.;:. /. ·- . .- .· . . ·.· WorlffBilnkllepl'int Series: Numb.er 418 ·. · . }'~~'..~~~~ was .qrst· p~bli!)hed 'in Foqd P~licy,~ yol. ·12,. no:. 4 ·.(November·· 1987),· pp. 365--ZS. Reprirife(l: Withpeflnission frotn But.terworth Sc:ieritific Ltd,, England. · .· ·· · ?) ', . . :, '· ,X::.:·;:·.-~:::·.-:: ~:.·, <. ~ '.:··'.- ., -.. , -· -. --~,;. 'h" Rejoinder Nutrition planning is alive and well, thank you Alan Berg This article is a rejoinder to an article by The reports of my death are greatly exaggerated. John Osgood Field which discussed Mark Twain (cable from London the failure of multisectoral nutrition to the Associated Press, 1897) planning. The author argues that, although nutrition planners may have been overly optimistic in their hopes Moved by John Osgood Field's recent post mortem for multisectoral that political systems could be made nutrition planning, 1 I went in sadness to the funeral parlour to pay my responsive to the problems, significant last respects. What a shock to find that the coffin was empty. Just as advances have been achieved. He out- lines many of the successes of nutrition puzzled were the many progeny of nutrition planning who were milling planning and the importance of multi- about. There were also a number of close relatives, who looked a lot sectoral work. Malnutrition Is a problem like nutrition planning but whose names were different - nutrition that escapes all the standard program- mes, and cannot be tackled through the surveillance, food security studies, 'adjustment with a human face' health and agriculture sectors alone. probes, living standards measurement studies, social marketing analysis in nutrition. There was no mistaking the stock from which they came. The author is Senior Nutrition Adviser at The World Bank, 1818 H Street, NW, Professor Field's provocative announcement of nutrition planning's Washington, DC 20433, USA. demise richly chronicles the negative side of the experience. It offers some criticism that is deserved, but much of his argument is based on information that is out of date, out of touch, and out of context. His article oversimplifies grossly. Most important, it stops giving answers at just the point where readers start asking questions. Among this reader's questions is what exactly Professor Field is attacking - is it nutrition planning, to which he repeatedly refers, or is it the much narrower area of multisectoral nutrition planning that his title proclaims? Even if it is only the latter, has that been the hapless odyssey he describes? And is the solution, which he proposes, simply to get 'on with the job of making nutrition an integral part of agricultural development and primary health care'? The article is lax in using the terms 'nutrition planning' and 'multisectoral nutrition planning' interchangeably. To damn all nutri- tion planning for the performance of one strain is a bit like damning all music for the performance of Boy George. Presumably the author's tirade is directed at the ambitious excursion into multisectoralism. In his wording, however, he makes a general indictment of the broader concept of nutrition planning, as in 'nutrition planning's unfounded 1 assumptions' and 'nutrition planning's obtuseness'. In all, the phrase John Osgood Field, 'Multisectoral nutri- tion planning: a post-mortem', Food Policy, 'nutrition planning', sans 'multisectoral', appears 55 times. Vol 12, No 1, 1987, pp 15-28. If readers came away with the impression that Professor Field's 0306-9192187/040365-11$3.00 © 1987 Butterworth & Co (Publishers) Ltd 365 Rejoinder: nutrition planning is alive and well, thank you attacks apply to all nutrition planning, it would indeed be unfortunate. What, r!fter all, is nutrition planning? Most simply put, it is the process of thinking systematically about solving a nutrition problem rather than not thinking systematically. As the distinguished US planner Alice Rivlin has put it, 'It is better to have some idea where you are going than to fly blind.' Though this may seem patently obvious, one need only recall the world of nutrition before the advent of nutrition planning. Projects, in those good old days, generally came into being because someone came along with an idea - a fish protein concentrate, a single-cell protein concept, a chain of mothercraft centres, ~ synthetic lysine, a commer- cially fabricated and marketed weaning food. The idea commonly reflected the background of the advocate; thus the food technologist saw solutions quite differently than the clinician did. More often than not, adoption of nutrition activities depended on the persistence and persuasiveness of the project advocate rather than a thoughtful look at nutrition needs and alternative ways of meeting them. Such efforts may or may not have been useful in isolation. Generally they were not. The revolution wrought by nutrition planning grew out of the realization that technical fixes may apply to certain specific deficiencies but fail to deal with the major issue - energy-protein malnutrition. Planning demanded careful definition of nutrition problems, objectives and target groups. Once the problem was defined, analysts began tracing the most important pathways and knots in the food and health systems. They also looked systematically for other causal factors and relations that might expose useful points of intervention, many of which the conventional approach to nutrition would never have encountered. The international nutrition community started to realize that a slight shift in price policy, for example, might in some instances have greater impact on nutrition than all of the technical fixes combined. Nutrition planning tried to open up the world of nutrition. The idea was to have an analytic framework comprehensive enough to capture not every determinant but every significant determinant. (There will always be some guesswork; nutrition planning just tried to remove some of it.) Those interested in diminishing malnutrition would then be in a better position to deal with policy makers to explain, to advocate, and, if successful in getting the right decisions, to lay the groundwork for implementation of programmes. It may be true that nutrition planners were overly optimistic in their hopes that political systems would be made more responsive to the problem. That they failed in some countries may say more about the politics of poverty than about the intellectual appropriateness of the framework within which they were trying to improve the understanding of the problems of malnutrition. But has nutrition planning been the debacle described in Professor Field's article? In a number of countries and in a number of development assistance agencies, nutrition problems and their solutions are today being looked at very differently than before all this started. And different kinds of people with different backgrounds and disci- plines are working in and studying nutrition. It is now respectable, for instance, for economists to work on nutrition consumption issues, which simply was not the case a decade ago. Even if nutrition planning achieved nothing else (but there is much else), such contributions may have justified the journey. 366 FOOD POLICY November 1987 Rejoinder: nlllrition planning is alive and well, thank you Let them eat plans Multisectora/ nutrition planning is, I suspect, the main object of Professor Field's guillotine. He correctly and quite eloquently (and perhaps more openly than any previous writer) captures its intent: The early proponents of multisectoral nutrition planning clearly defined protein-energy malnutrition as a structural problem embedded in poverty and underdevelopment; they recognized that multiple changes in socioeconomic conditions would be necessary to alleviate malnutrition and ultimately to eradicate it; they perceived a need to adjust existing government policy and to initiate new policy on a variety of fronts in order to achieve these changes; and they believed it essential to formulate a comprehensive strategy as the basis for mobilizing different agencies of government in a well-coordinated plan of attack. Not only were these insights and inferences not trivial; they were radical in conception. intent and design. Multisectoral nutrition planning sought to go beyond technical fixes ... in favour of ... changes going to the heart of a country's development effort. The original objective was not solely to serve the malnourished; it was to purge the total environment of those conditions disposing to and sustaining nutritional deprivation.~ Professor Field goes on to make a number of criticisms - certain of them having a ring of validity - suggesting that nutrition planners made an unholy mess in their effort to pull this off. There is no question that some people were carried away in a kind of planning mania. (This. after all, was the era in development when anything that smacked of 'systems' and 'models' seemed profound.) The infatuation with elaborate planning endeavours may have been at its peak in 1978 when, as Asok Mitra reported at a UN Protein Advisory Group meeting, the design and procedures set forth in one UN agency's planning manual would have required the full-time effort for two years of the entire staff of the Indian Planning Commission. 'If nutrition planners have to dig for root causes·. the former Secretary of the Planning Commission said, 'they should take care not to wind up in a hole so deep they can't climb out of it.' In the discussion, Sol Chafkin (chairman of the group) led the charge to 'decomplexify', and Karl-Eric Knutsson of Sweden (now deputy executive director of UNICEF) called for a moratorium on all systems diagrams. Almost everyone accepted the notion that causality can be dissected as endlessly as a frog can, but it too dies in the process and the remains are discouraging to any but the scientific mind. Professor Field's description of planning run amok only applied to \ part of the work in the field. Nutrition planning is no more monolithic ) than any other field, and some nutrition planning miscreants, even those . associated with multisectoral planning, warned from the beginning that an overly complicated approach was doomed to sink of its own methodological weight. Professor Field unfortunately relegates his acknowledgement of this school to a footnote, quoting from a 1973 publication: Systems practitioners tend to produce flow charts reflecting the relationships of everything to everything. the result being something more akin to a Jackson Pollack canvas than to a useful plann.ing chart. Comprehensiveness is desirable. but it becomes counterproductive if it focuses time and attention on tertiary variables or strives for precision that may be spurious because of limited or 2 /bid, pp 16-17. inaccurate data:' 3 /bid, p 20, from Alan Berg, The Nutrition Factor, Brookings Institution, Washington, Nonetheless, those who had begun the nutrition planning movement DC, 1973. were embarrassed by the excesses to which some of its advocates had FOOD POLICY November 1987 367 Rejoinder: nutrition planning is alive and well, thank you taken the idea, and there were mea culpas all around. But it was a decade ago that the need to advocate simpler questions and simpler actions was recognized, long before Professor Field tried to take the starch out of the movement. As a day-to-day worker engaged in searching for solutions to malnutrition, I find his description of multisectoral nutrition planning unrecognizable as a process practised today. It is an interesting historical description of an antique no more useful than a moustache cup or a buggy whip. The frequent references in the post mortem to obsession with and reliance on new and 'abundant data' and holding 'modest decisions hostage to elaborate manipulations of data' go too far. It is true that some multisectoral nutrition planners were disposed to a seemingly endless acquisition of data. Presumably it is they Professor Field is characterising and caricaturing. But they were the exception rather than the rule. Their work was never accepted as operationally credible and there is no evidence that as a result of their influence major resources were ever diverted from investments that would otherwise have had positive nutrition outcomes. Just as it did not take long to show how wrongheaded the complicated systems charts were and that it was impossible to collect all the data the charts required, it did not take long to see that some good indications of desirable direction could be obtained without elaborately detailed studies. From the early 1970s, governments were, in fact, advised that in the quest for the perfect model, nutrition planning could be so overdone that it became a straitjacket to operational movement. Nutrition planning should not be pursued at the cost of operational delay. New actions could be initiated on the basis of preliminary analysis and best judgements while more elaborate studies were under way. In fact, this is what commonly happens. A few years ago in Zimbabwe, for instance, where current data were lacking, emphasis was placed on obtaining 'best judgements' from knowledgeable observers. Agricultural extension field staff were asked in brief five-point questionnaires for their views on the sufficiency of food in their areas, the variation in seasonal needs, and· the causes of poor nutrition. Similarly, government health staff stationed in the field and doctors of religious missions and other non-governmental organizations working at village level were asked for their rough estimate of the prevalence of specific nutrition deficiencies in the area ('often', 'sometimes', 'seldom', or 'never'). Thus it was possible in short order to begin drawing a goitre belt, for example. In addition, medical students were sent around the country to make spot nutrition surveys, and questions on food consumption and nutrition status were added to surveys already planned on agricultural production and income. Also, the nutrition data collected in the agricultural surveys were analysed and compared with information that had been compiled at the time of independence. In a month a fairly good picture could be assembled of nutrition needs, what caused deficiencies, and what might be done to relieve them. Such data may never stand up in an academic court and are clearly inappropriate for publication in professional journals (hence academic analysts of nutrition planning are not likely to be aware of their existence), but taken together they can go a long way towards providing timely judgements. Data are increasingly being collected and used in this way. Even more formal data collection efforts need not paralyse action. In 368 FOOD POLICY November 1987 Rejoinder: nutrition planning is alive and well, thank you Mexico, practical efforts to measure the effects of the current economic crisis on the food consumption patterns and levels of the urban population produced useful and timely (and unexpected) results in eight weeks. And in the first major effort of the World Bank's Living Standards Measurement Surveys - in Cote d'Ivoire - reports were on the desks of key government officials 60 days after the data were collected. In sum, the post mortem again falls short. Professor Field has some basis for his skewering of overly elaborate multisectoral nutrition planning but he is beating a dead horse. The extreme permutation of multisectoral nutrition planning that he pictures held fascination for some people a decade ago. But it is not a current issue. Professor Field apparently felt it necessary to exhume the dead horse, prop up its carcass, and perform a belated autopsy. His concerns could as· easily have been levelled at other elaborate multisectoral efforts, such as the big agricultural sector models, which followed a trajectory similar to that of multisectoral nutrition planning. If, for example, 'agriculture and rural development' or 'urban development' were substituted every time Professor Field's post mortem reads 'nutrition', most of his conclusions would be unchanged. Few persons active in multisectoral nutrition planning ever expected that governments would do all of the things laid out. While the aim was to encourage multisectoral nutrition planning, according to James Pines (who perhaps has done more nutrition planning in more countries than any other practitioner), it was clear from the start that what was more likely to emerge would not strictly follow the blueprint. But what did emerge, he reports, benefited from the blueprint. Multisectoral analysis and multisectoral implementation are very different; in the post mortem they are lumped as one. The fact that there \ \l are multiple causes of malnutrition (inadequate food supply, wrong prices, sluggish marketing and distribution, an unconducive health environment, damaging behaviour - the entire constellation of factors which have an impact on nutrition status) does not mean that all those causes must be addressed within a single instrument. Clearly some are more important and some more actionable than others. Most people working in nutrition planning now recognize the importance of understanding not only how things are braided and connected but also which strands are strong and likely to endure,_ which likely to fray, which are dispensable and which indispensable. There is no prima facie case for ruling out multisectoral operational efforts if they make sense. Nutrition work in Indonesia - a country that takes its nutrition seriously - is as multisectoral as you can get. And the Tamil Nadu Integrated Nutrition Project, which is cited with increasing frequency as a large-scale model of a successful nutrition intervention (including 9000 villages), is unquestionably multisectoral. Today's nutrition world has been heavily influenced by the concepts 4 Giovanni Andrea Cornia, Richard Jolly of multisectoral planning. At or near the top of the list of important and Frances Stewart, Adjustment with a work now going on which affects the nutrition of large numbers of Human Face: Protecting the Vulnerable people are the multisectoral analyses of the nutrition consequences of and Promoting Growth, Oxford University Press, New York, 1987. economic stabilization and structural adjustment programmes. 4 And the 5 Shlomo Reutlinger and Jack van Holst food security studies that are being undertaken in a number of countries Pellekaan, Poverty and Hunger: Issues cut across organization charts just as they cut across disciplines. 5 The and Options for Food Security in Develop- ing Countries, World Bank, Washington, value of nutrition surveillance - looking at everything from the growth DC, 1986. of crops to the growth of children - is increasingly recognized. The 1987 FOOD POLICY November 1987 369 Rejoinder: nutrition planning is aliw and w.• ·~· . ... :;~,.,,· .. ;. ".~ ~ f;:, .; .. ,. " .. ~:: .. ···Telephone:(2Q2)47'.7'"'q.34 .· · Telex: WUI 64145 WORI_i?BANK . RCA.24.8423 V,VQ~I:pJ3K .··.Cable address: INTBAFRAD · ·.. . . · 'WASHJNGTONDC .European Office. · · '66, avenue d'.Iena .· ('5116 Paris, France . . Telephone: (1) 47.2~.54'.21. i; ·' ·· · Telex: 842-620628 · ·. Tokyo Office .... · · . Kokusai Building . · 1-1; MarunoµChi 3'-chome . Chiyoda-ku, Tokyo 100; Japan . Telepho~e: (03) :Z.14-5001 ····Telex: 781.;.26838·: : ·.· .. ·,_·· .· The full nulge of World Bank publications, bothfree arid for sale, .is described ..... ·• , , in the World ~~nk Ciltalog ofPublications; arid ofthe continuing researdl prqgraJ:ll_ ()f th¢. Wo'r)d Barik, in WorldBank Research Program: Abstracts of Curr,ent Stud!es. · The Il1ost-rece.nbedifion9feach is availablewithout charge from: ··. · · · · < ... . .·. PtIBLICA~IONS SALES UNIT.. . IBE WORLD BANK. 1818 H STREET, N.W. .· ·. WASHINGTON; D~C. 20433. ···.U.S.A. . .