best practices and lessons learned for sustainable...

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August 1999

A PRODUCT OF THE REGIONAL INITIATIVE TO REINFORCE CAPACITIES IN COMMUNITY NUTRITION

Kinday Samba Ndure

Maty Ndiaye SyMicheline NtiruSerigne Mbaye Diène

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Africa BureauOffice for SustainableDevelopment

BEST PRACTICES AND LESSONS LEARNEDFOR SUSTAINABLE COMMUNITY NUTRITIONPROGRAMMING

SANASustainable Approaches

to Nutrition in Africa

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A Product of the Regional Initiative to Reinforce Capacities in Community Nutrition

Academy for Educational Development (AED)

Kinday Samba Ndure, M.Sc.Regional Nutrition Advisor, West Africa, SANA

Maty Ndiaye SyTraining Consultant, SANA

Micheline Ntiru, M.Sc.Nutrionist, SARA/SANA

BASICSSerigne Mbaye Diène, PhDRegional Advisor

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Africa BureauOffice for SustainableDevelopment

BEST PRACTICES AND LESSONS LEARNEDFOR SUSTAINABLE COMMUNITY NUTRITIONPROGRAMMING

SANASustainable Approaches

to Nutrition in Africa

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SUSTAINABLE COMMUNITY NUTRITION PROGRAMMING

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This document would not have been possible without the sincere and profound dedication ofDr. Suzanne Prysor-Jones, Director of the SARA Project. Sincere thanks goes to the following peoplewho took time to read various drafts, giving invaluable guidance and suggestions: Dr. Tonia Marek,Public Health Specialist, World Bank and Dr. Ellen Piwoz, Nutrition Advisor, SARA/SANA.

The author greatly appreciates the contributions of the Mr. Ibnou Gaye of AGETIP and the different ORANAFocal Points, namely, Dr. Macoura Oularé, Guinée, Dr. Andrée Bassouka, Togo, Dr. Amadou Sall, Mauritaniaand Dr. Amadou Boukare, Niger.

Special thanks to Mr. Sidi Lamine Dramé for the wonderful illustrations, to Mr. Sié Somé for his excellentlayout work, and to Mrs. Renuka Bery, Mrs. Katrina Medjo-Akono and Ms. Lonna Shafritz of the SARAProject for their editing assistance.

�� SUSTAINABLE COMMUNITY NUTRITION PROGRAMMING

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ACC/SCN Administrative Committee on Coordination Sub-committee on Nutrition

AGETIP Agence d’Execution des Travaux d’Intérêt Public

(Agency for the Execution of Public Works)

BASICS Basic Support for Institutionalizing Child Survival

COGES Comité des gestion de la boîte à pharmacie villageoise

(Village pharmacy box managent committee)

CPC Contrôle de Promotion de la Croissance (Growth promotion control)

CNP Community Nutrition Project

HFR Hommes et femmes responsables (Men and women in-charge)

IEC Information, education and communication

ICN International Conference on Nutrition

IUNS International Union of Nutritional Sciences

KPC Knowledge, practice and coverage

MIS Management information system

NGO Non-governmental organization

ORANA Organisation pour la recherche alimentaire et la nutrition en Afrique

(Organisation for Food and Nutrition research in Africa)

ORS/ORT Oral rehydration solution/oral rehydration therapy

PNSAF/E Projet Nutrition Sécurité Alimentaire Familiale/Environnement

PRA Participatory rural appraisal

RKPC Rapid knowledge, practice and coverage

SANAS Service de l’Alimentation et de la Nutrition appliquée au Sénégal

SARA/SANA Support for Analysis and Research in Africa/Sustainable Approachs

for Nutrition in Africa

SCN Sub-committee on Nutrition

SECALINE Projet Sécurité alimentaire et Nutrition élargie

SIAC Système d’Information à Assise Communautaire

(Community-based Information System)

UNICEF United Nations Children’s FundUSAID United States Agency for International Development

WFP World Food Program

WHO World Health Organization

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ACKNOWLEDGEMENTS ....................................................................................... i

ACRONYMS........................................................................................................... ii

CONTENTS............................................................................................................iii

EXECUTIVE SUMMARY........................................................................................vii

SECTION IBACKGROUND INFORMATION

1. Introduction......................................................................................................... 12. The Nutrition Situation in Africa ......................................................................... 23. Background on the Initiative to Reinforce Capacities

in Community Nutrition Programming..................................................................44. Purpose of the Document ...................................................................................55. What do we mean by a Community Nutrition Program?......................................5

SECTION IIBASIC PRINCIPLES FOR PLANNING A COMMUNITY NUTRITIONINTERVENTION

1. Introduction ........................................................................................................................72. Supporting and Sustaining Community Participation for Nutritional Change.............83. Integrating Nutrition with Community Development.......................................................94. Demonstrated Political Commitment ............................................................................115. The Role of Gender in the Development of Community Nutrition Programs.............126. Developing Community Nutrition Program: A Learning Process...............................13

SECTION IIIFIVE ESSENTIAL STEPS IN DEVELOPING A COMMUNITY NUTRITION PROGRAM

1. Introduction....................................................................................................................... 14Step 1: Identifying the Key Partners involved in Program Planning� Identifying Key Partners from the community .......................................................16� Identifying the Key Partners from the Public and Private Sectors .................... 16� Making Intersectoral Collaboration Work ............................................................ 19


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Step 2: Understanding the priority nutrition problems� Assessing the Nutritional Situation .................................................................. 23� Analyzing the Causes of Malnutrition ............................................................... 26

Step 3: Selecting the most appropriate Program Approach� Defining the Program Goal and Objectives ..................................................... 27� Determining the Key Program Targets ............................................................. 27� Choosing the Most Appropriate Intervention Strategy ...................................... 30

Step 4: Developing the Institutional Framework for Action� Defining the Management and Programmatic Roles of Different Partners ...... 37� Eliciting Committing of Partners to Their Roles ............................................... 42

Step 5: Designing an Appropriate Program Action Plan� Defining Program Activities and Time Frame for Implementation ................... 45� Determining the Amount of Resources Needed ............................................... 45

SECTION IVENABLING COMPONENTS FOR AN EFFECTIVE PROGRAM FRAMEWORK1. Introduction ....................................................................................................... 482. Capacity Building for Action .............................................................................. 48� Maximizing Community Participation through The «Triple A» Cycle ............... 49� Designing an Appropriate Capacity Building and Training Plan ..................... 503. Participatory Approaches for Nutrition Communication ..................................... 52� Developing an IEC Strategy ............................................................................. 534. Progress and Impact: Management

Information Systems ......................................................................................... 54� Monitoring and Evaluation ............................................................................... 55� Making Good Use of Collected Data ................................................................ 57� Supervision ..................................................................................................... 58

SECTION VCONCLUSION & LESSONS LEARNED .............................................................. 60USEFUL REFERENCE MATERIALS AND ADDRESSES ..................................... 62

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LIST OF BOXES, FIGURES AND TABLES

BOXES

Box 1: Gambia/Reducing Women’s Workload: Better family diets......................10Box 2: Ghana/Improving Nutritional Status: The Credit with Education

Strategy ............................................................................................... 10Box 3: Burkina/Providing the Initiative for a Community Nutrition Intervention .....17Box 4: Senegal/An evolution: New Stakeholders of Community Nutrition

Projects.................................................................................................18Box 5: Senegal/Institutions Involved in Planning and Executing a Community

Nutrition Program ................................................................................. 19Box 6: Mali/Helping Villages Understand their Nutrition Situation ........................24Box 7: The Nutrition Minimum Package Intervention Strategy........................... 32Box 8: Niger/Matching the Intervention Strategies with the Nutritional Problem...34Box 9: Senegal/Women Monitor the Growth of their Own Children ................... 35Box 10: Common Roles of Different Community-Based Partners ...................... 39Box 11: Mauritania/Women at Work: Generating Resources for Community

Nutrition Activities................................................................................. 40Box 12: Head-hunting for the Best Community Service Providers...........................41Box 13: Togo/Communities Commit Themselves to Improving Growth

Promotion ........................................................................................... 43Box 14: Diversifying partnership: Contracting-out Community Nutrition

Services.............................................................................................. 44Box 15: Tanzania/How animation facilitates community participation?...................49Box 16: Senegal/An Approach for Maximizing Community Participation...............50Box 17: Senegal/What Topics for Community Service Providers?..........................52Box 18: Functional learning: Training women animators in Burkina Faso ........... 53Box 19: Gambia/The Kabilo Approach: An Indigenous Health Communication

Channel............................................................................................... 54Box 20: Burkina/Developing an IEC strategy: Stating Your Intent ........................ 55Box 21: Indicators Used by Community Nutrition Intervention..................................56


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Box 22: Guinea/Community Boards for Dissemination Nutrition Information............58Box 23: Senegal/Some Tips for Good Supervision.....................................................59

FIGURES

Figure 1: The Cycle of Economic Growth, Human Capital and Nutrition.......................3Figure 2: Possible Coordination Mechanisms for the Different Implementation

Levels ................................................................................................................21Figure 3: The «Triple A» Cycle..........................................................................................24Figure 4: The Simplified Conceptual Framework...........................................................25Figure 5: Levels of Targeting for Community Nutrition Programs..................................26Figure 6: Groups to be Targeted by a Community Nutrition Program...........................30Figure 7: The three developmental phases of a Community Nutrition Program............45

TABLES

Table 1: Indicators of Health and Nutritional Status in Selected African Countries.....2Table 2: Some Effects of Malnutrition on Health and Economics Status......................3Table 3: A Comparison of Services Demanded by Communities and Offered by

Community Programs ......................................................................................31Table 4: The Participatory Continuum ............................................................................33Table 5: Type of Roles Performed by Different Stakeholders and at Different

Levels .................................................................................................................38

APPENDICES

1. A Summary of Community Nutrition Programs Implemented in West Africa............662. Community Participation Matrix ....................................................................................683. Techniques to Collect Information for Assessing the Nutrition Situation.....................694. Type of Information Collected during Nutritional Status Assessment ........................715. Strategies Employed by Community Nutrition Programs ............................................726. Guidelines for Teaching Adults ........................................................................................74

GLOSSARY OF TERMS ....................................................................................................65


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In Africa, malnutrition continues to kill millions of children, act as a catalyst to various childhood diseases,exacerbate rates of illiteracy and unemployment and impede overall socio-economic progress. Facedwith alarming statistics of continuously high rates of malnutrition, their magnitude and multipleconsequences, African countries have become increasingly commited to improving the social well-being of their citizens.

One approach to addressing malnutrition has been to establish Community Nutrition Programs (CNPs)that provide interventions ranging from deworming to growth monitoring and health education to homevisits by health promoters. Although specific interventions have varied, these CNPs have had similarobjectives, namely, to implement effective, sustainable approaches to combatting malnutrition. Theseprograms have also experienced similar stumbling blocks, the most common of which includeinappropriate planning and ineffective management of program interventions caused by overly-centralized administrative and financial management; poor targeting of program beneficiaries; lack ofcommitment from political entities; and failure to garner adequate financial resources for nutritionactivities.

Various programs, however, have found ways to overcome these constraints and can provide invaluablelessons and enriching learning experiences. The unique feature of this document is that from beginningto end, it presents lessons learned from these diverse African experiences: basic elements, effectivestrategies, and necessary steps to sustainable community nutrition programming.

The highlights of these lessons are as follows:

Successful interventions are conceived of and implemented in a decentralized manner, centeringaround the community and encouraging community participation in every step of planning andimplementation and at all levels of decision-making.

� Program beneficiaries must be properly targeted to ensure that those at highest riskbenefit from the program’s inputs and resources, as well as to maximize the program’sefficiency and cost effectiveness.

� When governments understand the necessity and positive outcomes of community nutri-tion programs and are involved in all phases of planning and implementation, they are morelikely to be genuinely committed, provide moral and financial support, and become keyadvocates.

� Programs with built-in monitoring and evaluation components provide essential informa-tion on program progress and impact. This information should be regularly reviewed bymanagers and supervisors, and used to address and rectify programmatic issues.

Carefully linking interventions with other development sectors such as agriculture and microcreditcreates synergies that can enhance interventions and lead to positive outcomes. The most succesfullyintegrated activities are achieved logically and feasibly combined using existing political and organizationalstructures.

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This document also outlines a practical, five-step approach to establishing community nutrition programsusing these experiences. These five steps, presented in Section III of the document are:

1 . Identifying key partners involved in planning and implemetation of a CNP;

2. Understanding the nutrition situation at hand;

3. Selecting the most appropriate program approach;

4. Developing the institutional framework for implementation; and

5. Designing an appropriate program action plan.

This document provides guidance for improving the effectiveness of community nutrition programs inAfrica by illustrating pertinent country examples that re-enforce effective approaches to community nutritionprogramming. In doing so, it suggests ways that different governmental and non-governmental actors cancollaborate effectively; emphasizes the importance of nutrition as an integral part of development; andserves as a useful reference tool.

Whether it is the successul linking of credit with education in Ghana, the way in which village animatorstake the initiative to request financial assistance for a CNP in Burkina Faso, or the steps a Niger-basedCNP takes to ensure proper targeting, there are valuable lessons to learn for everyone involved inachieving succesful, sustainable community nutrition programming in Africa; in particular plannersand managers, central- and district-level nutritionists, and funding agencies.

Micheline K. Ntiru, MScNutritionist, SARA/SANA

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There could be no better time for addressing themalnutrition problems in the region. There isgrowing recognition of the impact and multiplebenefits of improved nutrition on human well-beingand sustained socioeconomic development.Simple, appropriate, cost-effective, and feasiblestrategies for reducing malnutrition are nowavailable.

The World Summit for Children and the Inter-national Congress on Nutrition (ICN) presentedan opportunity for governments to make publiccommitments to reduce malnutrition in its variousforms. Governments are meeting this challengethrough the formation of dedicated structures andprograms to address poverty and sustainablelivelihoods in the context of sound macroeconomicpolicies.

Actions to improve the overall nutritional status ofthe poor in developing countries have evolvedstrategically over the past decades. The earlynutrition intervention programs that addressed thefood-related causes of malnutrition and therehabilitation of malnourished children have givenway to more holistic approaches that integratenutrition intervention with primary health care andcommunity development. Multisectoral interventionstrategies have been introduced that take intoconsideration the linkages among agriculture,education, economic status, environmental health,sanitation, and nutrition.

In an effort to improve on the impact of nutritionprograms, more emphasis has been placed onthe community’s role in the planning andimplementation stages and in the mobilization ofindigenous resources to achieve the desiredobjectives. Thus, the employment of community-based strategies in nutrition interventions is agrowing trend that has been facilitated by

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popularizing the UNICEF conceptual frameworkand the «triple A» cycle. See Figure 3, page 24.

In spite of the growing awareness of theopportunities and potential offered by communitynutrition programs (CNPs) for improving nutritionand contributing to community development andself reliance, implementating such programs hasmet with mixed success because of theinadequacy of planning and implementationapproaches and processes. The more successfulprograms appear to be conceived as localinitiatives or pilot projects conducted within alimited geographic area or among a smallpopulation. Due to a lack of adequate follow-upand evaluation, resources, and politicalcommitment, these small-scale projects havelimited potential for replication and expansion.

Many fruitful attempts have been made to identifythe features of successful community nutritionprograms. This document is an attempt to bringmany of these ideas together for programmanagers and planners of community nutrition,health, and other development interventions, sothey can plan and implement programs that areappropriate, relevant, effective, and sustainable.

The document is presented in a manner that“touches the conscience” of the reader. It usesactual experiences to present best practices andlessons learned, proposes approaches and toolsto be used in support of certain key steps anduses illustrations to portray certain situations.Although the document uses examples mainly fromWest Africa, it can be applied to programsthroughout the continent.

Much effort has been made to improve the nutritionsituation in Africa, yet malnutrition in all its

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Country

BeninBurkina FasoCôte d’IvoireGuineaMaliMauritaniaNigerSenegalTogoEthiopiaGhanaTanzania

Source: a = UNICEF, The State of the World’s Children, 1998 ; UNICEF, The State of the World’s Children, 1999.

TABLE 1INDICATORS OF HEALTH AND NUTRITION STATUS IN SELECTED AFRICAN COUNTRIES

Maternaldeaths/100,000births

500930a

600670580550590560640a

1400a

210530

Under-fivemortality/1000

live births

167169150201239183320124125175107143

Low birth weightas % of all births

-2112131611154

20168

14

Prevalence ofwasting in under

5-year-olds

14138

12237

157-8

116

Prevalence ofstunting in under

5-year-olds

252924293044402334642642

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manifestations continues to affect large proportionsof the population of the continent.

Over the past 15 years, no progress appears tohave been made in reducing the prevalence of childmalnutrition in sub-Saharan Africa. In fact, there issome indication that the nutrition situation hasworsened largely because of population growth(ACC/SCN, 1997) and economic decline. Africancountries have among the highest infant and youngchild death rates in the developing world, much ofwhich is due to malnutrition (Murray et al., 1996).Of the top 20 countries with the highest under-fivemortality rates in the world, 18 are from sub-Saharan Africa.

A third of the world’s maternal deaths occurs insub-Saharan Africa (Graham, 1989) where analarming number of babies are born low birthweight, 40% of children are stunted and one outof ten children suffer from acute malnutrition (ACC/SCN, 1997). A high proportion of low birth weightinfants is substantially attributable to maternalnutrition prior to and during pregnancy and intra-

uterine growth retardation - the predominant causeof low birth weight in developing countries is animportant cause of stunting (ACC/SCN, 1997).

Micronutrient deficiencies are widespread in Africa.An estimated 42% of African women as a whole,half of pregnant women, and a third of children underage five are anemic (ACC/SCN, 1997). Nearly aquarter of the African population is at risk of iodinedeficiency disease (ACC/SCN, 1997), and overone million children between the ages of 0 and 4are affected by vitamin A deficiency (Murray et al.,1996).

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Malnutrition is caused by a combination ofindividual, household, community, national, andinternational factors, ranging from disease, culturalbeliefs and customs, and high fertility rates, to pooreconomic status and limited access to health, andother social services. The consequences ofmalnutrition make its prevention a highly pertinent

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priority. Table 2 (above) summarizes some of theadverse effects of malnutrition on the health andeconomic status of women and young children inparticular.

It is clear that significant efforts will have to bemade to prevent malnutrition and a furtherdeterioration in the nutrition situation. Significantimprovements in nutritional status and well-beingin the long term can only be achieved through

sustainable and equitable economic growth andsocial development, particularly through education.See Figure 1 below.

However, there is a major role for communitynutrition programs as a direct means of improvingnutrition in the short term, and as a means offocusing attention on nutrition concerns andpolicies.

TABLE 2SOME EFFECTS OF MALNUTRITION ON HEALTH AND ECONOMIC STATUS

� Diminishes the ability to fight infection

� Impairs the immune system and increases therisk of some infections

� Impairs growth

� Increases the chance of infant and youngchild mortality

� Heightens fatigue and apathy

� Hinders cognitive and mental development

� Reduces learning capacity.

� Increases the risk of complications during pregnancy� Increases the risk of spontaneous abortions,

stillbirths, impaired fetal brain development, andinfant deaths

� Increases the risk of death from spontaneousabortion, stress of labor, and other deliverycomplications

� Increases the chance of producing a low birthweight baby

� Reduces work productivity� Increases the risk for some kinds of infections,

including HIV and reproductive tract infections� Results in additional sick days and lost productivity.

Source: Adapted from: Baker J, Martin L, Piwoz E. A Timeto Act: Women’s Nutrition and its Consequences for ChildSurvival and Reproductive Health in Africa. SARA.December 1996.

In infants and young children In adults and women of childbearing age

FIGURE 1: CYCLE OF ECONOMIC GROWTH, HUMAN CAPITAL, AND NUTRITION

Source: Gillespie S, Mason J & Matorrel R. How Nutrition Improves. ACC/SCN, Geneva, 1996

Productivity

Enhanced humancapital

Current nutritional &health status of adults

Improved birth weight, nutrition,growth & development of children

Poverty Social Sector Investments

Economic Growth

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Africa), and The World Bank mission in Senegal,in collaboration with the Organization for Food andNutrition Research in Africa (ORANA), establishedthe “Regional Initiative for the Reinforcement ofCapacities in Community Nutrition.” The aim ofthe initiative is to contribute to an improvement inthe development and implementation of nutritioninterventions in the francophone region of WestAfrica. Under the auspices of this initiative, aregional workshop to exchange experiences fromcommunity nutrition programs was convened inDakar, March 23-27, 1998.

As a sequel to the workshop, a number of follow-up activities to strengthen the effectiveness,monitoring, and evaluation of community nutritionprograms in the region are in the process of beingrealized. Two articles have been written todisseminate the lessons learned from the workshopand advocate for community nutrition programs asa tool to promote community development andnutrition improvement. One of the articles has beenpublished in the 7th edition of “Dialogue sur la Santéde l’Enfant,” and another has been published inthe December 1998 edition of SCN News, a twice-yearly publication of the Secretariat of the UnitedNations Administrative Committee on CoordinationSub-Committee on Nutrition.

In additional, a number of documents are beingprepared in the continued effort to buildcompetence. One of these presents best practicesand lessons learned from community nutritionprograms/projects implemented mainly in sub-Saharan African countries. A table to facilitateself-evaluation of CNPs has also been developedand is in use.

Since the 1980s, a series of efforts have identifiedthe crucial elements of successful communitynutrition programs. These efforts have included:

� The 5th International Conference of theInternational Nutrition Planners Forum,Seoul, South Korea, in August 1989, whichhighlighted the crucial elements ofsuccessful nutrition programs;

� the 23rd session of the United Nations Sub-Committee on Nutrition (SCN) symposium,Accra, Ghana, in February 1996, whichreviewed a series of effective programsin Africa for improving nutrition; and

� the 16th meeting of the International Union ofNutritional Sciences (IUNS), Montreal,Canada, held in July 1997, where successfactors in community-based nutritionprograms were identified.

There is now agreement about what the factorsare for successful community nutrition programs.However, most successes with community nutritionprograms continue to be realized with small-scaleinterventions, and most efforts to “scale up”successful local programs or projects have failed.

The key challenges remain: What are the keyfactors for success of large-scale communitynutrition programs? How do we apply the lessonslearned from both small- and large-scale programsto ensure sustainability and replicability? How cansuccessful local programs be scaled up effectively?

In 1997, three USAID projects, BASICS (BasicSupport for Institutionalizing Child Survival), SARA(Support for Research and Analysis in Africa) andSANA (Sustainable Approaches for Nutrition in

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��Section 2presents a brief overview of key thematicissues to be considered when planningand implementing a community nutritionintervention.

��Section 3proposes the five stages for a step-by-stepapproach to the development of acommunity nutrition program, using as itsbuilding blocks indigenous knowledge andresources.

��Section 4summarizes the three key enablingcomponents for an effective and sustain-able institutional and organizationalframework around the management andimplementation of program activities.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

��Section 5presents key factors in the success andsustainability of community nutritionprograms based on lessons learned fromthe implementation of such programs inAfrica.

��Section 6lists useful reference materials andaddresses.

often conceptualized as projects to be implementedat the community level.

These projects view members of the communitymore as target beneficiaries than as active partnersand key players in the decision-making process.A lack of community power over decision-makingis matched by a lack of community involvementand, ultimately, a lack of impact (Gillespie, 1996).Such projects tend to rely heavily on externalresources so they do not foster ownership or long-term sustainability.

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The purpose of this document is to improve theeffectiveness of community nutrition programs by:

� reinforcing approaches and strategies that leadto effective, sustainable community nutritionprograms;

� suggesting areas for potential collaboration andpartnership between governmental and non-governmental partners and members of civilsociety in the implementation of communitynutrition interventions; and

� advocating for nutrition as an integralcomponent of the development agenda.

The document is written mainly for:

� planners and managers of health and nutritioninterventions;

� nutritionists at the central or regional levels;� program managers of community nutrition,

health, and other development programs; and� staff of donor organizations that provide

technical and financial assistance.

The document is organized around six sections:

� Section 1introduces the document with a statementon the current nutrition situation in Africaand describes the regional initiative toimprove capacity in the implementation ofcommunity nutrition programs.

A community nutrition program is a collection ofactivities aimed at solving the nutrition problemsof a community with the full participation and co-operation of its members in a flexible, thoughsystematic and well-researched manner.Community nutrition programs are implementedin both urban and rural settings.

The type of program described above is relativelyrare. More common in many of the countriesaround the region are community-based projects/programs that, although they share some of thecomponents of community nutrition programs, are

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� Responds to the priority felt needs of the community

� Involves the community as a key player in the decision-making process and at all stages of the

implementation process

� Integrates other sectors of development

� Is located close to the beneficiaries

� Uses communities local resources

� Affects the community as a whole

� Impacts directly and indirectly on nutritional status

� Reinforces the management and financial capacities of the community.

Source: Regional Initiative for the Re-enforcement of Competencies in Community Nutrition: “ Workshop on Exchanges ofExperiences” , 23-27 March 1998, Dakar, Senegal.

KEY FEATURES OF A COMMUNITY NUTRITION PROGRAM

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and participation, and human resourcedevelopment from the programs’ inception (USAID,1989), (SCN News, 1997). For a program toachieve nutritional improvement, sufficientconsideration must be given to the methods andprocesses used in planning and implementationand their capacity to result in sustainablecommunity development.

This section will discuss some of the basicprinciples to be considered when planning andimplementing a community nutrition program byattempting to address the following issues:

� Why is there an emphasis on communityparticipation at all stages of the imple-mentation process?

� Should programs addressed be limited tohealth- and nutrition-related issues?

� Why is political commitment an indispen-sable element of successful nutritionprograms and community development?

� Should community nutrition programs favorthe involvement of men in the planning andimplementation process, or should onlywomen be considered as primary targets?

� Is there a standard model for improvingnutrition at the community level?

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In the planning and implementation of communityprograms, the following questions are often posed:

� How will the community be involved? Is it goingto be involved at all stages of the implementationprocess?

� How well do the program approaches andstrategies comply with national policies forsustainable community development?

� How well do the services to be provided fit withthe plans and aspirations of the community forits own development?

� How well-equipped are the different stake-holders in terms of material and humanresources, to ensure that the program is ef-fective and sustainable?

� How effective, sustainable, and appropriate tothe local context are the strategies andapproaches to be used?

Often, community nutrition programs areplanned as a package of nutritional serviceswith attention given to “what is to be done,” “bywhom,” and “when.” As such, a program canappear to be well-planned and fully implementedand yet have little or no impact on the nutritionalstatus of the target population. The success ofcommunity nutrition programs relies on the in-corporation of certain critical elements such,as political commitment, community mobilization

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development in Africa, and growing constraints onpublic financing and provision of basic services atgovernment levels. It also promotes programownership and can ensure that programs complywith communities’ needs, aspirations, values, andnorms. These factors are essential if program benefitsare to persist after donor support and external assis-tance have been reduced or phased out.

Like many approaches, community participationdoes have its limitations. It can be difficult toenforce in areas with poor democratic traditions,such as a reluctance to share information andencourage participatory approaches to decision-making. It can be difficult to apply on a largescale and, when not done equitably, it can favorthose already in positions of power and the elitein a community.

One may pose the question that, after years ofimplementing nutrition intervention programs,

“Why is there an emphasis oncommunity participation at allstages of the implementationprocess?”

“Nutrition programs can and do make a differencein many countries... if they emphasize processesof empowerment and ownership and are thuscommunity-based in reality as well as in a name”Gillespie et al., 1996.

Community participation can lead to communityempowerment and self-reliance, attributes thatare crucial for sustained socioeconomic develop-ment in an era of dwindling economic support for

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In some cases, the opportunities presented bycommunity participation are missed becausepartners outside the community are neithercommitted to the approach nor well-versed themechanisms of the process. Although manycommunity nutrition programs now include ob-jectives related to community empowermentthrough capacity-building, success, and impact,they are more often equated with positive impacton malnutrition and behavioral change than withdegree of community participation and transferof skills at the community level.

A major challenge is how to ensure that at allimplementation levels - national, regional, andsub-regional - the principles of community par-ticipation are adhered to. This will require

� Improves the conceptualization process bymaking maximal use of local knowledge;

� Decreases dependence on external assis-tance and promotes self-help in tacklingcommunity problems through thestrengthening of community structures andleadership;

� Ensures that the project is adapted to localsocioeconomic and technologicalconditions; and

� Improves access to services for vulnerablegroups.

� Orientation meetings to inform and motivatecommunity leaders;

� community self-assessment of their needsfor action;

� coordination of activities through existingcommunity organizational structures;

� participation of community members in theimplementation of program activities; and

� in-cash or in-kind contributions to supportimplementation of program activities.

Source: Adapté de USAID, 1990. “InternationalNutrition Planners Forum, Crucial elements ofSuccessful Community Nutrition Programs.”15-18 August, 1989, Seoul, South Korea.

SOME BENEFITS OF COMMUNITY

PARTICIPATIONMECHANISMS FOR DIRECT COMMUNITY

PARTICIPATION

evaluation and consideration of (a) the interestsand frustrations of various partners in the processof involving communities, and (b) their training,motivation, and equipment needs to develop aparticipatoryculture. See Section IV, 1, page 48.

Community participation must be measurableso that its benefit can be assessed. Appendix2 presents a matrix for assessing communityparticipation at different levels of programplanning, management, and implementation.

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Should programs addressed belimited to health- and nutrition-related issues?

The compartmental and vertical nature of earlynutrition activities is considered to be a majorfactor in their limited success. Many determinants

of nutrition lie outside the health and nutritiondomain, so health services are a necessarycomponent of any strategy to improve nutritionalstatus, but they are not sufficient by themselves.

There is ample evidence to show that malnutritionis caused by a combination of factors that can allbe linked to poverty, such as inadequate feeding

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habits, poor access to health and education, lowagricultural production, unsanitary environments,poor education, women’s heavy workload, and lowincome (UNICEF, 1992). See Figure 4, page 25.

Improvements in nutritional status can only beachieved with interventions across differentsectors. An integrated community-basedapproach, in which nutrition may be an entry point,has facilitated success in many community nutri-tion programs (USAID, 1989). Programs aimedat reducing women’s workload, improving foodsecurity, and increasing income have been shownto have an impact on nutrition.

Coordination and integration are particularly im-portant operationally. See Figure 2, page 21.Programs must allow sufficient time to establishworking relationships with other sectors; findpractical ways to integrate nutrition into othergroup agendas; and develop appropriatestrategies, training, and support materials forcommunity-level workers whose primary job mightnot be health-related.

BOX 1 REDUCING WOMEN’S WORKLOAD:

BETTER FAMILY DIETS

BOX 2 IMPROVING NUTRITIONAL STATUS:THE CREDIT WITH EDUCATION STRATEGY Ghana

In Ghana, Freedom from Hunger is using the Credit with Education strategy to improve thenutritional status and food security of women in poor rural areas. This strategy combinessmall-scale loans with education in the basics of health, nutrition, birth timing and spacing,and small-business skills.

Women invest their loans in income generating activities, then meet weekly to repay theprincipal and interest, and deposit savings. Learning sessions are also delivered duringthese meetings. The program has had a positive impact on the nutritional status of one yearold children and on household food security. It has led to changes in infant feeding habits.

Source : Barbara MkNelly, Credit with Education Strategy for Improving Nutrition Security: Impact EvaluationResults from Ghana, Freedom from Hunger. Presented at the Mini-symposium on Sustainable Nutrition Security forSub-Saharan Women Subsistence Farmers. 22nd International Conference of Agricultural Economists, Sacramento,California, 11-14 August 1997.

In The Gambia, a study to determine theimpact of hand-powered ram presstechnology for sesame oil extraction on thenutritional status of women and childrenshowed that those women who used the rampress had better diets than their counterpartswho pressed sesame using the regionaldiesel-powered expellers. This was due toincreased oil consumption and the use ofsesame cake in local dishes.

Women with access to a ram press couldpress sesame into oil in small quantities forhome use whenever they need it and at alower cost. Before, they had to traveldistances to press sesame into oil, and thediesel-powered expellers could only handlelarge volumes of sesame.

Source: Silva-Barbeau et al., Small-scale sesame oilproduction—A means to improved child nutritionsecurity in the Gambia. Semi-Annual Project Report(7/1/97-12/31/97). Thrasher Award. March 1998.

Gambia

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� Existence of national policies and actionplans approving the use of community-based development programs as a meansof addressing national nutritional problems

� Employment of a consultative process andcommunity participation in policyformulation

� Enough resources allocated to implementsuch programs

� Major interest groups within or outside thepublic sector that support such programs.

Source: Adapted from, Cohen S., DevelopingInformation, Education and Communication (IEC)Strategies for Population Programs. Technical papernumber 1, UNFPA, 1993.

INDICATORS OF POLITICAL COMMITMENT

TO A PROGRAM

Why is political commitment anindispensable element of successfulnutrition programs and communitydevelopment?

Political commitment is necessary to enablecommunities to:

� explore possibilities for solving their nutritionalproblems and

� translate perceived possibilities into actionprograms.

Political commitment demands a decentralizationof power. It also demands that governments,institutions, and communities adopt the ap-proaches and processes that lead to communityself-reliance and empowerment.

In most countries, the institutional and politicalframeworks needed to support sustainablenutritional improvement and community develop-ment lack strength. Sectoral and institutional bud-gets still allocate a dispro-portionately largeramount to materials resources and infrastructurethan to capacity-building in support of com-munity-based development initiatives andactivities. Such initiatives, including nutrition-related ones, seldom receive high priority andare usually served by understaffed andunderequipped units.

At the national level, the political environment thatwill foster social development will also supportcommunity nutrition programming. Policiesrelated to poverty alleviation, population and

gender issues, education, food security, health,agriculture, and decentralization, translated intoconcrete action, are a prerequisite for such anenvironment.

These policies will need to be supported byappropriate institutional frameworks with lea-dership and outreach to the community level. SeeSection III, Step 4, page 37.

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broader community participation because theyemphasize women’s involvement. Approachesbased on gender should ensure that thepreoccupations of men and women are taken intoconsideration, and that responsibilities areallocated to men, women, or the community as awhole, depending on their nature. They shouldrespect communities sociocultural values and tra-ditions and promote collective communityownership. Furthermore, women from mostAfrican societies do not act alone. Their decisionsare influenced by others including their husbands,mothers, and traditional leaders. A well-designedand targeted program should involve thoseresponsible for decision making and those whoinfluence them. Therefore, involving men iscritical. See Section IV, Step 3.

Should community nutritionprograms favor the involvementof men in the planning andimplementation process, or shouldonly women be considered asprimary targets?

A number of community-based health and nutri-tion programs are built on the premise that, inaspects of health and nutrition, there exists nobetter agent within the family and for the childthan the mother. Women appear to be at theforefront of community-based programs. Whilesuch programs may have a positive impact onnutrition and women’s status, they often excludemen. In effect, these programs discourage

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Nutritional problems will not be alleviated if thelow social status and education levels of womenare allowed to persist, however. In addition, lackof control over income and decision-making withinthe household deprives women of economic andsocial power and the ability to take actions thatwill benefit their own well-being. See Box 19, page54. To ensure the success of community nutritionactions, the following elements should be present:

� Women’s capacities should be promoted andimproved to enable them to take control of theirown well-being and development.

� Women’s rights should be respected, and va-lue should be placed on the role of the womanin the household and within her community.

� Women’s decision-making capacities shouldbe enforced by involving women in programactivities wherever possible.

� Men should be more actively involved incommunity nutrition programs.

Is there a standard model forimproving nutrition at thecommunity level?

A review of different nutrition programs revealsthe broad spectrum of interventions used toimprove nutrition. While no unique strategy,approach, or intervention can be applied to allprograms, there is a recommended process forworking with communities to identify problems,solutions, and resources for action, andrecognized critical elements for success ofcommunity nutrition programs.

Within Africa, great variations exists amongregions and even among areas of the samecountry. Therefore, there is no best way toimprove com-munity nutrition. Each country andcommunity needs to define, implement, andsecure financing for the most appropriate strategyand programs.

The ideal approach to planning and implementingcommunity nutrition interventions is the “learningprocess” approach (Korten, 1989). In thisapproach, during implementation and evaluation,priority is given to “how” activities are/were carriedout, and “how” those activities are perceived by

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those who were involved and by those who wereintended to benefit. All partners are involved inplanning, monitoring, and evaluation activities sothat their perspectives are taken intoconsideration. A critical element in this approachis the formulation of lessons learned from moni-toring and evaluation activities that are fed backinto the program plan. As a result, modificationsin program activities and strategies are madecontinuously based on the lessons learned duringthe entire period of program implementation.

The design of a community nutrition programshould be viewed as a learning process in whichoptions are proposed for addressing the nutritionsituation. The implementation cycle should includerepeated monitoring and evaluation exercises toassess program impact, identify obstacles toprogress and allow for revision according to thechanging needs and lessons learned throughoperations research, and a flow of informationacross all levels of the institutional andorganizational framework.

Some community nutrition programs have alreadybeen evaluated, a summary of lessons learnedfrom past experience will be of great use inbriefing the program development personnel.

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managers, and those most affected by thenutrition issues to be addressed.

The foundations of a successful community nu-trition program are set at the conceptualizationand planning phase. This section review’s ingreater detail the steps and types of decisionsthat need to be made when developing acommunity nutrition program, according to thesequence proposed below:

A STEP WISE APPROACH TO DEVELOPING A COMMUNITY NUTRITION PROGRAM

Identifying the key partners involved in the planning and implementationof a community nutrition program� Identifying the key partners from the community� Identifying the key partners from the public and private sectors� Making intersectoral collaboration work

Understanding the priority nutrition problems� Assessing the nutrition situation� Analyzing the causes of malnutrition

Selecting the most appropriate program approach� Defining the program goals and objectives� Determining the key program targets� Choosing the most appropriate intervention strategy

Developing the institutional framework for implementation� Defining the management and programmatic roles of different partners� Eliciting commitment of partners to their roles

Designing an appropriate program action plan� Defining program activities and time frame for implementation� Determining the amount of resources needed

Enormous financial and human resources can bespent on programs that are not appropriate to thecountry or community situation. Even when theprogram is relevant it can sometimes lack impact.If a program is to be relevant to the people whomake decisions about policies and programs andto communities, it must address the problemsthey face and help them search for solutions.

Nutrition programs are more likely to be effectivewhen there is an extended, three-way process ofcommunication linking policy-makers, program

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�� Who in the community is affected

by the nutrition problems to beaddressed by the program?

� Which members of the communityare responsible for influencingdecisions that can affect thenutrition status of individuals andthe community as a whole?

� Who in the community is involvedin activities that contribute tonutrition and communitydevelopment?

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Designing a program, no matter how small, willbe the work of a team of individuals from a hostof sectors with a common goal and a joint interest-that is, the development of the community andthe alleviation of malnutrition.

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The initiative for the development of a communitynutrition program can emerge from one of anumber of sources including the community, agroup of concerned individuals within or outsidethe community, the government, or a non-governmental association (NGO). What is im-portant is that a multifaceted approach be takento address the perceived nutritional problems,recognizing the fact that there is no single causeof malnutrition.

The key issue is: Who in the community and whoelse, should be involved in the planning andimplementation of a community nutrition program?

A host of individuals and groups within thecommunity can be involved. They include womenof childbearing age; older persons; young childrenand girls; husbands; community leaders; religiousleaders; extension workers; community healthworkers; community development committees;women’s groups; youth groups; men’s groups;teachers; and traditional birth attendants.

Involving all of these individuals and groups in theplanning process might not be feasible or realistic.Therefore it is necessary to identify key in-dividuals, groups, or structures who will be ableto provide that relevant information for the planningprocess. Extension agents, who usually have agood knowledge of the community, can be usedto help identify the partners from the community.

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Collaboration between governments and membersof civil society (non-government organizations andlocal organizations) on the one hand, and amongdifferent sectors within government on the other,is crucial for success. Yet, identifying the keypartners from these different sectors andorganizations is not an easy task. Addressingthe following questions might make the task easier.

Away from the community, it is clear that not onlysectors and institutions dealing directly with food-and nutrition-related issues, such as the ministriesof health and agriculture, will be involved.

Many nutrition intervention efforts have failed toachieve the desired impact because an inter-sectoral and participatory approach was notapplied at the planning stage.

Traditionally, nutrition programs were implementedby ministries of health with little involvement fromother institutional members of civil society.

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�nnnnn Which members of the community

are well-informed about thecommunities nutrition problemscommunity and those affected?

nnnnn Who has influence on accessibilityto goods and services that have animpact on community nutrition?

nnnnn Who provides services from thepublic and private sector that have adirect influence on nutritionalstatus?

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Burkina BOX 3PROVIDING THE INITIATIVE FOR A COMMUNITY NUTRITION INTERVENTION

programs in an effort to make maximum use ofthe expertise and material and financial resources.

A review of the organizational roles of institutionsinvolved in the planning and execution ofcommunity nutrition programs suggests at leastfour organizational roles for institutions:

� Providing political leadership

These include those institutions that helpcoordinate national program interventions acrosssectors, at the national, regional, and sub-regional.Engaging the provincial or sub-central levelsbecoming increasingly important, given the trendtoward decentralization and communityinvolvement in decision-making, and the keypolitical and managerial roles local governmentauthorities play in integrated developmentapproaches...........................................

In Burkina Faso, the Village Women Animators Network evolved from a need observed duringa mission to two agricultural youth groups in the provinces of Sourou and Zoundweogo bystaff of the Ministry of Agriculture. The mission observed that wives of local farmers had alrelatively unaware of maternal health-related issues. Their children suffered frequently frommalnutrition and diarrheal disease, the causes of which were often related to superstitiousbeliefs. Mothers were worried that a many of their children were sick and dying, a trend whichwas having a profound effect on their agricultural productivity.

On returning to the capital, the mission approached UNICEF which assisted the communitywith food for the rehabilitation of malnourished children and later helped teach mothers howto prepare enriched weaning foods. Basic hygiene to prevent diarrheal disease was alsoencouraged.

The mission staff then initiated a small training project for the women of the two youth groupsconcerned. An evaluation of the project produced better than expected results in terms ofknowledge retention and behavior change, which led to an extension of the project to includemore women from the same locality.

Source: Ministries of Health, Agriculture, Social Action and UNICEF. The Village Women Animators Network inBurkina Faso. A presentation made at the UNICEF Technical Workshop on “Promoting Community-based Activities” ,1-4 November, 1997, Nouackchott, Mauritania.

Lately, a more diverse number of structures andinstitutions, such as non-governmentalorganizations, community-based organizations,and private institutions are taking active part inthe implementation of community nutrition

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� Managing of program activities:“executing” institutions

These are the institutions responsible for overallmanagement and coordination of a program orproject. They may be from central or localgovernment, or from the non-governmental orprivate sector. The selection of lead or executingagencies for community nutrition programs is akey strategic decision to be made.

� Providing technical expertisein nutrition

Designing a community nutrition program requirestechnical expertise in problem analysis, strategyplanning, capacity-building, monitoring andevaluation, operations research, and Information,Education and Communication (IEC).

The agency or committee responsible for nutri-tion should delegate such decisions to technicians,who can prepare proposals for approval by thepolitical decision-makers...............................

Technical assistance might be provided by a lo-cal consulting firm, university, local or internatio-nal research institution, government agency’stechnical unit, or an NGO.............

� Providing services to thecommunity

Source: Tonia Marek. Successful Contracting out of prevention services in Africa: The cases of Senegal andMadagascar in fighting malnutrition. Unpublished, 1998.

BOX 4 AN EVOLUTION: NEW STAKEHOLDERS OFCOMMUNITY NUTRITION PROGRAMS IN SENEGAL

MAIN STAKEHOLDERS IN THE OLD NUTRITION PROJECT EXECUTED BY THE MINISTRY OF HEALTH COMPARED WITH THOSE OF

THE NEW COMMUNITY NUTRITION PROJECT IMPLEMENTED BY AGETIP (AN NGO IN SENEGAL)

In most community nutrition programs, the focushas been on using indigenous structures and in-stitutions to provide services such as health pro-motion, growth monitoring and communitymobilization. (see Step 4, Page 37). Institutionsand structures operating at a higher level are thenresponsible for training and supervisory servicesand the provision of materials and equipment.(Included among these for example, are divisional-level and field personnel of ministries, NGO staff

PRESENT STAKEHOLDERS

President’s officeMinistry of HealthAGETIPMedical districtsNeighborhoodsNon-governmental organizationsWomen’s organizations

PAST STAKEHOLDERS

Ministry of Health

Medical districts

Non-governmental organizations

Women’s organizations

� Size and nature of the program itself

� Mandate, political position, and politicalcommitment to nutrition of the agency

� Its technical and managerial capacity

� Its mobilizing or outreach capacity

� Autonomy

� Access to funding

� Track recordSource: Sylvie I. Cohen, Developing Information, Educationand Communication (IEC) Strategies for PopulationPrograms. Technical paper number 1, UNFPA, 1993.

CRITERIA FOR THE SELECTION

OF EXECUTING AGENCIES

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and community-based agents, community-basedgroups etc.)

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Planning and implementation will involve muchof consultation among partners at the national,regional, and sub-regional levels. For example,assessing the nutritional status of the communityalone will require consultation among partners inthe collection, sharing, and review of information.This level of cross-sectoral interaction will requirepartnership, coordination, and commitment fromall sectors.

Integration of various sectors can be difficult, butit has been achieved through the use of existing

Source : AGETIP, Presentation on the Community Nutrition Project of Senegal. Presented at a Workshop on «Experiencesfrom Community Nutrition Programs». 23-27 March, 1998, Dakar, Senegal.

Role of institutions involved in the planning and execution of theSenegal Community Nutrition Program

Institutions that providePolitical Leadership

“Executing” ImplementingInstitution

Institutionsthat provide technicalexpertise

Institutions involved inservice delivery,promotion andmobilization

BOX 5 INSTITUTIONS INVOLVED IN PLANNING AND EXECUTING A COMMUNITY NUTRITION PROGRAM

BeneficiariesNutrition & health services- Infants 6 to 36 months- Pregnant women- Lactating women

National Commission for the alleviation of

malnutrition

Advisory Committee

Delegated Contract Manager AGETIP

Regional Committees andVillage Committees

Project Management Unit

Community-based supervisors(MOCS)

Community micro-enterprises (MICS)responsible for service delivery

Senegal

political and decentralized organi-zationalstructures and staff to plan and manage programs.Coordination will be enhanced by the establish-ment of intersectoral coordinating teams, with well-defined roles and responsibilities, that meetregularly to share activities and experiences.

At the community level, existing developmentcommittee, where operational, can be used asan entry point for coordination and planningactivities.

Figure 2, Page 21 shows a flow chart thatdemonstrates the potential coordination linkagesamong different sectors across and within dif-ferent levels.

Potable water supply- Populations from poor neighborhoods targeted

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MODE OFCOORDINATION

Periodicmeetings

Monitoringreports

Periodicmeetings

Informalcommunitymeetings

Periodicmeetings

Informalcontacts

LINKAGESLEVEL

NATIONAL

REGIONAL

COMMUNITY

FIGURE 2POSSIBLE COORDINATION MECHANISMS FOR THE DIFFERENT IMPLEMENTATION LEVELS

E x ecutingA gency

Community Nutrition ProgramCoordinating Committee

S ecto r R ep resenta tiv es

NUTRITIONCOM M ISSION

Head of region

Community Nutrition ProgramCoordinating Committee

S ecto r R ep resenta tiv es

E XT E N S IO N A G E N T S

CommunityDevelopment

Committee

N G O

C om m unity g roups(W om en ’s, you th

and re ligiousgroups… )

C om m unityLeader

H ouse ho lds

H ea lthF ac ilities

N G O

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√√√√√ The community to be served is the best source of infor-mation about itself. Its views on its needs and concernsare best learned through some form of participatoryresearch in which participants serve as respondents andcollectors of data, thereby having an important influenceon the program design.

THINGS TO BEAR IN MIND

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�nnnnn How do we ensure that the voices

of the community are heard, andthat community nutrition programstake their needs, concerns, andaspirations into consideration?

nnnnn What approaches will facilitatemaximum community participationin the planning stages?

nnnnn How do we build capacity at thecommunity level to improveassessment and analysis skills?

��A pre-requisite step to the identification ofappropriate strategies to combat or preventmalnutrition is precise knowledge of the nutritionsituation being considered and its causes.

A weak relationship between the services offeredand those demanded by the community iscommon among many community nutritionprograms. This is largely because nutrition isseldom a perceived need of the community(Bailey, 1995). Second, negotiation withcommunity members to decide on priority needsto be addressed is insufficient, and there is oftena different perception of the reality programplanners and community members. All thesefactors are exacerbated by an apparentunwillingness and poor capacity to stimulatedialogue and, in the process, “l isten” tocommunities, needs and ideas among sometechnical personnel, especially when dealing withlargely illiterate populations.

(See Section IV, 2, Page 48)

The key to a coherent understanding of the nutri-tion situation is the ability to listen and ask thequestions “who,” “why,” and “how,” to givecommunities the opportunity to expressthemselves, communicate their concerns, andexperience the planning exercise firsthand. Thisapproach places the community at the center ofthe planning process.

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Promotion and support of a process that involvesindividuals and communities in the assessmentof their nutritional problems and the mobilizationof local resources for action was found to be asuccess factor in South Asian community-basednutrition programs (Jonsson, 1995). Involving thecommunity from the outset is vital to encourage

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community ownership of the program, break downresistance to program activities, and expandknowledge of the nutrition issues at thecommunity level.

Community members, both men and women, arenot confused about what is happening aroundthem. Severe forms of malnutrition affectingyoung children may well be recognized bymembers of a community. Some may even beable to identify several of the contributing causes.Few may realize the presence or consequenceof mild to moderate forms of malnutrition and“hidden hunger,” however, many may be unawareof the magnitude or significance of theseproblems and how best to tackle them.

Community members seldom have enoughtechnical knowledge to carry out the assessmentprocess adequately. They need technicalassistance from government personnel. Nongovernmental organizations with the necessaryexpertise can also be of assistance, if they have

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of the situation ofchildren and women

ANALYSISof the cause ofthe problem

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based on theanalysis andavailableresources

Source: UNICEF. The Progress of Nations.Geneva, 1997.

FIGURE 3:THE TRIPLE A CYCLE

BOX 6: HELPING VILLAGES UNDERSTAND THEIR NUTRITION SITUATIONMali

In Mali, a series of village contacts known as “approche par village” help communities identifyappropriate practices aimed at improving nutritional status and addressing perceived healthand nutrition problems. The system is organized around three phases :

� In the first phase, vital demographic and health information is collected and analyzed fromall the villages in a particular health catchment area. From this information, a tentative listof priority health problems is developed.

� In the second phase, focus group discussions are held with village members to attempt toconfirm the existence of the problems identified in the first phase and propose solutions tothem. The results from the focus groups are compiled and discussed with the local healthcommittee, and recommendations are recorded by the community health agent. The goalis to select and implement those solutions that do not require outside support.

� In the third phase, the training needs of community health agents are determined based onthe solutions identified, and a training plan is formulated.

Source: Dr Alfani Shesoko et al., Health areas as an entry point for community development:The case of the BLA Health District, Segou Region. Presented at a workshop on “Promotion of Community-based

activities”, October 1-4, 1997, Nouackchott, Mauritania.

personnel and logistical resources to reach to thecommunity level. Whether the support is fromgovernment or an NGO, the community needs tounderstand why its involvement at this stage isimportant.

The emphasis should be on engaging in dialogueand collaboration with the community to collectand analyze basic socioeconomic data to helpcommunity members better understand their realsituation. Participation will be facilitated byworkshops and orientation sessions to train localstakeholders in the use of local resources and inthe technical and leadership skills needed for theiractive involvement in the assessment of thenutritional situation.

The Triple A cycle developed by UNICEF is auseful tool for articulating action in all aspects oflife. It is used widely in the identification ofcommunity-based solutions to child nutrition andhealth problems. As the name implies, it is acyclical process that involves three steps:

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MANIFESTATIONS

IMMEDIATE CAUSES

UNDERLYINGCAUSES

BASIC CAUSES

Economic Structure

Political and Ideological Superstructure

Source: Adapted from UNICEF, Food, Health and Care: The UNICEF Vision and Strategy for a World free from Hunger andMalnutrition. UNICEF: New York, 1992.

FIGURE 4THE SIMPLIFIED CONCEPTUAL FRAMEWORK

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Formal andNon-FormalInstitutions

Malnutritionand Death

Inadequate DietaryIntake

Disease

Insufficient HealthServices & Unhealthy

Environment

InadequateMaternal &Child Care

InsufficientHousehold

Food Security

PotentialResources

Causes addressed by comm

unity nutrition programs

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√√√√√ It is important to limit the amount of data collected while makingsure that all important indicators are being followed and used.Maximum use should also be made of available information atnational and sub-regional levels.

√√√√√ The results obtained from the assessment process should:

� be shared with the community to arrive at a consensusand to facilitate the community’s support for futureimplementation levels;

� lead to a good understanding of the problem andidentification of strategies with potential to improve thenutrition situation; and

� provide a concrete basis for prioritizing and targetingof action on those most in need.

√√√√√ The cycle of assessment, analysis and action should not beconducted as an on-off exercise. The Triple A cycle should berepeated periodically to ensure that program actions respondto changing needs and situations.

Assessing the problems facing the householdor community, in this case;) analyzing the cau-ses underlying those problems; and) developingactions to resolve the problems.

The different techniques that can be used toassess the nutrition situation are described inAppendix 3. The type of information that can becollected is listed in Appendix 4.

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After assessing the nutrition situation, a list of thefactors thought to cause malnutrition in thecommunity should be developed. This can bedone using a participatory rural appraisal methodsuch as the pocket voting method (described inAppendix 3). The UNICEF conceptual framework

(shown in Figure 4, page 25) can be used insynergy with the Triple A cycle to assistcommunities to identify the basic, immediate, andunderlying causes of malnutrition.

Conducting this exercise with the community isimportant, as it helps its members to discoverthe relationships among different factors, observehow some factors influence others, and to beginto see clearly which factors they have control overand are able to do something about.

As can be seen in Figure 4, community nutritionprograms address the immediate and underlyingcauses of malnutrition more often than they dothe basic causes, which tend to be more complexand expensive to deal with.

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After arriving at an understanding of the specificnutrition problems in the community and theircorresponding causal factors, the next step is todesign an effective solution to the problems. First,the goal and objectives of the program need tobe defined. Next, the most appropriate strategiesfor meeting the program’s objectives must beselected. This involves:

� a definition of “what” you expect the programsetting to look like after the program has solvedthe problem, the goal;

� the series of specific accomplishmentsdesigned to address the stated problems thatresult in your goal of a changed situation, theobjectives;

� a determination of “who” the program is goingto address, the target; and

� “how” the program is going to address them,the strategy.

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Issues to be taken into consideration when settinga program goal:

� The goal is a solution to the priority problemsidentified by the assessment. An assessmentof the nutrition situation should result in anunderstanding of the specific priority problemsthat could be addressed by the program. Thegoal statement presents the solution. Forexample, if the problems are high rates of mal-nutrition due to low female literacy, inadequateweaning practices, poor child care, and highmaternal workload, the goal may be: “Toreduce the rate of malnutrition in Jappineh vil-lage by increasing access of women to infor-mation, education, and communicationservices and appropriate post-harvestt e c h n o l o g y. ” . . . . . . . . . . . . . . . . . . . . . . . . . .

� A goal must be visionary but realistic Do notstate that your program will accomplish morethan it possibly can. For example, the goal“To reduce malnutrition” implies all forms ofmalnutrition among all types of people: men,women, and children, rich and poor, educatedand poorly educated. ..

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Issues to be taken into consideration when settingprogram objectives:

� Objectives should be clear to:√ make it easier to plan and implement

activities that will lead to their attainment,and

√ make it easier to monitor progress andevaluate the success of the program

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In most cases, not everyone in a community isaffected by the nutrition problems identified.Therefore, targeting the whole community will behighly costly and ineffective. Appropriate targetingis critical to improve the efficiency and cost-effectiveness of community nutrition programs.

Targeting permits the better use of limitedresources by focusing specific interventions onthose groups or individuals at greatest risk andmost likely to benefit from intervention. Nutritioninterventions have been shown to be mosteffective when tailored to the specific needs ofwell-defined target groups. This should not meanthat the most vulnerable to nutritional stressshould be targeted at the exclusion of everybodyelse. For example, in an effort to address theneeds of the most nutritionally vulnerable groupsin developing countries, emphasis has beenplaced on the mother and young child, anapproach that may have led to the misconception

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that nutrition is not a problem of the generalpopulation. A mother and child cannot take controlof their own development without an enablingenvironment around them both at the householdand community levels.

Approaches to facilitate targeting decisions

� Nutrition approaches

An analysis of six programs in the sub-region hasshown that 75% of the target is children betweenage 6 and 36 months due to the high rate ofmalnutrition among this age group. All of theprograms also targeted pregnant and lactatingwomen.

A review of a number of successful nutritionprograms identified a three-tiered approach totargeting described in (Figure 5, Page 29). Thisapproach can be viewed as descending from verybroad targeting (essentially non-targeting) ofcommunities to highly targeted programs focusingprimarily on individuals. In all cases, the focus oftargeting is on those deemed at nutrition risk.

nnnnn Which members of the communityare most affected by the nutritionalproblems identified?

nnnnn Which members of the communitycan have a major positive influenceon the lives of those at nutritionalrisk?

nnnnn Who are those with the capacity tomotivate and mobilize communitiestoward increasing self-relianceand nutritional improvement?

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Targeting may be based on geographic, socio-economic, demographic, or nutrition criteria, andmay take place on a community, household, orindividual basis. The statistics collected during theassessment exercise should facilitate this type oftargeting.

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Some programs take seasonal factors intoconsideration when targeting, in an effort toprovide support to individuals/households atperiods of acute food shortage e.g, foodsupplementation during the rainy season. Otherprograms consider the motivation and involvementof communities in making targeting decisions.

� Holistic approaches

As malnutrition and under-development persist,a more holistic and systematic approach shouldbe considered when targeting community nutritionprograms, that recognizes the interdependentrelationship between women and the family, social,cultural, and economic environment of which theyare a part.

This approach to targeting, referred to as theecological approach to health promotion (Green,1996), makes it possible to address the community

Level 3: Biological targeting–emphasis on malnourished individualsBeneficiaries are selected based on individual risk of morbidity or mortality. Used inprograms specifically targeted to those most at need in an effort to use limited funds ina cost -effective manner. Decisions are made with the assistance of anthropometricand socioeconomic data, and additional risk factors of pregnancy. Target groups caninclude malnourished children and high risk pregnant women.

Aug

men

tatio

n de

ta

ux d

e m

alnu

tritio

n

Level 1: Geographic targeting–emphasis on the communityProgram focuses on specific regions or districts. Scope of targeting can range from the national level to thecommunity level. Decisions are made based on some of the following: existing socio-economic data;nutritional surveillance information; existing services, infrastructure, and development activities; communityparticipation factors; and available resources

Level 2: Biological targeting–emphasis on vulnerable groupsSelection of intended beneficiaries is based on vulnerability to nutritional stress, such as childrenunder age 5, children of weaning age, pregnant and lactating women. At this level, the nutritionintervention can also be targeted at all household members.

Source: Adapted from Jennings et al., Managing successful nutrition programs, A report based on an ACC/SCNWorkshop at the 14th IUNS International Congress on Nutrition, August 20-25, 1989, Seoul, Korea, 1991.

FIGURE 5: LEVELS OFTARGETING FOR COMMUNITY NUTRITION PROGRAMS

setting and multiple targets within that setting. Italso recognizes the influence of other keyhousehold figures on the health practices andoutcomes of women and children.

Target groups for community nutrition programsshould include:

� Those with nutrition problems: Women ofchild-bearing age, infants and children of preschool age, and teenage girls.

� Those with an influence on the nutritionalstatus of the above: (a) influential persons inthe family - e.g., husbands, mothers, mothers-in-law, peers, other child caregivers (b)influential persons at the community level e.g.community leaders, religious leaders,representatives of community groups exten-sion workers, traditional communicators....................

Increasing rates of malnutrition

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� Those with the capacity to motivate:community-based service providers, peers,influential persons at the community level.

It should be noted that very few programs addressthe needs of men and other child caregivers onissues centered around the nutrition status of thefamily. Careful attention needs to be given to thisarea.

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The ideal is that a community recognizes itsnutrition problem and write proposals to remedythe situation. The action may be entirely supportedthrough the communities, own self-helppossibilities or it may require government or other“external” support. The reality, however, is thatmost community nutrition programs are initiatedexternally.

The specific interventions proposed and adoptedshould be based on the communities analysis oftheir particular situation. Since CNPs are definedas a collection of activities aimed at solving thenutrition problems of a community, decisions haveto be made with regards to which interventionstrategies/approaches best correspond to thenature and causes of the problems identified instep 2.

The table 3 page 31 compares the servicesusually offered by community programs with thoseusually demanded by communities.

The malnutrition causal analysis will expose thedifferent opportunities for addressing acommunities nutrition problems. For variousreasons including financial and material limita-tions, no single program will be able to addressall problems. The key is to identify what is possi-ble within the scope of the program and use the

FIGURE 6: KEY GROUPS TO BE TARGETED BY A COMMUNITY NUTRITION INTERVENTION

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TABLE 3A COMPARISON OF SERVICES DEMANDED BY COMMUNITIES AND OFFERED

BY COMMUNITY PROGRAMS

Source: UNICEF, 1997, Sub-regional workshop on Community-Based Activities, 1-4 November, 1997, Nouakchott,Mauritania.

SERVICES USUALLY OFFERED BY PROGRAMS SERVICES DEMANDED BY COMMUNITIES

� Growth monitoring� Nutrition education� Antenatal care� Immunization� Management of diarrheal disease� Environmental sanitation� Latrine construction� Promotion of food security� Income-generating activities� Micronutrient supplementation

micronutrient deficiencies� Training, sensitization, and mobilization of

communities.

� Improved access to health care� Health promotion and prevention of disease� Improved evacuation systems� Improvements in access to potable water� Improvements in food security� Access to credit� Construction of classes for literacy training� Improved transportation systems� Technology to reduce women’s workload� Provision of fertilizers� Vegetable production� Access to markets for sale of agricultural

produce.

existing coordinating systems to involve othersectors and partners in addressing some of theother problems.

Communities can participate at different levels inselecting program interventions strategies and inthe implementation of the programs as a whole.(Table 4, Page 33) shows various ways in whichlocal people can be involved with different levelsof participation.

The Nutrition Minimum Package or MINPAK,described in Box 7, page 32, is an example of anintervention strategy determined from the outsideand implemented with community assistance. Ittargets the six most important nutrition behaviorsfor improving child feeding practices andpreventing malnutrition. However, communitiesthemselves can decide on and take responsibilityfor the types of interventions they will seek out.

The conceptual framework can be used tofacilitate identification of appropriate actions.When a community has identified the causes ofits nutrition problems, it can seek technical ex-pertise to facilitate identification of suitable inter-ventions.

�nnnnn How do we avoid conflict of

priorities among program planners,service providers, donors, and thecommunity?

nnnnn How do we limit/manage the frus-trations of the community linkedwith its numerous expressed needsthat cannot be satisfied?

nnnnn How do we link the expressednutrition problems with theappropriate intervention strategies?

nnnnn How do we ensure that the servicesthat are ultimately offered are inharmony with the demands of thecommunity?

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There are five important considerations whenselecting the most suitable strategies to employin a community nutrition intervention:

� Appropriateness of the intervention to thecommunity. Does the community have thecapacity to sustain such an intervention?

� Social impact of the intervention. Does itsupport the mobilization of members of thecommunity, especially women?

� Proven impact on health and nutrition. Will theintervention make a difference?

� Economic impact. Has it the potential toincrease household income and communityeconomic status?

BOX 7 THE NUTRITION MINIMUM PACKAGE INTERVENTION STRATEGY

The MINPAK approach is being implemented in five African countries through integration withroutine maternal and child health activities.Source: Tina Sanghvi & John Murray. Improving Child Nutrition through Nutrition: The Nutrition Minimum Package, BASICS,1997.

Improving householdbehaviors

P art ic ip atory c om m un ityp lan nin g

H ous eh old tria ls to d evelopchild feedingrec om m en d ations

H ealth educ ation us ingcom m u nity h ealth w orkers ,trad ition al b irth a tten d ants ,w om en ’s groups , te ac h ers ,an d oth ers

P eer c ou ns elin g andbreas tfeed in g su p p ort grou ps

Improving com munitysupports

D is trib ut ion of vitam in Asupp lem ents

C om m un ity-bas ed sup pliers ofiron/fola te tab le ts

R eg ular acc ess to iod ized s alt

R eg ular acc ess to nutr ient-r ichfoods (inc lu d ing m ic ro-nu trient-fort if ied s tap les )

Improving facility-basedservices

H ealth w orkers rec eivead eq u ate tra in in g and too ls to-� P rovid e ap propr iate

nutr ition al c ouns ellin g� G ive m ic ronu trient

supp lem ents w h enn ec ess ary

� A ssess , c lass if y, and treats ick ch ildren (e .g. , IM C I)

H ealth fac ilities m ainta in-� S tocks of m ic ron utr ients� R eg ular su p ervis ory vis its� S up ply of in form ation,

ed uc ation andcom m u nic ation ( IE C )m ater ia ls

NUTRITION BEHAVIORS

1. For infants: Breastfeed exclusively forabout 6 months.

2. For infants and children: From about 6months, provide appropriatecomplementary feeding and continuebreastfeeding until 24 months..

..3. For women, infants and children: Con-

sume vitamin A-rich foods and/or takevitamin A supplements.

4. For all sick children: Administer appropriatenutritional management:� Continue feeding and increase fluids

during illness� Increase feeding after illness� Give two doses of vitamin A to measles

cases.

5. For all pregnant women: Take iron/folate tablets.

6. For all families: Use iodized salt regularly.

INTERVENTION STRATEGIES

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TA B L E 4THE PARTICIPATORY CONTINUUM

Source: Adapted from Pretty (1995) in Cornwall (1996). Towards Participatory Practice: Participatory Rural Appraisal and theParticipatory Process. In Korrie de Konig and Mation Martin (Eds). Participatory Research in Health: Issues and Experiences. London:Zed Books. Appearing in de Negri B, Thomas E, Illinigumugabo A, Muvandi I. Empowering Communities: Participatory Techniques forCommunity-Based Programme Development. Volume I: Trainers Manual. June 1998.

RELATIONSHIP OF RESEARCH/ACTION TO LOCAL PEOPLE

ON local people

FOR local people

FOR/WITH local people

WITH local people

WITH/BY local people

BY local people

MODE OF PARTICIPATION

Cooption

Compliance

Consultation

Cooperation

Co-learning

Collective action

INVOLVEMENT OF LOCAL PEOPLE

Token representatives are chosenbut with no real input or power.

Tasks are assigned with incentives;outsiders decide the agenda and di-rect the process.

Local opinions are asked; outsidersanalyze and decide on the courseof action.

Local people work together withoutsiders to determine localpriorities; responsibility remainswith outsiders for directing theprocess.

Local people and outsiders sharetheir knowledge and understandingto create new understanding andwork together to form action plans,with outsider facilitation

Local people set their own agendaand mobilize to carry it out in theabsence of outsiders initiators andfacilitators.

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� Existence of other complementarydevelopmental activities. Do other programsaddress similar issues or implement similarstrategies?

A package of services for community developmentis better appreciated than narrowly focusednutrition interventions, which tend to generatecommunity confusion. The key is to limit theprogram to a package of small but do-able numberof interventions.

Types of strategies employed by community nu-trition programs

A review of community-based nutrition programsreveals a wide range of strategies employed, fromgrowth monitoring and breastfeeding promotion

BOX 8MATCHING THE INTERVENTION STRATEGY WITH THE NUTRITION PROBLEMNiger

In Niger, an analysis of the nutrition situation revealed that a high population growth rate,poor access to health services, and inappropriate diets, coupled with a declining socioeconomicsituation and environmental degradation were largely responsible for the poor state of healthand nutrition among the population. Worst hit were women and children, as shown by highrates of infant mortality, high rates of low birth weight, acute and chronicmalnutrition, and micronutrient deficiencies.

The following strategies were identified to promote nutrition: vitamin A supplementation,community-based growth monitoring, nutrition education, literacy training and the placementof labor-saving equipment for women, promotion of strategies to rehabilitate and protect theenvironment and diversify food production, establishment of community cereal banks,promotion of food processing and preservation techniques.

Source: Dr Bakari Sedhiou, “Expérience nigérienne en matière de programme de nutrition communautaire :Cas du programme nutrition/sécurité alimentaire familiale/Environnement”, UNICEF-NIGER, 1995-1998.

to improved access to credit and women’s andgirl’s education. Most programs offer a minimumpackage of nutrition services, such as: growthmonitoring of children, including the referral ofmalnourished children; IEC activities, includingnutrition education for mothers and foodpreparation demonstrations; and home visits ofat-risk individuals.

Appendix 5 show the range of strategies that canbe used in CNPs.

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Senegal BOX 9 WOMEN MONITOR THE GROWTH OF THEIR OWN CHILDREN

In Senegal, selected women from local women’s groups in the Dioffior health district have beentrained to conduct monthly growth surveillance of infants ages 6 to 36 months and promote improvedfeeding practices to mothers of these children.

These women, known as nutrition promoters, organize monthly weighing sessions at the villagelevel and record vital information on each child in a register. After weighing the child, the promotercounsels the mother on appropriate feeding for her child based on a specially developed counselingchart. The mother is congratulated if the child is progressing well, and sick children are referred tothe nearest health facility.

This approach to growth promotion has led to an increased understanding by mothers of the factorsthat affect infant growth. A marked reduction in child morbidity has been observed, and communityleaders have noted an greater community interest in the welfare of their children.

Source: Dr Anta Tal-Dia, Rapport d’évaluation des activités de nutrition communautaire dans le districtsanitaire de Dioffior, 1996

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√√√√√ While the extent of targeting is determined by the availability ofresources, the most appropriate targeting strategy, criteria, andprocedures will depend on the program objectives, specificinterventions, and local conditions.

√√√√√ Targeting should be flexible enough to adapt to the changes innutrition status and needs.

√√√√√ Targeting strategies can vary by program component, to useprogram resources in the most efficient way possible.

√√√√√ It is important to limit the number of interventions/programcomponents to a few critical ones because it is not possible toaddress all the factors that affect nutrition status, and thesecritical components cut across sectors.

√√√√√ The selection of a simple, minimum, ‘do-able’ package ofinterventions tends to be more effective.

√√√√√ The selection of strategies that address some of the priority feltneeds of the community will be a good motivating tool.

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Once the appropriate program interventionstrategies have been selected, the key partnersshould decide who is going to do “what,” “how,”and “when” to make the program work.

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Community-level organizational capacity is a keyto success of community nutrition programs(Gillespie et al. 1996). This capacity can befacilitated through selection of simple and do-ableinterventions, and by building capacity to ensurethat roles are carried out effectively and efficiently.

In contrast, a high visibility of central-level actorsin the execution of activities at the community levelmay result in poor sustainability. This can happenwhere:

� there is a lack of coordination andinvolvement of communities in the planningprocess;

� there is a lack of organized and motivatedcommunity-based structures; and

� complex intervention approaches beyondthe capacity of community service providersagents and structures are selected.

What is important is to aim at achieving aninstitutional framework where structures operatingcloser to the community focus on technical andoperational input and supervision, and thosefurther away from the community on policy direc-tion and advocacy.

Table 5 (page 38) presents the typical roles ofdifferent partners involved in implementation ofcommunity nutrition programs.

The role of partners at the community level

Countries implementing the primary health carestrategy as a means of providing basic health ser-vices at the community level usually have healthworkers, such as community health nurses,traditional birth attendants, and village healthworkers who operate from this level. However,these workers usually have too manyresponsibilities. The assumption of roles bymembers of the community is a key factor forownership and success of community nutritionprograms.

The four essential partners operating at thecommunity level are members of the communitythemselves, community leaders, communitygroups, and community service providers. Thecommon roles of these partners are:

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located and performed at whichlevel, and by which institution?

� How do we ensure that differentpartners are committed to theirroles?

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TABLE 5TYPES OF ROLES PERFORMED BY DIFFERENT PARTNERS AND AT DIFFERENT LEVELS

Level

National level

National level

National level

Regional level

Community level

National level

Regional level

Community level

National levelRegional levelCommunity level

Regional &national Level

Community level

Regional level

Community level

Regional level

Community level

Key Roles

Policy Guidance

Advocacy

Planning

Resource Mobilization

Training and Capacity-Building

Monitoring and Evaluation

Supervision

Service Delivery

Who Concerned

Sectoral ministriesCoordinating teamsSectoral ministriesTechnical expertsExecuting agenciesSectoral ministriesTechnical expertsExecuting agenciesNGOsIntersectoral teamsCommunity leadersCommunity based organizationsExtension agentsCommunity service providersSectoral ministriesExecuting agenciesNGOsSub-central level headsNGOSCommunity-leadersCommunity-based organizationsCommunity membersCommunity service providersTechnical personnelNGOsSectoral representativesExtension agentsSectoral ministriesExecuting agenciesNGOsCommunity service providersCommunity membersSectoral ministriesExecuting agencies NGOsExtension agentsCommunity leadersSectoral ministriesExecuting agenciesNGOsCommunity groupsCommunity service providers

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THE COMMUNITY

� Participate in program planning exercises

� Establish a Community Nutrition Committee usingexisting community organizational structures

� Identify community nutrition agents and meansof motivating them

� Make in-kind or in-cash contributions in supportof program activities

COMMUNITY LEADERS

� Participate in program planning exercises

� Resolve conflicts and disputes related tomanagement of the program

� Mobilize community for action and resourceallocation

� provide leadership and guidance

COMMUNITY SERVICE PROVIDERS

� Conduct monthly weighing of under-five-year-olds

� Counsel mothers of malnourished children

� Refer malnourished children to appropriatehealth facility

� Conduct nutrition education sessions

� Conduct home visits to at-risk individuals

� Account for revenue generated by the program

� Collect basic data for monitoring of program

� Distribute of vitamin A, iron and folate supplements

COMMUNITY DEVELOPMENT COMMITTEE

� Cooperate with community nutrition agent tosensitize and mobilize the community

� Resolve organizational problems of the program

� Ensure the smooth running of the program

� Mobilize material and financial resources

� Supervise other locally based actors (such astraditional communicators and peer counselors)

BOX 10COMMON ROLES OF DIFFERENT COMMUNITY-BASED PARTNERS

� The role of women and women’s groups

Ensuring women’s active participation beyond thelevel of beneficiaries is of paramount importance.Women, more than other members of thecommunity, should be able to benefit more froma community nutrition program. This is due totheir major role in the feeding and nutrition of thehousehold and their poor access to services thatsupport this role. Community nutrition programsshould serve as a means of improving women’swell-being and socioeconomic status by:

� increasing their ability to make informedchoices that affect their lives as child-bearersand those they care for, through nutritioneducation;

� improving their socioeconomic status andfinancial independence through establishmentof income-generation activities and thepromotion of skills in functional literacy;

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BOX 11WOMEN AT WORK: GENERATING RESOURCES

FOR COMMUNITY NUTRITION ACTIVITIES

In Mauritania, groups of women from a low socioeconomic and highly populatedneighborhood of the capital of Nouackchott are forming income-generating enterprises toraise money to fund community-based nutrition activities. With a seed grant from UNICEF,community shops have been opened to sell basic commodities such as tea, rice, milk, sugar,and butane gas at highly competitive prices. The shops are also used as outlets for the saleof local weaning foods and iodized salt.

The revenue generated is divided into three parts. One part is used to replenish the shops’stock. Another part is shared among the members of the group, which range from 60 to 100women. A third part funds certain activities of the local nutrition center, such as cookerydemonstrations..

Source: Dr Aliou Momadou Sall, Nutrition Division, Ministry of Health and Social Affairs, Mauritania.

� reducing their burden of work throughpromotion of appropriate labor - saving devicesand post-harvest equipment; and

� improving their decision-making capacity byinvolving them in all aspects of the programplanning process and giving them keyresponsibilities in the management of theprogram.

The role of community service providers

Community service providers play a crucial rolein bringing community nutrition programs to life.Their selection and role definition are among themost important and difficult decisions to be made.Many programs choose a mix of locally selected,community service providers to conduct nutrition-related services such as growth monitoring,screening for supplementary feeding, nutritioneducation, and follow-up of at-risk persons suchas pregnant mothers and malnourished children.

Strategies such as the use of peer counselors toconduct home visits to at-risk mothers and childrenand the use of traditional communicators in mes-sage delivery will help to limit the responsibilitiesof community service providers.

Ensuring that the best person is chosenfor the job

In most programs, the community is responsiblefor identifying the most appropriate person to serveas a community service provider. In many Africancommunities, there is a lot of pressure oncommunities to select candidates based on theirrelationship with community leaders, andsometimes for political reasons. A lot of time andmoney can be wasted if unqualified candidatesare selected.

Almost all community nutrition programs use criteriato help select the right person for the job.Communities should be involved in a thoroughdiscussion of criteria for choice of serviceproviders. Ideally, communities should set theirown criteria. A process of negotiation is sometimesnecessary in circumstances where candidateswho meet all the criteria are difficult to identify.

Commonly used criteria for selection of communityservice providers can be divided into fourcategories:

1. Residency: An agent who is a local resident ofthe community and is known by members ofthe community is considered to be a key factorfor sustainability. It promotes community

Mauritania

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ownership, provides an opportunity to buildindigenous capacity, and reduces the risk ofattrition.

2. Gender: Some programs, because they targetlargely women of childbearing age, includecriteria relating to gender, showing apreference for female agents.

3. Educational level: Community serviceproviders will be expected to carry out a hostof tasks, such as community animation, infor-mation transfer, and record-keeping. Suchtasks require certain skills and capacities thatrequire a basic level of education.

4. Personality traits such as honesty, goodorganizational skills, high motivation, patience,and flexibility are important but often neglectedcriteria for selection of community serviceproviders. Such criteria are especially impor-

tant where local workers are voluntary or arepaid a token amount in cash or kind.

Motivation of community service providers

In rural African communities, high rates of urbanmigration among young educated men and lowlevels of female literacy can make identificationof a suitable candidate a daunting task. Afterselection, some of them are expected to work forno remuneration, and when they are paid, sala-ries tend to be very low. Therefore, it is importantto ensure that service providers are well-motivatedso that they will remain in the job and performeffectively.

Programs use various methods of motivation, suchas training exercises, awards, remuneration (cashor in-kind), and regular supervision. The issue

BOX 12 HEAD-HUNTING FOR THE BEST COMMUNITY SERVICE PROVIDERS

SENEGAL

The AGETIP Community Nutrition ProgramSelection of Youth Associations toserve as Community Service Providers� Educational level� Professional experience� Community experience� Gender ratio (more female than male

members)� Resident locally

TOGO

Ministry of Health, Growth Promotion ControlProgram (CPC)

Selection of «hommes et femmes responsables»� Minimum of six years of education� Resident in the community

NIGER

Ministry of Public Health, Promotion ofCommunity-based growth promotion (PSCAC)

Selection of growth promotion village teams

� Known by the community� Can read and write (where this is not possible and

the candidate is considered to be a good choice,he or she is exposed to a 45-day functional literacytraining)

� Women of childbearing age

GUINEE

Ministry of Public Health, Community-basedinformation system (SIAC)Selection of Community Service Providers

� Ability to read in at least one of the locallyspoken languages

� Will work voluntarily� Local resident� Has the confidence of the community� Female agents preferred

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of payment for community service providers isone most programs have to grapple with at sometime. Some programs expect community serviceproviders to work on a voluntary basis. This bringsinto question the ethics and feasibility of expectingpersons from poor communities with limitedeconomic and employment opportunities to workfor free for an extended period of time.

A study of the feasibility of using non-compensated community health volunteers,drawing from examples from Botswana,Colombia, and Sri Lanka, concluded that large-scale community volunteer programs will becharacterized by high attrition rates and lowactivity levels and will only be sustainable underparticular enabling conditions (Walt et al. 1989).

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In a community nutrition program, partners atvarious levels have different and important rolesand functions. Prior to implementation of fieldactivities, it is vital that all levels fully understandtheir responsibilities within the program and arecommitted to carrying them out.

Sensitizing partners on their roles

Once the responsibilities of partner organizationsand structures have been defined, each levelshould be fully briefed on its role in the program.The regional level plays a critical role and shouldultimately be responsible for coordination andsupervision of activities at the field level. As such,representatives from the central level and mana-gement from other partners should provide theirsubordinates operating from the sub-central levelwith a clear and well-defined mandate forimplementation.

In turn, the regional level should ensure that thepersonnel who operate at this level and below,such as staff of health facilities and extensionworkers, are fully aware of their roles. It is vitalthat extension workers who serve as supervisors

to community service providers have a completeunderstanding of the program and are motivatedto participate effectively in all stages ofimplementation.

Regardless of whether the community wasinvolved in the planning the program, particularattention should be paid to informing them abouthow and why they are involved. This can be donethrough community meetings with communityheads using the existing structure responsible forcommunity development as an entry point. Therole of the community and various prominentactors within the community, such as thecommunity service providers and the programcoordinating committee, should be reviewed withthe community.

Contractual agreements among partners

Appropriate mechanisms should be put into placeto ensure that partners are committed to theirrespective roles in the program and that they areaccountable for material and financial resourcesplaced at their disposal. The signing of contractual

SOME CONDITIONS THAT FAVOUR

VOLUNTARISM

� Where there are substantial numbers of young,relatively well-educated men and women in ruralareas, for whom further training or employmentopportunities are lacking.

� Where the religious or ethical value of servingothers through voluntary work is a strong culturalforce.

� Where traditional, often authoritarian, structuresunderlie expectations of voluntarism.

� Where political commitment, sometimes underadverse conditions, unites and stimulatesvoluntary effort.

Source: Walt G, Perera M and Heggenhougen K (1989). Arelarge-scale volunteercommunity health worker programmesfeasible? The case of Sri Lanka. SocialSciences andMedicine, 29 (5). In Jennings et al (1991) Managingsuccessculnutrition programmes. ACC/SCN State-of-the-ArtSeries, Nutrition Policy Discussion Paper, No 8.

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agreements between partners is a formal way ofdoing this and it should help encourageaccountability and efficiency in the provision ofservices.

What is a contractual agreement?

It is an accord between two partners orstakeholders obliging them to provide certainresources or infrastructure or perform certainroles and responsibilities. It can be signedbetween different stakeholders for differentpurposes and at different implementation levels.For example, it can be between the governmentand the executing agency responsible for overallcoordination of the program (if an NGO or privatesector); between the executing agency orgovernment and special institutions selected forthe provision of special services - e.g., trainingand IEC materials development; or the executingagency or government and NGOs or community-

based organizations for the provision of certainservices - e.g., management of income-generatingactivities, coordination of field activities; orbetween the executing agency or government andthe community for the provision of certain services,e.g., resource mobilization, identification ofcommunity service providers, and maintenanceof infrastructure.The final step in the programplanning process is development of a programaction plan.

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For each program objective and correspondingstrategy, there should to be a detailed list of allthe activities that need to be completed duringthe program, how each one will be done, who willbe responsible for doing it, and when each activitywill begin and end.

BOX 13 COMMUNITIES COMMIT THEMSELVES TO IMPROVING GROWTH PROMOTION

Togo

In Togo, to identify villages to be covered by the growth promotion control program (CPC),villages with low attendance rates at growth surveillance sessions held at peripheral healthunits are identified.

The villages are visited and meetings held with village heads to discuss the reasons for the lowattendance rates and to tell them the benefits that can be gained from participating in thecommunity growth promotion control program. The communities are given a month to thinkover the proposal and arrive at a consensus. A contract is then signed with those villages thatagree to meet the conditions of being a CPC village.

These are:

1. To identify of two men and two women known as “responsible men and women” (HFR) and three members to serve on the management commitee responsible for the village pharmacy box (COGES-comité de gestion de la boite a pharmacie villageoise). The HFR and members of the COGES should be well known by members of the community, resident in the community, have have concern for the general well-being of the community and be available at any moment to respond to their needs;

2. To propose ways of motivating the HFR; and

3. To construct a box with a lock with specified dimensions to store medicines.

Source: Interview with Andrée Bassouka, Nutrition Service, Department of Family Health, Lomé, Togo.

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MADAGASCAR

Community nutrition worker

—

NGO

Local consultant; localresearch institution; university

Project’s unit (SECALINE)

TYPE OF SERVICE CONTRACTED

Service-delivery e.g., weighing ofchildren, IEC, food distribution

Training

Supervision

Operations research

Overall project management

SENEGAL

Income-generating enterprise

Local consultant; local traininginstitutionIncome-generating enterprise orNGOLocal consultant; local researchinstitution; university

AGETIP

Source: Tonia Marek, “Successful contracting out of prevention services in Africa: The cases of Senegal and Madagascar in fightingmalnutrition.” Unpublished, 1998.

In Senegal, the Community Nutrition Project contracts out to NGOs, local groups, or local institutions the services to bedelivered as well as supervision, training and research activities. In Madagascar, some services of the Community-Nutrition Project are also contracted out to local NGOs and consultants.

TYPES OF SERVICES BEING CONTRACTED IN EACH PROJECT

BOX 14DIVERSIFYING PARTNERSHIP: CONTRACTING OUT COMMUNITY NUTRITION SERVICES


√√√√√ Allocation of roles and responsibilities should take intoconsideration the severe constraints on women’s time.

√√√√√ In an effort to emphasize on women’s capacity-building, thegender perspective should be taken into consideration.

√√√√√ Care should be taken in the identification of existing women asmanagers of an income generating activity, making sure thattheir current interests and capacities are compatible with themodalities of such an activity.

√√√√√ The roles assigned to community service providers should belimited to a narrow range of duties. Overburdening poorly paidcommunity service providers could provoke a loss of interest inthe job.

√√√√√ Their roles, work routines, and priority tasks should be clearlydefined.

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Time frame for development ofa community nutrition program

Time frame planning should take intoconsideration the fact that at the beginning of theprogram, staff might have to be trained andmaterials developed before implementation ofactivities in the form of services to the communitybegins. The initial phase of a program shouldfocus on community mobilization to identify keycommunity-based actors and build capacity ofprogram implementation staff so that they canassume their roles. Baseline studies, anddevelopment and testing of IEC materials andprogram pilots can also be conducted at thisstage. A pilot project allows the staff to go throughall essential steps from planning to evaluation inrapid succession, and it provides rapid feedbackon what works and what doesn’t (Parlato & Seidel,1998).

The next phase focuses on initiation of activitiesat the community level and expansion of coverageof programs that were previously implementedon a pilot scale. It might not be possible toaddress all intervention strategies at once.Different strategies can be introduced on a phase-

by-phase basis, leaving to last those that require asubstantial level of capacity-building.

As the program cycle progresses, focus shouldthen be on transferring responsibility of activitiesto the community. If this is achieved, thecommunity will be able to assume ownership ofthe program, and the program will have a greaterchance of sustainability.

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A budget is generally prepared once programactivities have been determined. It details theresources and costs for carrying out the program.

The costs of all proposed activities need to beincluded, such as research (baseline studies andassessment, pre-testing of messages, materialsand approaches; operational research; monito-ring; and evaluations); training exercises;community-based meetings; IEC materialsdevelopment; supplements; mobilization andpublic information activities; technical assistance,etc.

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FIGURE 7 THE THREE DEVELOPMENTAL PHASES OF A COMMUNITY NUTRITION PROGRAM

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Organization andcapacity-building

Initiation of activitiesby the community

Ownership of activitiesby the community

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Developing a financial plan

Many programs are planned without dueconsideration given to the generation and sourceof financial resources and, ultimately, the long-termfinancial sustainability of the program.

After cost estimates are made, cost sharingstrategies among the different stakeholders,including the community, need to be worked out.Such strategies should be feasible and realisticand are usually based on the type of services tobe provided by each partner and its financialcapacity. On the part of the community, a seriesof discussions will need to take place to determinethe level of contribution to be expected from it.

Complete community autonomy over the provi-sion of resources required is the ultimate intentfor sustainability of any community-basedprogram. This might not be totally feasible, butfor sustained effectiveness, it is imperative thatthe community and local/national program/servicedelivery agents - e.g. government and NGOs -are the major source of funding.

Where community nutrition programs are highlydependent on external resources, plans should be

made to progressively reduce this dependency,diversify the donor base, and link communitynutrition programs with other existing programse.g., government PHC, health service deliverysystem.

The following strategies will help secure thefinancial sustainability of programs:

� Obtaining the financial involvement of the state

� Obtaining the political commitment of the stateto invest in nutrition

� Avoiding high-cost intervention strategies

� Obtaining the financial participation ofbeneficiaries

� Discussing with communities from the onsetthe different types and modes of self-financing

� Involving the communities in the managementof financial resources

� Obtaining the financial participation ofcommunity development committees

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� Obtaining a more balanced involvementof women in the management of resources


√√√√√ The amount of time allocated to each activity and phase dependson experiences and situations in each country.

√√√√√ Time should be given to test approaches and strategies. Theinitial phase of the program should concentrate on testingapproaches to verify their appropriateness to the particular situa-tion, identify possible obstacles and problem areas, and makerevisions. A good idea is to start small before expanding or goingto scale.

√√√√√ Periods for systematic evaluations should be included in the timeframe.

� Exploiting the possibilities of linkage with otherlocal interventions

� Using local resources and appropriatetechnology.

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� Key partners responsible for change areequipped and supported to do their jobseffectively and efficiently.

This section focuses on some of the enablingfeatures for making this happen, including:

Þ Capacity-building for all key partners foreffective action

Þ Nutrition communication and education aimedat behavioral change

Þ Collection of reliable information to measureimpact and progress.

Capacity-building and human resourcedevelopment have made it possible for somecommunity nutrition programs to achievesignificant reductions in malnutrition (UNICEF,1993; Gillespie et al., 1996). Inherent in suchprograms is the notion that the program shouldempower community members so that theyhave the ability and confidence to actcollectively to influence their quality of life.

A key feature of the empowerment process ispromotion of community participation. However,maximum community participation can beimpeded by practices and circumstances suchas:

� a lack of involvement of community membersin the program conceptualization process,making ownership of programs difficult toassume;

� the poor listening capacity of technicalpartners operating at the community level,resulting in a tendency to dictate rather thanfacilitate development of community initiatives;

� high levels of illiteracy at the community levelthat limit members’ capacity to assume certainresponsibilities and enforce certain strategies;

� inadequate negotiation skills at all levels thatare necessary for building partnership in theprogram development and implementationprocess;

� a lack of confidence in the community is abilityto influence its members’ lives in a positivemanner; and

� a general perception on the part ofcommunities that the government providesservices” and the community receives

A well-designed and thought out program actionplan represents the initial framework for programimplementation. This framework should berefined and updated continuously based onfeedback from monitoring activities.

However, this is only a small step towardachieving the program goal. A community nutri-tion program can only be successful if:

� Program targets place some value on theperceived benefits of the intervention.

� Program targets are willing and able to changethose behaviors and practices that have anegative influence on nutritional status.

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Many communities will have had some experienceworking with external development partners todevelop and/or implement community developmentactivities. A good start will be to build on thecommunity’s current skills and experiences afterexploring its past role in such activities and theapproaches used to foster partnership.

A number of programs now use the UNICEF TripleA cycle and malnutrition conceptual framework astools to engage the community in assessing andunderstanding their own nutrition situation, anddeveloping of appropriate action based on availableresources. See Section III, Step 3, page 27. �

nnnnn What approaches and mechanismsexist to strengthen collaborationamong different partners in nutritionprograms and maximize communityparticipation?

nnnnn What knowledge and skills arerequired to ensure that each partneris able to fulfill its role?

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Tanzania BOX 15 HOW ANIMATION FACILITATES COMMUNITY PARTICIPATION

In Tanzania, the Child Survival Development Program used animators to encourage communityparticipation in the planning process. A month was spent gathering socioeconomic data in thevillage to obtain a comprehensive picture of the situation. To encourage the community toparticipate, animation was used as role-playing, case studies and stories, traditional songs, poetry,dance, and games to give villagers the opportunity to express themselves, communicate theirconcerns, and experience the analysis/planning exercise firsthand. The use of role-playingobjectified the problem and made apparent need for change obvious to everyone. Throughdialogue, the animator guided the villages in identifying actual causes, using the UNICEFconceptual framework. The program found existing extension agents to be effective animatorsbecause they lived in the villages, understood the prevailing problems, and could better stimulateinteraction between the indigenous system and institutions.

The responsibilities of the animator included:

� engaging villagers in dialogue and cooperate with them in collecting and analyzing basicsocioeconomic data to better understand their real situation;

� identifying different socioeconomic groups in the villages and stimulate these groups toinvestigate their needs and problems of concern;

� assisting people in exploring possibilities to enhance their opportunities and improve theirwell-being;

� assisting people to translate perceived possibilities into action, mobilize required resources,and involve the necessary local mechanisms to carry out the actions required; and

� linking animated groups with one another and with appropriate institutions to managedevelopment activities effectively.

Source: UNICEF. “We will never go back : Social mobilization in the Child Survival and DevelopmentProgram in the Republic of Tanzania.” New York: Dar es Salam, 1993

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Developing partnership and negotiation skills

A feeling of partnership among all partners,particularly those involved at the community level,is vital for building communities’ confidence intheir abilities to make a difference. Negotiationamong all stakeholders to arrive at common goalsand objectives is essential for buildingpartnerships.

The role of the community agent/health promotershould be to facilitate the negotiation process andenable communities to take control over theirhealth. He/she should facilitate rather thandictate and contribute to the process byencouraging and supporting community initiati-ves and the establishment of infrastructure andsystems that promote community activity.Community agents should not approach thecommunity with any preconceived solutions. Well-established program objectives and guidelinesshould provide community members with aframework to follow.

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Every program should have a training plan; noblueprint is advocated for all programs. Trainingplans should be developed based on the specificactivities to be implemented, approaches to beconsidered, and experience and skills of keypartners. Therefore, each partner should specifyits training needs so that these are addressed inthe training process.

Developing of a training plan should comprise thefollowing information: (1) Who will be trained? (2)What will they be trained in? (3) Who will train? (4)How will they be trained? (5) How long shouldtraining last?

� Who will be trained?

The tendency is for community nutrition programsto focus on those partners directly involved in theproviding services and operating at the village level.

BOX 16 AN APPROACH FOR MAXIMIZING COMMUNITY PARTICIPATION

The use of the Negotiation-Participation-Integration (NPI) model and Learning-by-Doing-while-Observing(LDO) approach developed in the design, implementation, and evaluation of a sustainable community-basednutrition education delivery system in Senegal.

This model demonstrates three essential and interrelated principles for an action process aimed atdeveloping partnership with communities so that they can become active partners in the process. Theprinciples work in the following way:

Step 1 Negotiation—The context, goals, and objectives are shared by all concerned parties/stakeholders.This sharing requires a willingness by each stakeholder with diverging interests to enter into partnership. Theoutcome of the process is agreements by each stakeholder on its respective conditions for participation in theprocess.

Step 2 Participation—The specific approach to participation used was the Learning-by-Doing-while-Observing approach described below.

In this approach, the participants or stakeholders are expected to learn what to do, why, and how. The conceptis applied to the assessment and analysis of their situation and formulation of potential solutions. Each stakeholderthen does what is expected of it to solve the community’s problems. In the process, all factors affecting theimplementation of the research are observed and documented to facilitate sharing information on the experienceand expanding its benefits.

Step 3 Integration—Integration is an outcome and an indicator of successful participation. It takes the form ofan internalization of the results in the form of knowledge or skills by the individual actors or institutionalization atan organizational level.Source : Serigne Mbaye Diene. Use of participatory approaches to design, implement, and evaluate a sustainablecommunity-based nutrition education delivery system in the Fatick region of Senegal. Ph.D.Dissertation, May 1995.

Senegal

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These include community-based trainers, com-munity service providers, village leaders, programcommittee members, and IEC agents.

Experience shows that stakeholders at all levelsof the implementation process, including the cen-tral and sub-central levels, might need some typeof training or capacity-building. This is particularlytrue for those who are expected to supervisecommunity-level workers.

Ideally, a pool of trainers and trainees should betrained to avoid the risk of compromising thesmooth progress of the program due to dropoutor attrition..............................................

� What will they be trained in?...................Implementation of a successful and sustainablecommunity nutrition program requires awareness,knowledge, and understanding of a variety ofissues and approaches and proficiency indifferent skills.

The following issues could be considered as partof the content of a training plan:

� Awareness of the importance of communityparticipation and engagement; the importanceof integrating nutrition into communitydevelop-ment programs; the importance ofdemon-strated political commitment; the roleof gender in developing of community nutri-tion programs; and an active and participatoryapproach to community nutrition programming..............................

� Knowledge and understanding of the TripleA cycle, the conceptual framework for malnu-trition causal analysis; the goal and objecti-ves of the program; the role of differentpartners; the nutrition problems and practicesin the community and how they will beaddressed; and the management informationsystem, including how the program will bemonitored and evaluated. .........................

� Skills in participatory assessment; socialmobilization; negotiation; teaching adults;counseling; financial management andentrepreneurship; IEC techniques; data col-lection methods; supervisory guidelines; andspecific skills related to the program interven-tion strategies employed, such as weighingand measuring of children, etc........................

● Who will train?

To the extent possible, training should beconducted in surroundings similar to those inwhich trainees work. For this reason, most trai-ning of community-based stakeholders isdecentralized and facilitated by training teamsoperating from the regional and district levels.These teams are usually composed of nurses,midwives, program managers, and nutritionistswho do not always have enough knowledge aboutthe types of teaching methods that facilitate adultlearning. Some CNPs now contract out trainingservices to consu l tants or ins t i tu t ionsspecializing in training. See Box 13, page 43.

� How will they be trained?

Adults come for training with a wealth of skills,experience, and specialized needs, and teachingthem requires the use of special skills andtechniques. Some guidelines for teaching adultsare provided in Box 17, page 52.

All community-based nutrition program workersreceive on-the-job training during routinesupervisory visits. Such training is usuallyconducted on-site and addresses the problemsthat hinder job effectiveness. In addition,refresher training at regular intervals isappreciated by community health workersas a motivating tool and as another way ofincreasing on-the-job effectiveness.

Training objectives and procedures must be tried,tested, standardized training manuals, andsubjected to periodic review. Training manualsshould contain the following information: learningobjectives; steps, processes and activities tomeet each objective; technical information fortrainers; and teaching aids.

� How long should training last?

The duration of training will depend on a numberof factors, such as the scope of the tasks thetrainee is expected to perform and the previoustraining and experience of the trainee. Mosttraining is not completed in a set period of timeor at the end of the formal training course.Agricultural calendars should be considered whensetting training schedules in rural settings.

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MODULES TREATED:1. Information on the Community Nutrition Program

� Genesis of the CNP� Organizational chart of the CNP� Organization of community nutrition centers

2. Entrepreneurship & contracting out services� Presentation on private enterprise� Associations and income-generating

associations� Private enterprises and the market� Contracts

3. Nutrition and health; basic concepts and strategies� Food groups and cooking demonstrations� Growth surveillance and promotion� Breastfeeding� Malnutrition, young child feeding� EPI, prenatal consultation, family planning,

assisted delivery� Acute respiratory tract infections

4. IEC/ Social mobilization� IEC concepts and strategies

BOX 17: WHAT TOPICS FOR COMMUNITY SERVICE PROVIDERS?

Source: Mr. Ibnou Gaye, AGETIP, Presentation on theCommunity Nutrition Project of Senegal. Presented ata Workshop on “Experiences from CommunityNutrition Programs.” 23-27 March 1998, Dakar,Senegal

Training community agents responsible for the management of the communitynutrition centers by AGETIP

Senegal

� Planning of center and community activities� IEC techniques

5. Guides and tools for management of CNC� Presentation on CNP� Program targets� Organization of the CNC� Roles and responsibilities of Community

micro-enterprises� Management tools� Activity reports� Monitoring of activities

1. Organization and management of beneficiary con-tributions

Traditional nutrition education approaches basedon health talks and the use of printed media havehad limited reach and impact. The originalapproaches were essentially based on the trans-mission of knowledge from a health agent totargets considered to be “ignorant,” using formaltechniques based on lectures, during which thetrainees remained passive listeners. Healthagents were usually health professionals, suchas nurses, nutritionists, and doctors, who tendedto teach what they themselves learned during theirprofessional training.

Nutrition education/communication strategies arenow moving into more innovative and interactivespheres that place greater emphasis on socialcommunication through interaction of trainers and

trainees of the same culture, using participatorylearning techniques.

A number of approaches have been used. Forexample, traditional communicators—e.g.,griots—have been used to relay health andnutrition information through theatre, role-plays,songs, and skits. Peer counselors have beenused to promote best practices with regard toinfant feeding and management of childhoodillness, and community and religious leaders havebeen used to promote family planning andpreventive health services.

The goal of any CNP/IEC strategy should be todeliver culturally appropriate nutrition messagesusing locally available communication channels.

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It should also foster a sense of friendly competitionbetween and among communities.

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Bringing about changes in nutritional statusrequires that target groups change deeplyembedded cultural practices and perform thesenew behaviors be performed daily or morefrequently over a period of years (Parlato & Seidel,1998). Planning the IEC component of acommunity nutrition program is a complexexercise that requires careful thought andcoordination.

The first step to developing an IEC strategy willinvolve selecting the priority target audiencegroup, identifying behaviors amenable to change,testing possible improvements in practice, andassessing the locally appropriate communicationchannels to reach the target.

A similar approach to identifying the target groupfor a community nutrition program should beapplied. (Described in Section 3, step 3)

The next step involves the development of theIEC strategy itself. This includes defining theobjectives of the strategy, (i.e. what changes areexpected), determining suitable IEC activitiesneeded to bring about the desired behavioralchanges, developing the messages andrecommended practices to be communicated, andchoosing the most appropriate combination ofcommunication channels.

Prior to message promotion at the community level,IEC communicators should be trained in nutritioneducation. As most programs use interpersonalcommunication as an outreach strategy, high priorityshould be given to training in interpersonalcommunication skills such as nutrition counseling,and conducting group discussions.

BOX 18FUNCTIONAL LEARNING: TRAINING WOMEN ANIMATORS

1. Training of Trainers - This is conducted over a period of five days by members of the“ Cellule Technique Nationale” (CTN) made up of four members from the ministries ofagriculture, health and social action. They train the trainers who are staff of the ministries ofhealth, agriculture and social action. The trainers then team up in groups of two’s to train thewomen animators. A team of trainers is responsible for training 30 women animators. Trainers arechosen based on their experience, responsibility and capacity. They are also resident in the areacovered by the animators they will train.

2. Training of Women Animators- There are two types of training conducted: a) the classictraining course and b) the specific training course for animators from guinea worm endemic zonesand zones with high rates of vitamin A deficiency. Each course is conducted in phases and beginswith the treatment of specific subject themes, after which the women return to their communitiesto practice what they have learned. Training continues with a review of the themes addressed inthe first phase. Animators are taught different communication techniques and then sent back to thefield to start testing their skills with mothers from their communities. From each group of 30women animators trained in one session, 3 women who can read and write are selected to serve assupervisors. They receive an additional one day training.

Source: Ministries of Health, Agriculture, Social Action and UNICEF. The Village Women Animators Network inBurkina Faso. A presentation made at the UNICEF Technical Workshop on “ Promoting Community-based activities” ,1-4 November 1997, Nouakchott, Mauritania.

Burkina

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BOX 19THE KABILO APPROACH: AN INDIGENOUS HEALTH COMMUNICATION CHANNEL

In The Gambia, the Kabilo Approach is the name given to a health program in the North BankDivision piloted by Save the Children Federation USA and the Gambian Ministry of Health andSocial Welfare. This approach to community health and family planning employs existingvillage social structures to channel development activities.

The strategy provides key women in the community with basic but important health informationthat gives them better control over their own lives. Because of the highly organized Kabilostructure, and because Kabilo women are so highly respected in their communities, the Kabiloapproach was found to be ideal for disseminating health information. It helped reduce maternaland child mortality by increasing community participation in primary health care, and sought tochange perceptions of family planning and increase the use of modern contraceptives.

Source: Social Mobilization for Community Health and family planning. The Kabilo/Imam Approach, Programme implementationmanual by Save the Children USA and the Agency for the Development of Women and Children.

Gambia

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serve the purpose for which planners, managers,and evaluators need the information.

The efficiency of any system will depend on anadequate understanding by program managersof the program objectives, procedures, and tools.Therefore, training and regular supervision ofpersonnel on implementation of the MIS is of keyimportance.

An efficient information system requires:

� Clearly defined program objectives, to facilitatedetermine of pertinent activities and selectuseful and simple indicators.

� Simple and flexible data collection methodsthat can be easily presented to decision-makers.

� Simple methods to analyze data that facilitatefeedback and understanding at the communitylevel.

� A rapid analysis of information andinterpretation at the decision-making level

The management information system (MIS) is anessential part of program management becauseit keeps program managers and decision-makersinformed about impact and progress. Programmanagers and their counterparts at the nationaland community levels should use the informationderived from the management information systemon an ongoing basis to monitor program progressand identify logistical bottlenecks, flaws inprogram design, and other potential problems.

Successful management information systems aresimple and straightforward to ensure that datagathered are error-free, understandable, and canbe used reliably for decision-making. An MISshould be able to respond to the changing needsof the program, so that adjustments can be madein a timely manner.

The more explicitly defined the program objecti-ves are, the easier it is to tailor the MIS to programneeds. An ideal MIS should use simple ways tocollect and present data to community membersand other partners. In addition, the system should

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� Application of mechanisms that allow forverification and validation of data

� Effective training, understanding, and regularsupervision of community agents and otherprogram personnel on the monitoring andevaluation procedures and systems.

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Monitoring and evaluation are the systemsthrough which information collected by the MIS isused to follow the process of implementing ofprogram activities and measuring their impact.Specifically, monitoring is the collection of valid,accurate data on processes and outputs that areuseful for making program decisions. Unlikeprogram monitoring, which involves comparing aprogram’s results to its own targets, performanceor impact evaluation assesses the overalloutcome or public health impact of a programagainst more objective measures such as chan-ges in key behaviors, capacities, or health status(BASICS, 1998).

The monitoring and evaluation system should bedesigned to facilitate the program’s ability to showimpact using a variety of tools, such as routinereporting systems, periodic KPC surveys, andoperations research using relatively inexpensiverapid assessment methods to address specificimplementation concerns as they are identified,impact evaluations.

Selection of Indicators

The selection of indicators is seen by many asthe essential first step in designing a monitoringand evaluation system, since it is the process ofdefines what will be measured during the courseof the program.

Several considerations must be kept in mind foreach indicator. These include:

� what is the nature of the issue being measured;

� what system will be used to collect the infor-mation (e.g., routine or special survey);

� how feasible is it to make accurate measure-ments of the issue;

BOX 20 DEVELOPING AN IEC STRATEGY: STATING YOUR INTENT

In Burkina Faso: The Nutrition Communication Project has been working with the Ministryof Health to improve the nutrition status of young women and children. The project has as itsprimary beneficiaries, pregnant and lactating women and children age 5 and under.

A qualitative study was conducted to identify behaviors amenable to change, and optimal messa-ges and media for reaching the community and health workers. Mothers and fathersof children under 5 were identified as the primary target audience for messages. Health workerswere designated as the main communication agents, with reinforcement from teachers andagricultural extension agents to influence fathers and increase community outreach.

For each primary target, a small set of “doable,” affordable, and culturally appropriate actionswere promoted. Several key channels were selected to communicate the nutrition strategy:interpersonal communication, relying heavily on health workers to communicate basic nutritioninformation to households; health center talks, the radio, outreach to men through agricultureextension agents and literacy programs.

Source: Fishman et al. Assisting NGOs Incorporate Nutrition Communication in Child Survival Programs, in Margaret Parlato &Renato Seidel (eds) 1998. Large-Scale Application of Nutrition Behavior Change Approaches: Lessons from West Africa. Publishedfor the USAID by the Basic Support for Institutionalizing Child Survival (BASICS) Project, Arlington, Va.

Burkina

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� are the resources available; and

� does the program have the capacity to monitorand supervise the program?

Characteristics of good indicators

� Must be relevant: must tell something aboutthe status of a program and should allowbetter decision-making or suggest correctiveaction.

� Must be measurable: since indicators areused to measure status with regard toachieving an objective, it must be possible toknow whether any progress has been madesince the last time information was collected.In many cases, this may mean that anindicator should be quantifiable.

� Must be economical: every indicator coststime and money to collect. It is important tobalance the cost of collecting an indicator withthe value of the information.

� Must have a time dimension: since anindicator will be used to measure status withregard to achieving an objective, the indicatormust specify the time by which a changeshould be seen.

A typical set of indicators used in communitynutrition programs is presented in Box 21. Themost common types of indicators used are resultindicators. Few impact or performance indicatorsare used. The latter type of indicators is usefulas it shows progress toward the attainment ofprogram objectives and can be used as proxyimpact indicators where these are difficult tocollect.

Appropriate data collection methods forcommunity nutrition programs

The issue of “how,” “when,” and “from whom” tocollect data is a difficult one for program planners.There is a constant need to balance the desirefor more and better data with the cost in timeand money of collecting those data and thecapacity of the persons responsible for collectingthe data. Care must be taken not to allow theprogram to be driven by information needs.

Common tools for program monitoring includemanagement information systems and existing datasources, such as growth-monitoring registers, vil-lage registers, training and meeting reports, and

1. Number of old registrations for the month2. Number of new registrations for the month3. Total number of infants registered4. Number of infants present5. Total number of infants 0-36 months

who gained weight6. Total number of infants 0-36 months who did

not gain weight (weight stayed stable)7. Total number of infants 0-36 months who lost

weight8. Total number of infants with moderate

malnutrition9. Total number of infants with severe

malnutrition10. Number of IEC sessions

1. Percentage of infants weighed in the month2. Percentage of infants who gained weight3. Percentage of infants whose weight stayed

stable4. Percentage of infants who lost weight5. Number of meetings organized with

the community6. Number of nutrition education activities

conducted (cooking demonstrations, healthtalks with mothers)

BOX 21: INDICATORS USED BY COMMUNITY

NUTRITION INTERVENTIONS

Indicators used by the CNPimplemented in Dioffior, Senegal

Indicators used by theSIAC in Guinea:

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that address specific implementation concernsas they are identified. It should be triggered byquestions raised during routine monitoringprocedures and evaluation exercises.Operations research should be easy to do andanalyze, and technical assistance should besought where necessary from other partners,such as local universities and researchinstitutions. The results generated should be fedback into management decisions to improveprogram strategy.

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In most programs, data are collected and sentto a higher level, either the sub-central or centrallevel, where they are analyzed, interpreted, andpresented in the form of a report. A managementinformation system will be little use if it does notresult in appropriate action being taken.Sometimes, information flows to the top andnever comes down again.

Data collected must have a visible impact ondecision-making at all levels. Effective feed- backmechanisms should be established to solveproblems and promote identified successes.

Community leaders and community agents needto use the data directly for continuous reviews ofperformance, without having to send them up tothe next level and wait for feedback. Communitymembers also need to get a clear picture of howthe interventions being taken are having an im-pact on their community. This is a greatmotivating factor, particularly for personnelinvolved in local implementation and sustainingcommunity interest.

Data collected must be simple enough to allow foranalysis and interpretation for decision-making at alllevels of the implementation process, particularly thecommunity level. For example, after weighingsessions, members of the community must beinformed about the total number of children weighed,and how many were in the different malnutrition zones(green, yellow, and red). See Box 22 Information fromprevious months will make it easy to determineprogress. This information can be posted in aprominent position on the community board for all tosee.

KEY ISSUES TO BE CONSIDERED WHEN

SELECTING A DATA COLLECTION METHOD

� Value vs cost: All data cost time andmoney to collect, and some datacollection methods, especially surveys,can be very expensive. It is importantto balance the cost of data collectionwith the value of the information thedata will provide.

� Health worker load: Health workerswho are already busy providingservices for their populations willprovide almost all data. Data collectionsystems must not overload theseworkers with filling out forms and otherreporting requirements.

� Data quality: It is easy to collect data;it is not so easy to collect data that arerepresentative and accurate. Biasesare often inherent in data collectionsystems and must be considered indesigning what data to collect and howto collect them.

� Analysis and interpretation: It is easyto collect data; but it is relatively moredifficult to analyze and interpret them.The use of the data should be wellunderstood at the beginning to simplifythe data collection process, ensure thatkey questions are being answered, andavoid “fishing expeditions.”

supervisory and progress reports submitted byprogram staff from different operational levels.

Some useful tools for performance and impactevaluation include: population-based householdsurveys, community assessment and planningexercises, mid-term and final evaluationexercises, and knowledge, practice, andcoverage surveys.

Operations research is another evaluation toolthat can be used to develop and test approaches

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Regular and effective supervision of community-basedagents is a management tool to ensure that theseagents accomplish their roles efficiently, and thatcommunity-level activities are in line with the objectivesof the program. Yet supervision is a weak point ofmost programs.

Most programs have supervision plans, that are notfollowed because:

� supervisors do not always accord much priorityto their supervisory roles;

� it is not always clear who is to supervise whomand how;

� supervision is often only one of many roles givento supervisors;

� supervision calendars are fully charged andunrealistic;

� the resources to facilitate regular supervisionare inadequate, especially when supervisorsare far away from those they are to supervise;

BOX 22COMMUNITY BOARDS FOR DISSEMINATING NUTRITION INFORMATION

In Guinea, after the village weighing sessions, the weight of all children is recorded on acommunity board. This board has a growth curve divided into three zones: a well-nourishedzone shown as green, a moderately malnourished zone shown as yellow, and a severelymalnourished zone shown as red. The board is placed in a part of the village where it can be seenby everyone.

A village meeting is convened with the head of the village, opinion leaders, political andadministrative leaders, and women. The two community agents present the results of the lastweighing session to the community, particularly pertaining to those children who aremalnourished, and the village is asked to propose solutions to address the malnutrition problem.

Types of decisions that have been taken:

• Building of improved latrines aimed at reducing the extent of diarrheal diseasein the community

• Establishment of a women’s vegetable garden• Establishment of a community farm where half of the produce is used in weaning food

demonstrations and the other half is sold by the women’s groups• Assistance to community agents in their local agricultural plots• Construction of supplementary classes at the local primary school

Source: Interview with Dr Macoura Oularé, Section Alimentation-Nutrition, Ministère de la Santé, Republic de Guinée.

Guinea

� and supervisory guidelines are unclear.

Supervision is particularly crucial where communityagents are volunteers because it helps legitimizeand give credibility to their role.

To put an efficient supervision system in place, thefollowing factors must be considered:

� Strengthen supervisory skills through initial andongoing training. The topic of supervision shouldbe integrated into the initial training of all healthagents with supervisory responsibilities.Supervision should not be seen as a “policing”mechanism but as part of a training and motiva-tion strategy;

� Establish a simple information system:Supervision activities should be linked to thissystem;

� Using the results of supervision: Informa-tion gathered from supervisory activities shouldbe used at all levels to orient the program

��


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59

BOX 23SOME TIPS FOR GOOD SUPERVISIONSenegal

In Senegal: The objective of supervision for the AGETIPcommunity nutrition program is to ensure thatcommunity nutrition agents accomplish their roleseffectively, and that center performance is in line withthe objectives of the program.

Roles of the supervisor� to ensure and respect procedures;� to control the quality of information;� to evaluate the performance of community agents

(MICs);� to evaluate the quality of services offered at the

center;� to ensure feedback of information to agents;� to inform the community;� to helpresolve a center’s problems;� to provide on-site continuous training; and� to motivate agents.

Methods of supervision� Direct methods are used, such as observing of agents

at work, talking with agents and analyzing informationcollected.

Supervision tools� Supervision calendar� Supervision form� Monthly activity report� Activity report summary form� Table for monthly follow-up of performance

Organization of supervision� Supervision ration—one supervisor per 20 agents� Frequency of supervision—each center should be

visited once a week

Source: AGETIP. Presentation on Community Nutrition Programs. Presented during the RegionalWorkshop on “ Experiences on Community Nutrition Programmes” , 23-27 March 1998, Dakar.

CHARACTERISTICS OF AN EFFECTIVE

SUPERVISOR

� Should take time at his/her work

� Should create a climate of security

� Should respect those he/she supervises and

their contributions

� Should have the ability to resolve conflicts.

and should be disseminated at the level ofthe community;

� Reinforcing the supports need for su-pervision: The resources needed forsupervision should be anticipated during theplanning of the program. In addition, astrategy for the motivation of supervisorsshould be considered;

� Integrate agents from other sectors toreduce the burden of supervision on healthagents;

� Establishment and maintenance ofsupervisory schedules: A lot depends on thenumber of contacts community serviceproviders have with their supervisor. Eachprogram should have a supervisory planwhich details, the number of persons to besupervised by a supervisor and thefrequency of supervisory visits. Although it

is important to follow, these schedules, itmay in some cases be necessary to adjustthe frequency of visit, according more visitsto those communities with problems.

��


��

60

��

Over the past two decades, there has beenconsiderable success in identifying workable so-lutions to the nutrition problems of Africancommunities. A substantial body of evidence existto suggest that the nutrition status of poorpopulation groups in developing countries canbe improved through community nutritionprograms, if certain critical elements are built intosuch programs from its inception and remain assalient characteristics throughout the programimplementation phase.

Most of the lessons learned that are presentedbelow are not new. The challenge now remainsfor governments, key partners, and communitiesto act collectively in transforming such informationinto positive action.

Fostering political commitment andcollaboration between key partners and thecommunity

1. The promotion of CNPs as an approachfor improving nutrition in developingcountries must start with advocacy.Decision-makers need to be convinced ofthe importance, feasibility, and cost-effectiveness of investing in nutrition at thecommunity level.

2. The strategies to be considered must besupported by clearly articulated nationalpolicy guidelines accompanied by clearlydefined institutional frameworks. Govern-ments need to create a political environ-ment conducive for partnership and collabo-ration among multiple partners from theprivate and public sectors and for successfactors to emerge.

3. For communities to be motivated andremain committed to solving their nutrition

problems, there is a need to createawareness of: (i) the high prevalence andthe serious consequences of malnutrition,and (ii) the availability of low-cost solutionsto the nutrition problem.

Building on existing community resourcesand organizational systems

4. The importance of community participationcannot be overemphasised. Communityparticipation is crucial to ensure theappropriateness and sustainability of inter-vention strategies and ultimate ownershipof the program by the community.Decision-makers and other partners mustbe convinced of the importance of involvingthe community in all phases of programplanning and implementation...............

5. Community nutrition programs are moresustainable when designed within thecontext and capability of a country’s localresources. Community involvement in themobilization of financial and materialresources required for the managementand implementation of CNPs reinforcesownership and will ensure that interventionslie within the scope of the community. Allprograms must plan to progressivelyincrease community responsibility for thefinancial costs of the program.............

6. Programs should be built around existingcommunity knowledge making maximumuse of existing organizational frameworks,such as local women’s groups andcommunity development committees, forkey management and decision-makingresponsibilities.....................................

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61

7. Service providers identified from thecommunity develop local capacity andbridge the gap between the service providerand the recipient. These community serviceproviders should be supported with training,regular supervision, and creativeapproaches to recognizing and awardingtheir efforts....

Strengthening the support infrastructure

8. Good management and guaranteed qualityof service demands committed, motivatedand results oriented staff with effective lea-dership. Relatively large investments aretherefore needed in simple and on-goingprogram relevant and program-driven trai-ning for all levels of staff.........................

9. Widening the net to include partners fromthe non-governmental and private sectorsmaximises the use of available resourcesand expertise. The use of a contractingapproach to commit private sector partnersto their roles promotes good governanceand accountability.

The programmatic context......................

10. Due to the complex nature of malnutri-tion, there is a critical need to complementnutrition activities with other components,in particular food security, credit andincome generation, functional literacy, andpotable water supply...........................

11. To have an impact, programs should adoptsimple, do-able intervention strategies thatwork and that communities themselvescan manage. Priority should be given tothose activities that comply with

communities’ felt needs and promotesolidarity among community members.

12. During targeting, a holistic approachshould be adopted to ensure that all thoseat nutritional risk, in addition to keypersons and factors that influence thepractices and behaviors of those at riskare taken into consideration..............

13. A simple management information systemwith linkages at all levels, supported byregular monitoring and supervision at thecommunity level, is crucial for assessingimpact and progress of the program...................................

14. Communities’ needs and priorities aredynamic. Program managers and keypartners should use the lessons learnedand conclusions drawn from the programto reassess and revise program prioritiesand strategies.

To end this contribution to the reflection of thenutritional situation in Africa, we recommend thatyou keep in mind that a nutrition intervention,specifically a community nutrition intervention,must be seen as an evolutionary and dynamicprocess, rich in learning experiences which arewell worth promoting.........................................


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62

References marked * refer to the case studyboxes. Those marked (*) refer to the text andcase study boxes.

Aubel J & Samba Ndure K. (1996). Lessons ofsustainability for community healthprojects. World Health Forum, vol 17, No. 1.

ACC/SCN. (1997). Third Report on the WorldNutrition Situation, December, 1997.

Bailey K. (1995). Community-Based NutritionProgrammes: Can they Work? , contactno. 145, October – November 1995.

*BASICS. (1998). Initiative régionale pour lerenforcement de compétences en nutri-tion communautaire. Atelier d’échangesd’expériences. Rapport final.

BASICS. (1998). Le Suivi et l’évaluation dansl’action. Dans «La survie de l’enfant,»Bulletin technique trimestriel, Numéro 5,Printemps 1998.

*Diene, S. (1995). Use of participatoryapproaches to design, implement andevaluate a sustainable community-basednutrition education strategy in the Fatickregion of Senegal. A dissertationpresented to the faculty of the graduateschool of Cornell University.

Gillespie S, Mason J & Matorell R. (1996). HowNutrition Improves. ACC/SCN State ofthe Art Series, Nutrition Policy Discus-sion paper No. 15, based on the 15th

IUNS Congress on Nutrition, Adelaide,Australia, 1993.

Graham WJ. (1989). Maternal mortality: levels,trends and data deficiencies. In FeachemRG, Jamison DT eds. Disease andmortality in sub-Saharan Africa. OxfordUniversity Press.

Jennings J, Gillespie A, Mason J, Lotfi M & ScialfaT. (1991). Managing successful nutritionprograms. A report based on an ACC/SCNWorkshop at the 14th IUNS InternationalCongress on Nutrition, Seoul, Korea, August20-25, 1989.ACC/SCN State-of-the-Art Series,Nutrition Policy Discussion Paper N

o8,

September 1991.

Jonsson U. (1995). Success factors incommunity-based nutrition-orientedprogrammes and projects. Paperpresented at the ICN follow-up meeting,New Delhi, November 1995, UNICEF,South Asia.

Kennedy E. (1991) Successful nutritionprograms in Africa: what makes themwork? Population, Health and NutritionDivision of the World Bank. The WorldBank, Washington

Korten DC. (1989). Social Science in theService of Social Transformation. InVeneracion, c.c. (ed). A decade ofprocess documentation research:Reflections and Synthesis. Institute ofPhilippine Culture, Ateneo de ManilaUniversity, Manila.

*Marek T. (1998). Successful contracting out ofprevention services in Africa: The casesof Senegal and Madagascar in fightingmalnutrition. (Unpublished).

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*Mknelly B. (1997) Freedom from Hunger’sCredit with Education Strategy forimproving nutrition security: Impactevaluation results from Ghana. Paperpresented at the mini-symposium onsustainable nutrition security for sub-Saharan women subsistence farmers, XXIIInternational Conference for AgriculturalEconomists, Sacramento, USA, August 11-14, 1997

Murray CJL & Lopez AD. (1996). The Global Burdenof Disease, Harvard University Press,Cambridge, USA,1996

(*)Parlato M & Seidel R (1998). Large-ScaleApplication of Nutrition BehaviourChange Approaches: lessons from WestAfrica. BASICS Technical Report.

*Sanghvi T & Murray J. (1997). Improving ChildNutrition through Nutrition: The NutritionMinimum Package, BASICS.

*SCF USA & ADWAC. Social mobilization forcommunity health and family planning:The Kabilo/imam approach. Programimplementation manual.

SCN News. (1997). Effective Programmes inAfrica for Improving Nutrition, SCNNews, N

o 14, July 1997.

*Silva-Barbeau I, Prehm M, Hull S & SambaNdure K. (1998). Small-scale sesame oilproduction: A means to improved childnutrition security in the Gambia. Semi-annual project report (7/1/97-12/31/97)

*Sedhiou B. (1998). Expérience nigérienne enmatière de programme de nutritioncommunautaire : Cas du programmenutrition/sécurité alimentaire familiale/environnement, UNICEF-NIGER,1995-1998.

*Tal-Dia A. (1996). Rapport d’évaluation desactivités de nutrition communautaire dans ledistrict sanitaire de Dioffior.

UNICEF, Food, health and care: (1992). TheUNICEF vision and strategy for a worldfree from Hunger and Malnutrition.UNICEF, New York.

(*)UNICEF. (1993). We will never go back:Social mobilization in the Child Survivaland Development Programme in theUnited Republic of Tanzania.

UNICEF. (1996) Guide to Monitoring andEvaluation: making a difference? (Draft)

*UNICEF. (1997). The progress of Nations.Geneva.

*UNICEF. (1997). Atelier technique sous-régional sur les activités à basecommunautaire (ABC), 1

er au 4 novembre

1997. Rapport final.

USAID. (1990). Crucial elements of successfulcommunity nutrition programmes,International Nutrition Planners Forum/USAID, 15-18 August, 1989.

WALT G, Perera M & Heggenhougen K. (1989).Are large-scale volunteer communityhealth programmes feasible? The caseof Sri Lanka. Social Science andMedicine, (5), pp 599-608.


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64

Dr Andrée BASSOUKADivision de la Santé familialeMinistère de la SantéBP 1991LoméTOGOTel: (228) 21 20 14Fax: (228) 22 06 99

M. Ibnou GAYEProgramme de nutrition communautaireAGETIPBP 143DakarSENEGALTel: (221) 839 02 02Fax:

Dr Amadou BOUKARIMinistère de la Santé publiqueDivision de la Santé familiale/NutritionBP 623NiameyNIGERTel: (227) 72 36 00 Poste3807Fax: (227) 72 24 24

M. Aliou Mamadou SALLDivision de la NutritionMinistère de la Santé et des Affaires socialesBP 334NouakchottMAURITANIETel: (222) 25-10-17Fax:(222) 25-13-74

Dr Tonia MAREKBanque Mondiale3, Place de l’ IndépendenceDakarSENEGALTel: 823 36 30Email: [email protected]

Dr Serigne Mbaye DIENEConseiller régionalBASICSRue 2 x Bld. de l’EstPoint EDakarSENEGALTel: (221) 825 30 47Fax: (221) 24 24 78Email: [email protected]

M. Ange TINGBOCRS/ BeninBP 518CotonouBENINTel: 30 36 73Email: [email protected]

BASICS Project1600 Wilson Blvd., Suite 300Arlington, VA 22209USAPhone: 703-3132-6800Fax: 703-312-6900

SARA ProjectAcademy for Educational Development1255 23rd Street NWWashington DC, 20037USATel.: 202-884-8700Fax: 202-884-8701E-mail: [email protected]

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65

Community : A collection of individuals living inthe same geographical area, united by commoninterests and sharing the same preoccupations.

Community participation: It is the process bywhich populations are involved in a conscious andvoluntary manner to take control of theirpreoccupations.

Empowerment: A social-action process thatpromotes participation of people, organizationsand communities towards the goals of increasedindividual and community capacity and control,political efficacy, improved quality of life and so-cial justice.

Good governance: This is the administration,supervision and overall administration of aprogram in a fair and egalitarian manner.

IEC: The definition of IEC varies depending uponthe context it is used. In this document, IEC canbe defined as a learning and teaching approachprovides information, education and communi-cation in a participatory manner and aims towardsachieving behavioral change in the long run.

Negotiation: The process that takes place whenindividuals having different needs and perspecti-ves strive to obtain common goals and ob-jectives.

Nutrition Intervention: A series of programstrategies and actions that are required to changebehaviors in a household or community with aimof improving nutritional status.

Political commitment: Sincere and steadfastdedication by political persons and/or bodies to aparticular cause. This requires advocacy and sup-port for the cause as well as direct or indirectinvolvement.

Social mobilization: A process by which avariety of actors and forces at different levels ofsociety engage in a sustained and concerted so-cial action around a commonly agreed-upon oraccepted objective or purpose.

Stakeholders: Those who hold a particularinterest in a program and are thus involved insome aspect of it. Examples of stakeholders of aCommunity Nutrition Program are Ministries ofHealth and UNICEF, who would have political andfinancial interest respectively.

Sustainability: It is the extent to which aprograms operational, management and financialsystems can be maintained over an extendedperiod of time to assure continued existence andsuccess of the program.

��

66

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ojec

tor

gani

zatio

n, b

ut d

evel

ops

som

eac

tiviti

es.

Smal

l am

ount

of r

esou

rces

rais

edby

the

com

mun

ity. C

PG h

as n

oco

ntro

l ove

r allo

catio

n of

reso

urce

s co

llect

ed.

CW

man

ages

inde

pend

ently

with

som

e in

volv

emen

t of t

he C

PG.

Eval

uatio

n co

nduc

ted

by p

roje

ctst

aff.

Crit

eria

for s

ucce

ssde

term

ined

by

proj

ect s

taff,

with

som

e in

put f

rom

CW

.

Aver

age

(fair) 3

CW

is a

ctiv

e re

pres

enta

tive

ofco

mm

unity

vie

ws,

and

asse

sses

com

mun

ity n

eeds

.

CPG

func

tioni

ng u

nder

the

lead

ersh

ip o

f an

inde

pend

ent

CW

.

CPG

impo

sed

by th

e pr

ojec

tor

gani

zatio

n, b

ut b

ecam

e fu

llyac

tive.

Com

mun

ity r

esou

rce

mob

ilizat

ion,

and

CPG

con

trol o

fex

pend

iture

s fo

r sel

ect a

ctiv

ities

(e.g

. com

mun

ity d

rug

fund

).

CPG

sel

f-man

aged

with

out

cont

rol o

f CW

’s ac

tiviti

es.

Eval

uatio

n co

nduc

ted

by p

roje

ctst

aff.

Crit

eria

for s

ucce

ssde

term

ined

by

proj

ect s

taff

and

CW

, with

inpu

t fro

m C

PG.

Ope

n(g

ood)

4

CPG

is a

ctiv

ely

repr

esen

ting

com

mun

ity v

iew

s, a

ndas

sess

es th

e ne

eds.

Activ

e C

PG, t

akin

g in

itiat

ive.

CPG

act

ivel

y co

oper

atin

gw

ith o

ther

com

mun

ityor

gani

zatio

ns.

Com

mun

ity r

esou

rce

mob

ilizat

ion,

and

CPG

cont

rol a

nd a

lloca

tion

ofre

sour

ces.

CPG

sel

f-man

aged

and

invo

lved

in s

uper

visi

on o

fC

W.

Eval

uatio

n co

nduc

ted

bypr

ojec

t sta

ff an

d C

W.

Crit

eria

for s

ucce

ss s

et b

yC

PG, w

ith a

ssis

tanc

e fro

mpr

ojec

t sta

ff.

Wid

e(e

xcel

lent

)5

Com

mun

ity m

embe

rs in

gene

ral a

re a

ctiv

ely

invo

lved

in n

eeds

asse

ssm

ent (

e.g.

thro

ugh

PAR

).

CPG

fully

repr

esen

ts v

arie

tyof

inte

rest

s in

the

com

mun

ity, a

nd c

ontro

lsC

W’s

act

iviti

es.

Exis

ting

com

mun

ityor

gani

zatio

ns h

ave

been

invo

lved

in c

reat

ing

the

CPG

.

Com

mun

ity m

onito

rsre

sour

ce n

eeds

, rai

ses

reso

urce

s w

hen

need

ed,

and

allo

cate

s th

em.

CW

resp

onsi

ble

to th

e C

PGan

d ac

tivel

y su

perv

ised

by

CPG

.

Eval

uatio

n co

nduc

ted

byC

PG. C

riter

ia fo

r suc

cess

set b

y C

PG, w

ith a

ssis

tanc

efro

m p

roje

ct s

taff.

CW

= C

omm

unity

wor

ker (

affil

iate

d w

ith p

roje

ct o

rgan

izat

ion)

CPG

= C

omm

unity

pro

ject

gro

up

*Ada

pted

from

Rifk

in, S

.B.,

Mul

ler,

F., B

ichm

ann,

W. (

1988

) «Pr

imar

y H

ealth

Car

e: O

n M

easu

ring

Parti

cipa

tion.

» So

cial

Sci

ence

and

Med

icin

e. 2

6(9)

: 931

-940

.


��

69

APPENDIX 3

TECHNIQUES TO COLLECT INFORMATION FOR ASSESSING THE NUTRITION SITUATION

Techniques involving the community

� Negotiations/Discussions with key members of the community - such as community leaders, women’s groups,traditional health workers such as community health workers and traditional birth attendants, family members andpotential beneficiaries such as women of child bearing age. The guiding principle to such discussions is theunderstanding that populations have the capacity and the creativity to use their own resources to ameliorate theirstandard of living. Techniques that can be used are key informant interviews and focus group discussions with theconceptual framework as a guide.

� Participatory Rural Appraisal methods –These are a collection of methods, such as those described in table 3 below,that can be used to collect information from community members about a range of issues, from communityorganization and structures to traditional beliefs and working practices.

PRA methods for sensitizing and mobilizing communitiesMethod

Community mapping

Seasonal calendars

Venn diagrams

Three pile sorting

Pocket voting

Matrix sorting

Story with a gap

Community action plan

Description

Community members draw a map of theircommunity, including geographicalfeatures, other resources.

Identifies activities, problems, andopportunities taking place throughout theyear; shows how things changethroughout the year

A social (organizational) data gatheringtool that shows how institutions in thecommunity are linked using circles and amap

Pictures are sorted into categories suchas good (beneficial), neutral, and bad(harmful) practices; facilitated discussionsof reasons why, and how to move fromharmful to positive categories/ practices

Simple method for collecting opinions onproblems, causes, solutions

Method of ranking alternatives accordingto community determined criteria; useful inprocess of building consensus to moveforward

Before and after scenes are given andcommunity members are asked how tomove from the before to the after;a pre-planning toolA plan developed with/by communitymembers

Potential Uses in Nutrition SituationAssessmentIce breakerIdentify community resourcesDefining the community boundaries,fields, gardensHousehold food securityFood pricesWork patternsWater availabilityDisease patterns

Identifying potential organizations andstructures that can be involved insolutions to priority problems

Categorizing foodsCategorizing practicesIdentifying ways to move from bad toneutral to positive practices or situationsIdentifying locally feasible solutions toproblemsCauses of malnutrition, poverty, healthproblemsPriorities in the community

Prioritizing actions and solutions

Hygiene conditions/ behaviorsSanitation conditions/ behaviors feeding behaviors

Defines the way forward

Source: Developing an Integrated Nutrition Program through Assessment, Analysis and Action: A trainer’s guide. The University of Western Capeand the Academy for Educational Development (AED), 1998, (draft).


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70

OTHER SOURCES OF INFORMATION

♦ Review of nutrition situation analysis reports - Such reports although they mayprovide more country specific than area specific data are a source of valuable informa-tion on the extent and trends in nutritional related problems, efforts to address suchproblems, how they were addressed and who was involved.

♦ Rapid Knowledge, practice and coverage studies - The R-KPC is a tool to collectbaseline information, evaluate programs and to focus on priority health needs of popu-lations. It can be used to provide reliable indicators of knowledge, practice andcoverage status on the topics such as: Breastfeeding and infant nutrition, growth moni-toring and vitamin A supplementation, diarrhoeal disease, acute respiratory tract infec-tions and maternal health/family planning.

♦ Ethnographic studies on maternal and child feeding practices - such studies canprovide a solid base of information leading to a broader understanding of the range ofbiological, cultural and environmental factors influencing diet and nutritional status.They are particularly useful for the development of appropriate IEC strategies.

♦ Expert advice- Each country has a pool of persons who can serve as sources oftechnical and up-to-date information. They include researchers, health and medicalprofessionals, economic planners, demographers, extension agents, governmentplanners etc.


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71

SUBJECT STUDIED

Nutritional status

Economic Factors

Food Production

Health factors

Education

Other types ofinformation

FACTORSGrowth faltering

Clinical malnutrition

Biochemical methods

Food Prices

Food ExpendituresIncome

Employment

Production

Factors affecting production

Morbidity

Health and Nutrition Services

Environmental hygiene

Level of education

Community mobilization

Development activities

Community resources

INDICATORS% of babies born with low birth weight �% of infants with height <90% of the standard height for age �% of infants with weight <80% of the standard weight for height �

% of persons examined with clinical signs of: goitre, night blindness��

% of individuals with hemoglobin levels less than the norm fixed for their age,sex and physiological status �Average price of «household food basket» �Average price of staple cereals (or vegetables) during a definite observationperiod �

Average expenditure on food as a percentage of total expenditure �

Average household income per capita��

Proportion of population in active employment �Proportion of mothers working outside the home��Average time spent by mothers on child care �Number of kilos of basic foods (cereals, vegetables, etc.) produced per familyper year��Monetary value of annual food produced per family��

Number of hectares of arable land per capita�Average annual rainfall in mm �Proportion of infants with one or more episodes of diarrhoea in the last month��Proportion of consultations (admissions) related to diarrhoea, out of the totalnumber of consultations (admissions) for a given age �

Number of hospital beds /1000 persons �Number of doctors/1000 persons��Proportion of communities with access to health services �Proportion of persons correctly immunized in the target population by vaccine �Number of pregnant women with prenatal care out of 1000 live births �Proportion of children 6-71 months who received at least two vitamin Acapsules within the past 12 months��Proportion of households using iodized salt��Proportion of women who tool the recommended number of iron/folate tabletsduring their last pregnancy

Proportion of households with access to potable water��Proportion of households with access to safe latrines �

Proportion of persons > 15 years with complete primary level education (out oftotal population or population of women) �Proportion of persons >15 years who can read or write (out of total populationor population of women)��

Number of community based groups that can be mobilized for action��Nature of leadership �

Number of development efforts initiated by the community or their leaders �

� = frequently used � = often used � = rarely used*Based on a review of 6 community nutrition programs implemented in the sub-region

APPENDIX 4

TYPES OF INFORMATION COLLECTED DURING NUTRITIONAL STATUS ASSESSMENT*


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72

APPENDIX 5

STRATEGIES EMPLOYED BY COMMUNITY NUTRITION PROGRAMS

♦ Promotion and monitoring of growth – it permits the early identification of malnourished children. Growthmonitoring can be used as an educational tool to teach mothers how to monitor the progress of their child’sgrowth and detect when things begin to go wrong in order to seek special attention. Community participa-tion can be enhanced with the use of community based growth monitoring which has the capacity topromote empowerment at the community level to the extent that mothers in particular can understand andmonitor the health of their own children. It can be linked with food supplementation programs to screen foreligible beneficiaries.

♦ What should/could it involve?

� Community based weighing of children between the ages of 0 and 3 years, and interpretation of the growth curve so that a mother can follow the progress of her child’s growth� Counseling to identify causes of poor growth, discuss remedial actions, and give encouragement when things are going well� Referral of children identified as malnourished to the nearest health facility� Follow-up of malnourished children at the home level to monitor progress and identify possible obstacles and constraints to adoption of good practices.

♦ The fight against micro-nutrient deficiencies – it favors the reduction in prevalence rate of micro-nutrientdeficiencies at levels of public health concern. Due to the relationship between the deficiency of certainmicro-nutrients and some childhood diseases, micro-nutrients interventions are sometimes employed toreduce the risk of childhood diseases such as measles, acute respiratory tract infections and diarrhoea.The micro-nutrients most often considered are vitamin A, iron, folic acid and iodine..


� Distribution of micro-nutrient supplements, in the case of vitamin A, iron and folic acid� Promotion of production and consumption of micro-nutrient rich foods� Deparasitation in areas of parasitic infestation� Malaria prophylaxis particularly to reduce risk of anaemia in pregnant women� Salt iodisation to address iodine deficiency.

♦ The utilization of participatory IEC techniques - it is aimed at helping individuals make informed choicesthat will result in behavioral and attitudinal change where inappropriate behavior, attitudes and practices asa result of cultural beliefs, poor education, poverty are contributing factors towards high malnutrition. It canbe used to favor the adoption of best practices by the community.


� Interpersonal communication (peer counseling – improves outreach and community participation)� Cooking demonstrations, promotion of weaning foods based on locally available products� Mass communication,� Participatory/interactive methods of communication (e.g. griots, role plays, songs, games, opinion leaders e.g. religious leaders)

♦ The prevention and management of childhood diseases – e.g. diarrhoea, malaria and acute respiratorytract infections. Childhood infections are a major cause of malnutrition and mortality.


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73


� Promotion of ORS/ORT� Education on appropriate feeding of sick children during and after illness� Promotion of good hygiene and sanitation� Referral of sick children to an appropriate health facility for treatment of infections� Immunization against childhood communicable diseases

♦ Promotion of maternal health – it is aimed at improving well-being during pregnancy and preventingchildhood malnutrition through the reduction in incidence of low birth weight babies. Maternal healthinterventions are usually employed in communities where poor access to proper antenatal care, inadequatefood intake during pregnancy, high fertility rates and high rates of pregnancy anemia are major factorscontributing to childhood malnutrition and maternal morbidity and mortality.


� Promotion of good ante-natal care� Promotion of family planning and birth spacing� Promotion of improved maternal dietary practices (Maternal dietary supplementation should only be

considered where the supplement is based on locally available commodities and if the community is able to provide some of the resources needed for the procurement of the commodities).

♦ The implementation of community development activities – these involve strategies to address thebasic causes of malnutrition such as insufficient income, illiteracy, high maternal workload, food insecurityetc. They contribute indirectly to the improvement of nutritional status.


� Functional literacy and numeracy skills training,� Promotion of income generation activities, (micro-enterprise development)� Promotion of agricultural diversification� Promotion of increased food security,� Construction of cereal banks,� Promotion of animal husbandry,� Training in food preservation and processing techniques,� Improved access to credit,� Improved access to labor saving devices.


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74

APPENDIX 6

GUIDELINES FOR TEACHING ADULTS

• Lessons should be well organized and prepared at a basic level.

• Lessons should be brief and to the point. Most adult trainees will forget the essentialpoints if too much is presented at one session.

• Teach the skills that the trainees want to learn. The order of the sessions can bechanged to suit the needs of the group. Begin with those topics of most interest to thetrainees.

• Teaching adults new techniques and ideas is a slow process requiring repetition.Tact and patience is needed. Repeat all important ideas and procedures, several times,if necessary. Use the beginning of each session to revise the lessons of the previoussession. Repeat important ideas at the end of each session. Go through the revisionquestions at the end of the session and/or at the following session.

• Demonstrate all lessons where this is possible. For example, bring real foods andcook a balanced meal. Ask the trainees to demonstrate and practice all practical skills.Go to a family compound for demonstrations when possible.

• Conduct role playing exercises. This is a very good way to act out a procedure or aproblem situation. Take care to explain the purpose of the role play clearly. Avoidcriticizing a trainee during a role play or demonstration. Afterward, discuss what happenedand what was learned.

• Encourage trainees to participate in discussions as equal partners. Trainees havevaluable experiences and knowledge of local conditions. They understand the customs,beliefs and practical problems faced by their communities. Questions and discussionskeep trainees alert and interested. Do not be judgmental, nor criticize opinions withwhich you disagree; rather, facilitate a discussion to obtain different opinions.

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