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World Bank Document Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized ~~~~ .0 C) LA~~~~~~~~~~~~~~A A~~~~~~~~~~~~~~~~~~~P -14~~~~~~~~~~~~~~~~~~~~ M7~~~~~~ ENHANCING THE CONTRIBUTION OF THE EEALTHSECTOR IN THE PREVENTION OF MNAJUTRIflON Review of Project Appraisalsin Africa Edited by Tonia Marek DIVISIONOF HUMAN RESOURCES TECHNICAL DEPARTMENT AFRICA REGION WORLD BANK NOVEMBER1993 Translated from the French by Alison SondhausCarroll With support from the Afica Bureau of The U.S. Agencyfor InternationalDevelopment ARTSIHealthand Human Resources Analysis for Africa (HIRAA) Support for Analysis and Research in Africa (SARA) To obtain a copy of this report or to send comments, please contact: Tonia Marek The World Bank 1818 H St., NW Washington, DC 20433 USA Tel: (202) 473 4086 Fax: (202) 473-8216 This document was written for the benefit of project designers, implementors, and specialists in the nonindustrializedcountries, and in developnmentagencies. Each chapter may be consulted independentlyfor assistance in setling up a program or mnakingdecisions related to the experiences sumnarized here. The author(s) of this documentbear(s) euclusiveresponsibilityfor the observations,interpretations, and conclusionsexpressed here. They do not representthe vews of the World Bank, its affiliated institutions, the membersof the Board of (Executive)Directors, or the countries they represent. CONTENTS FOREWORD .................................................... ii SUMMARY..................................................... iii ACKNOWLEDGEMENTS ............................................iv 1. INTRODUCTION 1............................................... A. Choice of interventionstrategies 1................................. B. Impact on operations design .................................... 2 II. THE HEALTH SECTOR AND NUTRITIONINTERVENTIONS IN AFRICA ......... 4 A. Benefits already provided by the health sector .......................... 4 1. Prevention of diarrheal diseases ............................. 4 2. Prevention of intestinalparasites .............................. 5 3. Prevention of malaria ................................... 5 4. Control of preventable childhooddiseases (vaccinations). ... : ........ S5 B. Nutrition services that could easily be provided by the health sector .. ......... 6 1. Prevention of vitamin A deficiency........................... 6 2. Prevention of iron deficiency ............................... 18 3. Prevention of iodine deficiency ............................. 27 4. Promotingbreastfeeding .................................. 39 5. Dietary managementof infection ......................... 53 C. Nutrition services that could be provided by the heal sector if a radical change in approach were adopted ................................... 73 1. Food supplementation ................................... 73 2. Nutritional rehabilitation ................................. 88 3. Growth monitoring and promotion ........... ................ 101 D. Nutrition education .................................. .. 122 Im. CONCLUSIONS ................. ................... 139 BIBLIOGRAPHY.................................................. 140 NOTES .......... 180 i FOREWORD Malnutritionin Africa has many causes,but most of them ire linked to poverty. The World Bank, in its efforts to reduce poverty in Africa, has identifiedsix interventionpoints': 1. Macroeconomicpolicies to ensuregrowth and improvementin income,better distributionof inicometo the poor, and more efficientallocation of resources. 2. Measures to ensure that the poor have access to food, and to improve their use of that food with a view toward improvingtheir nutritionalstatus. 3. Measures Lo ensure that the poor have access to physical and financial resourcesand social servicesand to improvethe efficiencyand effectiveness of these services. 4. Programs to shield the poor from the hamful effects of seasonal variations in income,drought, or macroeconomicshocks. 5. Prograns aimed at increasing the participation of the poor, particularly women, in the socioeconomicchoices that affect thei.rlives. 6. Programs aiuned at eliminating discriminationagainst certain groups, in particular womenand the poor. This documentis airnedspecifically at improvingmeasures related to number three above. it does not pretend to be an exhaustivestudy; therefore, certain topics, such as the nutritional status of refugeesand displacedpopulations, are not addressed. This documentwas first publishedin French under the title "CnmmentAni6liorer la Contribution du Secteur de la Sant6 dans la Lutte Contre la Malnutrition: Revue d'Evaluations de Projets en Afrique". Copies in both languagescan be requested. 1. Source:Foreword by EdwardV.K. Jaycox, Vice-President, Africa Region. The World Bank, in Salmen,Lawrence, 1992. REducingPoverty. Povcrty and SocialPolicy Series, PaperNo. 1. WorldBank. ii SUMMARY Thisdocument reviews many assessments of interventionsin the healthsector in the area of nutrition,principally in Africa. It proposesto illustratewhat may be this sector'smost effectivecontribution to the preventionof malnutrition. It is intendedfor those responsiblefor the design and implementationof projects,project directors, and nationaland intermationalspecialists. This reviewof publishedand unpublishedproject appraisals underscores the health sector's decisiverole in the preventionof malnutrition,but it also emphasizesthe necessity for rigorouslydefined interventions to avoidfailure and wastedresources. As a result, this documentrecommends that the healthsector (a) continuewith the benefitsit alreadyprovides: vaccinations,therapeutic treatments (for malaria,infections, dehydration), which also have a considerableimpact on malnmtrition;(b) undertake new and easilyprogrammable services thatrequire only a smallsupplementary investment of resources:promotion of breast-feeding and preventionof iron, vitaminA, and iodinedeficiency; (c) take on more complexand/or demandingactivities (for example, nutritional recuperation, the monitoring of growth, and food supplementprograms) only through a more community-basedapproach and subjectto the availabilityof all the necessaryresources and a detailedprogram; if theseconditions are not met, such activitiesshould not be undertaken,and efforts insteadshould be focusedon the first two types of benefitsto increasecoverage and improveits quality;(d) undertake work in the area of nutritioneducation only in conjunctionwith communicationsprofessionals and only when enough resources are availableto train staff, along with other requirements. iii AUTHORS This document was conceived, compiled, and edited by Tonia Marek, nutritionist, AFTHR. The chapter authors are as follows: a Dr. Bernard Maire, researcher in nutrition at ORSTOM, Montpellier (France), recruited as a consultantby AFTHR to write the sections on preventingiron, vitamin A, and iodine deficiency, nutritional rehabilitation, the monitoring and promotion of growth, nutritional education, and food supplements. * Mrs. Margaret Kyenkya-lsabirye, consultant on child feeding, UNICEF-New York (USA); Mrs. Gabrielle Fahmer, consultantto UNICEF-NewYork, and Mrs. Helen Armstrong, training coordinatorfor the Baby Friendly Hospital Initiative, UNICEF-New York (USA), wrote the section on promotionof breast-feeding. * Dr. Ellen Piwoz, consultantto the project "SupportforAnalysis and Research in Africa (SARA),Academyfor EducetionaiDevelopment,Washington (USA), wrote the section on dietary treatment of infectionwith support from the Africa Bureau (HHRAA Project) at USAID. * The section on activitiesalready undertakenby the health sector was taken from the document, "Malnutritionalid Infection: A Review" (with the authorizationof the ACC- SCN department of the United Nations), published by Andrew Tomkins and Fiona Wilson in October 1989. ACKNOWLEDGMENTS This report benefited greatly from the commentsof numerous colleagues, including specificallyDr. Mary Ann Anderson,specialist in breast-feedingat USAID; Dr. John Mason at ACC-SCN; Dr. Nicholas Cohen at WHO; Mr. Dick Heyward at UNICEF; Dr. Suzanne Prysor-Jones of the SARA Project at the Academyfor EducationalDevelopment; Dr. Hope Sukin, nutritionist in the Africa Bureau at USAID-Washington;Drs. Jacques Baudouy,Yves Genevier, Jean-Louis Lamnboray,and Maryse Pierre-Louis, public health specialists at the World Bank; Dr. Michele Lioy, IEC specialist at the World Bank; Dr. Judith McGuire, nutritionist at the World Bank; and Mr. Timothy Stone, independent expert on micronutrients. The report was typed by Mr. Jim Shafer of the World Bank. Its presentationwas designed by Ms. Marit Hammond, design consultantfor the SARA Project, Academy for International Development, Washington (USA), with support from the Africa Bureau (HHRAA Project) at USAID. iv I. INTRODUCTION *l Choiceof interventionstrategies Beforeidentifying any interventionstrategy to anything else? Or is it a problem of access to prevent malnutrition, each program and project health care? Or of lack of knowledgeabout how leader passes through the following decision to raise a child? These three causesoften coincide stages, illustrated in the "Triple A" cycle in Africa. popularizedby UNICEF: * What does one do to resolve these Figure 1. The "Triple A" cycle problems? Each sector (particularlyagriculture, education, health, industry) can and should contributeto their solution(action). EVALUATIONOF THESITUATION This docunent deals essentiallywith actions (ASSESSMENT) relevant to the health
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