AFRO-NETS> Food for a sceptic's thought

[Claudio Schuftan <aviva@netnam.vn>]

Food for a sceptic's thought
----------------------------

AIMING AT THE TARGET: WHAT'S LEFT FOR THE DEVIL TO ADVOCATE?

Some thoughts on the setting of goals and targets in nutrition: Have 
they helped progress or not?

The big hype:

There is a big difference between the excitement and the expectations 
generated while preparing for a big international gathering to set or 
to monitor the status of time-bound, monitorable global goals and 
targets, and saying that the same will be or are being really useful. 
Keep in mind that setting these goals is the result of a process in 
which public admission of dissent is difficult. Therefore, countries 
pledge, but do not really embark and comply.

The real challenge, therefore, comes after the (usually expensive) 
international gathering. It comes during the process of preparing, 
finding the funding and executing down-to-earth action plans. Unfor-
tunately, this process is rarely participatory. And for this process, 
the international conference, more often than not, is not too help-
ful, because the respective strategies to achieve the targets are 
left a bit in the air (or in the paper).

The outcome-process riddle:

Getting to where we want to go requires not so much knowing and quan-
tifying where we want to be at a given time, but more so the proc-
ess(es) through which we are going to get there. Goals and targets 
address the former. Processes are left to the planners and implemen-
ters to decide/execute --often excluding community representation. 
But it is the process that carries in it the seed of sustainability. 
Unfortunately, as nutrition professionals, we fear prescribing proc-
esses (or denouncing processes we know do not work or are not work-
ing). We also have not spent the time to arrive at universally ac-
ceptable indicators that can measure sustainable progress in proc-
esses such as participation, mobilisation and empowerment. Instead, 
we have spend time and money choosing and monitoring outcome goals 
and targets that have unduly overmedicalised the nutrition problem. 
Think about it.

Being realistic:

With a pinch of self-criticism, some goals and targets set in the 90s 
called for a number of pretty unrealistic measures, unaffordable to 
most developing countries' state coffers. With low resources, one 
cannot but get low coverages --and this is by definition, not only 
ineffective, but also wasteful. The danger I see is that we may be 
doing it again for goals to 2015. At the moment, we have no assur-
ances that the new set of goals will mobilise leaders, the media and 
members of civil society any more than before. Business as usual will 
not get us there for anaemia, stunting and underweight: at present 
rates, it will take us decades to halve the prevalence of child mal-
nutrition.

Moreover, three serious concerns arise here.

One is on who the judges should be of what is realistic. Certainly 
not only us the technicians. And certainly, realism can no longer be 
based on global, across-the-board targets. Another related concern is 
that being realistic also has to do with the quality of the data we 
use to monitor progress towards achieving the respective goals. If 
the latter is poor, the intrinsic value of the number reflecting how 
far one is from achieving the target can certainly be misleading. 
This comes out clearly in the responses we received to the question-
naire sent out to field workers which you can find in the next sec-
tion. The third concern is that I still find colleagues saying that 
this or that goal may be ambitious. I think the time has passed for 
'maybe' positions. [I am reminded of a small poster hanging on the 
wall of my office which reads "I said maybe, and that's final!"]. The 
facts are out. After democratic consultation, we are expected to en-
dorse concrete advice on directions and finish lines.

On convergence:

An issue not often touched is the convergence of some of the goals 
and targets set in the 90s. Even if they branch out to achieve dif-
ferent primary outcomes, actions to overcome more specific aspects of 
malnutrition can be additive. For example, improvements in vitamin A 
status positively affect nutritional anaemia; improvements in iron 
status can positively affect the appetite of a child. Quite a few 
other examples can be found. Our actions to address micronutrient de-
ficiencies and chronic malnutrition are thus complementary and impact 
on the overall well-being of individuals. But these individuals live 
in imperfect societies that cause them to suffer from the different 
forms of malnutrition. I guess what I want to highlight is the cen-
trality of the individual with her/his multifaceted problems. With a 
goals and targets mindset, we tend to forget and depersonlise the in-
dividual, especially the fact the s/he lives in an adverse environ-
ment. Yes, we can get the retinol levels of a child up to normal, but 
the child goes on to die very anaemic from malaria. So, to what avail 
our efforts? We simply cannot afford to miss the big picture.

When it comes to processes, it behoves us to jointly embark on the 
processes needed to make change sustainable. The processes still in 
need of much more convergence are those related to tackling the un-
derlying and basic causes of malnutrition. Much more needs to be done 
on this, perhaps starting with the demedicalisation of our goals, as 
well as with focusing more on these processes than mostly on out-
comes. And this applies to all of us.

The Human Rights twist:

As members of institutions and/or as individuals, many of us are mov-
ing towards a change in the paradigm giving direction to our work. 
What we may not have thought enough about is that goals and targets -
-many of them intermediate in nature-- are, in a way, antithetical to 
the Human Rights paradigm. This, because it rests on the principle 
that we cannot rest until the rights of all are restored or instated, 
i.e. a target of 100% ...not ten years down the road, but the soonest 
possible. Consequently --and being realistic-- we should be talking 
of steps to be achieved in the process of fulfilling the Human Rights 
of all claim holders. In our case, the issue is nutrition rights and 
food as a right. And, for most of us, this is a whole new approach.

A complementary compromise position could be to start working on 
goals and targets in reverse. We could express targets as an expected 
decrease in the number of malnourished (or what it will still take to 
close the gap and uphold the right of 100% of them).

The equity factor:

Reaching targets (usually followed by a congratulatory stage) can be 
misleading. Applying all prescribed interventions primarily to the 
easier-to-reach near poor --say the second lowest income quintile-- 
can, eventually, get us to achieve national targets on schedule. I do 
not need to tell you what this means to equity. Here, I just want to 
bring to your attention what some are calling the distributional con-
cerns of (sometimes short-cut) actions (imposed) to achieve goals.

On accusations of dependency and top-down implementation:

The achievement of micronutrient goals has created dependency. How? 
Not only are many iodine deficiency disorders (IDD) and vitamin A de-
ficiency disorders (VADD) schemes top-down --with an element of de-
pendency there-- but supplies and other resources are, more often 
than not, donor provided. In the long run, in terms of sustainabil-
ity, what worries some of us is the 'ownership-donorship' interplay. 
At the end of the day, it is a zero sum game.

On this issue of top-down, I do disagree with what some colleagues 
imply when they tell us that solutions lie in a continuum from verti-
cal micronutrient interventions to those addressing stunting and un-
derweight so that the former call for vertical goals which need lit-
tle action at community level and only the latter need active commu-
nity involvement; I disagree with them when they say that it is only 
when goals need action at community level that actionable levels must 
be consulted with community representatives. To me, the idea of 'some 
amount of community action' is non-sensical. Implying that for child 
chronic malnutrition most actions are to be devised and carried out 
by the community implies shifting the responsibility for having so 
many malnourished children among them to the community itself --so 
they better deal with it.

Donors (and we ourselves) touch some projects more than others: What 
are the reasons for a lack of commensurate donor support for iron de-
ficiency anaemia (IDA) and for the reduction of child malnutrition? 
Does it have something to do with donor fatigue or with targets for 
these two having been set at unreasonable levels? (Remember that, 
justifiably or not, UNICEF dropped the monitoring of the underweight 
goal from its mid-decade review). Are we then in part responsible for 
having set ourselves up for failure? I tend to think that the re-
sponse to the latter two questions is no. In the eyes of donors (.and 
many amongst us) IDA and chronic malnutrition are more messy to deal 
with than IDD and VADD. There is all this bottom-up, community ac-
tion, poverty alleviation, equity and other such involved in them, as 
well as longer time horizons. Donors pay plenty of lip service to 
these more than, so far, embarking head-on on working on solutions 
for them. That is not fatigue; it is not a lack of will, it is a po-
litical choice. Internal and external resources allocated to IDA and 
under five malnutrition have thus remained a pittance, unmatched to 
the challenge. And there is nothing in sight that tells me that this 
is changing soon.

Again, it is in the process of selecting the strategies and the steps 
to progressively achieve them where donors and many amongst us have 
been and continue to be undemocratic and where we have failed those 
whose nutrition rights are being violated. As long as we consider the 
strategies needed to tackle the basic causes of malnutrition to be 
outside the realm of our professional scope of work, we should con-
sider ourselves part of the problem and not the solution.

The poverty alleviation connection:

Will the new global shift of all donor agencies towards poverty alle-
viation strategies happen? and will it change what has been said 
above? The reduction of child malnutrition has now been selected as a 
key outcome indicator to measure progress in poverty alleviation. 
But, alas, this does not automatically translate into greater advo-
cacy, more actions and more donor resources going for the prevention 
of malnutrition. Being an indicator does not translate into being the 
object of concerted new efforts and investments directed at halving 
malnutrition. We have a lot more to do here. Improved socio-economic 
status will improve nutrition, but we know that is only part of the 
story --although quite a big one.

To sum up, the take-home message perhaps is that there is probably no 
such thing as across-the-board realistic targets. At most, they can 
be proposed by us on some technical grounds. But consensus must be 
painstakingly built for them in many, many places with both bottom-up 
and top-down inputs. There simply are no short-cuts. Goals or no 
goals, for people to gain control over the resources they need to 
overcome all aspects of malnutrition remains the key. Remember UNI-
CEF's conceptual framework of the causes of malnutrition and the bot-
tom-centred (top-down and bottom-up) AAA (assessment-analysis and ac-
tion) process.

Claudio Schuftan
Hanoi, Vietnam
mailto:aviva@netnam.vn 

--
Send mail for the `AFRO-NETS' conference to `<afro-nets@usa.healthnet.org>'.
Mail administrative requests to `<majordomo@usa.healthnet.org>'.
For additional assistance, send mail to:  `<owner-afro-nets@usa.healthnet.org>'.