Successful
Community
Nutrition
Programming:
Lessons from Kenya, Tanzania,
and Uganda
Successful
Community
Nutrition
Programming:
Lessons from Kenya,
Tanzania, and Uganda
June 2002
Successful Community Nutrition Programming: Lessons from Kenya, Tanzania, and Uganda is a
publication of LINKAGES: Breastfeeding, LAM and Related Complementary Feeding
and Maternal Nutrition Program, the Regional Centre for Quality of Health Care at
Makerere University in Uganda, and UNICEF. The USAID Regional Economic Devel￾opment Support Office for East and Southern Africa (REDSO/ESA) and UNICEF
funded the development and publication of this document. LINKAGES is supported
by the GH/HIDN of the United States Agency for International Development (USAID)
under the terms of Cooperative Agreement No. HRN-A-00-97-00007-00 and managed
by the Academy for Educational Development (AED). The opinions expressed herein
are those of the author(s) and do not necessarily reflect the views of USAID or AED.
The LINKAGES Project
Academy for Educational Development
1825 Connecticut Avenue, NW
Washington, DC 20009
Tel: 202-884-8000
Fax: 202-884-8977
E-mail: linkages@aed.org
Website: www.linkagesproject.org
Regional Centre for Quality of Health Care
Makerere University Medical School
P.O. Box 7072
Kampala, UGANDA
Tel: 256-41-530321
Tel: 256-41-530888
Fax: 256-41-530876
Email: mail@rcqhc.org
Website: www.rcqhc.org
UNICEF
3 United Nations Plaza
New York, New York 10017
Tel: (212) 326-7000
Fax: (212) 887-7465
Website: www.unicef.org
Acknowledgements iii
Acknowledgments
Funding and technical support for the following study was provided by:
USAID/Regional Economic Development Support Office for East and Southern Africa
(REDSO/ESA), LINKAGES/AED, the Regional Centre for Quality Health Care
(RCQHC), and UNICEF
Assessments of community nutrition programs were carried out by teams from
Kenya Coalition for Action in Nutrition (KCAN-Kenya)
Tanzania Nutrition Coalition (TANCO-Tanzania)
Uganda Action for Nutrition Society (UGANS-Uganda)
UNICEF/Tanzania
Analysis and writing of the final report was completed by
Lora Iannotti, LINKAGES, and Stuart Gillespie, IFPRI
Appreciation is also expressed to the many representatives from the community nutrition
programs for giving so generously their time and ideas for the assessments. Other indi￾viduals providing significant contributions to this study and report are the following:
Hanifa Bachou, Krishna Belbase, John Dunlop, Man-Ming Hung, George Kahuthia, Sam
Kazibwe, Elizabeth Kiboneka, Rose Rita Kingamkono, Wilbald Lorri, Luann Martin, Rob￾ert Mwadime, Godwin Ndossi, Micheline Ntiru, Englebert Nyang’ali, Ruth Oniango,
Leslie Perry, Jay Ross, Victoria Quinn, and Olivia Yambi.
iv
List of Acronyms v
List of Acronyms
ACC Administrative Committee on Coordination
ADP Area Development Programme
AECI Spanish Cooperation Agency
AMREF African Medical Research Foundation
ANP Applied Nutrition Programme
BASICS Basic Support for Institutionalizing Child Survival
BCC behavior change communication
BCM breastfeeding, complementary feeding, and maternal nutrition
CAP community action plan
CBDA community-based distribution agent
CBNP community-based nutrition program
CBW community-based worker
CCF Christian Children’s Fund
CHANIS Child Health and Nutrition Information System
CHV community health volunteer
CHW community health worker
COOPIBO Belgium International Association for Development Cooperation
CRP community resource person
CSPD Child Survival, Protection and Development Programme
DANIDA Danish Agency for Development Assistance
DFID Department for International Development
EBF exclusive breastfeeding
ECD early childhood development
DANIDA Danish Agency for Development Assistance
FFH Freedom from Hunger
FGD focus group discussion
FOCCAS Foundation for Credit and Community Assistance
GHAI Greater Horn of Africa Initiative
GMP growth monitoring and promotion
GRHRP Gulu Relief & Health Rehabilitation Project
HAZ height-for-age z score
IEC information, education, and communication
IMCI Integrated Management of Childhood Illnesses
IP Sustainable Integrated Reproductive Health Services Project
IPPF International Planned Parenthood Federation
JOICFP Japanese Organization for International Cooperation in Family Planning
KAP Knowledge, Attitude, Practice Survey
KCAN Kenya Coalition for Action in Nutrition
KPC Knowledge Practice Coverage Survey
MCH maternal and child health
MICAH Micronutrient and Health Project
MIHV Minnesota International Health Volunteers
MINPAK Nutrition Minimum Package
MIS management information system
MOH Ministry of Health
MTCT mother-to-child transmission (HIV/AIDS)
NGO non-governmental organization
NID National Immunization Day
NIS Nutrition Information Systems
vi
NPAN National Plan of Action for Nutrition
ORT oral rehydration therapy
PANS Participatory Approach for Nutrition Security
PATH Program for Applied Technologies in Health
PEM protein energy malnutrition
PET Participatory Educational Theatre
PRA participatory rural appraisal
PRE participatory research and extension
PVO private voluntary organization
RCQHC Regional Centre for Quality of Health Care
REA resource efficient agriculture
REDSO USAID Regional Economic Development Support Office for East and
Southern Africa
SANA Sustainable Approaches to Nutrition in Africa Project
SARA Support for Analysis and Research in Africa Project
SCN Subcommittee on Nutrition
SCSP Ssembabule Child Survival Project
SITE Standard Indicator Tool for Evaluation
TANCO Tanzania Nutrition Coalition
TBA traditional birth attendant
TFNC Tanzania Food and Nutrition Centre
TIPS trials of improved practices
TUFF Tool Used for Focus
UGANS Uganda Action for Nutrition Society
UMATI Uzazi na Malezi Bora Tanzania (Family Planning Association of Tanzania)
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VECO Vredeseclander COOPIBO
VHD village health day
VHW village health worker
WV World Vision
WAZ weight for age z score
List of Acronyms
Table of Contents vii
Table of Contents
1 Introduction ...................................................................................................................... 1
2 Lessons from Experience .................................................................................................. 3
2.1 Characteristics of a successful nutrition-relevant program ........................................ 4
2.2 Program design and content...................................................................................... 6
2.3 The importance of process ........................................................................................ 7
3 Characteristics of Programs in Kenya, Tanzania, and Uganda .......................................... 9
3.1 Program types ............................................................................................................. 9
3.2 Implementing agency and donors ........................................................................... 10
3.3 Location and coverage ............................................................................................. 10
3.4 Program costs ........................................................................................................... 10
3.5 Nutrition outcomes .................................................................................................. 11
4 Process Leading to Program Development ..................................................................... 14
4.1 Conducive policy environment ................................................................................ 14
4.2 Assessing and analyzing the nutritional situation ................................................... 14
4.3 Selection of an entry point ....................................................................................... 15
4.4 Complementary ongoing programs and/or local government structure ................ 16
4.5 Prefunding and time ............................................................................................... 16
5 Program Design and Content.......................................................................................... 17
5.1 Growth monitoring and promotion ......................................................................... 17
5.2 Nutrition education ................................................................................................. 19
5.3 Adopting a multisectoral approach ......................................................................... 21
5.4 Advocacy ................................................................................................................... 22
5.5 Income generation................................................................................................... 23
5.6 Improving care of women and children................................................................... 25
5.7 Capacity development and training ......................................................................... 26
6 Program Management and Implementation................................................................... 27
6.1 Community involvement .......................................................................................... 27
6.2 Working through groups.......................................................................................... 29
6.3 Coordination with ongoing programs...................................................................... 30
6.4 Staff remuneration and incentives........................................................................... 31
6.5 Leadership ............................................................................................................... 31
6.6 Information Systems ................................................................................................. 31
7 Evolution, Sustainability, and Scaling up ........................................................................ 32
7.1 Sustainability ............................................................................................................ 32
7.2 Scaling up................................................................................................................. 34
8 Conclusions ..................................................................................................................... 36
viii
References.......................................................................................................................... 38
Annexes:
1 The Triple A Cycle and Conceptual Framework of the Causes of Malnutrition............. 40
2 Nutrition Essentials Package and The Nutrition Minimum Package Intervention
Strategy (MINPAK) ............................................................................................................ 44
3 Summary Information of 10 Community Programs ........................................................ 46
Boxes, Tables, and Figures:
Table 1: Projects in community nutrition assessment .......................................................... 9
Box 1: Program abbreviation key .......................................................................................... 9
Box 2: Knowledge, practice, and coverage ......................................................................... 12
Box 3: Lessons from growth promotion programs.............................................................. 18
Box 4: Behavior change communication (BCC) ................................................................ 20
Box 5: Nutritional impact of credit with education ............................................................ 24
Figure 1: The PANS Triple A cycle .................................................................................... 28
Table of Contents
Executive Summary ix
Executive Summary
Learning from success is the most effective and efficient way of learning.
This report brings together the main findings of a series of assessments of successful
community nutrition programming carried out in Kenya, Tanzania, and Uganda between
1999 and 2000. The overall aim of the assessments was to identify key lessons, or the main
driving forces behind the successful processes and outcomes in these programs. Such ele￾ments of success fundamentally have to do with both what was done and how it was done.
Experience with community-based nutrition programming, as documented in various
syntheses and reviews during the 1990s, does show that malnutrition can be effectively ad￾dressed on a large scale, at reasonable cost, through appropriate programs and strategies,
and backed up by sustained political support. In most cases, successful attempts to over￾come malnutrition originate with participatory, community-based nutrition programs un￾dertaken in parallel with supportive sectoral actions directed toward nutritionally at-risk
groups. Such actions are often enabled and supported by policies aimed at improving ac￾cess by the poor to adequate social services, improving women’s status and education, and
fostering equitable economic growth.
Successful community-based programs are not islands of excellence existing in an im￾perfect world. Rather, part of their success has to do with contextual factors that provide an
enabling or supportive environment. Some of these contextual factors are particularly in￾fluenced by policy, some less so. Contextual factors may include, for example, high lit￾eracy rates, women’s empowerment, community organizational capacity and structures,
appropriate legislation. Nutrition program managers cannot normally influence contex￾tual factors, at least in the short term.
In addition to favorable contextual factors, certain program factors contribute to success￾ful programs, such as the design, implementation, and/or management of the program or
project, which can, of course, be influenced by program managers. Both contextual and
program factors, and the way they interact, need to be identified in order to understand
the dynamics behind success.
In 1998, under the Greater Horn of Africa Initiative (GHAI) supported by the United
States Agency for International Development (USAID), nutrition coalitions were formed
in Kenya, Tanzania, and Uganda. These nutrition coalitions, comprising individuals rep￾resenting government, non-governmental organizations (NGOs), donors, academic insti￾tutions, and the private sector, seek to advance the nutrition agenda both in policy and
programming through coordination and advocacy efforts. One of the first tasks of the nu￾trition coalitions, under the leadership of the Program for Applied Technologies in
Health (PATH) in Kenya, the Tanzania Food and Nutrition Centre (TFNC) in Tanzania,
and the African Medical Research Foundation (AMREF) in Uganda, was to prepare an in￾ventory of community nutrition programs in their respective countries and identify of bet￾ter practices in community nutrition programming. Country teams, supported by USAID/
REDSO/ESA and LINKAGES/AED, then selected three successful programs in their re￾spective countries based on preestablished "process" and "outcome" criteria.
UNICEF has a long history of promoting and supporting community-based programs
in Eastern and Southern Africa and has supported many reviews and evaluations. As part
of its continued effort to strengthen community-based programs by learning from new suc￾cess stories, UNICEF also identified for review a relatively large scale successful program
in Tanzania.
x
Assessments were conducted for each of the 10 programs, using a predefined but
open-ended assessment tool. The main success factors from the country assessments follow,
categorized according to the chronological phase of program development. Not all of the
recommended factors can or should be feasibly included in programs.
Process Leading to Program Development
✔ Existence of a conducive policy environment with supportive structures and policies
amenable to project goals. Programs should either select areas with conducive envi￾ronments or work to create them before beginning operations. This is important at
national and regional levels, but especially at district levels where the project is oper￾ating;
✔ Understanding by stakeholders of the political, economic and social determinants of
malnutrition in the area based on a systematic analysis;
✔ Community awareness and commitment to nutrition, either existing or created for
the proposed project areas. A general understanding is needed of both the high
prevalence and the serious consequences of malnutritionand the availability of low￾cost solutions to the nutrition problem;
✔ Selection of an appropriate entry point that is responsive to the community’s wishes
and needs. After assessing the situation, programs should determine the interven￾tion/services desired by the community to complement the nutrition-related activity;
✔ Presence of complementary ongoing programs and/or local government structure;
and
✔ Funding and extra time allocated by donors and program managers for program de￾velopment.
Program Design and Content
✔ Growth monitoring and promotion (GMP) programs that are community or group￾based, provide proper feedback and counseling, and ensure information is used effi￾ciently at all levels;
✔ Nutrition education related to tangible resources, as behavior change communica￾tion, as participatory educational theatre, and as positive deviance approach (maxi￾mizing local learning from caretakers who have succeeded in raising well-nourished
children despite being from poor households);
✔ Advocacy and creation of by-laws to promote nutrition and the activities of the project.
Programs should, in cooperation with community members, work to convince deci￾sion makers of the importance, feasibility, and cost-effectiveness of investing in nutri￾tion;
✔ Credit and income-generating activities for women;
✔ Improving care for women and children—via reduction in women’s workloads using
appropriate technology such as milling machines, solar dryers, and water wells;
✔ Capacity development and training for programming staff and community members
that is task oriented and part of professional development for staff; and
✔ Multisectoral approach adopted in program design to maximize convergence with
other relevant programs, such as those that deal with the underlying food, health, and
care-related causes of malnutrition.
Executive Summary
xi
Program Management and Implementation
✔ Community involvement in program planning and implementation using participa￾tory processes such as the Triple A process, participatory rural appraisal (PRA), par￾ticipatory research and extension (PRE), participatory approach for nutrition security
(PANS), and community representation and voice within program hierarchies;
✔ Social groups of varying forms (e.g., women’s groups, farmers’ cooperatives, and
credit associations), either existing or created depending on the context, used as
target audiences and implementers;
✔ Collaboration with ongoing, complementary programs;
✔ Sufficient remuneration, incentives, capacity-building, and professional development
for staff provided by programs;
✔ Recruitment of dynamic project leaders, transparency and accountability of fund allo￾cation, and donor flexibility to allow programs to adapt as needs arise in communities;
and
✔ Relevant information shared and used at all levels. Programs should create systems
that ensure that nutrition-related (and other) information is not only collected, but
communicated and applied to improve interventions and services.
Evolution, Sustainability, and Scaling up
✔ Community commitment of human resources, with active engagement in program;
✔ Financial viability ensured by donors, with funding sustained for over 10 years and
self- financing in place through revolving loans or community contributions for ser￾vices;
✔ Organizational and legal frameworks established. Programs should support the for￾mation and continuation of community and women’s groups. By-laws may be created
to ensure program interventions and behavior practices;
✔ Preplanning and careful program documentation undertaken early in program. Pro￾grams should prepare for later expansion by documenting lessons and planning for
growth; and
✔ Gradual consultative scaling up in three phases: pilot, expansion, and dissemination.
Many of the above elements of success were apparent in most of the programs, though
again not all programs can or should include all of these characteristics. It is hoped that
careful documentation of these lessons learned in Kenya, Tanzania, and Uganda may
prove of benefit to communities, program managers, governmental and non-governmen￾tal organizations, and others involved in community-based nutrition programming
throughout sub-Saharan Africa and around the world.
Executive Summary
xii
1
1 Introduction
This report brings together the main findings of a series of assessments of successful com￾munity-based nutrition programs carried out in Kenya, Tanzania, and Uganda between
1999 and 2000. The overall aim of the assessments was to identify key lessons about the
successful processes and outcomes in these programs. Such elements of success funda￾mentally have to do with both what was done and how it was done.
It is hoped that careful documentation of such lessons may prove of benefit to com￾munities, program managers, governmental and non-governmental organizations, and
others involved in community-based nutrition programming in sub-Saharan Africa.
In 1998 under the Greater Horn of Africa Initiative (GHAI) supported by the United
States Agency for International Development (USAID), nutrition coalitions were formed
in Kenya, Tanzania, and Uganda. These nutrition coalitions, comprising individuals rep￾resenting government, non-governmental organizations (NGOs), donors, academic insti￾tutions, and the private sector, seek to advance the nutrition agenda both in policy and
programming through coordination and advocacy efforts. One of the first tasks of the nu￾trition coalitions, under the leadership of the Program for Applied Technologies in
Health (PATH) in Kenya, the Tanzania Food and Nutrition Centre (TFNC) in Tanzania,
and the African Medical Research Foundation (AMREF) in Uganda, was to prepare an in￾ventory of community nutrition programs in their respective countries and identification
of better practices in community nutrition programming. Country teams supported by
USAID/REDSO/ESA and LINKAGES/AED then selected three successful programs in
their respective countries based on pre-established “process” and “outcome” criteria.
Once the inventories were completed, the coalitions identified the most successful
programs in each country based on pre-established process and outcome criteria. The
“process” relates to how a community nutrition program is developed, implemented, and
managed, while “nutrition outcomes” may include any of the following: child anthropom￾etry, nutrition-related behaviors (knowledge, attitudes, and practices), and coverage of mi￾cronutrient interventions.
As part of its continued effort
to strengthen community-based
programmes by learning from new
success stories, UNICEF also iden￾tified a relatively large scale suc￾cessful programme in Tanzania
using similar criteria.
Teams from Kenya, Tanzania,
and Uganda then adapted a
UNICEF-developed community
program assessment protocol for
use in their respective countries'
context. A literature review on each
of the 10 programs was then con￾ducted, after which teams traveled
to program sites to observe and
conduct a series of key informant
interviews and focus group discus￾sions. The data were then analyzed,
Introduction
(IP-Tanzania)
2
and country reports were prepared for each of the 10 programs (AMREF 2000a–d; PATH
2000; TFNC 1999a–d). The country nutrition coalitions also compiled summary country
reports and conducted feedback workshops to present the results.
The major success factors identified in these country assessments and discussed in
detail in this report have been placed in the following four categories, based on the chro￾nological phase of the community nutrition program:
● Process leading to program development, including role of contextual factors;
● Program design and content;
● Program management and implementation; and
● Evolution, sustainability, and scaling up of the program.
Following a historical review of experiences with community-based nutrition program￾ming in the region and elsewhere, the report discusses the findings of the assessment
and describes the key elements of success in each of the above categories.
Introduction
3
2 Lessons from Experience
Experience with community-based nutrition programming has been documented in vari￾ous syntheses and reviews, particularly during the 1990s. These include the following:
● Three comprehensive reviews carried out by the United Nations ACC/SCN that at￾tempted to unravel the dynamics underpinning success in nutrition—either at a na￾tional level or with regard to a specific program (Gillespie and Mason 1991; Jennings
et al 1991; Gillespie et al 1996);
● A study of 22 community-based nutrition programs in South Asia (Jonsson 1997) and
a review of 8 effective programs in Africa (ACC/SCN News 1997);
● A synthesis of lessons and tools for sustainable community nutrition programming in
primarily USAID-funded programs of West Africa (Ndure et al 1999);
● A review of another four African programs by the World Bank (Abosede and McGuire
1991) and a questionnaire survey of 66 programs in Africa also undertaken by the
World Bank (Kennedy 1991);
● A summary of findings from 7½ years of USAID experience in testing consumer- and
community-based strategies to improve the nutritional status of women and children
through nutrition education
and social marketing (Parlato
et al 1996);
● A review of community-based
programs undertaken before
formulation of the UNICEF nu￾trition strategy (UNICEF
1990); and
● A recent review of successful
programs in Asia (Allen and
Gillespie 2000).
In sum, experience shows that
malnutrition can be addressed ef￾fectively on a large scale, at reason￾able cost, through appropriate
programs and strategies, backed up
by sustained political support. In
most cases, successful attempts to
overcome malnutrition were undertaken through participatory, community-based nutri￾tion programs in parallel with supportive sectoral actions targeted at nutritionally at-risk
groups. Such actions are often supported and enabled by policies aimed at improving ac￾cess by the poor to adequate social services, improving women’s status and education, and
fostering equitable economic growth.
As is also demonstrated in this assessment, both contextual and program-specific factors
are important. One key condition is adequate institutional capacity and resource commit￾ment to implement broad-based and multifaceted strategies to address the causes of malnu￾trition within such a supportive policy environment. Because community-based programs
are not usually initiated for nutrition alone—communities have broader priorities—means
must usually be found to foster multifaceted programs in which nutrition and health activi￾ties can be embedded.
Lessons from Experience
(FOCCAS–Uganda)
4
2.1 Characteristics of a successful nutrition-relevant program
The main success factors distilled from these reviews relate to both contextual and pro￾gram-specific factors. Characteristics associated with success between programs and, in￾deed, across different continents, are surprisingly consistent. Obviously not every factor is
required for a program or project to work, but those below do serve as a useful checklist of
desired characteristics for a community-based program.
2.1.1 Contextual success factors
● Political commitment, often concretized in the form of explicit nutrition-related goals
and operational plans of action or policies;
● Gender equity;
● Community organizational capacity such as women’s groups and village development
committees;
● Literacy, especially among women;
● Child-friendly culture;
● Leadership, in the form of certain charismatic individuals and/or pro-active local or
central government; and
● Convergent, enabling policies and programs—e.g., poverty alleviation policies and
women’s income-generating programs affecting the underlying and basic causes of mal￾nutrition.
2.1.2 Program success factors
Program success factors are again divided into four categories: program development pro￾cess; design and content; management and implementation; and evolution, sustainability,
and scaling up.
Program development process
● Awareness of malnutrition (its nature, causes, and consequences). This is often
achieved by using growth monitoring and promotion as an entry point, while under￾standing of causes may be facilitated through development and adoption of an ex￾plicit conceptual framework (see below);
● Continual awareness building through communications and social mobilization;
● Recognition of other community priorities, e.g., water;
● Process orientation (e.g., through adhering to the “Triple A” decision-making ap￾proach of assessment, analysis, action—see annex 1), along with an outcome orienta￾tion (including time-bound goals and intermediate targets);
● Identification of community-level “mobilizers,” usually by the community itself, and a
clear definition of their role as local change agents;
● Identification of supervisory “facilitators,” who may be local primary health care work￾ers or NGO workers and who often cover more than one village or community. NGO
workers’ involvement as facilitators is often very valuable, but other support structures,
including the private sector, may be used;
Lessons from Experience
5
● Community ownership of process, not just with regard to implementation but con￾cerning all stages of problem assessment and analysis, program design, implementa￾tion, and monitoring (i.e., the entire Triple A process); and
● Capacity development emphasis, building on already existing human, economic, and
organizational capacity.
Program design and content
● Planned actions should originate from a consensus among stakeholders about the
priority problems, available capacity, and resources.
● Actions are usually, at least initially, based on strengthening existing capacity and
household and community coping strategies.
● An initial process of prioritization and sequencing of a few feasible actions is recom￾mended, rather than all-encompassing, multisectoral, centrally-coordinated action.
● Targeting should be appropriate with respect to objectives, need, and responsiveness.
● Personnel ratios should be appropriate (“intensity” [see below]).
● Job descriptions should be clear, with an emphasis on quality, not quantity—with care
to prevent worker overload.
● Both top-down and bottom-up actions may be relevant.
● Communication and education to improve home-based care is usually critical to pre￾venting young child malnutrition.
● The program should focus on a limited set of highly specific, do-able behavioral
changes.
Program management and implementation
● Strong leadership;
● Clear, efficient, action-oriented, management information system, usually including
community-based monitoring, e.g., growth monitoring and promotion; and
● Cost consciousness (including people’s time) and clear, visible accounting proce￾dures.
Evolution, sustainability, and scaling up
● Sufficient time for community-driven programs to evolve and take root;
● System for scaling up that takes heed of the different forms of scaling up, such as
size/coverage of program and number and type of activities;
● Flexibility to adapt to changing situations;
● Sustained and flexible donor involvement and support;
● Partnership building (e.g., community-government partnerships); and
● Ongoing evaluations and operational research with findings communicated exter￾nally for advocacy and internally to improve the program.
Lessons from Experience
6
2.2 Program design and content
Although there is no blueprint design, activities that
are regarded as “direct nutrition” interventions tend
to be similar across countries: growth monitoring and
promotion, promotion of breastfeeding and appro￾priate complementary feeding, communications for
behavioral change (nutrition information-education￾communication [IEC] or nutrition education),
supplementary feeding, health-related services (e.g.,
deworming and the Integrated Management of
Childhood Illness [IMCI] program), and micronutri￾ent supplementation. One distinct variation with im￾portant resource implications is whether
supplementary feeding is included in the program,
how it is targeted, and how long it lasts.
Most reviews of community nutrition program￾ming found that success is not linked to any particu￾lar implementation framework, though some studies
revealed more specific findings related to particular
nutrition issues. For example, the Nutrition Commu￾nication Project that documented lessons learned
from five large-scale communication programs found
that to promote vitamin A, specific foods and prac￾tices should ideally be identified with strategies used
by the food industry that are highly attuned to sup￾ply/cost, taste, convenience, and other consumer
preferences. Promoting exclusive breastfeeding,
while discouraging dangerous behaviors such as giving water along with breast milk, is
most effective when building on new concepts about breastfeeding. More than any other
behavior, complementary feeding requires time-intensive interpersonal contact. Improv￾ing maternal nutrition must come from strategies that address a wide range of areas, in￾cluding women’s social status in the family, household food security, and other issues
related to household dynamics (Parlato et al 1996).
Along with program content and organization, coverage, targeting, and intensity are
other key considerations. Coverage relates to the proportion of the population participat￾ing in the program. Targeting concerns the degree to which this coverage is oriented to￾ward the most needy among those who are able to respond. For example, despite
evidence suggesting that malnutrition is a problem throughout the life cycle, only 6–24-
month-old children may be targeted initially, because this is both the most responsive and
the most vulnerable age group. Pregnant women will also usually be included, given their
relative nutritional vulnerability and the known links between their nutritional status and
birth weight.
Intensity concerns how many resources are used per participant, expressed either fi￾nancially as dollars per participant per year or with regard to population and worker ra￾tios, for example, the number of children per community-level worker or mobilizer or the
number of facilitators or supervisors per mobilizer. Experience suggests that effective pro￾grams expend around $5–$10 per participant per year—at least programs that do not in￾clude provision of additional food, which approximately doubles the cost (Gillespie et al
Lessons from Experience
(SCSP–Uganda)
7
1996). With regard to personnel ratios, a 20/20 target has been suggested, whereby one
community mobilizer covers 20 households, and one facilitator in turn supervises 20
mobilizers (Tontisirin and Gillespie 1999).
The relationship between intensity and impact is almost certainly not linear. Below a
certain resource/capacity threshold, program impact is at best negligible. In other cases,
well-conceived programs may be ineffective simply because their coverage is too low to
have a broad impact on the problem, or they do not reach those most in need. Large-scale
programs have wide coverage but are often poorly targeted, while small-scale programs—
often run by NGOs—are sufficiently “intense” to ensure good targeting, yet impact is lim￾ited by their low coverage.
2.3 The importance of process
Beyond such design issues lie critically important considerations of how these activities
should be initiated, implemented, managed, and monitored. Indeed, these “how” ques￾tions are the main stumbling blocks to realizing the potential of nutrition interventions
shown in small-scale, highly supervised efficacy trials.
Experience shows that success in nutrition requires more than just the achievement
of certain desirable outcomes, such as reduced child malnutrition. It requires that these
outcomes be achieved by way of a good process. Both the means and the ends are thus im￾portant, not least because outcomes achieved to date are unlikely to endure without estab￾lishing an appropriate process.
But what is a good process? Increasingly it is defined as one in which participation, lo￾cal ownership, and empowerment are the driving forces. A focus on process thus aligns
with the human rights rationale for action. “Beneficiaries” are considered as subjects of
their own growth and development, rather than as passive recipients of welfare-oriented
transfers. Where different partners are involved, it is essential to generate a working con￾sensus on the nature of the problem and its main causes before any attempt is made to de￾sign solutions.
Top-down, outcome-focused service delivery or nutrition interventions—e.g., micro￾nutrient supplementation—have tended in the past to dominate the field of nutrition.
Often with limited community ownership and little if any attention to strengthening local
nutrition- improving processes, long-term effectiveness is consequently weak and
sustainability dubious. Process-focused initiatives, on the other hand, are more bottom up
in their emphasis on participation and empowerment. These initiatives are often small
scale and supported by NGOs. Most of the 10 programs described in this report adopted a
quality-oriented, community-driven approach to nutrition programming. While they may
be sustainable and effective, their impact may nonetheless be constrained by their limited
coverage. Most successful programs have combined both outcome and process orienta￾tions.
Another USAID-supported review of community nutrition programs located primarily
in West Africa confirmed the importance of lessons learned in both the “what” and “how”
of programming. The review lays out the following five-step approach for establishing pro￾grams (Ndure et al 1999):
Step 1: Identifying the key partners involved in the planning and implemention of a community nu￾trition program
● Identifying the key partners from the community
Lessons from Experience
8
● Identifying the key partners from the public and private sectors
● Making intersectoral collaboration work
Step 2: Understanding the priority nutrition problems
● Assessing the nutrition situation
● Analyzing the causes of malnutrition
Step 3: Selecting the most appropriate program approach
● Defining the program goals and objectives
● Determining the key program targets
● Choosing the most appropriate intervention strategy
Step 4: Developing the institutional framework for implementation
● Defining the management and programmatic roles of different partners
● Eliciting commitment of partners to their roles
Step 5: Designing an appropriate program action plan
● Defining program activities and time frame for implementation
● Determining the amount of resources needed
Some other pivotal tools and approaches that were identified by several of the reviews
described above also appear in the assessment of 10 nutrition programs of East Africa.
These include the Triple A process of decision making, the UNICEF-pioneered concep￾tual framework of the causes of malnutrition in society, and the USAID-supported behav￾ioral change communication approach. Full descriptions of these tools are provided in
annex 1 and in the report that follows.
Lessons from Experience
9
3 Characteristics of Programs in Kenya,
Tanzania, and Uganda
The Nutrition Coalitions in Uganda, Tanzania, and Kenya and their assessment teams
were asked to identify successful community nutrition programs. The result was a mix of
programs with varying emphases (see table 1).
3.1 Program types
The programs are not limited in
scope to nutrition, but encom￾pass broad development objec￾tives across many sectors. Only
two programs (CBNP/Kenya
and MICAH/Tanzania) had im￾proving nutrition and micronu￾trient status as their primary
objectives. Nutrition objectives
for the remaining eight pro￾grams complement or are even
secondary to health, child sur￾vival, reproductive health, or
microfinance objectives.
Three of the programs in
the study can be classified as
Child Survival programs: SCSP/
Uganda, CSPD/Tanzania, and
MICAH/Tanzania. These pro￾grams place a high priority on
improving nutrition and other health-related objectives. ANP/Kenya and CCF/Kenya in￾clude improving nutrition with other community development and health-related out￾comes, as does the GRHRP/Uganda, the only emergency program included in the study.
IP/Tanzania concentrates on reproductive health but used nutrition as an entry point
early on. For the two remaining programs—IFCPP/Tanzania and FOCCAS/Uganda—im￾proving nutrition was neither an objective nor a primary intervention. Because of their
perceived indirect effects on nutrition, these programs were selected for the study.
Box 1: Program abbreviation key
Kenya
ANP Applied Nutrition Project
CBNP Community-based Nutrition Programme
CCF Christian Children’s Fund Programme
Tanzania
CSPD Child Survival, Protection and Development Programme
IFCPP Ileje Food Crops Production Project
IP Sustainable Integrated Reproductive Health Services Project
MICAH Micronutrient and Health Project
Uganda
FOCCAS Foundation for Credit and Community Assistance
GRHRP Gulu Relief & Health Rehabilitation Project
SCSP Ssembabule Child Survival Project
Table 1: Projects in community nutrition assessment
# Of Projects Type Name
3 Child survival SCSP/Uganda, CSPD/Tanzania,
MICAH/Tanzania
1 Reproductive health IP/Tanzania
2 Community development CBNP/Kenya, CCF/Kenya
2 Agriculture/food security IFCPP/Tanzania, ANP/Kenya
1 Microfinance/credit FOCCAS/Uganda
1 Emergency GRHRP/Uganda
Characteristics of Programs in Kenya, Tanzania, and Uganda
10
Annex 3 provides a summary of information on each of the 10 community programs,
including name of project and dates of operation; implementing and donor agencies;
population coverage; goals and objectives; donor contributions; interventions; and nutri￾tion outcomes.
3.2 Implementing agency and donors
The implementing organization and the donor agency have a direct influence on pro￾gram interventions, implementation, evolution, and scale up. In only a few cases does an
organization both fund and implement the program. More often several layers of agendas
seem to influence programming from implementing and donor agencies.
Only two of the programs are carried out by government agencies, though several are
in cooperation with government staff. CBNP is implemented by the Department of Social
Services within the Ministry of Home Affairs, Heritage and Sports and funded by
DANIDA. The Family Planning Association of Tanzania (UMATI) implements IP with
JOICFP and IPPF funding. Only CSPD/Tanzania is primarily funded by a multilateral,
UNICEF. All of the remaining programs are implemented by NGOs, most with funding
from foreign governments: World Vision implements MICAH and the GRHRP, MIHV
implements SCSP with funding from USAID and the Canada Micronutrient Initiative,
and Vredeseclanden COOPIBO (VECO) implements IFCPP from the Belgium Interna￾tional Association for Development Cooperation (COOPIBO). AMREF implements
ANP/Kenya with funding from the Spanish Cooperation Agency (AECI). Only CCF/
Kenya both implements and funds its programs on its own, and FOCCAS is the only pro￾gram with private sector support.
3.3 Location and coverage
The population coverage and the number of targeted individuals
vary across programs, from 16,000 to more than half a million.
CSPD/Tanzania, CBNP/Kenya, and IP/Tanzania reach the most
beneficiaries, and FOCCAS/Uganda the fewest. Nearly all of the
programs target children under five years and women for nutri￾tion interventions, though a few cover a wider age span. IP/Tanza￾nia includes school-age and adolescent boys and girls. IFCPP/
Tanzania is one of the few targeting mostly men, though also tar￾gets women farmers.
3.4 Program costs
Information on program costs relative to outcomes is invaluable in demonstrating success,
yet few systematic cost studies were conducted on these programs. Some however did esti￾mate costs per capita. As stated above, studies have shown that effective nutrition program￾ming requires an annual investment of approximately $5–$10 per beneficiary (Gillespie
and Mason 1991). ANP/Kenya estimated $4 per capita annual cost, while the SCSP/
Uganda program estimated $5. CCF/Kenya requires a $24/month donation ($288/year)
from the sponsor for each school-aged child. One-half of this amount ($12/month) goes di￾rectly to the child and his/her family to pay for education and related costs such as books,
uniforms, and some medical costs, while the remaining amount goes into community or
group projects and administrative costs.
Characteristics of Programs in Kenya, Tanzania, and Uganda
11
FOCCAS/Uganda qualifies as one of the most expensive programs included in this
study, with US$1,391,101 budgeted over two years targeting a small beneficiary population
of 16,000 women ($43/beneficiary/year). This is partly due to the financial costs of credit.
One of the least expensive programs administratively is CCF/Kenya, with only 20% of ex￾penditures related to administration and the remaining 80% devoted to programming.
Other programs (i.e., ANP/Kenya, IFCPP/Tanzania) have kept costs low through cost
sharing and working through salaried government staff. In general, though, information
is insufficient with respect to both unit costs and cost-effectiveness of programs described
in this report.
3.5 Nutrition outcomes
Nutrition outcomes in the assessment were defined to include behavioral, anthropomet￾ric, and biochemical improvements. Only four programs collected impact data on nutri￾tion outcomes that could be statistically associated with program interventions. Several
others had baseline studies but had not yet collected data to demonstrate positive
changes in nutritional “outcomes” as a result of programming.
3.5.1 Anthropometry
Relatively few of the programs reported improvements in nutrition outcomes using an￾thropometric indicators—weight for age (w/a), height for age (h/a), and weight for
height (w/h).
● IP/Tanzania reported decreases in moderate un￾derweight nutrition (WAZ < -2) from 44% to 41%
and in severe underweight from 7% to 2% over a
four-year period based on the District CSPD
Baseline Survey in 1995 and the CSPD Annual Re￾port in 1999 (TFNC 1999c).
● GRHRP/Uganda was able to reduce severe wasting
(WHZ < -3) from 5% from the Baseline Survey in
June/July 1998 to 2% from the GRHRP Nutrition
Survey taken in 1999 (AMREF 2000c). Unfortu￾nately, the GRHRP surveys also revealed increases
in stunting and moderate wasting.
● CBNP/Kenya showed decreases in stunting and
wasting for children under five years.
● The District Annual Review reports of CSPD/Tan￾zania in 1998 and 1999 showed impressive reduc￾tions in underweight malnutrition during this
two-year period, reporting a 70% drop in preva￾lence of moderate underweight (WAZ < -2) and an
80% drop in prevalence of severe underweight
(WA Z < -3).
These reported improvements in nutritional sta￾tus, however, were not shown to be clearly linked to pro￾gram intervention and may instead, at least partially,
reflect secular trends. This major shortcoming needs to
be addressed in the design of monitoring and evalua￾tions systems in future nutrition programming.
Characteristics of Programs in Kenya, Tanzania, and Uganda
(ANP–Kenya)
12
3.5.2 Behavior change, knowledge, and awareness
Some programs used the knowledge, attitudes, and practices (KAP) tool and the knowl￾edge, practices, and coverage (KPC) methodologies. These surveys reveal information
about breastfeeding practices, current knowledge about nutrition, and nutrition-related
behaviors (box 2).
Based on KPC studies in 1994 and 1996, SCSP/Uganda reported an increase in ex￾clusive breastfeeding rates from 65% to 100% and an increase in early initiation of
breastfeeding from 3% to 40%. Mothers reporting that vitamin A should be added to
complementary foods increased from 3% to 25%, and mothers reporting that oil and
sugar should be added to complementary foods increased from 3% to 68%.
Focus group discussions conducted for the assessment indicated that the program
had increased awareness and knowledge of nutrition. Most parents and caretakers partici￾pating in the study understood what it meant for a child to be in the “red” on a growth
chart. Food taboos, widely apparent before the project, have diminished in program com￾munities. Significant improvements in behavioral outcomes were reported, especially for
exclusive breastfeeding, breastfeeding frequency, early initiation of breastfeeding, im￾proved complementary foods, and increased feeding frequency. Parents reported in￾creased attendance at growth monitoring and promotion (GMP) sessions, TBA-assisted
births, and health facility visits. The quality of complementary foods was also reported to
have improved through increased variety, better hygiene, and the addition of micronutri￾ent-rich foods.
3.5.3 Other outcomes
Reductions in infant and childhood mortality were viewed as an improved nutrition-re￾lated outcome. In IP/Tanzania, discussions with community leaders suggested that 9 of
the 11 severely underweight children identified in the GMP program had been saved as a
Characteristics of Programs in Kenya, Tanzania, and Uganda
Box 2: Knowledge, practice, and coverage (KPC)
The Child Survival Support Program (CSSP) of the Johns Hopkins University, with support from
USAID, developed the knowledge, attitudes, and practices (KAP), later to become the knowledge, prac￾tices, and coverage (KPC), in an effort to facilitate PVO assessments of Child Survival programs. The
current survey KPC2000+, which uses a 30-cluster sampling methodology, contains 15 modules that track
behaviors and yield indicators related to child health. Each of the following modules corresponds to the
child survival technical interventions:
1a. Household Water and Sanitation 4d. Acute Respiratory Illness
1b. Respondent Background Information
2. Breastfeeding and Infant/Child Nutrition
3. Growth Monitoring and Maternal/Child
Anthropometry
4a. Childhood Immunization
4b. Sick Child
4c. Diarrhea
4e. Malaria
5a. Prenatal Care
5b. Delivery and Immediate Newborn Care
5c. Postpartum Care
6. Child Spacing
7. HIV and Other Sexually Transmitted Infections
8. Health Contacts and Sources of Information
http://www.childsurvival.com/kpc200/kpc200.cfm
13
result of programming interventions. CSPD/Tanzania
reported a reduction in infant mortality rates by 18%
and in childhood mortality by 44% over a one-year pe￾riod from district annual review reports in 1998 and
1999 (UNICEF 1999).
As discussed later, all 10 of the programs re￾ported related improved outcomes in other sectors:
water and sanitation, crop production and diversifica￾tion, reproductive health/contraceptive use, women’s
solidarity, and financial viability of households.
Characteristics of Programs in Kenya, Tanzania, and Uganda
(IP–Tanzania)
14
4 Process Leading to Program Development
The assessment explored the conditions that existed before the design and implementa￾tion stages within program areas, i.e., initial problem situation (nutritional status, determi￾nants of malnutrition), initial capability/resource situations (role/participation analysis
of key stakeholders, resource/capability analysis), and policy and programmatic environ￾ment. The objective was to identify key lessons in this essential process leading to pro￾gram development. Notably, programs rarely exhibit all these characteristics. Yet too often
insufficient time and resources are devoted to this critical first phase of program develop￾ment.
The following success factors are related to the process leading to program development:
✔ Existence of a conducive policy environment, especially at district levels;
✔ Understanding by stakeholders of the political, economic and social determinants of
malnutrition in the area based on a systematic analysis;
✔ Community awareness and commitment to nutrition, either existing or created for
the proposed project areas;
✔ Appropriate entry point responsive to the community’s wishes and needs;
✔ Presence of complementary ongoing programs and/or local government structure;
and
✔ Funding and extra time allocated for program development.
4.1 Conducive policy environment
A common finding across several program assessments was that a conducive policy envi￾ronment at all levels, from district to national, is essential to successful community nutri￾tion programming. Programs in Tanzania, especially, emphasized this factor. If policies
promoting nutrition did not exist in program areas, they were often created during the
life of the project. The SCSP/Uganda program attributed part of its success to a change in
policy. Ssembabule had been a subdistrict of Masaka District but in March 1997 became its
own district with its own governance systems. Decentralization brought services and re￾sources closer to people and facilitated the interventions offered by MIHV. Another ben￾efit of the project operating within the Ssembabule administrative boundaries was that the
enclosed homogeneous communities responded in similar ways to program interven￾tions. IFCPP/Tanzania also successfully chose to operate in a context where district poli￾cies and government were amenable to project goals.
National policies may be less important than district-level policies that have a greater
and more immediate impact on communities and programs. For example, the Entandikwa
National Poverty Reduction Scheme in existence in Uganda for three years was not per￾ceived to have facilitated program implementation, though it was designed to address
many of the food security determinants of malnutrition in the area (e.g., by providing
loans to peasant farmers and unemployed, promoting land ownership, and encouraging
mixed farming).
4.2 Assessing and analyzing the nutritional situation
Most of the programs included in the assessment applied nutrition conceptual frame￾works, indicating organized analysis of the determinants of malnutrition in program areas
Process Leading to Program Development
15
at some level. Various tools were used to gather insight into
the sociocultural and economic reasons for nutrition prob￾lems in the area—for example, FOCCAS/Uganda used the
KAP tool and SCSP/Uganda, the KPC tool. Some programs
used the Triple A process of assessment, analysis, and action
(see annex 1). Assessment and analysis of the nutrition situ￾ation by the community members themselves is the pre￾ferred approach, albeit one for which allocated time and
resources are rarely sufficient.
Focus group interviews during the assessment showed that many program staff felt
that cultural practices played a large role in determining nutritional status of households.
For example, before CCF/Kenya programming, some believed that breast milk could be￾come sour or hot if a mother stayed in the sun too long. “Cleanliness of the breast” was
cited in many East African programs as a barrier to breastfeeding. This is also an issue in
the early initiation of breastfeeding after delivery when there is no available water.
The programs assessed in Tanzania found that several people believed malnutrition
was caused by zongo (witchcraft). Others believed that curses from deceased ancestors or
from mothers practicing sex during lactation caused malnutrition. Households were re￾ported to have contacted traditional healers (Mganga or Fundi) for treatment. Food taboos,
a common occurrence in the region, were addressed and dispelled by several of the pro￾grams. Pregnant mothers and children in Morogoro District, where IP/Tanzania is operat￾ing, were prohibited from eating liver and eggs for various reasons.
In only a few cases did a positive cultural belief facilitate the design and implementa￾tion of programs. CSPD/Tanzania cited the value placed on milk by Masai communities.
Socioeconomic determinants were also assessed, primarily by examining household
food security of program areas. Programs later responded to these determinants with in￾come-generating activities to help families afford and buy foods (as well as other goods
and services) for improving nutrition. In the political and economic spheres, macro-level
determinants were not included in the program assessments.
4.3 Selection of an entry point
Several of the assessed programs cited the selection of an appropriate entry point as a suc￾cess factor in their programming. Determination of an appropriate entry point should be
made during the phase before program
design or during the process leading to
program development. Once the politi￾cal, economic, and social context is un￾derstood, an implementing agency,
together with the community, selects the
problem deemed most pressing to ad￾dress first. Though only 3 of the 10 pro￾grams identified the selection of an entry
point as an element of success, there is
evidence that all of the programs are ad￾dressing priority problems of the commu￾nity, whether or not these problems are directly related to nutrition.
“Mothers who deliver at night wait until the
next morning to initiate breastfeeding, when
water is available and the mother can bathe
and clean her nipples”
(FGD mothers—Labongo-gali)
“Masai community related milk with health of
calves. They believed that if calves were not
given milk they die. This belief has made them
value breastfeeding and, therefore, colostrum
was given to their infants”
(FGD Samaki Maini and Nronga villages)
Process Leading to Program Development
16
In the MICAH/Tanzania program, general experience showed that actions produc￾ing quick and positive results were the most convincing and attractive. MICAH chose to
strengthen basic MCH services, upgrade school buildings, build teaching facilities, and
form groups for income-generating activities. Program managers suggested that the quick
results created trust within the community and ensured continued participation. ANP/
Kenya also made efforts to select an entry point that was meaningful to the community. Be￾cause lack of clean water was a serious problem in Kibwezi, where ANP planned to oper￾ate, installation of water wells was integrated into program design from the beginning.
Interestingly, IP/Tanzania used nutrition and parasite control as the entry points to
introduce reproductive health initiatives. This strategy might be attributed to significant
awareness of nutritional problems in the region created by the operation of CSPD for over
10 years in the same region as IP/Tanzania.
4.4 Complementary ongoing programs and/or local
government structure
The success of a program may be enhanced where complementary programs are provid￾ing other relevant inputs and services in the program area. This is especially apparent in
the Ileje Food Crop Production Project (IFCPP)/Tanzania. Many projects in the area aim
to improve nutrition. As discussed below, the IFCPP program does not offer direct nutri￾tion interventions itself and relies completely on
others (CSPD and DFID) to provide health services.
IP/Tanzania also benefited from complementary
programming of CSPD, in operation since 1985.
Few programs included in the assessment, how￾ever, can depend on the comparative advantage of
other programs, which mostly do not exist.
4.5 Pre-project funding and time
To adopt the elements of success identified for this
phase of program development, pre-project funding
and time are needed. Sufficient time must be al￾lowed to undertake proper assessments with the
community to create a joint understanding among all stakeholders about the nutrition
problems and determinants. To gather quantitative data and qualitative information on
the sociocultural and socioeconomic conditions, time and resources are necessary.
“The whole process of project conceptualization—i.e.
needs assessment, problem analysis, choosing strategies
and planning action—requires adequate time and re￾sources to facilitate active community participation.
Donors and implementing agencies should be prepared
to provide prefunding as an investment in good project
planning. The benefits of such investment far outweigh
inherent risks.”
(SCSP/Uganda)
Process Leading to Program Development
17
5 Program Design and Content
Consensus is growing on the most critical technical issues for nutrition programs (annex
2). These issues are contained in both the BASICS Nutrition Minimum Package
(MINPAK) and the Regional Centre for Quality of Health Care (RCQHC) Nutrition Es￾sentials Package, but how to integrate these packages into a progam effectively needs to
be better understood.
The 10 programs included in the assessment emphasize the following issues from
these technical packages: improving breastfeeding practices; improving the quality of
complementary foods; and increasing micronutrient intake (through food and supple￾ments). Maternal nutrition and complementary feeding practices are included to a lesser
degree.
The main interventions and associated lessons learned include the following:
✔ Growth monitoring and promotion (GMP) programs that are community or group-based,
provide proper feedback and counseling, and ensure information is used efficiently at all
levels;
✔ Nutrition education related to tangible resources, as behavior change communica￾tion, as participatory educational theatre, and as positive deviance approach;
✔ Advocacy and creation of by-laws to promote nutrition and the activities of the project;
✔ Credit and income-generating activities for women;
✔ Improving care for women and children—via reduction in women’s workloads using
appropriate technology such as milling machines, solar dryers, and water wells;
✔ Capacity development and training for programming staff and community members,
which is task-oriented, and part of professional development for staff; and
✔ Multisectoral approach adopted in program design to maximize convergence with
other relevant programs, e.g., those that deal with the underlying food, health, and
care-related causes of malnutrition.
5.1 Growth monitoring and promotion
The effectiveness of improving nutrition through GMP pro￾grams, which may be costly and difficult to implement prop￾erly, has been a source of controversy. One fact became clear
from the assessment: most (8 of 10) “nutrition” programs
currently use GMP as the centerpiece of nutrition program￾ming. Given the continuing interest and investments al￾ready made in GMP, programs could increase effectiveness
enormously by making a few suggested adjustments. Les￾sons from the past (box 3) need to be internalized. The as￾sessment identified the strengths and weaknesses associated with GMP interventions.
Adding community-based GMP to facility-based GMP increases effectiveness consider￾ably. CSPD/Tanzania holds village health days (VHDs) every three months at schools, day
care centers, and so on. The VHDs are announced at churches, mosques, and schools in
advance to increase attendance. Health education provided during these village health
days includes demonstrations of improved complementary foods. SCSP/Uganda and
“There is reason to believe that there is interest
in growth monitoring in addition to what is
expressed in the FGDs, and that the current
failure of the community-based GMP activity is
due more to the way it is conducted than to
lack of interest.”
(ANP/Kenya)
Program Design and Content
18
MICAH/Tanzania also hold GMP monthly at health facilities and once every three
months at the community or even hamlet levels. Focus group discussions from the IP/
Tanzania assessment reported that caretakers found it easier to communicate with and re￾ceive feedback from community-based workers than health fa￾cility staff. Children in the GRHRP/Uganda program are
weighed and measured every two weeks. One suggestion aris￾ing from the ANP/Kenya program was to have group-based GMP.
Existing women’s groups could be trained and equipped to
conduct weighing of their own and others’ children.
Attendance varies across the programs. When GMP is
linked to an immunization schedule, attendance falls dramati￾cally after six months. In Kenya attendance was linked to ef￾forts made by CHWs to bring caretakers to GMP.
Feedback and counseling following the weighing and measuring of a child was re￾peatedly cited as crucial to the success of GMP. Traditional birth attendants (TBAs), com￾munity-based distribution workers (CBWs), and village health workers (VHWs) all make
home visits and conduct site analyses after GMP in the CSPD/Tanzania program. IP/Tan￾zania supported and strength￾ened the GMP of CSPD. In
addition to the VHWs and
TBAs, community leaders and
village health committees
make follow-up visits. IP’s
GMP program is viewed as ex￾traordinarily participatory at all
levels—household, hamlet, vil￾lage, and ward—and funda￾mentally derives from the Triple A cycle (UNICEF) of the project, as does that of the
MICAH program.1
1 The social structure (10-cell unit) of Tanzania is particularly conducive to contacts at the household
level. During the country’s socialist regime, the government helped to ensure that the 10-cell leaders
visited households of malnourished children (e.g., as per the Iringa program).
“GMP is still linked to immunization. Few
mothers appreciate its value and discontinue
with it after the age of six [months]. Thus,
most children weighed are under six months of
age, the period when the risk of malnutrition
is the least”
(SCSP/Uganda)
Program Design and Content
“A quick review of CHW monthly reports from the last few
months in Mbooni found that attendance varied from 10%
to 60% of total children under five years in different commu￾nities. Low attendance was attributed to inactivity of the
CHWs, although there may be other factors."
(CBNP/Kenya)
Box 3: Lessons from growth promotion programs
● Programs should be community- or neighborhood-based and aim for universal coverage.
● Monitoring of weight for the individual should begin at birth and be done monthly for the first 18–24
months.
● Child caretakers should be involved in the monitoring.
● Adequate growth (weight gain) rather than nutrition status should be the indicator for action, by it￾self or combined with other easily obtained information about the child’s condition.
● A growth chart should be used to record the child’s growth progress to make his/her growth status
visible to the child caretaker.
● An analysis of the causes of inadequate growth is required and should lead to clear and feasible op￾tions for action.
● Negotiation should take place with families, guided by tailored recommendations on what they can
do to improve their children’s growth.
● Follow-up should be done.
World Bank 1996
19
Often GMP programs have no feedback
loop from health workers to mothers/caretak￾ers. Though GRHRP/Uganda has a very orga￾nized GMP, using a double entry system
(measurements recorded in a registry book
and on the child’s health care), there is no in￾teraction between VHWs and mothers. The
CBNP/Kenya assessment found GMP to be
primarily a weighing and recording exercise.
Very often GMP information is fed into
broader national information systems with no
follow up. For example, the MOH divisional
office feeds GMP data into the Child Health
and Nutrition Information System (CHANIS)
in Kenya, a clinic-based data surveillance sys￾tem intended for use by district and regional
planners. Summary statistics are forwarded to
headquarters, but further action is rarely
taken.
Fees associated with weighing and measuring appear to be another potential deter￾rent to effective GMP programming, especially in poorer communities. IP/Tanzania
charges approximately $.06 for each weighing; CBNP/Kenya charges $.07-$0.13 per
weighing. Fees are charged in ANP/Kenya as well, and were reported to reduce atten￾dance. In addition to the strain on household budgets, the lack of accounting for the fees
charged creates distrust within the community. Therefore, the economic situation of the
community should help determine whether a fee is charged and the amount. In commu￾nities where a fee is charged, indigent families should be exempt from the costs. Trans￾parency is also recommended in the communities in how the fees will be used (i.e.,
purchasing supplies or transport costs).
In sum, GMP programming should be structured to include the following aspects:
community or group-based, linked to adequate counseling and feedback to caretakers, ac￾tions taken at all levels based on information collected, and weighing and measuring ser￾vices offered without cost or at a cost appropriate for households’ economic status.
5.2 Nutrition education
Some form of nutrition education is provided in nearly all of the 10 projects. The assess￾ment identified particular models of imparting knowledge and changing behavior that go
beyond the usual didactic,
top-down approach.
Nutrition education
sessions are generally un￾dertaken by community
workers (e.g., VHWs and
TBAs) with caretakers in
different venues (e.g.,
women’s groups, village
health days, credit associa￾tions, and GMP). In the
“Through discussions with key informants, it was pointed out
that the data generated during VHD, particularly those re￾lated to growth monitoring, were used to sensitize and mobilize
parents to take the leading role in improving the condition of
their children. Based on data generated, the VHWs were able to
advise parents on appropriate actions to be taken. It was said
that by plotting the weight of a child on a MCH card, parents
were able to monitor the growth pattern of their children. The
color of the card was self-explanatory to enable the parents to un￾derstand whether the child was malnourished, even for illiterate
parents. It was further reported that the card was a simple tool
for initiating triple 'A' cycle between parents and heath workers
or VHWs”
(MICAH/Tanzania)
“The team did not observe any feedback being given to the
mother or caretaker, even in cases where the child had a
health card and where the child was found to be malnour￾ished. The lack of follow up of underweight children and
non-attendees, [and] inadequate nutrition education and
counseling were among problems pointed out during the re￾fresher training of CHWs.”
(CBNP/Kenya)
Program Design and Content
20
CCF/Kenya program, social workers visit homes or focus groups to provide health and nu￾trition education. For MICAH/Tanzania, CSPD/Tanzania, IP/Tanzania, ANP/Kenya, and
CBNP/Kenya, VHWs are responsible for providing nutrition education, along with TBAs
and staff nurses. FOCCAS/Uganda includes nutrition education in its weekly education
sessions for the credit associations/village banks. Many use food demonstrations to im￾prove complementary feeding practices and diets.
Emphasis on behavior change communication (BCC) appears in some of the programs,
though there is no systematic approach to nutrition BCC. The GRHRP/Uganda assess￾ment states, “In an attempt to impact positive behavioral change in child practice, the project has
concentrated on capacity building.” Community health workers (CHWs) and volunteers
(CHVs), TBAs, and mothers are trained using the MOH training package. CHWs and
CHVs then monitor behavior change through regular home visits, and, where there are
deficiencies, they organize health education sessions for the whole community. MICAH/
Tanzania promotes positive behaviors through support of gardening activities and food
production, community education, and distribution of posters. MICAH/Tanzania and
others also recommend providing nutrition education together with tangible resources
for nutritional improvement (e.g., seeds, improved livestock, and vitamin A and iron cap￾sules). Box 4 describes a BCC strategy that has evolved from community programs sup￾ported by the Academy for Educational Development (AED).
Box 4: Behavior change communication (BCC)
BCC is a programming methodology becoming popular across many different sectors. The Academy for
Educational Development (AED) has worked extensively in this area, most recently for improving nutri￾tion. For example, LINKAGES/AED has demonstrated results in the early initiation of breastfeeding,
exclusive breastfeeding, appropriate complementary feeding, and maternal nutrition applying BCC
methodologies in programs in Madagascar and Ghana. The BCC strategy includes the following:
● Quantitative baseline and endline surveys;
● Formative research: interviews, focus groups discussions, observations, 24-hour recalls, etc., con￾ducted to understand local feeding and dietary practices and identify simple changes in practices
that are affordable and culturally acceptable;
● Trials for improved practices (TIPS): trials to determine practices most likely to be tried by mothers
and adopted over the long term;
● Strategy design: plan completed by counterparts and partner institutions that includes target audi￾ences and messages and strategies for each audience;
● Community-based approaches: working through home visits, community mobilization techniques,
mother-to-mother support groups, and volunteers;
● Promotion of local foods;
● Materials and media development;
● Training and capacity building on technical content and counseling skills: NGOs, government per￾sonnel, and community-based workers; and
● Monitoring and evaluation.
Academy for Educational Development 2000
Program Design and Content
21
A recommended element of success coming from CBNP/Kenya for nutrition educa￾tion, sensitization, and mobilization of the community is participatory educational theatre
(PET). CBNP trained PET groups of men and women who had some previous experience
in drama and performing arts. These groups perform drama, puppetry, or songs they have
developed on social and health themes and engage the audience in dialogue about the
stories or situations portrayed. The PET groups are not receiving the compensation or in￾centives they desire, but as a result of their experience, the groups are being recruited by
NGOs, business, and so on to develop dramas on other topics. For example, CARE-Kenya
contracted the PET groups to perform a drama on the theme of HIV/AIDS.
A few of the programs also use a form of positive deviance approach to nutrition behavior
change—that is, maximizing local learning from caretakers who have succeeded in raising
well-nourished children despite being from poor households. The CCF/Kenya program
encourages selected role models within focus groups to provide nutrition education to the
other members of the group. GRHRP/Uganda, among others in the assessment, train se￾lected mothers from the community to offer food demonstration sessions. During the ses￾sions, mothers teach others about preparing complementary foods and about child
survival strategies, including appropriate breastfeeding and complementary feeding prac￾tices.
In sum, the lessons learned with regard to nutrition education at the community level
are to provide tangible resources along with education, focus on nutrition behavior
change communications, and use innovative techniques such as participatory educational
theater and/or the positive deviance approach.
5.3 Adopting a multisectoral approach
Because malnutrition is a multisectoral problem, solutions need to be sought from several
sources. All 10 programs have incorporated
various sectors into program interventions
or collaborated with other programs ad￾dressing these sectors within the same
populations. The second strategy is more
difficult in practice, and most programs
seemed to have opted for incorporating sev￾eral sectors into their own implementation
plans. Many programs appear to focus on
one sector (e.g., Micronutrient and Health
Project or Integrated Reproductive Health
Services Project or Applied Nutrition
Project), but closer examination shows a
wide array of interventions in education,
health, agriculture, and so on.
Nearly all the programs address food pro￾duction and agriculture because agriculture is
a source of livelihood for most of the popu￾lations served. The overall aim of IFCPP/
Tanzania is to improve small-scale farmers’ living standard through increased food pro￾duction. To address other dimensions of the nutrition problem, IFCPP relies on CSPD/
Tanzania. The Kenya programs promote organic farming as well as general food produc￾tion.
Program Design and Content
Education
Nutrition
programming
Agriculture
Health
22
Another intervention used
by several programs and identi￾fied as a lesson learned in the
assessment is the promotion of
drought-resistant crops and locally
available materials and foods.
Ssembabule/Uganda has suc￾ceeded in promoting micronu￾trient-rich foods through a
food-based approach. Several
schools, communities,
women’s groups, and house￾holds in the project area now
maintain small gardens for the
purpose of production and
consumption of micronutrient￾rich foods.
Health-related interventions are widely apparent in the community nutrition programs.
Malaria control, a need strongly expressed by many communities, was incorporated into
most programs. The review of IP/Tanzania identified parasite control as a critical element
in community nutrition programming. Hookworms are widely prevalent in the program
areas, causing high rates of morbidity related to malnutrition. Interventions to address
problems having to do with water and sanitation were also widely used by the programs as￾sessed. One health issue noticeably still absent from programs is HIV/AIDS. Given the se￾verity of the problem in the region and the synergistic relationship with nutrition in
populations, additional efforts seem necessary in this area.
Interventions in the education sector are also common. IP/Tanzania, in cooperation
with NGOs such as World Vision/Tanzania, works to improve education and literacy lev￾els. The assessment team observed the impact of these efforts in the requests made by
community members for teams for newspapers and printed materials to read. CSPD/Tan￾zania addressed and improved literacy rates in its project areas.
With regard to child development, CCF/Kenya has established Early Childhood Develop￾ment (ECD) Centres—attached to public schools and/or community-based—for children un￾der five years. CCF provides food for school lunches to the Centres. The ECD Centres in
the CCF program have resulted in observed improvements in psychomotor skills and in￾tellectual development of the children, improved hygiene practices by children, and ad￾ditional time for mothers to work in the shambas (small plots of land) or on other
income-generating activities. Women have demonstrated their appreciation for the ECDs
through monetary contributions to costs of operation. CSPD/Tanzania has also estab￾lished day care centers and even some institutionalized preschools attached to primary
schools.
5.4 Advocacy
Advocacy efforts are closely related to information and communication campaigns. Advo￾cacy can be carried out within communities and by communities to a larger audience.
Ssembabule/Uganda established advocacy groups using peer groups, clubs, and associa￾tions to reach a critical mass with key messages. Drug shopkeepers, TBAs, and others are
forming their own associations to lobby for recognition and systematize their activities.
Program Design and Content
(SCSP–Uganda)
23
The project has also been successful at national advocacy
efforts. In 1997, the project pioneered the linking of vita￾min A supplementation with national immunization days
(NIDs). In 1998, MIHV broadened the scope of activities
during NIDs to include iron supplements to mothers
and antihelminthics for children over one year.
Efforts made in Tanzania to advance nutrition agendas in the policy realm have resulted
in the creation of by-laws to protect caring practices. The IP/Tanzania program initiated the
formulation of by-laws. The Hai District Council where CSPD/Tanzania operates has also
enacted several by-laws as a mechanism for sustaining the program, including the Hai Mater￾nal and Child-Care by-law of 1995 aimed at empowering communities to run village health
days.
5.5 Income generation
Responding to community demand, 5 of the 10 programs in the study included a credit
or income-generating activity component in their nutrition programming, the premise be￾ing that household access to food could be improved through income-generating activi￾ties.
FOCCAS/Uganda, supported by Freedom from Hunger, implements its effective
credit with education model (see box 5). Community-level credit associations (village
banks) composed of approximately 40 persons and organized into solidarity groups of 4 to
7 women were first created. The solidarity group members then received loans starting at
about $44. Annual market interest rates (around 12%) are charged, and 5% of the origi￾nal loan is expected to be saved in 16-week loan cycle. The solidarity groups meet once a
week to repay loans and to participate in education sessions provided by the FOCCAS
field agents. During these sessions, banking and business development lessons are pro￾vided, as are health, nutrition, and family planning lessons on such topics as
Program Design and Content
(FOCCAS–Uganda)
“People are now better equipped to vocalize their
needs.”
(SCSP/Uganda)
24
breastfeeding promotion, infant and child feeding, birth timing and spacing, diarrhea
treatment and prevention, and immunization
Changes in behaviors related to initiation of breastfeeding, exclusive breastfeeding,
and quality of complementary foods are reported to have resulted from the training pro￾vided by FFH and FOCCAS. Women also claim that more resources are available now to
purchase better foods for their families. Other outcomes may indirectly improve nutrition
as well. The program has also improved women’s solidarity and organizational capacities.
Box 5: Nutritional impact of credit with education
Since 1989 Freedom from Hunger (FFH) has been working with local partners in developing countries
to develop and implement a credit with education strategy. In an effort to demonstrate positive program
impact, FFH, together with the Program in International Nutrition, University of California-Davis, car￾ried out evaluation research on the Lower Pra Rural Bank Credit with Education Program in Ghana.
Four categories of impact were examined in two data collection rounds (1993 baseline and 1996 fol￾low-up): child nutritional status, mothers’ economic capacity, women’s empowerment, and mothers’ adop￾tion of key child survival health/nutrition practices. Women with children under three years from 19
communities were placed in three categories: 1) program participants of at least one year, 2) nonpartici￾pants in program communities, and 3) residents in control communities selected not to receive the pro￾gram for the period of the study.
Significant impacts were documented in women’s economic capacity (i.e., increases in nonfarm
monthly income: $36 for participants, $18 for nonparticipants, and $17 for residents in control commu￾nities) and women’s empowerment (increased self-confidence and vision of the future and improved
status and networks in the community). Though status improved in the community, women participants
did not achieve significantly greater bargaining power or status within the households (i.e., in decisions re￾garding number of household investments—clothing, medicine, agricultural inputs—or home im￾provements).
Impact on health and nutrition practices was also achieved. Participants reported significantly
greater positive change than nonparticipants and/or residents in control communities in the following
nutrition-related practices among other health and hygiene practices:
● Giving newborns colostrum;
● Introducing liquids and first foods (in addition to breast milk) closer to the ideal age of about six
months;
● Not using feeding bottles;
● Enriching the traditional complementary food (koko) with bean/cowpea, egg, fish, groundnut, milk,
and palm oil; and
● Enriching Weanimix (a complementary food promoted and distributed by the Ministry of Health)
with fish powder.
The Credit with Education program documented improved nutritional status using anthropometric
measures. The mean height-for-age z-score (HAZ) for participants’ one-year-olds was almost 0.3 greater
than the baseline HAZ of future participants’ one-year-old children. The mean HAZ for children in
control communities was 0.2 less for the same period of time. No impact on women’s nutritional status
as measured by body mass index (BMI) was found, however.
Program Design and Content
25
Other programs participating in the assessment are supporting “merry-go-rounds,” a
popular model of asset-building and credit security used by social groups in East Africa.
Each participating member of the group contributes a predetermined amount per month
and has a turn to use the pooled amount on priority needs approved by the group. The
pooled resources also serve as insurance against emergencies.
ANP/Kenya provides loans to women’s groups through “merry-go-rounds,” as well as
technical assistance and inputs such as improved goat breeds and seeds in support of in￾come-generating activities. IP/Tanzania supports income-generating activities (dairy
goats, fish ponds, sewing machines, milling, and carpentry) of program participants
through groups. Ssembabule/Uganda assists women’s groups such as MAWODA in such
areas as rearing goats, making cheese, and growing coffee. CSPD/Tanzania, among oth￾ers, does not have its own credit component but networks with NGOs that offer income￾generating activities.
5.6 Improving care of women and children
Efforts made by programs to reduce women’s workload may improve women’s and young
children’s nutrition by allowing more time to
breastfeed and undertake proper complementary
feeding practices.
Several programs in the assessment addressed
this issue by introducing labor-saving technologies
such as water wells, milling machines, and solar
dryers. ANP/Kenya strove to reduce workload by
minimizing distances to water source, promoting
and providing assistance in animal traction, and as￾sisting women in income-generating activities. IP/
Tanzania introduced solar dryers and milling ma￾chines to reduce time spent by women walking to
mills and searching for vegetables during the off
season. IFCPP/Tanzania
constructed shallow wells
and installed water pipes
and milling machines. Ef￾forts were also made to cre￾ate awareness about
women’s workload through
public meetings, mass me￾dia, newspapers, and radio.
One effective approach
to reducing women’s
workload was the FOCCAS/
Uganda credit financing
strategy. With the extra rev￾enue coming in from busi￾nesses, women are now
hiring others to carry out ac￾tivities they themselves
would normally undertake,
“Apart from being engaged in business, women had a lot
of work involving the household, such as cooking, wash￾ing clothes, collecting firewood, collecting grass for feeding
cows, fetching water, and much more. This contributed to
low child feeding frequency and sometimes resulted in er￾ratic breastfeeding during the day”
(CSPD/Tanzania)
Program Design and Content
(IP–Tanzania)
26
such as collecting water and digging gardens. They also claim that the weekly credit asso￾ciation meetings provide them with rest from domestic work.
5.7 Capacity development and training
All 10 programs in the assessment have training components, and several approaches to
training have been identified as desirable in community nutrition programming. The
SCSP/Uganda program developed task-oriented training modules for community volun￾teers. An individual’s skills and interests are evaluated and corresponding tasks and train￾ing are assigned. National training guides and curricula are replaced by training adapted
to fit the needs of the community and the abilities of the volunteers.
Training in MICAH/Tanzania, in contrast, is based on Ministry of Health guidelines
and protocols. Emphasis in training VHWs and TBAs is on growth monitoring, family
planning, and disease control. Counseling mothers with malnourished children is in￾cluded, as is data reporting. Women’s and youth groups are also trained by program staff
on topics related to income-generating activities. MICAH places great importance on the
ongoing professional development and continuous training of its own staff as well. Regu￾lar seminars and workshops are held to build particular skills and knowledge, and further
incentive is provided for staff to continue working with the program.
IP/Tanzania and CSPD/Tanzania recommend training all stakeholders at all levels of
implementation. At the village level, community-based distribution agents (CBDAs), vil￾lage health committees, village government representatives, and local steering committee
members were all trained to acquire various skills. At the ward level, training was offered
to the ward executive officer, ward development committee, and some of the extension
staff, and at the district level, training and sensitization seminars were offered to district
leaders.
Field agents from FOCCAS/Uganda are trained using well-developed, standardized
curricula in particular topical areas developed by FFH. Field agents then train credit
groups during weekly meetings held throughout the loan cycle. Women are expected to
repeat lessons learned the following week in skits, songs, or discussion. IFCPP/Tanzania
also offers an innovative approach, in which farmers can participate in “look and learn vis￾its” to other farms through the Farmers Training Centres established by the project. Sev￾eral of the programs build capacity within local administrative structures. For example,
ANP/Kenya trains extension workers in food production, managing systems, seed banks,
and livestock breeding.
In sum, training should be task-oriented for community volunteers, provide ongoing
professional development for program staff, be offered to all stakeholders at all levels,
and, as far as possible, include hands-on components such as “look and learn” visits.
Program Design and Content
27
6 Program Management and Implementation
The key success factors for this phase of a program’s evolution, listed below, address how a
program should be implemented and managed to achieve its objectives.
✔ Community involvement: Involve the community in program planning and imple￾mentation using participatory processes such as:
– Participatory assessment, analysis, and action (Triple A process);
– Participatory rural appraisal (PRA);
– Participatory research and extension (PRE);
– Participatory approach for nutrition security (PANS); and
– Community representation and voice within program hierarchies.
✔ Social groups of varying forms (e.g., women’s groups, farmers’ cooperatives, and
credit associations), either existing or created depending on the context, employed
by the project as target audiences and implementers;
✔ Collaboration with ongoing, complementary programs;
✔ Sufficient remuneration, incentives, capacity building, and professional development
for staff provided;
✔ Recruitment of dynamic project lead￾ers; transparency and accountability
of fund allocation; program flexibility
and adaptability allowed by donors as
needs arise in communities; and
✔ Relevant information shared and
used at all levels.
6.1 Community
involvement
By definition the programs included in
the assessment involved communities in
program implementation. What needed
to be understood, however, was how the
programs endeavored to accomplish
this. In all 10 of the country program as￾sessments, community involvement was
identified as a critical programming ele￾ment, mostly with respect to problem identification, planning, and implementation.
For programs applying the Triple A approach to nutrition programming, community
involvement appears most readily in the “analysis” and “action” stages of the cycle. Most
programs admitted the relative lack of involvement of communities in the “assessment”
and “program planning” phase. This was attributed to the lack of funding and time pro￾vided for this initial stage. Communities, however, were involved in analyzing problems,
presenting proposed activities to address the problems, and taking action to alleviate
them. To complete the cycle, communities reassess the problem and thus evaluate the
chosen solution.
Program Management and Implementation
(FOCCAS–Uganda)
28
CBNP/Kenya uses the participatory approach for nutrition security (PANS). A PANS
team established in each community includes CBNP members, local government officers,
and community representatives. The team sensitizes the community to the PANS and be￾gins gathering data through village mapping, a village transect, farm sketches of poor and
successful farms, seasonal calendars, an historic timeline, social and economic trend
lines, institutional analysis, gender analysis focusing on division of labor, and focus group
discussions on nutrition. Data are presented to the whole community and discussed. The
community then ranks problems identified and develops community action plans
(CAPS). CAPS are later evaluated to achieve objectives. The plans are then revised and
implemented again.
IFCPP/Tanzania uses a similar approach—participatory research and extension
(PRE)—that involves identifying the problem, looking for solutions, trying out the solu￾tions, and evaluating the results. Some programs apply the participatory rural appraisal
method (PRA).2
 In CSPD/Tanzania, community members select community-based work￾ers, plan development activities, and mobilize resources within the community.
Community representation within program hierarchies was also considered crucial to
program success in the study. The MICAH project divided areas of operation into clusters
called Area Development Programmes (ADPs). Each ADP has a committee of representa￾tives from all villages implementing project activities. ADP committees have five subcom￾2 Participatory rural appraisal (PRA) is a collection of tools/methods used to collect information from community
members about a range of issues, from community organization and structures to traditional beliefs and work￾ing practices. These methods may include community mapping, seasonal calendars, venn diagrams, three-pile
sorting, pocket voting, matrix sorting, story with a gap, and community action plan (Ndure et al 1999).
7. Review CAP
9. Revised CAP and
implementation
8. Analysis of progress in
CAP implementaion
Assessment
1. Baseline survey
2. Social marketing to leaders, GOK/
NGOs
3. Getting to know the village
Action
6. Community Action
Plan and implemen￾Analysis
5. Problem analysis and
prioritisation
Figure 1: The PANS Triple A Cycle
Program Program Management and Implementationgement and Implementation
29
mittees that monitor project implementation (agriculture, health, water, education and fi￾nancial control, and audit). CCF/Kenya places all parents of sponsored children into Fo￾cus Groups that develop activity proposals with support from program staff. The proposals
are submitted directly to the CCF office for funding approval. CBNP/Kenya works
through the following community-based committees: village health committees, village wa￾ter committees, social welfare committees, and school committees.
6.2 Working through groups
Consensus among many programs in the assessment and others in sub-Saharan Africa is that
working through social groups is an effective strategy for program implementation. Some
programs advocate working through existing groups, while others have been equally suc￾cessful in creating groups for program purposes. Many groups are formed for economic rea￾sons, such as the credit associations of FOCCAS/Uganda or the “merry-go-rounds” of CCF/
Kenya or ANP/Kenya. Other groups emerge as sources of support and solidarity, such as
Kanini Kaseo of ANP/Kenya or MAWODA women’s development association of
Ssembabule/Uganda. Some exist for information exchange and networking, such as the
Farmers Groups in IFCPP/Tanzania. Finally, some groups are formed for the sole purpose
of channeling program interventions, such as the Focus Groups of CCF/Kenya or PRE
Groups in IFCPP/Tanzania.
The Kanini Kaseo (“small is beautiful”) is a dynamic women’s group associated with
ANP/Kenya. The women joined together to ease the transition to a new environment af￾ter being forcibly resettled in Muuni. ANP/Kenya began working with the group, prima￾rily through extension workers. The workers provide technical assistance and education
on agricultural production, seed bank development, improved livestock breeding, and
health and nutrition. ANP also provides loans to the women’s groups. Kanini Kaseo
(Group A) helped to form and train a second group (Group B) in the area. Group B is
operating without any support from ANP/Kenya to pool resources for its own seed bank,
start a group shamba and purchase improved breeds of goats and chickens. Group mem￾bers also extend their solidarity and assistance to community members in need outside
the group.
The Focus Groups of CCF/
Kenya serve as a case study of
building capacity in “democratic
processes.” CCF organized parents
of sponsored children into groups
of 15 from the same “neighbor￾hoods.” Each group has a formal
structure with a chairperson, sec￾retary, and treasurer. These posi￾tions rotate among all members of
the group. Other members are
designated to be educators in vari￾ous areas such as nutrition and
family planning, and are respon￾sible for training other group
members. The Focus Groups meet
once or twice a month and send
one representative to the zonal
committee meetings of the project
Program Management and Implementation
(ANP–Kenya)
30
to present minutes from meet￾ings and various issues. Some
issues and proposals are re￾ferred to management commit￾tee meetings for CCF funding
consideration. Social workers
attend some, though not all, Fo￾cus Group meetings to provide
information and guidance on
CCF policies, regulations, and
procedures.
IFCPP/Uganda also cre￾ated groups for program
implementation and transfer
of skills. Farmers were orga￾nized into participatory re￾search and extension (PRE)
groups to reach all farmers in
the region and encourage a
bottom-up approach. Farmers and extension workers in each group used the PRE four￾step process: 1) identify major problems, 2) find possible solutions, 3) try out different
identified solutions, and 4) evaluate outcomes of the trial.
Other programs provided services and skills-building interventions through groups,
as discussed in other sections: village banks and solidarity groups of FOCCAS/Uganda,
farmers groups of IFCPP/Uganda, and various associations and groups in Ssembabule/
Uganda.
6.3 Coordination with ongoing programs
Coordination and collaboration with ongoing programs varied greatly among those in￾cluded in the assessment. NGOs tended to operate more in isolation than government
programs, though this was not always the case. For example, the country assessment report
of CCF/Kenya does not describe any systematic cooperation with other programs in the
area. GRHRP/Uganda, managed by the NGO World Vision, works together with other
World Vision projects in the area.
In contrast, some programs rely heavily on their cooperation with other programs to
improve nutrition outcomes, offering services based on comparative advantage. IFCPP/
Tanzania provides inputs in the food production/availability sector, while CSPD/Tanza￾nia addresses the health and behavior aspects. IFCPP/Tanzania also cooperates with the
district council in the region, in part because it was initially a joint venture with the Ileje
District Council, Community Development Trust Fund, and COOPIBO. The district
council provides extension workers and transport facilities such as vehicles and fuel.
IP/Tanzania and CSPD/Tanzania, often called “sister” projects, also collaborate
closely. IP joined forces with CSPD after IP had been in operation for many years to
strengthen its nutrition interventions, including the GMP program. The assessment team
noted that the two projects are so closely integrated that beneficiary populations are un￾sure of the origins of project activities and inputs. Although it is not clear why programs in
Tanzania seem to be collaborating most effectively among the three countries, some rea￾sons are apparent. The small size of the donor community makes communication and co￾Program Management and Implementation
(SCSP–Uganda)
31
operation easier. Also, use of a commonly accepted conceptual framework of the causes of
malnutrition in the country is widespread among programs in operation. And finally, the
coordinating role played by the Tanzania Food and Nutrition Centre (TFNC) among nu￾trition programs could be another reason for this effective collaboration.
6.4 Staff remuneration and incentives
Community-based workers need adequate remuneration or incentives, whatever form
these take. This was particularly true for the Kenyan programs. Community resource
people (CRP) in CBNP/Kenya are volunteers. Although they receive training, which is
intended to serve as an incentive, the dissatisfaction and turnover of CRPs indicates that it
is insufficient. The TBAs in these communities are paid directly by their clients.
In several projects, provision of equipment and transport for community workers suf￾fices as remuneration. In the IP/Tanzania program, for example, CBDAs and VHWs re￾ceive bicycles and pumps, uniforms/shoes, raincoats or umbrellas, diaries, and register
books. IFCPP/Tanzania gives village extension workers bicycles and ward extension work￾ers motorcycles for transport. In addition, both receive a nominal fee payment. CSPD/
Tanzania found that poor remuneration of VHWs did in fact result in their dropping out,
declining GMP activities, and poor quality of community-based GMP data. In sum, the
context must be evaluated before determining appropriate staff remuneration and other
incentives.
6.5 Leadership
Effective, dynamic leadership was frequently cited as an element of success. Financial man￾agement and transparent accountability were issues for many
programs. A lack of trust exists in some programs where these
transparencies are absent. Flexibility and timeliness in fund al￾location for activities outside the budgeted activities was also val￾ued. GRHRP/Uganda project officers are able to approve up to
3 million Tshs (approximately $3,750) to handle problems that
arise.
6.6 Information systems
All 10 program assessments called for information to be exchanged more readily at all lev￾els. The CCF/Kenya program provides an effective model for monitoring and information
sharing. Information entered on family cards (including parents’ knowledge, primary
health care indicators, and year of enrollment) is fed into the Standard Impact Tool for
Evaluation (SITE). The SITE, which is updated annually and sometimes semiannually or
quarterly, summarizes these data on one page and provides the status of the population at
each project site. The data collected on the SITE are analyzed at all levels of the pro￾gram—Focus Group, zonal committee, project management committee and office, and
the national office. Red flags are raised where SITE data indicate problems. Actions are
subsequently prioritized and targets set. Another one-page format for listing priorities
and interventions, called the Tool Used for Focus (TUFF), facilitates selection of the pri￾ority intervention. This allows the project to maximize effective use of time and other re￾sources. Several programming staff participating in the assessment indicated that while
program information is fed into national information systems, action is taken or follow-up
response is received very infrequently.
“The quick response of the donor and regular su￾pervision to the project area also create confidence
and mutual working relationship”
(GRHPP/Uganda)
Program Management and Implementation
32
7 Evolution, Sustainability, and Scaling up
A community nutrition program may also be examined with respect to its future prospects
in the community and beyond. The assessment identified the following lessons learned
pertaining to sustainability and scaling up or replicability of program models:
✔ Community commitment of human resources, with active engagement in the pro￾gram;
✔ Financial viability ensured by donors, with funding sustained for over ten years and
self-financing in place through revolving loans or community contributions for ser￾vices;
✔ Organizational and legal frameworks established, including community and women’s
groups; by-laws created;
✔ Preplanning and careful program documentation undertaken early in program; and
✔ Gradual consultative scaling-up in three phases: pilot, expansion, and dissemination.
7.1 Sustainability
A program may be deemed successful by virtue of its improved outcomes in the short
term, but such effects may not endure, particularly if there are deficiencies in the process
through which they were achieved. Process factors are critical for sustained success and
should be assessed to capture the totality of change. Process relates most importantly to
the means through which
changes are occurring in people’s
power, capabilities, and behaviors.
Participation, ownership, and em￾powerment are important aspects
of such a process and for long￾term sustainability. If real
sustainability is to be taken seri￾ously, then the process through
which nutrition improves should
be seen as part of the ultimate
goal, not just the means.
Creating sustainability in nu￾trition programming may mean
that more time is required. Cer￾tain problems may be solved rap￾idly with top-down, vertical, and
outcome-focused programming,
yet such changes may prove to be
transient and cosmetic in the long run. Ultimately the aim should not be to produce a sus￾tainable program or project, but rather to create and sustain nutrition-improving processes.
Fostering ownership must be integral in these processes. If a project or program is to be
truly successful, then it needs to become part of the way of life, embedded in routine be￾haviors and actions.
Consideration should be given to sustainability during the planning and implemen￾tation stages. The following factors were found in the assessments to be particularly impor￾Evolution, Sustainability, and Scaling Up
(ANP–Kenya)
33
tant: human resource commitments, financial viability, and organizational and legal frame￾works.
First, human resource commitment. Being community-based and drawing on community
members for staffing and volunteers helps to ensure this commitment. All 10 programs
have engaged communities to the point of ownership and created a willingness to con￾tinue program activities. Capacity building and training of CHVs, TBAs, CBDAs, VHWs,
and so on is an investment with
sustainability payoffs. Notably, hu￾man resource commitment is
highly dependent on the other
two factors, financial viability and
organizational/legal structures.
The second factor, financial
viability, is probably the most criti￾cal. The ideal is to be ultimately
nonreliant on donor funding. But
this may require longer-term resource
commitment from donors to ensure
continuity of activities and liveli￾hood security of staff. CBNP/
Kenya, for example, has received
funding from the Danish govern￾ment since 1979, completing
three project phases. IFCPP/Tan￾zania has also had over 10 years of
consistent donor support from COOPIBO. Recognizing that it cannot support IFCPP in￾definitely, COOPIBO has taken steps to institutionalize the program in the region. It has
assisted VECO to acquire its own NGO status, and worked very closely with the Ileje Dis￾trict Council to build capacity and commitment over the long term. Both of these pro￾grams have benefited from not having to spend time searching for follow-on funding.
Self-financing is the long-term goal of a program. FOCCAS/Uganda provides the best
example of this. FOCCAS established operational systems and credit associations during a
pilot phase. The recovery rate on loans is almost 100%, with collection of 12% interest per
16-week loan cycle, ensuring that the program pays for itself and eventually grows.3
 During
the expansion phase, the program established additional credit associations to achieve fi￾nancial self-sustainability and perfected its operational systems. FOCCAS expects
sustainability to be achieved three to five years after start-up in most areas.4
 Other mecha￾nisms for self-financing have been put in place by other programs. Community members
in the IP/Tanzania program contribute to water and health funds. They reported to as￾sessment teams their willingness to continue contributing for services provided to im￾prove their health. However, villagers called for more transparency in the use and amount
of funds collected for this to continue. Considerable contributions in labor from commu￾nities are made in the CSPD/Tanzania program for construction and rehabilitation of
structures and roads as well as financial contributions.
3 Caution may be required in interpreting the 100% recovery rate and the financial viability of women.
Anecdotal evidence is beginning to be collected that women may be borrowing from friends and rela￾tives to pay back loans, thereby incurring additional debt.
4 Although financial viability seems possible, the sustainability of the nutrition education session remains
in question largely because capacity is still lacking in field agents, and partnerships with other pro￾grams have not been prioritized.
Evolution, Sustainability, and Scaling Up
(ANP–Kenya)
34
The final factor essential for sustainability is the organiza￾tional and legal frameworks established to continue program ac￾tivities. Several of the programs in the assessment worked
through existing or newly created community groups, most of￾ten women’s groups. This strategy not only provides effective
delivery of services, but also increases the likelihood of con￾tinuation and institutionalization of services and activities.
Ssembabule/Uganda supported MAWODA, the women’s de￾velopment association that has now inspired other local
groups to launch their own income-generating activities and request assistance from do￾nors. The Kanini Kaseo Group A has assisted several more women to form Group B, which
receives no assistance from ANP/Kenya. Instead, the group is self-sustaining with contri￾butions from members and support from Group A. This phenomenon has occurred in
several other programs, where groups have spawned other groups to form and mobilize
for action and funding. CSPD/Tanzania has inspired the creation of a new NGO called
Hai Gender Initiative and several others during the life of the project.
In the Tanzania programs in particular, by-laws have been put in place aimed at sus￾taining programs and household behavioral changes. The Hai District Council 1990 has
enacted several by-laws, including the Hai Education Trust Fund, the Hai Maternal and
Child-care Service by-law (described above), the Hai District Water Source Conservation
by-law, the Universal Primary Education Fund, the Environmental by-law, and the Forty Per￾cent of Developmental Levy. In the IP/Tanzania program, village governments actively en￾force nutrition-relevant actions and have established by-laws to ensure that children are
taken to clinics for immunization and growth monitoring. In combination with other ef￾forts in the country, these by-laws have instilled a sense of nutrition as a right.
7.2 Scaling up
Understanding how a program evolves helps to provide insights into its dimensions today
and its likely future. An interesting commonality among several of the programs was the
transformation of relief activities into development. Many projects were initiated to serve
severely malnourished children through rehabilitation programs but in recent years have
begun phasing out these activities. For example, CBNP/Kenya currently operates only 3
of its original 11 nutrition rehabilitation centers and will phase these out by the end of
this project phase.
Another similarity in the evolution of many of the programs is the transition of top￾down to bottom-up approaches to nutrition programs. Communities have become gradu￾ally more involved. Many programs continue to emphasize the food-based determinants of
malnutrition, and, consequently, programs in the agriculture sector concentrating on
food production. Yet, there is clearly growing recognition of the multisectoral nature of
malnutrition problems, reflected in the inclusion of health, water, and sanitation compo￾nents in programming.
Inputs from the agricultural sector and activities related to food production and han￾dling led to the adoption of the food cycle model of planning nutrition programs. Conse￾quently, food production, processing, quality control, and food development received
considerable attention. But the unisectoral nature of the model limited its utility. Care￾fully planned nutritional surveys also revealed the socioeconomic-related causes of mal￾nutrition that the food cycle model was not addressing. In the process, the multisectoral
and multidisciplinary nature of the problems of malnutrition became evident.
“Although it is not only the effect of one
project, it was found that families recognized
nutrition as a right to any member of the
community, especially children”
(IP/Tanzania)
Evolution, Sustainability, and Scaling Up
35
A more recent trend is to integrate programs with interventions intended to address
micronutrient deficiencies. Most programs in the assessment have some component dedi￾cated to improving micronutrient status of populations. More attention is needed, how￾ever, to assess the micronutrient problems in the region and find effective programming
options. Another area in which programs will likely evolve and replicate is nutrition and
HIV/AIDS, e.g. concerning nutrition care and support, mother-to-child transmission
(MTCT), and the food and nutrition security implications of the pandemic’s spread.
Most of the programs participating in the assessment have at some stage scaled up op￾erations, some more than others. GRHRP/Uganda, for example, has replicated both its
Gulu Food Security Project and Gulu Relief and Health Rehabilitation Project in the
neighboring district of Kitgum, which faces similar problems of insurgency and displace￾ment. Phase III of CBNP/Kenya was
titled a demonstration phase in
which the University of Nairobi Ap￾plied Nutrition Programme was
contracted to implement the pilot
program using participatory ap￾proaches (PANS and PRA). PANS
was piloted in 26 communities
served by the Mbooni center in
Makueni District, Eastern Province.
The model was then replicated,
with modifications, in 15 additional
communities. During Phase IV of
the program, the Department of So￾cial Services proposes to replicate
the model in 228 communities over
the next five years, with three com￾munities per division in each of the
14 districts where CNNP is located.
FOCCAS/Uganda, again, provides a useful model for sustainability and scaling up.
One of the objectives of the program is “To develop, implement, and document a replicable credit
with education system, including organization and training systems as well as credit delivery and
management systems using the FFH Burkina Faso Credit with Education program as a model”
(FOCCAS/Uganda). As described above, FOCCAS/Uganda began with a two-year pilot
phase and later expanded within the pilot zone, creating more credit associations and
perfecting the operational system, with the objective of achieving financial self-sufficiency.
In sum, the processes for sustaining relevant activities and scaling them up to maxi￾mize impact require preplanning and careful documentation before and during opera￾tions.
Evolution, Sustainability, and Scaling Up
(IP–Tanzania)
36
8 Conclusions
The key success factors from the country assessments have been identified and catego￾rized according to the chronological phase of program development.
Similar to other reviews in Asia and Africa, this assessment has emphasized under￾standing the processes involved, or the “how” questions of program development, imple￾mentation, and expansion. Several important content-related (“what”) factors were also
highlighted—for example, the particular characteristics that determine the effectiveness
of growth monitoring and promotion programs that continue to be used in nutrition pro￾gramming in East Africa. Particular forms of nutrition education, such as nutrition behav￾ior change communication and participatory community theater, were found to be
successful. Such models of nutrition programs merit further analysis for their direct asso￾ciation with nutritional outcomes.
Another important conclusion is that both contextual factors and program-specific factors
are relevant and important. The degree to which program implementers can influence
the context is limited, at least in the short term. A two-pronged approach is thus called
for—first, to catalyze the development of programs where the context is favorable and, sec￾ond, to devote more efforts to fostering the enabling contextual factors—through advo￾cacy and social mobilization at all levels.
While there was sufficient evidence to suggest that these programs were successful in
broad terms in relation to their objectives, the monitoring and evaluation components in gen￾eral were not strong. This is a common problem with community-based nutrition program￾ming—a problem that has to do in part with the difficulties in measuring
nutrition-relevant outcomes and attributing them to specific program activities. Also, in￾sufficient resources are committed to determining impact. Adequate budget lines need
to be dedicated to evaluation and to the development and maintenance of action-ori￾ented management information systems.
Other gaps between recent research evidence and program practice need also be ad￾dressed. For example, many of the programs target children under five years of age using
nutritional status as an indicator. If growth failure is to be prevented, then activities
should be focused on the first 12–
18 months of a child’s life, with
growth velocity being tracked.
Among the various strategies to
promote optimum breastfeeding
and complementary feeding prac￾tices, capacities should be devel￾oped to enable such caring
practices. The food bias seems to
linger in several of these programs,
despite strong evidence showing
the importance of care-and health￾related causes of malnutrition.
There does, however, appear to be
a positive trend toward recognizing
and acting on the nonfood causes.
The lessons that were learned
from these assessments and in￾Conclusions
(SCSP–Uganda)
37
cluded in this report could now be applied at several levels of policy and programming
and used by a wide array of audiences: donor agency executing organizations (govern￾mental and non-governmental), communities, and policy makers. The lessons could be
used as
● Programming guidelines for NGOs and government staff designing new initiatives;
● Policy guidelines for investments in a country-level effort to improve nutrition; and
● Motivation for additional work on monitoring and evaluation efforts linking interven￾tions with nutrition outcomes and documenting particular programming models.
Ultimately, it is hoped that careful documentation of these lessons may prove to be of
benefit to communities, program managers, governmental and non-governmental organiza￾tions, and others involved in community-based nutrition programming in the sub-Saharan
Africa region.
Conclusions
38
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Kennedy, E. 1991. Successful Nutrition Programs in Africa: What Makes Them Work? Policy, Re￾search and External Affairs Working Paper WPS 706. Washington, DC: World Bank.
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Ndure, Kinday, et al. 1999. Best Practices and Lessons Learned for Sustainable Community Nutri￾tion Programming. Washington, DC: Sustainable Approaches to Nutrition in Africa
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40
Annex 1: The Triple A Cycle and Conceptual
Framework of the Causes of Malnutrition
The Triple A Cycle is essentially a sequential problem-solving, decision-making process of
assessment, analysis, and action that individuals and communities undertake in their daily
lives for many different reasons. When each step in the process is clearly articulated, ap￾propriately focused action can be undertaken to deal with complex problems such as mal￾nutrition. The Triple A has been described as no more than “common sense,” but it is
much more: it is an explicitly democratizing tool that, when institutionalized, helps to
avoid premature decisions made on actions without a clear consensus among stakehold￾ers on the main causes of the problem. Through each iteration, the Triple A cycle helps
to improve the relevance, focus, and targeting of actions.
Another essential requirement of this process is full participation. Community owner￾ship is fundamental to sustainability, but ownership does not only mean a role in imple￾mentation; it means pro-active involvement at all stages in the Triple A, from problem
assessment to monitoring and evaluation (reassessment).
● Assessment: The Triple A cycle starts with assessment, whether it is the mother who as￾sesses the growth of her child, the community that assesses the nutrition situation, or
the Ministry of Health that assesses trends in infant mortality rates. The decision to as￾sess is dependent on awareness and commitment. The quality of the assessment is de￾pendent on existing views concerning the nature of the problem. Awareness,
commitment, and views depend on the information available and the capability to un￾derstand it.
● Analysis: After an initial assessment of the situation, analyses of positive and negative
processes follow. The causes of malnutrition may be complex. Some are general, oth￾Analysis
of the causes of the
problem and capac￾ity
Assessment
of the situation of
women and children
Action
based on the analysis
and available re￾sources
 The Triple A Cycle
Annex 1: The Triple A Cycle and Conceptual
Framework of the Causes of Malnutrition
Reassessment
41
ers are very context specific. It is likely that the whole exercise will be more successful
if it is done by a combination of people who live with or very close to the situation un￾der review and people who are trained and experienced in such analysis. In addition
to the causes of malnutrition, the quantity and quality of existing and potential re￾sources and capacity must be analyzed.
● Action: Based on this analysis of causes, and an assessment of available and potential
resources, actions can be designed and implemented. However, most situations
change, and many will not necessarily improve with the first set of actions. The first ac￾tions may, nonetheless, contribute to a new situation that is conducive to other actions
that were not feasible before.
● Reassessment: After the situation has been assessed and analyzed and actions have been
implemented, it is necessary to reassess the impact of the actions taken and to reana￾lyze, taking into account this change. This process will then lead to further actions,
which are likely to be more effective and better focused because they are based on a
better understanding of the problems and on practical experience gained. Monitor￾ing and evaluation are processes of reassessment—the former for management pur￾poses and the latter to assess the degree of overall success or failure of the project .
Assessment, analysis, and action are all dependent on current views of the nature of
both the nutrition problem and existing positive and negative processes in society. People
may agree on the existence of a problem based on visible and dramatic manifestations
such as severe malnutrition, but they may disagree on the causes of the problem. If there
is disagreement on what causes the problem, there is probably also disagreement on ac￾tions that should be taken to alleviate it. An explicitly formulated conceptual framework
will help identify and explain both positive and negative processes contributing to the
current nutrition situation.
The conceptual framework can serve as a guide in decisions about what should be as￾sessed, how causative relationships should be identified and analyzed, and what objectives
should be set for the actions selected. It is a “pair of glasses” to guide us in what to look
for.
The following criteria are desirable for the development of a conceptual framework:
● Clearly show how various processes in society affect the situation of children and
women, particularly malnutrition.
● Facilitate identification and analysis of the causes of the situation and, at the very
least, include a set of hypotheses about which are the most important causes.
● Accommodate the potentially multisectoral nature of the situation by being compre￾hensive enough to accommodate all possible main determinants, but also facilitate re￾duction to the most important determinants in a given context.
● Facilitate a dialogue among people of different professions, which helps to guard
against the common tendency to assess and analyze a situation according to profes￾sional, institutional, or personal preconceptions or even biases.
● Facilitate consideration of the time dimension (history, seasonality, and etiology).
● Accommodate analysis of processes at different levels of society, desegregating data
according to geographic areas, age, sex, and socioeconomic groups.
● Be easy to popularize and thus facilitate communication, training and mobilization.
Annex 1: The Triple A Cycle and Conceptual
Framework of the Causes of Malnutrition
42
Annex 1: The Triple A Cycle and Conceptual
Framework of the Causes of Malnutrition
Basic
causes
Underlying
causes
Immediate
causes
Outcomes
Conceptual framework for the causes of malnutrition in society
Potential
Resources
Inadequate
access to food
Inadequate
care for mothers
and children
Insufficient health
services and unhealthy
environment
Inadequate
dietary intake Disease
UNICEF 1990
Malnutrition
and death
Inadequate education
Economic Structure
Formal and non-formal
institutions
Political and ideological
superstructure
43
Annex 1: The Triple A Cycle and Conceptual
Framework of the Causes of Malnutrition
In a given context, the initially formulated conceptual framework will change and be￾come more focused as reassessment, reanalysis, and so on take place. Such refinement
should be achieved through a broad-based consensus-seeking process.
The key assumptions of the framework are the following:
● Nutritional status is an outcome of processes in society.
● Malnutrition is a result of immediate, underlying, and basic causes occurring hierarchi￾cally.
● The necessary conditions for nutritional well-being (nutritional security) are access to
food, adequate care of children and women, and access to basic health services, to￾gether with a healthy environment.
● The potential for fulfilling three of the necessary conditions (food, health, and care)
for nutritional security is determined by availability and control of resources (human,
economic, and organizational).
● The choice and use of resources in efforts to achieve the necessary conditions for nu￾trition security are influenced by education.
● The availability and control of resources are determined by previous and current tech￾nical and social conditions of production and political, economic and ideological/cul￾tural factors.
44 Annex 2: Nutrition Packages
The Nutrition Essentials Package
Health Sector Strategy to Improve Infant, Young Child, and Maternal Nutrition
Essential Actions
The Health Sector Strategy adapts and builds on the one developed by the BASICS
Project in 1997. The strategy focuses on a package of essential actions at the health fa￾cility and community levels to improve the nutrition of pregnant and lactating
women and children under two years of age. Other components of the strategy in￾clude quality assurance, monitoring and evaluation, capacity building, and advocacy.
The essential actions, detailed in tools and papers developed for the strategy, are
based on existing evidence of their feasibility and effectiveness in improving child
and maternal survival, health, and nutrition. They can occur during six contact
points (antenatal, delivery and immediate postpartum, postnatal, well-baby and im￾munization, sick child, and family planning). To guide and remind health care pro￾viders of these actions, LINKAGES/AED supported the development of a wall chart
and nutrition job aids for regions with high and low HIV prevalence. Six orientation
modules (one for each health sector contact point) are available to inform, prepare,
and motivate health workers to implement these actions. Each module can be com￾pleted in two to two-and-a-half days.
Ten Priority Outcomes
The objective of the essential actions is to achieve ten priority outcomes to improve
infant, young child, and maternal nutrition.
1. Prevention and treatment of malaria during pregnancy in endemic areas
2. Prevention and treatment of hookworm infection during pregnancy in endemic
areas
3. Adequate food intake during pregnancy and lactation
4. Adequate micronutrient intake (particularly iron) during pregnancy and lacta￾tion
5. Exclusive breastfeeding for about the first six months
6. Adequate complementary feeding starting at about six months, along with con￾tinued breastfeeding to 24 months and beyond
7. Adequate intake of iodine (iodized salt) by all members of the household
8. Adequate intake of vitamin A by all women, infants, and young children
9. Appropriate nutritional care of sick and malnourished children
10. Birth spacing of three years or longer
Annex 2: Nutrition Packages
45
The Nutrition Minimum Package Intervention Strategy
The MINPAK approach is being implemented in five African countries through integration with routine
maternal and child health activities.
Source: Tina Sanghvi & John Murray. Improving Child Nutrition
through Nutrition: The Nutrition Minimum Package, BASICS, 1997.
Intervention
Strategies
Nutrition Behaviors
1. For infants: Breastfeed exclusively for
about 6 months.
2. For infants and children: From about 6
months, provide appropriate
complementary feeding and continue
breastfeeding until 24 months..
3. For women, infants and children:
Consume vitamin A-rich foods and/or
take vitamin A supplements.
4. For all sick children: Administer appropriate
nutritional management:
● Continue feeding and increase fluids
during illness.
● Increase feeding after illness.
● Give two doses of vitamin A to measles
cases.
5. For all pregnant women: Take iron/folate
tablets.
6. For all families: Use iodized salt regularly.
Improving household
behaviors
Participatory community
planning
Household trials to develop
child feeding recommen￾dations
Health education using
community health workers,
traditional birth attendants,
women's groups, teachers,
and others
Peer counseling and
breastfeeding support
groups
Improving community
supports
Distribution of vitamin A
supplements
Community-based suppliers
of iron/folate tablets
Regular access to iodized
salt
Regular access to nutrient￾rich foods (including micro￾nutrient-fortified staples)
Improving facility-based ser￾vice
Health workers receive ad￾equate training and tools to-
● Provide appropriate nutri￾tional counselling
● Give micronutrient supple￾ments when necessary
● Assess, classify, and treat
sick children (e.g., IMCI)
Health facilities maintain-
● Stocks of micronutrients
● Regular supervisory visits
● Supply of information, edu￾cation and communication
(IEC) materials
Annex 2: Nutrition Packages
46
A
n
n
e
x
3: S
u
m
m
a
r
y In
f
o
r
m
a
tio
n
O
f
1
0
C
o
m
m
u
nit
y
P
r
o
g
r
a
m
s
Name of Project Implementer and P
opulation G
oals/Objectives D
onor Nutrition and Related Nutrition and Related
(Operating Dates) D
onor Agencies co
verage C
ontributions Interventions Outco
mes
(approximate)
U
S$
Applied Nutrition African Medical and 49,000 inhabitants Goal: “Child health status N
G
Os and *G
MP—project trained 116 * Breastfeeding more
Program, Kenya Research Foundation in Makindu and improved in Makindu and foundations C
H
Ws and TBAs to do G
MP frequently and longer (but
(1986–present) (A
M
REF) Mtito, Divisions of Mtito Divisions of Makueni (1986–1994 ): in 18 centers * still not EBF)
Donor: Spanish Makueni District District.” $60,000 per Women’s Groups, support for * Complementary food
Agency for Purposes: “1) Nutritionally year. EU and improved food production diets improved, more
International vulnerable households IFA
D (1994–96): (drought-resistant crops; variety. Improved food
Cooperation (AECI) using appropriate skills and $100,000 per initiation and maintenance of hygiene practices
technologies for promoting year. seed banks; systems Related: Improved
livestock, crop production, Spanish Agency management; and distribution sanitation. Malaria (67%
and income generation; for International of loans through “merry-go- in last 4 weeks); cough
2) Accessibility to safe Cooperation rounds”) 91.2%; and diarrhea
drinking water increased at (1998-2000): Related: Water (pipelines), (5 %). Crop diversification.
household level; 3) Mothers $380,000 per sanitation, food production,
using appropriate year. livestock, diarrheal disease
technologies to improve Approximately management, etc.
feeding practices for $4 per capita
children under 5 years.” per year.
Christian Children’s Christian Children’s 38,000 children A
mong several health $12 or more * Early Childhood * Improved knowledge and
Fund Program
me Fund (C
CF) throughout the objectives: “To reduce rate per child by Development Centres with food awareness of kwashiorkor
Kerwa Child and Donor: C
CF country of malnutrition of under- sponsors until provided and marasmus
Family Project in fives and their siblings age 15 yrs, but * Nutrition education by social * Improved behavior, EBF for
Kiambu, Kenya from 20% to 0%.” benefits whole workers to households and 5–6 months instead of 1–-2
(1995–present) family. 20% focus groups months
administrative *G
MP * Improved diets to include
costs, and 80% * Focus groups (15 parents balanced meals, micronutrient
program. Costs and social worker) decide rich foods (kale)
minimized with interventions most needed. * Feeding frequency from 2-3
few vehicles (3), “merry-go-rounds” times a day to 4-5 times a day
facilities and Related: interventions in
equipment. health, education, sanitation,
water, food production
Annex 3: Summary Information Of 10 Community Programs
47
Com
munity-Based Government of Kenya,- Inhabitants in Development Objective: D
A
NID
A * G
MP * Mothers keep babies (6-
Nutrition Program, Department of Social Mbooni Division “Welfare of families improved contributions * Training (through C
RPs) in 12 months) with them; take
Kenya (1997–present) Services under Ministry (pilot), Kisau in the CBNP service areas.” PhaseI-II health and nutrition, organic babies to farm. Begin giving
of Home Affairs, Division of Purpose: “Malnutrition among (1980–1994): farming, and water protection complementary foods 4-6
Heritage and Sports Makueni District children under five years of $187,000 per * PA
N
S
Nutrition Information months.
Donor: D
A
NID
A age in CBNP reduced.” year. System and Com
munity Actions * More mothers use TBA
Phase III (94–99): Plans (C
APS). Triple A cycle for deliveries. Longer birth
$670,200 per * Participatory educational spacing.
year. theater (PET). Project trained * Use variety of foods for
G
O
K contribution troops to perform drama, children; measured
$156,000 per puppetry, or songs on social portions given to children.
year and health themes. * More mothers using G
MP
About $95,000 sessions.
per com
munity Related: Alcoholism down.
for 5 years. Next Hygiene practices
phase $30,000 improved.
per com
munity.
Child Survival, Government of 250,000 inhabitants Overall objective: “To alleviate $3.21 per child * Training and establishment of * District annual review
Protection and Tanzania living in Hai District malnutrition and improve the per year. 2 V
H
Ws per village; 65 health reports between 1988 and
Development Donors: U
NICEFand livelihood of people.” Specific $614,000 from posts established 1999: W/A dropped 70% for
Program
me in Hai District Council objectives among others: U
NICEF1997-99 * V
H
W conduct G
MP, give children under 80% of
District Tanzania “* To improve water and Hai District health and nutrition education standard W/A; 80% for
(1987–present) environmental sanitation; Council and demonstrations. children under 60%
W/A.
* To improve the knowledge contributions for * Institutionalized day care Infant mortality reduced by
and understanding of children and centers and preschools 18%; childhood mortality
com
munity members women: * Mtoto wa Hai (Hai Child) reduced by 44%
regarding normal growth 1999: $2,922 booklets for caring practices of * Improved colostrum,
pattern of young children; 1998: $2,750 children 0–6 years breastfeeding practices
* To monitor growth of 1997: $3,343 Five integrated projects: water * Improved feeding
children at household level.” and environmental sanitation, frequency and quality of
health services, maternal and complementary foods.
child health (deworming, O
R
T), Related:
household food security * Improved water situation,
(irrigation, diary cattle breeds), food security, literacy,
and project supervision and sanitation.
management * Positive impact on
Related: Literacy; HIV/AID
S knowledge, attitude, and
transmission com
mitment of decision
makers at household and
com
munity levels.
Annex 3: Summary Information Of 10 Community Programs
Name of Project Implementer and P
opulation G
oals/Objectives D
onor Nutrition and Related Nutrition and Related
(Operating Dates) D
onor Agencies co
verage C
ontributions Interventions Outco
mes
(approximate)
U
S$
48
Name of Project Implementer and P
opulation G
oals/Objectives D
onor Nutrition and Related Nutrition and Related
(Operating Dates) D
onor Agencies co
verage C
ontributions Interventions Outco
mes
(approximate)
U
S$
Ileje Food Production Vredeseclanden 106,000 inhabitants Aim: “To improve small- 1997: $77,000 Food security interventions: * More foods available: paddy,
Project, Tanzania C
O
OPIBO(VEC
O) in Ileje District,- scale farmers’ living standard Proposed * Training related to agriculture maize, beans, potatoes, finger
(1989–present) Donor: Belgium
Mbeya Region through increased food expenditures in extension at Ileje Training millet.
International production.” 1998: $91,000 Centre. “Look and learn visits” to * Increased production of
Association for Specific goal: “* To increase District Council share knowledge among farmers. maize.
Development production of food crops in pay for extension * Com
munity participation in * Expanded use of fertilizers,
Cooperation sustainable way through use worker salaries building Farmers Service Centre, good cereal storage
(C
O
OPIBO) of Resource Efficient in planning activities: oxen technologies, and irrigated
agriculture (REA) technique, mechanization, farm trials, agriculture.
through use of locally farmers days, seminars, and * Improved livestock.
available resources whenever training
possible, and strengthening * Farmers organized by project
the organizational skills of into groups (PRE Groups);
small holder farmers.” advisory com
mittees for each
group share experience through
M
VIWAI network—farmers
com
munication network
* Installation of water taps
Micronutrient and World Vision 197,767 inhabitants. Objectives: “* To reduce the U
S$4,400,000 *G
MP * Severe underweight
Health Project Donors: U
S
AID, 3,250 under 5 prevalence of micronutrient per year. * Com
munity members trained prevalence reduced from 25%
(MIC
A
H), Tanzania World Vision years old 9 regions deficiencies through increasedSeventy-two to be V
H
Ws and TBAs. to 10% in Mzundu dispensary
(1997–present) in Korogwe and access to and intake of development * Nutrition and health education * Awareness among
Handeni Districts micronutrients, particularly projects in the being provided by V
H
Ws, com
munity members about
vitamin A and iron; regions of TBAs, and staff nurses children in “red” on growth
* To reduce prevalence of Tanzania * Improve school and health chart
diseases that affect benefiting 2 facilities and accessibility to * Villages each with 2 trained
micronutrient status (diarrhea, million health services V
H
Ws and 4 or more TBAs
parasites, and vaccine Approximately * Com
munity-based nutrition * More pregnant women
preventable diseases); $2.2 per capita rehabilitation seeking M
C
H services at
* To build local capacity for per year. * Promotion of nutrition health facility, mobile services,
delivery systems to improve essentials, positive behaviors and from trained TBAs
micronutrient status.” Related: Linked to Area * Colostrum being given;
Development Program
me (A
DP) children eating more
in which agriculture, water, frequently; food taboos
education, and health projects disappearing
being implemented Related: Maize seeds,
cassava cuttings and
pesticides to com
munity.
Vegetables improve house￾hold incomes. Toilets in 50%–
70% of household,
comparewith 20% at outset
of project.
Annex 3: Summary Information Of 10 Community Programs
49
Name of Project Implementer and P
opulation G
oals/Objectives D
onor Nutrition and Related Nutrition and Related
(Operating Dates) D
onor Agencies co
verage C
ontributions Interventions Outco
mes
(approximate)
U
S$
Sustainable Integrated Family Planning 590,037 inhabitants Objective: “To improve 1998: $170,000 * G
MP (follow-up visits, Severe underweight: 7%
Reproductive Health Association of Tanzania in 3 regions of accessibility and provide advisory services) (1995) to 1% (1999)
Services Project (IP), U
M
ATI Kilimanjaro, Morogo, sexual and reproductive * Behavior change (reduce Moderate underweight:
Tanzania Donor: Japanese M
wanza Adolescent health information and women workload, breastfeeding, 43.7% (1995) to 40.6%
(1999)
(1996–present) Organization for girls and boys, services to underserved rural child feeding) * Most pregnant women
International schoolchildren, and and peri-urban population * Control of micronutrient and some men attending
Cooperation in Family children under 5 through multipronged deficiencies (home gardening) clinics
Planning(JOICFP) years com
munity based service Related: * Promotion of family * Increase in use of
delivery approaches.” planning services through contraceptives by both men
CBD
As and women
* Disease control such as * Awareness that breast milk
intestinal worms through mass alone suffices for 4 months;
deworming and improvement of importance of colostrum;
latrines. children need more meals;
* Income-generating activities restriction of foods because
(dairy goats, fish ponds, sewing of taboos decreased
machines, milling, carpentry) Related
* Reduced women’s
workload (milling machine,
deep wells for water
installed, mortar and pestle,
solar dryers to preserve
fruits)
* Food security, health, water,
education, family planning,
housing, roads improved.
Foundation for Credit FO
C
CA
S 16,000 targeted * Develop a self-sustaining Year 1 (’98): * Loans starting at $44 given to * Increased consciousness of
and Com
munity Donor: Freedom from
women in Mbale and credit with education program $655,000 women in solidarity groups of care-giving practices
Assistance Hunger (FFH) three other districts through organization and Year 2 (’99): 4-7. Market interest rate (12%) * Colostrum to their newborns.
(FO
C
C
A
S), provision of credit services $956,879 charged; 5% expected to be * Mothers breastfeed within
Uganda and education services to Approximately saved per 16 week loan cycle first hour of birth
(1996–present) women. *To develop methods, $40–$60 per * Credit with education sessions * Awareness of types of
materials, and management beneficiary per offered over loan cycle. Topics porridge and when to begin
systems for nutrition and year of education include: giving complementary foods
economic education for credit Approximately 1) Breastfeeding promotion; Related: Women’s solidarity
association members. 1% in 2) Infant and child feeding; and com
munity action.
* Other related credit 1financial costs 3) Birth timing and spacing; Women’s financial viability
education objectives 4) Diarrhea treatment and and self-sufficiency.
prevention; 5) Im
munization
Annex 3: Summary Information Of 10 Community Programs
50
Name of Project Implementer and P
opulation G
oals/Objectives D
onor Nutrition and Related Nutrition and Related
(Operating Dates) D
onor Agencies co
verage C
ontributions Interventions Outco
mes
(approximate)
U
S$
Gulu Relief &
Health World Vision 24,306 in 5 relief “1) Improve PH
C in IDP Year 1: $291,630 * G
MP of under 5s, W/A charts * Five feeding centers
Rehabilitation Project Donors: World Vision, camps of project camps in Kilak and O
moro Year 2: $223,117 on health cards * Nutrition established targeting 3,500
(G
R
H
RP), Uganda U
SAID
Targets internally counties, 2) Increase Year 3: $247,717 education for mothers of mild to moderately
(1996–present) displaced populations institutional capacity of malnourished children malnourished children
and hosts in O
moro com
munity health services, * Demonstration gardens * Reduction in malnutrition.
and Kilak counties in 3) Facilitate IDP to have * Supplementation of vulnerable Severe weight for height from
Gulu district. access to improved and safe and/or undernourished children 5% (1998) to 2% (1999)
water and sanitation facilities.” and moms using local foods * G
MP established in 5 camps
* Deworming of all children in * Demonstration gardens
camps every 6 months established in each camp
* Com
munity capacity built
through service training of
com
munity service providers,
meetings, and regular
supervision
Related: Improvements in
water and sanitation
(protected springs, wells
drilled, latrines, rubbish pit),
deworming, im
munization,
food security
Ssembabule Child Minnesota International 6,500 infants 26,700 Increase from 39.3% to 50%
Nutrition activities * Vitamin A interventions: 240 * EBF from 65% to 100% up
Survival Project Health Volunteer children 1–5 years the proportion of infants only (1996-2000): teaching/resource gardens, to 4 months
(S
C
SP), Uganda (MIH
V) 30,900 women breastfed within one hour of $295,586 total demonstration gardens at every * Infants breastfed within 1
(1993–present) Donors: U
S
AID, Baganda and birth. Increase from 35% to $73,896 per year health unit, at number of schools, hour of birth, from 35% to
Micronutrient Initiatives Banyankole ethnic 45% the proportion of children (nutrition) at TBAs’ homes and com
munity 40.4%; within 8 hours, from
through PAT
H/Canada groups in Kasangati age 20–23 months who are Total Child organizers’ home 16% to 66.7%
county. still breastfed. Increase from
Survival Project: * Gardens at women’s or * Proportion of mothers
39.6% to 50% the proportion $1,333,334 groups’ homes reporting that oil, sugar
of mothers reporting $333,333 per * Seeds and seedlings provided, should be added to
consumption of animal protein year and subsequently sold to complementary foods, from
and other protein-rich foods. Per capita colleagues 3% to 67.6%
expenditure per * Training to com
munity * Proportion of mothers who
year $5 volunteers, TBAs, im
munizers report vitamin A-rich foods
* VAC distribution at im
muniza- should be added to
tion clinics, outreach, and NID
S complementary foods, 25.5%
* Women’s groups trained on
nutrition and provided goats for
milk and meat, rabbits for meat
Related: Drought-resistant crops,
goat and rabbit production, food
preservation, processing, and
storage, caring practices (make
toys from banana fibers, cotton
pieces, etc), health, water, and
sanitation, malaria nets, HIV/AID
S
Annex 3: Summary Information Of 10 Community Programs