What Is the Secret of Success

Although undernutrition is clearly related to poverty, some countries are better nourished than others at similar levels of national wealth. Some countries are much better than others with a similar gross national product (GNP) in terms of indicators of nutrition and health, such as food available for consumption and infant mortality. Countries that have done best to improve under-nutrition in recent years are those in which there is greater equity or in which policies have concentrated on ensuring the satisfaction of basic needs, including adequate food. Their political ideologies range from communist China to capitalist South Korea and Taiwan. China is the classic example of a country that is still poor but has largely dominated malnutrition and famine through effective organization of food production and distribution. Other examples are Costa Rica, Chile, Cuba, Kerala state in India, Sri Lanka, and Thailand, which have better nutrition conditions than other counties with similar GNPs. In contrast, some countries have extensive chronic malnutrition despite massive aid (e.g., Bangladesh) and rapid economic growth (e.g., Brazil).

These improvements cannot all be ascribed to specific nutrition policies. What are the lessons that can be learned about the effectiveness of the nutrition interventions commonly used to implement nutrition policies? This is not an easy question to answer because the evaluation of effectiveness of specific interventions is theoretically simple but practically difficult since evaluation has to take into account general economic change. An important function of international development and research agencies such as the World Bank, the International Food Policy Research Institute, FAO, UNICEF, and WHO since the 1970s has been to draw together research on the impact of policies and programs on the economic, health, and nutritional status of beneficiaries to distinguish the characteristics of success. Most of these have concentrated on developing countries. Several features of successful large-scale nutrition interventions in relation to undernutrition have been extracted and are summarized next.

The objectives must be based on a careful analysis of the real problem and be achievable in a time-scale set within the program design. Community and local nongovernment organization involvement is essential in the design and implementation so that there is a sense of joint ownership for self-sustaining success. The overall effectiveness depends on coverage, and if interventions are targeted at specific groups there has to be a trade-off between the cost-effectiveness of targeting and wider coverage of the population. Charismatic leadership and good management are essential, and the appropriate mix of components must be accompanied by effective administration with a balance between bottom-up and top-down actions. Most successful programs include strong training and supervision. Effective implementation is helped by setting clear targets and by monitoring and evaluating the process, with flexibility to modify the program where necessary. The attitude of the workers is crucial in determining the potential for scaling up from a pilot project with selected staff to a large-scale operational program that has to use existing staff. Awareness of the consequences and causes of malnutrition and a political commitment at all levels are important. These common characteristics are a useful basis for the planning of future programs to maximize their success.

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