problem

Each member is given one card on which she/he writes what is perceived as one consequence of the problem. If the Assessment Team is small, such as only five or six members, each member may fill in more than one card in order to identify several consequences. Each consequence should be written down on a separate card and be described in a maximum of five to seven words (in one word if possible) and written in large characters to be readily readable by other members when the cards are put up above the statement of the basic problem. Cards that refer to the same or very similar consequences can be grouped together and if needed, re-labelled, based on consensus within the Team.

Step 3: Identifying the causes of the problem

Identifying causes follows a similar process. This is the main purpose of the analysis, so more time and energy needs to be devoted to this aspect. Identification of causes is crucial to developing strategies and designing actions to eliminate or mitigate the problem (if the underlying hypothesis of the problem is correct). Again each member is given one or more card to write down succinctly what are the underlying causes of the problem and these cards are placed below the statement.

Step 4: Building a hierarchy of the causes of the problem

In the group discussion that follows, causes are clustered and if needed, each cluster is renamed. A hierarchy of causes is established, from those most immediate to the problem, down to the fundamental causes. Links can also be established between the causes themselves (see the example on the next page). This is important because where there are links among causes, several parallel actions may be required to eliminate the problem.

Step 5: Using the problem tree to identify actions

The Team should return to the problem tree after completing each Assessment Section. Based on its assessment, the Team may wish to add or remove causes. Then the problem tree and the assessment can be used to identify actions relevant to each section.

Remember that undergoing the process is as important as obtaining the results, because it encourages participation from those who normally tend to participate little. The process is also designed for the participants to take ownership of the implementation of the followup actions.

3) SPIDER GRAM AND METHODOLOGY FOR USING THIS

Reproduced by permission of Macmillan, Oxford. “Partners in Planning. Information, Participation and Empowerment”. Susan B. Rifkin and Pat Pridmore, Macmillan Education Ltd., 2001. © Copyright text Susan B. Rifkin and Pat Pridmore, 2001.

Appendix 2: Using the spidergram to measure participation

The spidergram has lines on which the participation in a programme can be measured in five key areas - needs assessment, leadership, organisation, resource mobilisation and management. We can use the spidergram to help us decide whether participation in each of these five areas is broad (mark 4 or 5) or narrow (mark 1 or 2). When the level of participation has been marked on each arm of the spidergram the marks can be joined up to show a spider web as shown in FIGURE 41. At a later stage of the programme the activity can be repeated to decide whether the level of participation has changed over time.

From experience:

Assessing participation in Tanzania

A district health management team in Lushoto district, Tanzania wanted to know how much local participation there was in a health programme in one of the communities in their district. They decided to use the spidergram as a tool to help them conduct an exercise to measure the participation. This exercise was facilitated by an ‘outside’ development professional. It started with a four-day workshop to help the team understand the spidergram and develop skill in using it. The team then went to the community and interviewed 22 people and made observations to gather the information they needed. When this fieldwork had been done the team reviewed their information. Then they agreed where to put a mark on each of the five lines of the spidergram. They completed their diagram by joining up the marks on each arm to start a spiderweb. The results drawn on the spidergram showed that participation in the needs assessment was very broad. However, in the other areas (leadership, organisation, resource mobilisation and management) participation was quite narrow.

When the team discussed their experience of using the spidergram as a tool for measuring participation they concluded that:

1It gave individuals new insight about how co-operation took place in the community.

2It provided a systematic collection of information on each of the five key areas on which future decisions could be based.

3It helped clarify problems in participation in the community that the team ‘felt’ existed but which could not otherwise be documented.

4It helped the team to clarify their own view of participation.

5It promoted a good exchange of views between the team of government officials and the local people.

(Source: Adapted from Schmidt, D. H. and Rifkin, S.B. (1996) ‘Measuring participation: its use as a managerial tool for district health planners based on a case study in Tanzania’. International Journal of Health Planning and Management, Vol. 11, October-December, pp.345–58)

Training exercise:

Measuring participation using the spidergram

Purpose: To develop understanding and skill in using the spidergram as a tool to measure participation.

Time: One and a half hours.

Materials: Copies of the Primary Health Care programmes given in the case study from Peru in Appendix 3. Flipchart paper and thick pens.

Preparation: If possible, give a copy of the case study and the list of questions to each participant to read before the session. As the facilitator you will need to read this case study and also look at the spidergrams in FIGURES 40 and 41 which have been drawn to help you facilitate this training exercise.

Steps:

1Explain the purpose of the session and using a blank sheet of flipchart show how to draw a spidergram, one step at a time. You can use FIGURE 40 above as a model and make your drawing as large as possible. Start by placing a large dot in the middle of the paper and then draw a line out from the centre to represent each of the five lines of the spidergram.

2Explain that each of the five lines represents one of the five key areas in which we can measure participation - needs assessment, leadership, organisation, resource mobilisation and management. Label each of the lines.

3Explain that each of the lines can be viewed as a continuum starting with narrow participation in the centre of the spidergram which gets broader as you move outwards towards the end of each arm. Explain that none of the key areas can be marked at zero because there is always some participation in the community.

4Make points along each of the lines to divide them into five equal sections. Explain that we can use these five points as a scale to measure participation. For example, if we find that professionals are making most of the decisions and providing most of the resources then participation is narrow. But if local people are planning, implementing and evaluating the programme using the professionals as resources then participation is broad.

5Take each of the five areas in turn and ask participants to brainstorm about questions to describe how narrow or broad participation is. For example, we need questions to show how:

•needs assessment is broad if local people do it and narrow if the professionals do it.

•leadership is broad if the community leaders show that they care about the entire community by stressing the needs of the poor, leadership is narrow if only the leaders' personnel needs are considered.

•organisation is broad if the programme is linked up with other community programmes and narrow if a new programme is started which is not linked up to existing programmes.

•resource mobilisation is broad if the community contributes money, materials and people, and narrow if all resources come from the outside agency.

•management is broad if the community manages the programme and narrow if professionals manage it.

6Divide participants into small groups and ask each group to draw a large diagram of a spidergram on flipchart paper. Check that they have labelled each of the five lines and divided each axis into five sections to give a five-point scale.

7Explain that they are going to measure the experience of participation given in the case study of the urban health programme in Peru. (If they were not given the case study to read in advance give them time to read it now.)

8Suggest that they start by selecting one of the five lines and come to an agreement about how broad the participation is in this key area at an early stage when the programme is just being started. They should record their decision by making a mark on the scale from 1 (narrow) to 5 (broad). They should repeat this until a mark has been made on each of the five lines. Then they should draw a line to connect each of the five points they have made - to make the spider web.

9Now ask each group to do this exercise again but this time they should come to an agreement about how broad the participation is in each of the five key areas at a later stage when the programme has become established.

10Display all the spidergrams and ask each group in turn to explain their diagram. Lead a discussion to explore any major differences between the diagrams. Finally, ask people to compile their own criteria for defining how narrow or broad participation is - based on their own experience and the experience in the classroom.

[1]Many quotes and text in boxes in this Assessment Tool refer to this document as: FAO’s in-depth study of nine programmes (2003).

[2]Guidance on how to do this is provided in Annex 4.

[3]SWOC = Strengths, Weaknesses, Opportunities and Constraints. Instructions on how to carry out a SWOC analysis are provided in Annex 4.

[4]An acronym that may be helpful is SMART: Specific, Measurable, Achievable, Relevant, Time-bound

[5]In some unique situations, lack of knowledge is the only impediment to nutritional improvement.

[6]This statement assumes that supplementation will continue to be needed ad infinitum, whereas if the food-based approach achieves a real behavioural change in dietary practices these will continue with no further inputs, or with no additional inputs that are not already provided by a good GMP programme.

[7]Various titles are used for community-level workers whose task is to work with communities, to help them organize, identify needs, plan and implement activities: popular titles are mobilizers, promoters, facilitators, community or village workers, development workers. If unpaid, they may be called community volunteers. Existing staff, such as community health workers, extension staff, can also play a mobilizing role.

[8]Thailand made good use of this approach and found it essential to the smooth running of the programme. Social recognition can take the form of badges or t-shirts, public recognition through various ceremonies, or training opportunities even outside the community. Arguably, funding spent on a social recognition programme is more effective than funding spent on salaries for the volunteers.

[9]More important than providing technical training, which of necessity will be basic, is training mobilizers to know when, where and how to seek expert assistance, and to recognize the limits of their knowledge.

[10]If paid by the programme, sustainability after the programme ends may be in doubt.

[11]If child anthropometric status is selected as an indicator (and it must be if reducing malnutrition is an objective of the programme), we strongly urge you not to use clinic-based GMP data. Such data are likely to be biased because of incomplete coverage and age of attendance at GMP sessions. Moreover, GMP data generally provides weights only, hence levels of wasting and stunting cannot be assessed.

[12]You should ask to see evidence of the system when you visit communities.

[13]FAO’s in-depth study of nine programmes (2003) found that the partnership with the Catholic Church in Brazil’s Child Pastorate programme led to a high degree of commitment and motivation on the part of community mobilizers.

[14]These figures are difficult to obtain in many countries. If you cannot obtain such figures, then you must turn to qualitative information, based largely on an assessment of the extent of dependence on external resources and on the size of the nutrition unit in comparison to the size of other units.

[15]The coordinating committee may in some cases be the same as the intersectoral committee referred to in the previous subcomponent. It may also be a committee charged with overseeing the Poverty Alleviation Strategy or the Rural Development Strategy. What you are seeking is a committee that brings together a substantial number of relevant international agencies, bilaterals and non-governmental organizations and that focuses on nutrition improvement as a first step in the development process.

[16]Some countries are too small to support a national institution. In such cases, research and training is provided at regional institutions. Examples of such regional institutions are the University of the West Indies and the University of the South Pacific. Some countries also offer programmes in nutrition that are open to other countries in the region. Kenya, the Philippines and Guatemala (INCAP) offer such regional masters’ level programmes.

[17]The availability of technical expertise at subnational levels is especially important in countries that have either achieved full decentralization, or are moving towards it.

[18]In general, it is preferable to avoid treating nutrition as a welfare issue. Such an approach tends to lead to unsustainable food distribution activities and curative rather than preventive measures.

[19]In some situations, it may be acceptable to draw comparisons with other countries, both in the prevalence of malnutrition and in the actions taken to address the problems. Such comparisons can spur governments to action. In this context, you can make use of United Nations’ publications (such as FAO’s State of Food Insecurity reports, UNICEF’s State of the Children reports, UNDP’s development reports) to highlight the position of your country in relation to others.

[20]In general, short courses can be accommodated, but lengthy senior-level training is too costly.

[21]Bilateral agencies are often willing to provide scholarships for training in their countries.

[22]Terminology for administrative demarcations varies from one country to the next.

[23]You need not assess diversity in-depth if it is not relevant to the programme’s implementation process and impact. If, for example, your programme targets a particular agro-ecological zone or socio-economic group, then diversity may not be an issue.

[24]User friendly manual for reference reading: Seaman J, Clarke, P, Boudreau, T and Holt, J. The Household Economy Approach. A Resource Manual for Practitioners. Save the Children Development Manual No. 6. London, Save the Children Fund, 2000.

[25]There may be questions related to other sectors that are relevant to your programme. You should seek answers to these as well.

[26]The Basic Minimum Nutrition Package proposes a list of health and nutrition behaviours to be achieved through primary health care. These are: exclusive breastfeeding for 6 months; appropriate complementary feeding from 6 to 24 months; adequate vitamin A intake for women, infants and young children; appropriate nutritional management during and after illness; iron and folate supplementation for all pregnant women; regular use of iodized salt by all families. See Annex 2 for the full reference for the Basic Minimum Nutrition Package (Tontisirin and Gillespie 1999).

[27]In some countries, GMP programmes are implemented as community activities rather than clinic-based activities.

[28]Attendance is usually high during the first year, when mothers bring their babies for immunization. Attendance during the crucial weaning age period (1-2 years), when the child is most vulnerable to malnutrition, is often low.

[29]Dietary advice and encouragement should be provided regardless of whether the child is growing well.

[30]Many nutrition activities are based on outdated science. Thus, for example, we still see an emphasis on protein deficiency, when it is now well established that protein intake is more or less constant in relation to energy intake.

[31]Community-level workers, paid or volunteers, are discussed in greater detail in Section I, as part of community mobilization and the participatory approach.

[32]Terminology and the nature of the structures vary substantially from country to country. In an ideal situation what you are seeking is a multisectoral coordinating committee focused on local level development. Committees may exist at different levels: regional, provincial, municipal or district (depending on the administrative structure of the country). If there is a choice, you should focus on those that are closest to communities.

[33]In some cases it may be better to create a separate women’s group. Women in some cultures are able to be more vocal and active in such an environment. In the future, when women have become stronger and more self-confident, they can become active members of an integrated community group, which must remain the ultimate goal.

[34]These components should still be viewed as part of the nutrition programme, subject to overseeing by an intersectoral committee on food and nutrition and subject also to routine monitoring and evaluation.

[35]Examples of such changes include the impact on nutrition of events such as the AIDS epidemic, urbanization, meeting the needs of a growing population of elderly people, increasing prevalence of diet-related chronic disorders.

[36]Assessing Programme Design; Assessing the Macroenvironment; Assessing the Microenvironment; Assessing Sustainability

[37]If groups are formed in Step 1, the groups should work separately to compile one list per group.