In villages across Tanzania, a seemingly modest process began in the early 1980s when villagers, many of them in poor and remote areas, began to track the weight of their children. With financial support from the Government of Italy and day-to-day technical support from UNICEF, the Child Survival and Development (CSD) Programme began in five districts in the Iringa region, eventually reaching more than half the population of the country.
The result was the virtual disappearance of severe malnutrition -- and striking reductions in mild and moderate malnutrition. The lives of thousands of children were saved. These improvements were accomplished against the backdrop of previously high mortality and malnutrition rates among young children that began to climb in Tanzania following the economic decline in the 1970s and 1980s. Of crucial importance was the Government's continued commitment, even during this difficult period, to policies worked out with the full participation of communities and families. This approach that was to prove one of the greatest strengths of the CSD Programme.
A community-wide picture
A major feature was community-based growth monitoring, which allowed the parents and other community mem bers to assess the nutritional well-being of their own and other children in the village. The results could then be compared with figures for neighbouring villages and those throughout the country.
These assessments provided a baseline at the start of the programme and were repeated every three months thereafter to follow the progress of individual children. When the results for all the children in the village were added together, they provided a concrete measure of nutritional well-being and development for the whole community. These quarterly weighing sessions sparked the participation not only of fathers and mothers, but also of the whole community in analysing why children were malnourished and why some seemed to thrive while others did not.
An improved understanding of the factors involved in the nutritional well-being of their children in turn helped the villagers to plan and initiate actions that would contribute to better growth and overall child health.
Subsequent weighing sessions helped parents and villagers evaluate the results and effectiveness of the actions taken and consider new or modified actions. In this way, continuous cycles that combined assessment, analysis and action -- the 'triple A' approach -- were established, helping spark successive nutrition improvements in the programme villages (Fig. 8 Panels 9 and 10).
The steps the villagers took were aimed at increasing feeding frequency; encouraging better use of basic health services; training health workers, including skilled birth attendants and healers; improving the home treatment of diarrhoea and other illnesses; strengthening household technology to improve the porridge made for young children; re ducing vitamin and mineral deficiencies; supporting activities such as small animal husbandry and home gardening; and improving sanitation.
From bystanders to participants
The simple tool of growth monitoring allowed the villagers to make better use of their own creativity and resources, to express their requests for external support more clearly and to become less dependent on such support.
One thing the Tanzanian CSD Programme did not do was increase the production or availability of basic food. While food is obviously essential for good nutrition, the success of the Tanzanian approach suggested that an overall lack of food at the household level was not the major cause of malnutrition in young children and pregnant women in the villages. Less tangible, but singularly important, was the transformation that many communities underwent. From passively enduring economic decline and marginalization, villagers became active participants for change, formulating and carrying out policies that led to better lives for their children and themselves. A major feature of this transformation was the emergence of women as central players, making decisions at both the community and household levels, with local support in the form of start-up financing for their income-generating activities.
Two other factors underpinned the success of the programme: univer sal education, including adult education, and a high level of political mobilization in Tanzanian villages that provided an organized system of communication.
Despite setbacks, durable progress
The Tanzanian experience was hardly perfect. When decisions are made through a repetitive, collective pro cess, false starts and mistakes are inevitable. Gains also have been difficult to sustain in some areas. But durable progress has been made: Com mun ities have actively taken up the fight against malnutrition, and they have collected and analysed information themselves. The sense of power and commitment gained through such a process is not quickly relinquished.
Photo: When women are respected and manage resources in a community, their own and their children's nutritional status improves. Women in Bangladesh gain experience through their own small businesses.
About 10 years after the first successes in Iringa were reported, a comparable approach is now achieving very similar results in Mbeya, another part of Tanzania (Panel 11). Virtually the same community-based approach that had proven successful in Iringa and elsewhere in Tanzania was introduced in Mbeya. The improvement in the nutritional status of children there, again carefully monitored and documented, independently confirms the validity of this approach.
Nor is the community learning approach used in Tanzania by any means unique. In the heart of the Sahel, villagers in the Maradi region of Niger, with support from UNICEF and bilateral donors, have also begun to record their children's weight on a regular basis. These villagers face many obstacles that communities in Tanzania did not have -- little rainfall and a very short growing season, much less experience with participatory development, less support from the central level and a history of village-level decision-making that explicitly excluded women. But malnutrition has been significantly reduced, and the scale of their activities seems on track to rival that of Tanzania (Panel 12).
In Thailand, another success story
On the other side of the globe, Thai land has achieved stunning improvements in the nutrition of millions of its children through a combination of approaches, aided by a booming econ omy. The Thai Government estimates that malnutrition of under-five children fell from about 51 per cent in 1982 (measured as a proportion of underweight children) to about 19 per cent in 1990, and that severe malnutrition virtually disappeared during that period. At the local level, growth monitoring and promotion (GMP) coverage increased nationwide from about 1 million children to about 2.6 million.
GMP was combined with supplementary feeding activities in some locations. In addition to this increased attention to nutrition, a number of policy and programme measures contributed to reducing malnutrition and poverty. Targeted to poorer regions, these included: school lunch programmes; surveillance of 'basic minimum needs' indicators; village-level planning to ensure that priority needs were met; rural job creation; and support for small-scale food producers. Community participation, in vary ing degrees, was part of all Thai programmes.
There is general recognition that more needs to be done in Thailand, but these remarkable gains are a solid foundation for the future.
Figure 8. Better Nutrition Through Triple A
The 'triple A' cycle of assessing a problem, analyzing its causes and taking action based on this analysis can be used at all levels of society to create processes whereby people's right to good nutrition is fulfilled.
Source: UNICEF, 1997
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