Supplementary feeding projects to

selected population groups are one

outlet for the food aid which is sent

to developing nations. The author

discusses the costs and benefits,

both nutritional and non-

nutritional, of supplementary

feeding projects, with two

questions in mind. He asks: are

supplementary feeding pro-

grammes an effective nutrition

intervention ; and should such

programmes be supported by food

aid or would their purpose be better

achieved with local food?

The author is currently agricultural

economist with the British Tropical

Agricultural Mission, Casilla 359,

Santa CFUZ, Bolivia. At the time the

article was written, he was a

temporary research officer at the

Institute of Development Studies,

University of Sussex, Brighton, UK.

Part of the research on which this article is based was carried out for Professor H.W. Singer at the Institute of Development Studies, in connection with A Survey of Studies of FoodAid which he undertook for the UN World Food Programme (WFP/CFA 5/5-C, March 1978): neither WFP nor Professor Singer bear any responsibility for the views expressed here. Professor Singer, however. provided guidance, encouragement and constructive criticism, for which many thanks. Thanks

continued on page 290

Food aid for supplementary feeding programmes

An analysis

Simon Maxwell

The idea of using the agricultural surpluses of rich countries to feed those left hungry by underdevelopment in poor countries has an appealing logic: appealing, of course, to those who see feeding programmes supported by food aid as an efhcient and appropriate development tool. However it is appealing, too, to farmers in rich countries who discover new markets for their products, to aid agencies which tap new resources and new layers of support for programmes overseas, to donor governments which solve domestic problems with foreign measures, and to recipient governments which by accepting aid can be seen to demonstrate a tangible commitment to the eradication of poverty.’

Such unusual confluence of interest makes it all the more important to be clear about the developmental impact of programmes. Programmes which are used to provide supplementary feeding to specific groups absorb only 10% of food aid2 but in 1973 accounted for an estimated 95% of all child nutrition programmes in developing countries.” Those figures, and the scope of this article, exclude emergency rations, but include all supplementary feeding programmes designed to increase the food intake of pregnant or lactating women and of children from the age of 6 months up to the end of primary school. There are some 40 million people in these groups receiving food aid each year, at a total cost in excess of $300 million4

The justification for supplementary feeding has often extended beyond the obvious nutritional case to incorporate a variety of non- nutritional benefits, ranging from improved school attendance and better relations between health clinics and their clients, to the stimulus of government ‘basic needs’ policies. Critics, on the other hand, have argued that the nutrition~ benefits are doubtful and that the non- nutritional costs are substantial, including a decline in breast feeding, the diversion of staff time at clinics and schools and greater dependence on imported food. To clarify the debate, this article will assess the nutritional impact of supplementary feeding and review the non-nutritional issues, and come to a conclusion on whether there are

0306-9192/78/040289-10 $02.00 0 1978 IPC Business Press 289

Food aidfor supplemelltan,feedingprogrammes

cunt;~uedffomp~ge 289 are due, too, to Ivan Behgin, Mark Bowden, Gill Gordon, Richard Longhurst, Sunil Mehra, Philip Pavne, Chris Stevens, and the participants of the International Peace Research Association workshop, Food Aid versus Self-reliance, in Amsterdam, January, 1978.

’ It is instructive, for example, that CARE is said to derive 90% of its annual budget from PL 480 food; Robert Gersony, private communication, February 1978. ’ Calculated from OECD Development Assistance Committee, Deve/upme~t Cooperation, OECD, Paris, 1976; US Congress, Food for Peace Program 19 74 Annuat Report, House Document No 94- 352, Washington DC, 1976; and WFP, Ten Years of WFP Development Aid, 7963-1973, WFP, Rome 1973. Most food aid (about two thirds) is sold on the market to extend supplies and generate funds: about 16% is used on food-for- work projects and the rest for emergency relief. 3Alan Berg, The Nutrition Factor, The Brookings institute, Washington DC, 1973, p 760. 4 Calculated from the sources indicated in Ref 2, allowing a third of total cost to be non-food, following the example of WFP, FoodAid and Education, WFP Studies No 6, Rome 1965, p 8; and WFP/FAO, ‘Strategies for establishing national supplementary feeding programmes’, in Protein-Calorie Advisory Group, The PAG Compendium, Worldmark, New York, 1975, Table 5. Berg, op cit. Ref 3, provides an unsubstantiated estimate that

125 million children receive supplementary feeding at a cost of $750 million per year. 5 Calculated from the sources indicated in Ref 2.

6 Cooperative for American Remit- tances to Everywhere and Catholic Relief

Services. 7 Mothers and young children were 61% of WFP’s recipients over the period 1963-

1972. 8 WFP, Ten Years of WFP Development Aid, op cit. Ref 2, Table 1 1. 9 Taken from PL 480 Annual Reports, US Congress, Washington DC. ‘OThere are other ways in which

supplementary feeding programmes might be categorized, differentiating urban programmes from rural ones, emphasizing the amount of food or the types of product consumed, or distinguishing the presence of a nutrition education comoonent. ri See, for example, International Bank for Reconstruction and Development (IBRD), Nutrition and Health of Indonesian Construction Workers: Endurance and Anemia, Staff Working Paper No 152. IBRD, Washington DC, 1973. ‘2 With regard to mortality: studies from

the American continent (R.R. Puffer and C.V. Serrano, Patterns of Mortality in

continued on page 29 1

290

better ways of tackling the nutrition problem, and of using food aid, than by supplementary feeding.

As a preliminary step, it is necessary to dispose of some descriptive material, since the term ‘supplementary feeding’ covers a number of non-comparable activities. In particular, the 40 million beneficiaries include three principal categories of people: school children, pre- school children and pregnant or lactating women (hereafter ‘mothers’). Historically 70-80% of recipients have been children receiving a snack or meal at school and most of the rest have been mothers; only a small proportion (less than 10%) have been children under six, the hardest group to reach but arguably that of greatest priority.5

The overall bias in favour of school children IargeIy reflects the orientation of the US Food for Peace Programme, which is the biggest both bilaterally (mainly through CARE and CRS6) and multilaterally (through its contribution to the World Food Programme - WFP). WFP has concentrated on mothers and young children,’ but it has a much smaller programme than the US, reaching 10 million recipients during the whole of the period 1963-72, compared to an annual average of over 40 million for the US’s PL 480 bilateral assistance programme. In recent years the American programme (excluding its contribution to WFP) has shown a decline in total numbers, from 47.6 million recipients in 1973 to 25.5 million in 1975, but an increase in the proportion of mothers and children, from 20% in 1969 to 30% in 1975.9 This latter trend is likely to continue.

Since most supplementary feeding is of schoolchildren, schools obviously constitute the most important outlet; health clinics and nutrition rehabilitation centres are also important outlets, however, and a significant part of supplementary food is handed over to families in bulk for consumption at home. No quantification is possible, but for analytical purposes three broad delivery systems must be considered: ‘on-site’ feeding; ‘take-home’ feeding; and intensive nutrition rehabilitation centres (NRCs). Several other factorsi will also be taken up in the following discussion, within the broad outline of a framework which stresses types of recipients and delivery systems as the key variables.

Nutritional impact

An assessment of the nutritional impact of supplementary feeding must be made in the context of a brief statement about nutrition priorities and alternative intervention strategies, if only to establish the point that there are priority objectives and alternative ways of reaching them: supplementary feeding is to be judged on a relative scale.

Priorities There is a clear case for concentrating effort on children under six who are already severely malnourished or are at risk of becoming so. Although malnutrition in adults may increase the prevalence of disease and reduce productivity,” severe malnutrition in pre-school children is recognized as both a greater threat to life and more likely to cause long term, irreversible damage to survivors.”

Research studies suggest that the priority group consists of the small proportion of pre-school children who have fallen into severe

FOOD POLICY November 1978

cuntjnued from page 290

Chj/d~oad, Scientific Publication No 262,

Pan American Health Organisation, Washington DC, 1973, pp 165ffi and the Indian subcontinent (S. Ghosh, The Feeding and Care of Infants and Young Children, New Delhi, 1976, p 46) are agreed that over half of all deaths of children under five are associated with either immaturity caused by maternal malnutrition, or developing malnutrition as children are weaned. In many cases malnutrition does not kill directly but acts synergistically with infection to produce fatal attacks of ‘weanling diarrhoea’ or of such infectious diseases as measles. See N.S. Schrimshaw, C.E. Tavlor and J.E. Gordon, Interaction of ~utrjtion and fnfection, WHO Monograph Series No 57, WHO, Geneva, 1968, pp 27 and 141. For data on measles see Puffer and Serrano, supra. p 165. The younger the child, the greater his/her vulnerability: mortality declines rapidly with age, falling in the case of one Indian study from 5.8% in the first month to only 0.55% in the whole of the third year. See A.A. Kielmann, et a/, The Narangwal Nutrition Study: A Summary Review, Department of International Health, School of Hygiene and Public Health, Johns Hopkins University, mimeo, Baltimore, 1977. Confirmato~ data from 8angladesh are reported by A. Sommer and M.S. Loewenstein, in ‘Nutritional status and mortality: a prospective validation of the QUAC stick’, in American Journat of Clinical Nutrition, No 28, March 1975.

Malnourished children who survive infancy may suffer permanent stunting (see J. Cravioto and R.R. de Licardie, ‘The effect of malnutrition on the individual’ in A. Berg, N.S. Scrimshaw and D.L. Call, eds, Nutrition, National Development and Planning, Massachusetts Institute of Technology Press, Cambridge, MA, 1973) and it is often argued that there is irreversible damage to mental development and learning capacity. Belli. for example, concluded that ‘malnutrition may reduce the intellectual capacity of a normal person to the level of an idiot’. See P. Belli. ‘The economic implications of malnutrition: the dismal science revisited’ in E/XC, Vol 20, No 1, 1971, p 15. See also M. Selowsky, ‘A note on pre- school-age investment in human capital in developing countries’ in EDCC, Vol 24, No 4, 1976. This view remains controversial and there is continuing debate on the respective roles of malnutrition and other psycho-social factors such as maternal attention and social stimulation. Nevertheless, a World Health Organization (WHO) symposium in 1974 did conclude that a child’s intellectual status was ultimately determined by an interaction between nutrition and other environmental factors. See WHO, ‘Malnutrition and mental development’ in WHO Chronicle, No 28, 1974.

continued on page 292

Food aidfor s~~ppletnentav~~eedingprogrammes

malnutrition and the larger numbers who are in risk of suffering the same fate. A WFP/FAO estimate in 1971 suggested a target population for these purposes of 130 million children and 65 million mothers;13 even this large number seems low compared to the 200 million children estimated to require supplementary feeding, in papers prepared for the World Food Conference in 1974.14 Even with a greatly restricted definition, therefore, the malnutrition problem remains immense.

By contrast, existing efforts at supplementary feeding are seen to be largely irrelevant to the real nutritional problem and, where they are reievant in terms of their target group, so small as to be insignificant. At least 70% of food aid is going to the lower priority recipients (school children),l~ but even if all of the 40 million recipients of food aid feeding programmes were in the priority group, 80% of those in need would be left untouched. An important argument against food aid supplementary feeding as a strategy is therefore that no conceivable programme is likely to do more than scratch the surface of the problem.

Alternatives Of course supplementary feeding is only one intervention tool, and it may not be the best. The list of alternatives is long, ranging from village health measures and nutrition education at one extreme, to land reform or higher prices for cash crops at the other.16 The list is long because the malnut~tion problem has many dimensions and choosing a particular strategy to apply in a given situation requires prior knowledge of just why malnutrition occurs.” Evidence is accumulating on the ‘ecology’ of malnutrition and suggests that poverty is the matrix binding other factors together. Individual nutritional status depends on such factors as food intake, infection, health care and the nutritional content of foods consumed;‘* but at a more general level the malnourished are the poor, the landless, the indebted and the unemployed. lg Within poor families, children suffer particularly,20 and among children, girls suffer more than boys.21

This type of observation leads some to believe that malnutrition can only be tackled by attacking poverty; often by this they mean an attack on structural problems such as inequitable asset distribution. Such interventionist tools as supplementary feeding are seen as ineffective because ‘unless the family income constraint is addressed the benefits of nutrition programmes to the poor may be minima1’.22 In particular, short term benefits may be lost when ‘children return to living conditions characterized by extremely deficient sanitation (and) a high risk of infectious diseases’.23

Studyingprogramme impact Is the negative view of supplementary feeding borne out by the facts? Surprisingly, considering the amount of money devoted to supplementary feeding, there are very few good, empirical studies of the impact of individual programmes, There are many descriptive evaluations but very few which measure changes in nutritional status during the course of a programme and fewer still which compare that change with an outside control group in order to eliminate biases caused by generally rising or falling conditions in the project area. Many studies which do report quantitative data are (legitimately) concerned with programmes that combine supplementary feeding

FOOD POLICY November 1978 291

Food aidfor supplement~r~feedi~g pragra~nme~

Table 1. Breakdown of case studies by food distribution method and recipients.

Take-home On-site Nutrition rehabilitation

Mothers

Pre-school children

Primary school children

A 8

India (Project Poshakj E Bangladesh (WFP 2226) F

G

K L M N

Colombia (WFP 095 & 549) Guatemala (INCAP)

centres

India (Project Poshak) Mexico (WFP 307) Colombia (WFP 095 & 549)

Andhra Pradesh, India Orissa, India Coimbatore, India (I) Coimbatore, India (2)

H Haiti (1) I Haiti (2) J Guatemala

Sources: (A) and (G) Colombia: WFP, Terminal Report on Project Colombia 095: Feeding Programmes in the repayment of Caldas, WFPflGC 18/l 0 Add 9, Rome. 1970, and WFP, Inferim Evaluation Report (Project Colombia 5491, WFP/IGC 30/l 1 Add A2, Rome, 1974; (B) Guatemala (INCAP): J.P. Habicht et al, ‘Relationships of birthweight, maternal nutrition and infant mortality’ in Nutrition Reports international, Vol 7. No 5, 1973: (C) and (E) India: T. Gopaldas et al, Project Poshak, two volumes, CARE, India, New Delhi, 1975; (0) Bangladesh: WFP, interim Evaluation Summary Reporf, Bangladesh 2226: Vulnerable Group Feeding in DistressedAreas, WFP/CFA 3/l 4 Add AlO, Rome, 1977; (F) Mexico: WFP, interim Evaluation Report {Project Mexico 3071, WFP/IGC 26/l 1 Add A3, Rome, 1074; (H) Haiti (1): W. fougere and K.W. King, ‘Capitulation as a key ingredient to eradication of severe malnutrition in children’ in Environmental Child Health, October, 1975; (I) Haiti (2) and (J) Guatemala: M. Beaudry-Darisme and M.C. Latham, ‘Nutrition rehabilitation centres: an evaluation of their performance’ in PAG Compendium, Worldmark, New York, 1975; (K) Andhra Pradesh, India: P. Roy and K.G. Krishnamunthy, Evaluation of Mid-day Meal Programme (Pilot Study Andhra Pradesh). Council for Social Development, New Delhi, 1970; (L) Orissa, India: P. Roy and R.N. Rath, School Lunch in Orissa, Council for Social Development, New Delhi, 1972: (M) Coimbatore, India (1): G. Xamalanathan et al, ‘Nutritional evaluation of school lunch programme in two selected villages’ in lnternafionai Journai of Nutrition and Diet, Vol 6. No 4, 1969; and (N) Coimbatore, India (2): U. Chandrasekhar and M. Amirthaveni, ‘The impact of school lunch programme on physical development, mental ability and certain behavioural aspects of selected primary school children’ in /nfernationalJournal of Nutrition and Diet, Vol 13, No 8, 1976.

con?;nuedfrom page 29 1

The WHO symposium also stressed a point often neglected in the literature on the effects of malnutrition, namely that ‘damage’ of whatever sort depends greatly on the degree of malnutrition. Thus severe malnutrition may produce severe effects, but mild malnutrition may not: in Bangladesh, for example, Sommer and Loewenstein (supra) have shown mortality rates of children suffering from severe, mild and no malnutrition to be in the ratios 13.4/l .7/l. Data from Guatemala, on the mortality associated with different birth weights, shows a similar risk curve, rising steeply as malnutrition worsens. See L.F. Mata, ‘Nutrition and infection’ in PAG B&et&, No 1 1, 1971. The important point, of course, is that depending on the country studied only 0.5-5.0% of the population under 6 suffer from severe malnutrition, whereas 4-40% suffer from moderate forms which may put them at risk but which are in themselves less damaging. See WHO, ‘Malnutrition and mental development’, supra. For confirmatory data, see F.J. Levinson. Morinda: An Economic Analysis of Malnufrition Among Young Chi/dren in Rural India, Cornell-MIT International Nutrition Policy Series, Cambridge, MA, 1974. I3 WFPfFAO, ‘Strategies for establishing national supplementary feeding programmes’, op cit. Ref 4. ?a UN World Food Conference, The World Food Problem: Proposals for National and International Action, Dot E/Conf 6514, Rome, August 1974, paragraph 482. I5 Calculated from the sources indicated in Ref 2.

with other interventions, notably nutrition education or health services, so that it is not possible to distinguish the change due to supplementary feeding alone;24 many are pilot studies which are of doubtful replicability;25 and finally, even where the quantitative impact of supplementary feeding can be isolated, there are disagreements about what constitutes an acceptable measure of nutritional status.26

In Table 1 a selection of the few available case studies which contain hard data is broken down into the main categories, discussed above, of recipients, and mechanisms for food dist~bution. The distribution of studies in the table reflects the availability of material and/or the direction of academic interest rather than the allocation of supplementary food, so that Nutrition Rehabilitation Centres, for example, are over-represented and school feeding is under- represented. Nevertheless it is possible from these studies to estimate in broad terms the impact of supplementary feeding. This may be done by looking first at the overall impact of the programmes and then, more particularly, at distributional questions.

The overall results are presented in Table 2, which distinguishes short term and long term impacts of the supplementary feeding programmes studied. At first sight the table is impressive with ten out of fourteen entries showing a significant short term impact and three out of four studies where the long term effects were studied showing a significant long term impact. One obvious conclusion is that the long term effects of supplementary feeding need further study; otherwise the results seem to show that at whatever cost supplementary feeding works.

Unfortunately, closer examination of the studies casts some doubt on this conclusion: several of them are really experiments with unusually good supervision (C, E and B); and others are evaluations

292 FOOD POLICY November 1978

a Letters refer to case studies in Table 1. Sources: See Table 1.

YE These and other alternative interventions are discussed by O.T. Oftedal and F.J. Levinson. Equity and Income Effects of Nutrition and Health Care, Princeton University-Brookings Institution project on income distribution in less developed countries, mimeo, 1974. “The importance of knowing who is malnourished and why is emphasized by L. Joy in ‘Food and nutrition planning’ in Journal ofAmerican Economics, No XXIV, January 1373. ‘*A simple framework for analyzing the source of malnutrition is provided by Levinson, op cit. Ref 12, p 6.

“Joy, op cit. fief 17, brings out the importance of aggregate demand rather than aggregate supply. “‘The income elasticity of food expenditure on children is perhaps only one tenth of that for the family as a whole - 0.08 as opposed to 0.8. See Levinson, OP cit. Ref 12, D 53; and S. Reutlinaer and G. Selowsky, ‘Malnutrition and Poverty: Magnitude and Policy Options, World Bank Staff Occasional Paper, No 23, Johns Hopkins University Press, Baltimore, 1976, p 38. ” See, for example, Indian Council of Social Science Research (ICSSR), Status of Women in India, ICSSR, New Delhi, 1975; Levinson, op cit. Ref 12: and Kielman et al, op tit, Ref 12. 22 Oftedal and Levinson, op cif, Ref 16, p 60. ” UN World Food Conference, op tit, Ref 14. p 146. z4For example, OS. Miller et a/, ‘The Ethiopian applied nutrition project’ in Proceedings of the Royal Society B, 194, London 1976: and Kielman et a/, op cif, Ref 12. “This is a point made in reviewing some promising pilot study results by D. Gwatkin, Health and Nuirition in India. a report to the Ford Foundation, New York, 1974. See also Behgin et a/, ‘The integration of nutrition into the health services of Northeast Brazil: supervised supplementary feeding’ in E&logy of Food and Nutrition. Vol 1, No 4. 1972.

26 For example, the weigh~age chart and its associated Harvard standard and Gomez classification (standards of ‘normal’ and varying degrees of malnutrition, based on weight-for-age norms) to measure degrees of malnutrition, are widely adopted but have been dismissed by one team as unacceptable. See I.D. Behgin and F.

continued on page 294

Food aidfor supplementaryfeedingprogramrnes

Table 2. Analysis of case studias.a

Long term impact: Significant Not significant Not assessed

Short term impact significant

H I N J ABCEFG

Short term impact not significant

DKLM

of programmes in good conditions rather than average ones (N). In at least one case the optimistic conclusions drawn are not warranted by the facts; statistical tests on certain results reported from Project Poshak (C) do not confirm the significant impact claimed.” Finally, in some cases (C, E and F) the value of the results is undermined by the failure to account for drop-outs.28

In many cases, therefore, it seems that supplementary feeding has not produced substantial nutritional benefits. The evidence suggests that well managed experiments can succeed but that large scale programmes are much less certain. In the literature, among the things that go wrong particular attention has been given to the mount of food programmed, to interruptions in feeding caused by logistical or financial problems, to health problems which prevent the benefit of extra food being realized, and to the ‘substitution effect’ whereby children share food with siblings or lose meals at home because of their participation in feeding programmes.29

All these di~culties apply more forcefully in backward rural areas than in progressive, urban ones, and the literature concludes that supplementary feeding has not generally been an efficient way of overcoming ‘urban bias’ or of redistributing to the poorest.30 Although programmes have been planned and implemented in rural areas, the use of existing networks of clinics or schools and unequal access to these institutions has often limited the impact.3’

It remains true that some forms of supplementary feeding have shown better results than others. Whereas the results for school feeding and take-home feeding are disappointing, and those for on-site feeding of pre-school children are at best ambiguous, the studies on maternal dietary supplementation and on nutrition rehabilitation centres have been more encouraging. There seems to be a particularly good case for maternal supp1ementation.32

Cost-effectiveness Whether those interventions that work are necessarily the best interventions is a question which can be answered by cost-benefit or cost-effectiveness calculations. Cost-benefit analysis of nutrition intervention has found valuation of the benefit extremely difficult, particularly when attention is focused not on such short term benefits as lower hospital costs, but rather on long term increases in productivity, income and national growth.33 Cost-effectiveness analysis has been preferred, therefore,34 but here direct Iinks have often been assumed, unjustifiably, between the provision of supplementary food and the realization of a nutritional benefit.35 In practice, no programme will affect all children equally and cost- effectiveness calculations should be based on anthropometric field data.

Such field studies as there are suggest that supplementary feeding is a relatively expensive way of saving lives. With the exception,

FOOD POLICY November 1978 293

continued from page 293

Viteri, ‘Nutritional rebab~~itatjon centres: an evaluation of their performance’ in PAG Compendium, Worldmark, New York, 1975. Their key argument is that malnutrition leads to stunting and thus distorts weight/age ratios. Other measures are available (eg, weight/height, akin thickness) but for the purposes of this analysis it is assumed that where weight/age has been used it provides a reasonable measure of progress over time. For no very good reason it is assumed that the bias is likely to be small. 27T. Gopatdas et a,, Project Poshak, two volumes, CARE, India, New Delhi, 1975. Tests for homoscedasticity and appropriate t-tests were applied to results from the ‘extensive’ take-home phase of the experiment. No significant differences were detected at the 5% level of confidence. *8 Different assumptions about the nutritional status of drop-outs have been explored (see F, Tables 1 and 2) for the Mexico project by the author and produce very different results. At best 45% of malnourished children demonstrate significant improvement: at worst only 24%. 29 For general discussions of what goes wrong with suppiementa~ feeding see Berg. op tit, Ref 3, pp 371-176; UN World Food Conference, op cit. Ref 14, paragraph 472: Behgin et al, op cit. Ref 25; and J. Gongora and D.J. Shaw. WFP Assistance for Supplementary Feeding Programmes, paper presented to FAO consultation on improving nutrition of the rural poor in Asia and the Far East, FAO, Bangkok, March, 1977. 30See WFP, Ten Years of WFP Development Aid, op cit. Ref 2, p 40: Oftedal and Levinson, op &jr, Ref 16, p 2 1; and Berg, up fit, Ref 3, p 7 70. 31 See, for example, C. Stevens, ‘Food aid and nutrition: the case of Botswana’ in Food Policy, Vof 3, No f r 1978. 3t Kietmann et al, up tit, Ref 12. 33 M. Selowsky and 1. Taylor, The economics of malnourished children: an example of disinvestment in human capital’ in &XXX, Vol 22, No 1, 1973. For a discussion of the assumptions used in this analysis see D.L. Call and R. Longhurst, Evaluation of the Economic Consequences of Malnutrition, Cornell Agricultural Economics Staff Paper No 43, Ithaca, New York, 1971. See also Befli, op cir, Ref 12, and discussion in ED&C, Vol23, No 2,197s. 34 J.M. Pines, ‘supplemental feeding and cost-effectiveness analysis’ in Cajantts, Vol 9, No 1, 1976. Other observers have included such criteria as community concern and political acceptibiiity. See D. Morley, Paediatric frioriries in the Develhping World, London, 1973. 35 Berq, for example fop cit. Ref 3. P 25),

assumes in his’ calculations that all children benefit equally; Reutlinger and

continuedonpage 295

294

perhaps, of matrxnal su~~l~m~~tati~n, basic health measures and nutrition education seem to be cheaper.36 The evidence suggests, therefore, that supplementary feeding may not be the way to tackle malnutrition. Some argue that improvements in feeding programmes can make them more cost-effective, 37 but this ignores the argument that the main reason supplementary feeding has failed is that it is au inappropriate, technical response to a social and political problem. As long as whole families are poor and hungry, attempts to feed children institutionally are likefy to be frustrated by health problems and ‘substitution’. Others argue, in favour of suppfementary feeding, that it may be a second-best intervention but it is the only one availabfe to foreign agencies whose resource is food. On this argument, the choice is not between supplementary feeding and, say, health care, but between feeding and nothing. 38 Such an argument has some appeal, but consideration is best deferred until below, after the non-nutritional factors have been examined.

Non-nutritional benefits

Cynics might suggest that the emphasis on the non-nutritionai benefits of supplementary feeding varies in inverse proportion to the nutritional success. Be that as it may, some authors have given great weight to non-nutritional benefits. 3g The benefits claimed inciude the provision of an income transfer to the poor, the improvement of school attendance and performance, the provision of a vehicle for heafth and nutrition education, the improvement of relations between health clinics and their clients, and the stimuIation of community organization.

Supplementary feeding does indeed provide an income transfer to poor families, and the subsidy invafved can be high. Stevens calculated that in Botswana a package of supplementary feeding for mothers and children might contribute 12% of income for families at the thirtieth percentile of income distribution and as much as 3 I % for the very poorest families in the first percentiles4 It is important not to double-count, by taking both nutritionaf improvement and the income transfer as benefits of supplementary feeding, but the notion of an income transfer provides a ~a~icularly useful way of affowing for food fast to the actual recipient by substitution. Data from India, for example, suggest that perhaps half of the food provided to school lunch recipients leaks as an income supplement to the rest of the familyq4’

School feeding does have a small impact on school attendance as well, and may improve performance. The evidence on this question is largely qualitative 42 but two studies in India by Prodipto Roy have found evidence of a 510% increase in attendance, especially in the lower classes of primary schools and among tribal chiIdren.43 The studies were not able to find any impact on performance, though one study at a school with a we11 organized programmer in Coimbatore India, did find significant improvements in mental abihty and behaviouraf characteristics.44

Supplementary feeding as a vehicle for he&h and nutrition education has been controversial, Stevens describes the debate between the ‘ration school’ and the ‘no ration school’: on the one hand it is argued that rations are a necessary incentive and that they provide the raw material for experimentation; on the other hand,

FOOD POtlCY November 1978

continued from page 294

Selowsky (op ci?, Ref 20, p 51.. failing into a different trap, define their objective in terms of food intake and not in terms of nutritional improvement in children who may be too ill to make use of extra calories. 36 In one Indian study. it was found that an infant death could be avoided for $222 by supplemental feeding, but for only $148 by providing basic medical services, and, for children aged 1-3 years, nutrition supplementation was up to 11 times more expensive in terms of lives saved than medical services. See Kielmann et al, op tit, Ref 72. In one case in Guatamafa, it was found that a child’s recuperation in a nutrition centre cost as much as $2671 when failures and control group comparisons were included in the costing. See M. Beaudry-Darisme and M.C. Latham, ‘Nutrition rehabilitation centres: an evaluation of their performance’ in PAG compendiums Worldmark, New York. 1976, p 11. 37 For example. M.C. Swaminathan, ‘Reaching the target group for supplementary feeding programme’ in Indian Journal of Nutrition and Dietics, Vol 14, No IO, 1977: and S. Reutlinger, ‘Malnutrition: a poverty or a food problem’ in World ~e~a/opment, Vol 5, No 8.1977. ” Stevens, op tit, Ref 3 1. 39 For example, P. Roy and R.N. Rath, in School Lunch in Orissa, Council for Social Development, New Delhi, 1972, p 106. 40 Stevens, op tit, Ref 31, Table 4. 4i P. Roy and K,G. Krishnamunthy, ~~a~~a~jon of ~~d-d~~ Meaf Programme IPiiot Study Andbra Pradesh), Council for Social Development, New Delhi, 1970. In the case of take-home distribution methods leakage will be even higher. See WFP, Interim Evaluation Summary Report, Bangladesh 2226: Vulnerable Group Feeding in Distressed Areas, WFPiCFA 3114 Add AfO, Rome 1973; and T. Gopaldas et a/, op cii, Ref 27. 42 See, for example. G. Coutsoumaris et al, Analysis and Assessment of the Economic Effects of the US PL 480 Programme in Greece, Athens, 1965; WFP, Jnterim Evaluation Report Malawi 525: Feeding in Educational and Public Health Cenfres, WFPiCFA I/l0 Add A9, Rome, 1976; and WFP, Food Aid and Education. op tit, Ref 4. 43 Roy and Rath, op cit. Ref 39; and Ray and Krishnamunthy, op tit, Ref 41. a’ U. Chandrasekhar and M. Amirthaveni, The impact of school lunch programme on physicat development, mental ability and certain behaviourat aspects of selected primary school children’ in lndian Journal of Nutrition and Dietics, Vol 13. No 8,1976. .a’ C. Stevens, The Uses of Food Aid in Upper Volta, Overseas Development Institute Working Paper No 5, mimeo, London, 1377. 45 For positive views see Berg, op tit, Ref

continued OR page 296

Food uid.fos supplernentar??/l?edingprograrnmes

rations increase the IikcI~hood that r~ip~ents will attend classes simply for the sake of a free handout.4s There is evidence on both sides.46 Perhaps a consensus was established by Behgin et aI who suggested that supplementary feeding could help nutrition education provided that the programme gave priority to education and used local foods within the budget limitation of the target famify.47 This, of course, imposes limitations on the role of food aid.

How far supplementary feeding improves relations between health clinics and their clients depends partly on how successfully the health programme reaches those who do not normally attend clinics. One study concluded that tnalnourished children very often do not attend clinics,48 but supplementary feeding programmes may tend to correct this. On the other hand it has been argued that if clinics provide basic services, clients are attracted irrespective of whether or not supplementary feeding exists. Supplementary feeding may then cover up deficiencies in clinic services.49

With regard to the stimulation of community organization, there is very little evidence; although on one WFP project the community contribution to non-food costs rose during the life of the project to 30% of the totaI,50 and in Botswana 86% of feeding centres were rurt by voluntary groups. 51 A priori, it would seem that mother/child programmes are mare likely to stimulate participation than routine school feeding, and that on-site feeding will stimulate the community more than take-home dis~ibution. However, in general it does not seem very likefy that supplementary feeding alone, independent of a community development programme with specific objectives, will have a very large long term impact.

In general the non-nutritional benefits of supplementary feeding can be characterized as small but significant; hardly sufficient to justify programmes on their own, but a useful addition to any nutritianal benefits. In addition, there are non-nutritional costs to be taken into account: supplementary feeding is said to have a disincentive effect on local agriculture, to be associated with a decline in breast feeding, to change food habits and lead to dependence on foreign food, and to cause a diversion of resources, affecting especially the work of teachers and health personnel.

That supplementary feeding should be linked to a disincentive effect is at first sight surprising. One of the inviolable assumptions of the food aid literature is that food aid used fur projects such as supplementary feeding increases consumption at the same time as it increases supply and thus eliminates any impact on price; while on the other hand food aid used to extend market supplies may (but may not) depress prices, discourage local agriculture and remove the urgency for government policy making tu increase agricultural output. 52 Yet there is some evidence that even food aid used in projects may have a disincentive effect, affecting not so much the price of agricultural products but rather the willingness of farmers to work their fields.5J On the other hand, disincentive effects are probably much less likely to occur as a result of routine supplementary feeding programmes than as a result of emergency feeding or food-for-work projects, where the quantities of food shipped are much larger and where there is a greater chance that

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con~jn~ed from page 295 3. p 175: and Gongora and Shaw, op tit, Ref 29. For negative views see G. Gordon, The Evaluation of a NutritiDn Programme in Northern Ghana, paper presented to Van der Burghs and Jurgens Ltd Nutrition Award Seminar, London, 1976: Guest 1 in New Internationalist, October 1977; and S. George, How the Other Half Dies, Penguin, Harmondsworth, 1976, chapter 8. 47 Behgin et al, op cit. Ref 25. 48 0. Cowan, Can Severe Childhood Malnutrition Be Prevented?, paper presented to Van der Burghs and Jurgens Ltd Nutrition Award Seminar, London, 1976. 49 Gill Gordon, private communication, December 1977. 5o WFP, Interim Evaluation Report (Project Colombia 549). WFP/IGC 30/t 1 Add A2, Rome, 1974. 51 C. Stevens, The Uses of Food Aid in Botswana, Overseas Development Institute Working Paper No 3, mimeo, London, 1976. 5* See, for example, A.H. Boerma, ‘The evolution of international food aid policy’ in Sir A. Cairncross and M. Puri, eds. Employment, Income Distribution and Development Strategy, London, 1976; and H. Mettrick. Food Aid and Britain, Overseas Development Institute, London, 1969. 53 F.C. Cuny, Food Donations After Disaster and in Relation to Agricuttural Development, edited interview, mimeo. February, 1977: R. Bunch and W. Ruddell, The Relationship between PL 480 Food Distribution and Agricultural Development in Guatemala, edited interview, mimeo, August, 1977: and WFP, Studies of the Role of Food Aid in Relation to Trade and Agricultural Development in Botswana, Lesotho and the Arab Republic of Egypt, WFPiCFA l/l 0 Add, Rome, 1976. 54 C. Stevens, ‘Food aid: more sinned against than sinning?’ in UDI Review, No 2, 1977. 55 George, op tit, Ref 46, p 198. 55 On the general milk question see New Internationalist, August 1973, March 1975, and April 1977; and D.B. Jelliffe, ‘Advertising and infant feeding’ in

Environmental Child Health. Vol 2 1, No 4, 1975. On the role of milk in distribution programmes see discussion in Berg, op cit. Ref 3, pp 89-106: and P. Hakim and G. Solimano, ‘Supplemental feeding as a nutritional intervention: the Chilean experience in the distribution of milk’ in Environmentat Child Health, Vol22, No 4, 1976. $’ With respect to high protein foods, Orr has found indications that ‘the lowest income groups, for whom these products are primarily intended, are not likely to be the orincioal beneficiaries, unless through institutional distribution’. See E. Orr, The Use of Protein Rich Foods for the Relief of Malnutrition in Developing Countries: An

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donated food will find its way onto the market. If there is a risk of a disincentive, it can usually be avoided by careful control, and Stevens has concluded from case studies in Botswana, Lesotho and Upper Volta that the disincentive effect of project food aid is insignificant.54 It does not in fact seem very likely that a man will work less hard because his child has lunch at school.

However, the child may come home with different tastes and it has been argued that supplementary feeding can change food consumption habits, leading the family to a consumption pattern that is somehow suboptimal and increasing the dependence of the country on imported foods. A detailed exposition of this argument has been written by George, who concludes that the ‘vital role of Food for Peace in its professed aim of developing commerci~ markets is definitely not to be sneered at’.“5

The mechanism by which this process is said to occur is that family expenditure patterns are distorted in favour of high cost products as a result of familiarity bred by feeding programmes. Milk products and protein-rich infant foods would be the two likely items of expenditure: neither is necessary to a child’s diet, both are relatively expensive and both are used in feeding programmes. There is some evidence that the use of milk products in food aid has contributed to the decline of breast feeding, with a heavy economic cost and negative impact on health.56 But the mechanism is not well established: many families in receipt of supplementary feeding will be too poor to afford ‘status’ foods at any price so that they will be unaffected by the composition of their rations.57

A clearer relationship can be established with regard to the diversion of human resources caused by supplementary feeding. Here the argument is that administering supplementary feeding programmes diverts people from their primary jobs, so that the value of the programme has to be offset against the cost of other work left undone. The argument applies not only to planners, administrators and nutritionists at the central government level, but also, and more particularly, to school teachers and workers in health clinics, who are expected to service supplementary feeding programmes in addition to their normal duties. Roy and Rath chronicle the misery of the teachers responsible for the school lunch programme in Orissa, with no government grant for a cook and no assistance with the administrative burdens of food collection or storage; the general impression is that there is little time for actual teaching.58 Similar effects may be found in health clinics,5g which leaves the net effect of supplementary feeding very much in question.

Clearly the sum of these indirect, unintended costs is difficult to assess in general terms; and clearly it will vary from case to case. The effect of supplementary feeding on agricultural production and on imports of food will depend very much on government policy; the effect on family consumption habits is likely to be outweighed by other in~uenccs; and the effect on teachers and health workers will depend primarily on how well supplementary feeding programmes are financed and on how well the community is organized to support the programme. Taken together, the indirect, non-nutritional effects at best introduce a risk of unintended costs; at worst the costs counter- balance any non-nutritional benefits and may well outweigh them.

Thus, the non-nutritional impact of supplementary feeding is certainly not overwhelmingly positive: there are small but significant

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Foodnidfor supplementaryfeeding programmes

benefits, notably a subsidy to family income, an increase in school attendance and a better relationship between clinics and clients. But these are to a certain extent offset by the amount of time which the staff of feeding institutions must spend servicing feeding programmes and which is therefore lost from their normal duties. There are other benefits, less well established, such as the potential for nutrition education; but there are also other potential costs, such as a decline in breast feeding and greater dependence on imports. In aggregate it seems not unlikely that all of these will cancel out.

coniinued from page 296

Analysis of Experience, Report G 73 of the UK Tropical Products Institute, London, 1972, p 55. Gopaldas, reporting on an attempt to distribute weaning foods through market mechanisms, concluded that ‘the most needy of the target children could not be reached even through the most heavily subsidized food distribution mechanism’. See Gopaldas, op tit, Ref 27, p 190. Even where less poor families are switching from traditional ‘cheap’ foods to modern, ‘expensive’ ones, there are likely to be other influences in addition to the supplementary feeding programme. The decline of breast feeding, for example, has been attributed to a rise in the participation rate by women in the work force, to advertising, to stress, to convenience and to social attitudes. See Berg, op cit. Ref 3. and Selowsky, op tit, Ref 12. se Roy and Rath, op tit, Ref 39, p 54. See also F.J. Levinson, ‘Our child feeding overseas’ in Journal of American Diet,

Vol 57, No 6, 1970. 59 Berg, op cit. Ref 3. p 161. 60 See Gordon, op cif, Ref 46: and Behgin et al, op cit. Ref 25. 61 Gopaldas, op cit. Ref 27. ” Ibid.

Conclusion

From the discussion above, a number of conclusions have emerged. First, existing supplementary feeding reaches only a very small proportion of the priority target group. Second, supplementary feeding has in practice proved largely ineffective in nutritional terms. Third, even where it has been nutritionally effective supplementary feeding has not proved to be cost-effective. Fourth, small non- nutritional benefits may be balanced by non-nutritional costs. It would seem that a more frontal attack on poverty is needed. But what if such an attack is not forthcoming? Can supplementary feeding then be a way for international agencies to provide a palliative? Two final points will suggest that the answer to this question is ‘no’.

If supplementary feeding is to be undertaken at all, there are very good reasons for using local food. There are very good educational reasons, especially in cases where mothers are expected to absorb new food habits and apply them at home;‘jO and often there are also very good cost reasons, as has been demonstrated by Gopaldas.61 In the course of Project Poshak in India, experiments were carried out with an indigenous weaning food prepared in the villages. Acceptibility was found to be better than for imported food, the impact on weight was found comparable, and the local preparation of the food was found to encourage community participation. Most important, the indigenous food was much cheaper: although it had a slightly lower protein content than the imported commodity, the calorie count was similar and the indigenous food cost only one third the price of its imported competitor: 0.13-0.15 rupees per 100 g distributed, compared to 0.40 rupees.62 If not for the fact that imported food is often food aid and apparently free, this difference in cost would probably ensure a greater use of domestic food resources for supplementary feeding. But as it is, the availability of food aid seems to encourage continued use of imported commodities, with the high cost and attendant risk of taste distortion that imported food entails.

A second reason for a negative answer to the question posed above is that the food aid used in supplementary feeding programmes is not actually ‘free’, because although it may be grant aid, it does have alternative uses. The most important of these is sale on the market in recipient countries to extend food supplies and generate funds; other uses include the payment of workers on food-for-work sites, the building up of stabilization reserves and (in the case of dairy products) assistance in the development of local dairy industries. All of these uses remain controversial and food aid has been criticized on many grounds. It is seen by some observers as a tool of foreign policy used to reward allies and provide indirect support to military budgets;

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53 These arguments, and others, are extensively discussed in S.J. Maxwell and H.W. Singer, ‘Food aid to developing countries: a survey’ in World Development, forthcoming. 64 Ibid. 651bid. Certain products do, however, present special problems and the survey recommends further research on the use of dairy products, notably on the income distribution effect of dairy industry pump- priming operations, such as Operation Flood in India. A rather different problem is presented by products manufactured specifically for feeding programmes, such as wheat-soy blend. These have few alternative outlets, and add considerably to the cost of food aid shipments without adding noticeably to their nutritional value. It may be that they are not required. 66 Reviewed in S. Maxwell, Food Aid, Food for Work and Public Works, Discussion Paper 127. Institute of Development Studies, University of Sussex, UK, 1978. “A recent IBRD study, for example, which examined the experience with public works, found B:C ratios of 2.0-3.6 with a discount rate of 12%, and internal rates of return of up to 18.4%. These are certainly much better figures than the literature on supplementary feeding has been able to produce. IEiRD, Public Works Programmes in Developing Countries: A Comparative Analysis, IBRD Staff Working Paper No 224, Washington DC, 1976. Public works programmes do, however, raise a number of problems and are bound by many of the same political constraints that limit the effectiveness of supplementary feeding. The literature is reviewed in S. Maxwell, op tit, Ref 66.

it is seen by others as a way for donor countries to expand their commercial food exports; and it is seen by others still as seriously damaging to self-reliance efforts through its effect on the price and hence the production of food in developing countries (the so-called ‘disincentive effect’).63

While there is evidence in specific countries to support many of these criticisms, it is not clear that they have universal applicability, and a recent survey has concluded that food aid can be a valuable development resource if the products are appropriate and the uses carefully controlled. 64 It seems that open market sale may be the best way to use food aid, provided that local production is safeguarded by demand expansion and that complementary aid is available to prevent inflation in other sectors.65

That some of these alternative uses of food aid offer a greater return than supplementary feeding may be illustrated by reference to the literature on public works and food-for-work.66 Food aid may be used either to pay workers directly in kind, or, preferably, for open market sales to provide governments with some of the real resources needed for public works. The benefits of such schemes accrue largely to the poor, at least in the short run, and the rates of return may be considerably higher than from supplementary feeding.67 Public works prqjects are focused on the poor to at least the same extent as is supplemel~tary feeding. Their benefits may not reach children in particular as ef~ciently as do those of supplementary feeding, but other measures may compensate (for example nutrition education) to modify intra-familial distribution.

The use of food aid in supplementary feeding should be approached with caution. Even if the case for supplementary feeding per se can be made in certain circumstances, the case for supporting supplementary feeding with food aid is much harder to establish. As long as more attractive outlets exist for food aid and until supplementary feeding can be seen to be more successful than it has been, the logic underlying the use of food aid to support supplementary feeding is less appealing than at first appears.

Simon Maxwell will continue his discussion with a supplement to this article, illustrating the importance of tracing the nutritional status of dropouts from supplementary feeding programmes, in the February 13 73 issue ofFoodPolicy.

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