February 1993 Growth Promotion for Child Development Proceedings of a colloquium held in Nyeri, Kenya, 12-13 May 1992 Edited by J. Cervinskas, N.M. Gerein, and Sabu George Co-sponsored by the Canadian International Development Agency (CIDA), Cornell University, and the International Development Research Centre (IDRC) INTERNATIONAL DEVELOPMENT RESEARCH CENTRE Ottawa • Cairo • Dakar• Johannesburg • Montevideo • Nairobi • New Delhi • Singapore Materiaf contained in this report is produced as submitted and has net been subjected to peer review or editing by IDRC Public Information Program staff. Unless otherwise stated, copyright for material in this report is held by the authors. Mention of a proprietary name does net constitute endorsement of the product and is given only for information. ISBN 0-88936-676-4 0 Printed on recycled paper Contents Foreword vii Acknowledgments xi Dedication xii The Nyeri Declaration on Growth Promotion for Child Development 1 History, Principles, and Implementation of GMP Growth Promotion for Child Development Michael C. Latham 5 Growth Monitoring and Promotion: A Development Strategy Lukas Hendrata 19 Growth Monitoring in Primary Child Health Care in Developing Countries C. Gopalan 23 Evaluation and Policy Change in UNICEF: The Case of GMP Roger Pearson 33 Frameworks for Growth Assessment and Promotion Summary 45 Conceptual Analysis of GMP Urban Jonsson 52 Challenge of Policy Formulation for Growth Promotion Yves Bergevin and Nashila Mohamed 59 Causal Factors Influencing Childhood Malnutrition Carl E. Taylor and Mary Ann Mercer 73 lndividual, Family, and Community Perspectives on Growth Promotion Gail G. Harrison 92 Culture and Growth Promotion Cecile De Sweemer-Ba 106 Research, Evaluation, and Case Studies Summary 113 Growth Monitoring and Promotion in the Health Services Setting AA. Kielmann 119 When Research does not Shape Programming: GMP in Zaïre Nancy Gerein 129 Successful Growth Monitoring in South lndian Villages S.M. George, M.C. Latham, and R. Abel 150 Evaluation of the Community-Based GMP Program in Embu District, Kenya John Njera Gacoki 167 Growth Monitoring in Rural Kenya: Experiences from a Pilot Project GA. Ettyang, AA. Kielmann and G.K Maritim 178 Community-Based Growth Monitoring David Morley and Mike Meegan 188 Tamil Nadu Integrated Nutrition Project (TINP), lndia M. C. Latham 195 GMP Implementation in lndonesia: Does Behaviour Change Take Place? Satoto 197 GMP Programs in Ecuador Marta Medina 208 Action, Research Needs, and Policy Summary 217 Nutrition Improvements in Thailand: National Policies and Strategies Kraisid Tontisirin 226 Growth Monitoring in Health and Nutrition Information Systems: Tanzania Bjom Ljungqvist 232 Growth Promotion in Primary Health Care Carl E. Taylor and Mary Ann Mercer 259 Terms 265 Participants 267 Foreword This book contains the proceedings of the colloquium "Growth Promotion for Child Development," held in Nyeri, Kenya, from 12 to 13 May 1992. The meeting was organized by Cornell University, USA, the Canadian International Development Agency (CIDA), and the International Development Research Centre (IDRC), Canada. The meeting brought together 24 participants from 12 countries, and were selected for their experience and expertise in health promotion. Besides bringing field and programmatic experience from more than 20 countries in Africa, Asia, Latin America, and North America, these participants brought knowledge gleaned from a number of scientific disciplines ranging from community health, nutrition, policy formulation and planning, anthropology, education, and public policy analysis. Although attempts had been made in the planning of the colloquium to ensure the representation of key agencies and individuals involved with growth monitoring and promotion (GMP) initiatives, it was regretted that a number of persans who indeed were invited, were unable to attend, for a variety of reasons. The participants met to discuss critically growth monitoring (GM) and produce recommendations useful in the promotion of child growth and development. The broad objectives of the Colloquium were to: • Review what is known about growth promotion and growth monitoring; • Consider the scientific basis to judge the effectiveness of child GM strategies and the role of growth monitoring in these programs; • Outline the circumstances, conditions, and actions that are necessary for GM to be successful and, in this context, to discuss to what extent the current forms of GM have contributed to growth promotion; • ldentify gaps in research knowledge; and • Produce recommendations on growth promotion strategies and program management that might be useful for governments (local health policymakers, planners, and communities), international agencies, NGOs, and donor organizations. vii The Colloquium was ta focus on growth promotion, rather than be confined ta an evaluation of recent experiences with GM programs. Our hopes were that this could be a constructive colloquia that by reviewing past experiences and considering the diversity of views about GMP would lead ta an articulation of possible actions ta promote growth for optimum child development. The final purpose was ta reach some international consensus on how best ta promote the growth of children. In the Colloquium, the historical evolution of G MP in developing countries and different perspectives on GMP were described. Conceptual frameworks that examined growth promotion were presented by some ·af the participants, whereas others made presentations about research studies, pilot projects, and national level experiences in implementing national GMP programs that began as pilot projects. The timing of this meeting was set sa that it would directly benefit from a UNICEF-organized workshop on "Evaluation of Growth Monitoring and Promotion (GMP) Programs" held in Nairobi, Kenya, from May 7 ta 9, 1992. The UNICEF meeting discussed lessons learned from UNICEF-supported GMP programs. About half of those at the Colloquia had attended the Nairobi workshop. We see the two meetings as being complementary ta each other. These proceedings include the revised edited version of the papers presented. The summary sections that precede sections provide the reader with the context for understanding the discussion points, which are also presented. On a more persona! note, I have been a strong supporter and advocate of growth monitoring for many years. Saon after David Morley published bis findings from Nigeria in 1968 and described the use of the Ilesha weight chart, I began ta write, lecture, and advocate its use. Now GMP, by which we mean weighing and charting, as a strategy ta promote good growth, bas become controversial with strong proponents and opponents. There are many different strategies and actions that individual families and international or local agencies can, and do, take ta promote good and healthy growth and development of children. But the most visible programs supported by agencies (including UNICEF) and by governments consist mainly of the provision of weighing scales, growth charts, and instructions for weighing and charting. During work and travel in several countries in Africa and Asia, I much more often see ''bad" GM than "good" GM programs in operation. "Bad" GM certainly does not achieve the objective of improving growth, and "good" GM programs have not been adequately evaluated ta determine their effectiveness. viii I have, in the last several years, become very concerned that so much money, time, and energy, including the time and energy of mothers, are devoted to this one, poorly managed strategy. I see so much more "GM," than I see "P." Weighing a baby and charting that weight does not in itself improve nutritional status. So often in GM programs very little else is done, and so little attention is given to counselling the mother. Weighing and charting is not a magic bullet like immunization. People compare GM with measles immunization, which, it is claimed, had major problems when first introduced, but now is deemed highly effective. But weighing and charting are comparable to the syringe and needle and not to the measles vaccine. What I see in many countries is use of the syringe and needle without a vaccine, and I learn of efforts to improve the syringe, not to improve the vaccine. The equivalent of the vaccine in GMP is the counselling and other actions that the growth chart is meant to trigger. So UNICEF and others have spent millions of dollars on the design and distribution of scales and charts, but pitifully little on the vaccine, that is, on the actions that are essential after weighing and charting if the monitoring exercise has even the slimmest chance of preventing or curing growth failure. My current view is that we need to devote much more time and energy to various actions to promote good growth and development of children and to decide if and when it is appropriate and likely to be useful to have growth charts included among the tools chosen to achieve this objective. The alternative is to select actions and implement programs that promote growth without regular weighing and charting. Using the vaccine analogy, this becomes like deciding, in programs to prevent poliomyelitis, when to use a syringe and needle for injectable inactivated poliovirus vaccine (IPV) and when to use oral poliovirus vaccine (OPV) without the syringe. In either case, the vaccine is much more important than the syringe or other vehicle and, in growth promotion, actions to promote good growth are much more important