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Rejoinder
Nutrition planning is alive and well,
thank you
Alan Berg
This article is a rejoinder to an article by The reports of my death are greatly exaggerated.
John Osgood Field which discussed Mark Twain (cable from London
the failure of multisectoral nutrition
to the Associated Press, 1897)
planning. The author argues that,
although nutrition planners may have
been overly optimistic in their hopes Moved by John Osgood Field's recent post mortem for multisectoral
that political systems could be made nutrition planning, 1 I went in sadness to the funeral parlour to pay my
responsive to the problems, significant last respects. What a shock to find that the coffin was empty. Just as
advances have been achieved. He out-
lines many of the successes of nutrition puzzled were the many progeny of nutrition planning who were milling
planning and the importance of multi- about. There were also a number of close relatives, who looked a lot
sectoral work. Malnutrition Is a problem like nutrition planning but whose names were different - nutrition
that escapes all the standard program-
mes, and cannot be tackled through the surveillance, food security studies, 'adjustment with a human face'
health and agriculture sectors alone. probes, living standards measurement studies, social marketing analysis
in nutrition. There was no mistaking the stock from which they came.
The author is Senior Nutrition Adviser at
The World Bank, 1818 H Street, NW, Professor Field's provocative announcement of nutrition planning's
Washington, DC 20433, USA. demise richly chronicles the negative side of the experience. It offers
some criticism that is deserved, but much of his argument is based on
information that is out of date, out of touch, and out of context. His
article oversimplifies grossly. Most important, it stops giving answers at
just the point where readers start asking questions.
Among this reader's questions is what exactly Professor Field is
attacking - is it nutrition planning, to which he repeatedly refers, or is it
the much narrower area of multisectoral nutrition planning that his title
proclaims? Even if it is only the latter, has that been the hapless odyssey
he describes? And is the solution, which he proposes, simply to get 'on
with the job of making nutrition an integral part of agricultural
development and primary health care'?
The article is lax in using the terms 'nutrition planning' and
'multisectoral nutrition planning' interchangeably. To damn all nutri-
tion planning for the performance of one strain is a bit like damning all
music for the performance of Boy George. Presumably the author's
tirade is directed at the ambitious excursion into multisectoralism. In his
wording, however, he makes a general indictment of the broader
concept of nutrition planning, as in 'nutrition planning's unfounded
1
assumptions' and 'nutrition planning's obtuseness'. In all, the phrase
John Osgood Field, 'Multisectoral nutri-
tion planning: a post-mortem', Food Policy, 'nutrition planning', sans 'multisectoral', appears 55 times.
Vol 12, No 1, 1987, pp 15-28. If readers came away with the impression that Professor Field's
0306-9192187/040365-11$3.00 © 1987 Butterworth & Co (Publishers) Ltd 365
Rejoinder: nutrition planning is alive and well, thank you
attacks apply to all nutrition planning, it would indeed be unfortunate.
What, r!fter all, is nutrition planning? Most simply put, it is the process
of thinking systematically about solving a nutrition problem rather than
not thinking systematically. As the distinguished US planner Alice
Rivlin has put it, 'It is better to have some idea where you are going than
to fly blind.'
Though this may seem patently obvious, one need only recall the
world of nutrition before the advent of nutrition planning. Projects, in
those good old days, generally came into being because someone came
along with an idea - a fish protein concentrate, a single-cell protein
concept, a chain of mothercraft centres, ~ synthetic lysine, a commer-
cially fabricated and marketed weaning food. The idea commonly
reflected the background of the advocate; thus the food technologist
saw solutions quite differently than the clinician did. More often than
not, adoption of nutrition activities depended on the persistence and
persuasiveness of the project advocate rather than a thoughtful look at
nutrition needs and alternative ways of meeting them. Such efforts may
or may not have been useful in isolation. Generally they were not.
The revolution wrought by nutrition planning grew out of the
realization that technical fixes may apply to certain specific deficiencies
but fail to deal with the major issue - energy-protein malnutrition.
Planning demanded careful definition of nutrition problems, objectives
and target groups. Once the problem was defined, analysts began
tracing the most important pathways and knots in the food and health
systems. They also looked systematically for other causal factors and
relations that might expose useful points of intervention, many of which
the conventional approach to nutrition would never have encountered.
The international nutrition community started to realize that a slight
shift in price policy, for example, might in some instances have greater
impact on nutrition than all of the technical fixes combined. Nutrition
planning tried to open up the world of nutrition.
The idea was to have an analytic framework comprehensive enough
to capture not every determinant but every significant determinant.
(There will always be some guesswork; nutrition planning just tried to
remove some of it.) Those interested in diminishing malnutrition would
then be in a better position to deal with policy makers to explain, to
advocate, and, if successful in getting the right decisions, to lay the
groundwork for implementation of programmes.
It may be true that nutrition planners were overly optimistic in their
hopes that political systems would be made more responsive to the
problem. That they failed in some countries may say more about the
politics of poverty than about the intellectual appropriateness of the
framework within which they were trying to improve the understanding
of the problems of malnutrition.
But has nutrition planning been the debacle described in Professor
Field's article? In a number of countries and in a number of
development assistance agencies, nutrition problems and their solutions
are today being looked at very differently than before all this started.
And different kinds of people with different backgrounds and disci-
plines are working in and studying nutrition. It is now respectable, for
instance, for economists to work on nutrition consumption issues, which
simply was not the case a decade ago. Even if nutrition planning
achieved nothing else (but there is much else), such contributions may
have justified the journey.
366 FOOD POLICY November 1987
Rejoinder: nlllrition planning is alive and well, thank you
Let them eat plans
Multisectora/ nutrition planning is, I suspect, the main object of
Professor Field's guillotine. He correctly and quite eloquently (and
perhaps more openly than any previous writer) captures its intent:
The early proponents of multisectoral nutrition planning clearly defined
protein-energy malnutrition as a structural problem embedded in poverty and
underdevelopment; they recognized that multiple changes in socioeconomic
conditions would be necessary to alleviate malnutrition and ultimately to
eradicate it; they perceived a need to adjust existing government policy and to
initiate new policy on a variety of fronts in order to achieve these changes; and
they believed it essential to formulate a comprehensive strategy as the basis for
mobilizing different agencies of government in a well-coordinated plan of
attack. Not only were these insights and inferences not trivial; they were radical
in conception. intent and design. Multisectoral nutrition planning sought to go
beyond technical fixes ... in favour of ... changes going to the heart of a
country's development effort. The original objective was not solely to serve the
malnourished; it was to purge the total environment of those conditions
disposing to and sustaining nutritional deprivation.~
Professor Field goes on to make a number of criticisms - certain of them
having a ring of validity - suggesting that nutrition planners made an
unholy mess in their effort to pull this off. There is no question that
some people were carried away in a kind of planning mania. (This. after
all, was the era in development when anything that smacked of 'systems'
and 'models' seemed profound.) The infatuation with elaborate
planning endeavours may have been at its peak in 1978 when, as Asok
Mitra reported at a UN Protein Advisory Group meeting, the design
and procedures set forth in one UN agency's planning manual would
have required the full-time effort for two years of the entire staff of the
Indian Planning Commission. 'If nutrition planners have to dig for root
causes·. the former Secretary of the Planning Commission said, 'they
should take care not to wind up in a hole so deep they can't climb out of
it.' In the discussion, Sol Chafkin (chairman of the group) led the charge
to 'decomplexify', and Karl-Eric Knutsson of Sweden (now deputy
executive director of UNICEF) called for a moratorium on all systems
diagrams. Almost everyone accepted the notion that causality can be
dissected as endlessly as a frog can, but it too dies in the process and the
remains are discouraging to any but the scientific mind.
Professor Field's description of planning run amok only applied to \
part of the work in the field. Nutrition planning is no more monolithic )
than any other field, and some nutrition planning miscreants, even those
. associated with multisectoral planning, warned from the beginning that
an overly complicated approach was doomed to sink of its own
methodological weight. Professor Field unfortunately relegates his
acknowledgement of this school to a footnote, quoting from a 1973
publication:
Systems practitioners tend to produce flow charts reflecting the relationships of
everything to everything. the result being something more akin to a Jackson
Pollack canvas than to a useful plann.ing chart. Comprehensiveness is desirable.
but it becomes counterproductive if it focuses time and attention on tertiary
variables or strives for precision that may be spurious because of limited or
2
/bid, pp 16-17. inaccurate data:'
3
/bid, p 20, from Alan Berg, The Nutrition
Factor, Brookings Institution, Washington, Nonetheless, those who had begun the nutrition planning movement
DC, 1973. were embarrassed by the excesses to which some of its advocates had
FOOD POLICY November 1987 367
Rejoinder: nutrition planning is alive and well, thank you
taken the idea, and there were mea culpas all around. But it was a
decade ago that the need to advocate simpler questions and simpler
actions was recognized, long before Professor Field tried to take the
starch out of the movement. As a day-to-day worker engaged in
searching for solutions to malnutrition, I find his description of
multisectoral nutrition planning unrecognizable as a process practised
today. It is an interesting historical description of an antique no more
useful than a moustache cup or a buggy whip.
The frequent references in the post mortem to obsession with and
reliance on new and 'abundant data' and holding 'modest decisions
hostage to elaborate manipulations of data' go too far. It is true that
some multisectoral nutrition planners were disposed to a seemingly
endless acquisition of data. Presumably it is they Professor Field is
characterising and caricaturing. But they were the exception rather than
the rule. Their work was never accepted as operationally credible and
there is no evidence that as a result of their influence major resources
were ever diverted from investments that would otherwise have had
positive nutrition outcomes.
Just as it did not take long to show how wrongheaded the complicated
systems charts were and that it was impossible to collect all the data the
charts required, it did not take long to see that some good indications of
desirable direction could be obtained without elaborately detailed
studies. From the early 1970s, governments were, in fact, advised that in
the quest for the perfect model, nutrition planning could be so overdone
that it became a straitjacket to operational movement. Nutrition
planning should not be pursued at the cost of operational delay. New
actions could be initiated on the basis of preliminary analysis and best
judgements while more elaborate studies were under way.
In fact, this is what commonly happens. A few years ago in
Zimbabwe, for instance, where current data were lacking, emphasis was
placed on obtaining 'best judgements' from knowledgeable observers.
Agricultural extension field staff were asked in brief five-point
questionnaires for their views on the sufficiency of food in their areas,
the variation in seasonal needs, and· the causes of poor nutrition.
Similarly, government health staff stationed in the field and doctors of
religious missions and other non-governmental organizations working at
village level were asked for their rough estimate of the prevalence of
specific nutrition deficiencies in the area ('often', 'sometimes', 'seldom',
or 'never'). Thus it was possible in short order to begin drawing a goitre
belt, for example. In addition, medical students were sent around the
country to make spot nutrition surveys, and questions on food
consumption and nutrition status were added to surveys already planned
on agricultural production and income. Also, the nutrition data
collected in the agricultural surveys were analysed and compared with
information that had been compiled at the time of independence.
In a month a fairly good picture could be assembled of nutrition
needs, what caused deficiencies, and what might be done to relieve
them. Such data may never stand up in an academic court and are
clearly inappropriate for publication in professional journals (hence
academic analysts of nutrition planning are not likely to be aware of
their existence), but taken together they can go a long way towards
providing timely judgements. Data are increasingly being collected and
used in this way.
Even more formal data collection efforts need not paralyse action. In
368 FOOD POLICY November 1987
Rejoinder: nutrition planning is alive and well, thank you
Mexico, practical efforts to measure the effects of the current economic
crisis on the food consumption patterns and levels of the urban
population produced useful and timely (and unexpected) results in eight
weeks. And in the first major effort of the World Bank's Living
Standards Measurement Surveys - in Cote d'Ivoire - reports were on
the desks of key government officials 60 days after the data were
collected.
In sum, the post mortem again falls short. Professor Field has some
basis for his skewering of overly elaborate multisectoral nutrition
planning but he is beating a dead horse. The extreme permutation of
multisectoral nutrition planning that he pictures held fascination for
some people a decade ago. But it is not a current issue. Professor Field
apparently felt it necessary to exhume the dead horse, prop up its
carcass, and perform a belated autopsy. His concerns could as· easily
have been levelled at other elaborate multisectoral efforts, such as the
big agricultural sector models, which followed a trajectory similar to
that of multisectoral nutrition planning. If, for example, 'agriculture and
rural development' or 'urban development' were substituted every time
Professor Field's post mortem reads 'nutrition', most of his conclusions
would be unchanged.
Few persons active in multisectoral nutrition planning ever expected
that governments would do all of the things laid out. While the aim was
to encourage multisectoral nutrition planning, according to James Pines
(who perhaps has done more nutrition planning in more countries than
any other practitioner), it was clear from the start that what was more
likely to emerge would not strictly follow the blueprint. But what did
emerge, he reports, benefited from the blueprint.
Multisectoral analysis and multisectoral implementation are very
different; in the post mortem they are lumped as one. The fact that there \
\l
are multiple causes of malnutrition (inadequate food supply, wrong
prices, sluggish marketing and distribution, an unconducive health
environment, damaging behaviour - the entire constellation of factors
which have an impact on nutrition status) does not mean that all those
causes must be addressed within a single instrument. Clearly some are
more important and some more actionable than others. Most people
working in nutrition planning now recognize the importance of
understanding not only how things are braided and connected but also
which strands are strong and likely to endure,_ which likely to fray, which
are dispensable and which indispensable.
There is no prima facie case for ruling out multisectoral operational
efforts if they make sense. Nutrition work in Indonesia - a country that
takes its nutrition seriously - is as multisectoral as you can get. And the
Tamil Nadu Integrated Nutrition Project, which is cited with increasing
frequency as a large-scale model of a successful nutrition intervention
(including 9000 villages), is unquestionably multisectoral.
Today's nutrition world has been heavily influenced by the concepts
4
Giovanni Andrea Cornia, Richard Jolly of multisectoral planning. At or near the top of the list of important
and Frances Stewart, Adjustment with a work now going on which affects the nutrition of large numbers of
Human Face: Protecting the Vulnerable people are the multisectoral analyses of the nutrition consequences of
and Promoting Growth, Oxford University
Press, New York, 1987. economic stabilization and structural adjustment programmes. 4 And the
5
Shlomo Reutlinger and Jack van Holst food security studies that are being undertaken in a number of countries
Pellekaan, Poverty and Hunger: Issues cut across organization charts just as they cut across disciplines. 5 The
and Options for Food Security in Develop-
ing Countries, World Bank, Washington, value of nutrition surveillance - looking at everything from the growth
DC, 1986. of crops to the growth of children - is increasingly recognized. The 1987
FOOD POLICY November 1987 369
Rejoinder: nutrition planning is aliw and w<!ll, thank you
annual meeting of the ACC Sub-Committee on Nutrition, the focal
point of nutrition for the UN system and bilateral assistance agencies
working in nutrition, assigned great importance to this work. 6 The
impressive body of nutrition studies undertaken for planning purposes
by the International Food Policy Research Institute (IFPRI) is nearly all
multisectoral, 7 as is the body of work ofleading scholars such as Michael
Lipton and Shlomo Reutlinger. Further, the Living Standards Measure-
ment Surveys being undertaken in a number of countries are highly
multisectoral. 8
Clearly the multisectoral nutrition sector work undertaken in 20
countries by the World Bank and the Situational Analyses undertaken
in several times that number by UNICEF had their roots in multisector-
al nutrition planning. Even the important movement that passes under
the label of 'social marketing' cuts across sectoral boundaries and is
itself multisectoral nutrition planning of a sort. Marcia Griffiths, one of
its leading practitioners, reports that in social marketing
we follow the same type of planning procedures that combine national priorities
with community needs. Our research may point to the need for legislation, a
consumer subsidy, sanitation infrastructure and an intensive education effort to
improve household practices. Often we cannot implement the entire package.
But at least we understand the context and the priorities and are guided
accordingly. The end product is no longer a poster or a nutrition talk promoting
the four food groups.
What is there operationally to show for all this? In addition to the
projects in Tamil Nadu and Indonesia, large-scale multisectoral
nutrition activities are under way in places as diverse as Morocco and
Papua New Guinea. Mexico's food and nutrition policy serves as the
framework for a sizeable multifaceted programme reflecting extensive
multisectoral nutrition planning. Colombia's ambitious multisectoral
nutrition programme - based on multisectoral nutrition planning - had
its teething problems and disappointments (parts of it were prime
6
'Report of the thirteenth meeting of the casualties of the conservative government's austerity drive) but,
United Nations ACC/Sub-Committee on according to both Per Pinstrup-Andersen's and Janet Lowenthal's
Nutrition (SCN)', 2-6 March 1987, studies of the programme, it was not without contributions. 9 Contrary
Washington, DC. See also John B. Mason,
Jean-Pierre Habicht, H. Tabatabai and V. to the impression conveyed in the post mortem, parts of the Colombia
Valverde, Nutritional Surveillance, World programme did well - water supply, small-scale food production, a much
Health Organization, Geneva, 1984. strengthened primary health care system - and the new government
7
See, for example, Per Pinstrup-Andersen,
'Assuring food security and adequate elected in 1986 is reinstituting other key portions of the plan.
nutrition for the poor during periods of The current concern that vulnerable groups do not bear a disprop-
economic crisis and macroeconomic ortionate share of the consequences of structural adjustment is leading
adjustments: policy options and experi-
ence with food subsidies and transfer to increasing use of targeted food programmes, which reflects the hand
programs', paper prepared for the Second of multisectoral nutrition planning. In both Tunisia and Morocco, for
Takemi Symposium on International example, structural adjustment programmes have recently been ex-
Health, Harvard University, Cambridge,
MA, May 1986; and Eileen T. Kennedy and amined for their nutrition consequences - something that would never
Bruce Cogill, 'Income and nutritional have happened in the past. While nutrition planning units in Mocorro
effects of the commercialization of agricul- and Tunisia have not reached the scale and scope envisioned, they have
ture: the case of Kenya', IFPRI Research
Report, International Food Policy Re- done a great deal to sensitize the government. As a result there are
search Institute, Washington, DC, forth- people in those governments now who better understand the direct
coming. relation of inflation, devaluation, and other economic phenomena to
8
Ramesh Chandler, Christiaan Grootaert
and Graham Pyatt, Living Standards Sur- the nutrition condition of low-income groups.
veys in Developing Countries, World Bank UNICEF's heavily marketed GOBI strategy (the combination of
Living Standards Measurement Study Growth monitoring, Oral rehydration, Breast feeding and Immuniza-
Working Paper 1, Washington, DC, 1980.
9
Unpublished studies prepared for the tion to enhance child development and chances for survival) would not
government of Colombia. have happened - or at least not in the way it did - without the systematic
370 FOOD POLICY November 1987
Rejoinder: 1111trition planning is alive and well, thank you
analytical approach to multiple casuality used in nutrition planning, the
collection of data that the planning effort stimulated, and the
sensitization to nutrition issues. It is true that scientists may have long
been familiar with the health and nutrition activities that the UNICEF
programme combines. But the policy implications of a coordinated
programme probably would never have been investigated or arguments
marshalled as they were without the nutrition planning experience.
To take just one element of GOBI, what is more multisectoral than
efforts to promote breast feeding? The issue came to a head when
analysis showed that inadequate breast feeding was a major cause of
infant malnutrition and that there were a number of reasons behind this.
'
J
Finding a solution for the problem has involved many sectors -
ministries of health, industry, education, social welfare, labour and
communications. A prime example of the multisectoral approach is
Brazil's national programme which involves five ministries.
Even non-governmental organizations have been moving increasingly
to adopt the principles of nutrition planning to rationalize and undergird
their operations. The breadth of analysis now prepared by CARE, for
instance, bears little resemblance to the planning practices of that
agency in earlier years.
The changes brought about by multisectoral planning are important
and cumulative, but they should not be magnified out of proportion.
Many mistakes were made - just as mistakes have been made in other
aspects of development. This was, after all, an experiment, one marked
with more than a modicum of idealism. It involved an approach that had
never before been pursued.
Where multisectoral nutrition planning ran into difficulty was in its
assumptions and in its tactics. The presumption that policy people
would rush to concern themselves with malnutrition obviously was not
valid. Also, many of those involved in nutrition planning did not have
an adequate sense of management, and they failed to anchor nutrition
programmes or policies in established interest groups or ministries.
Further, although Professor Field's charge that 'nutrition planning [was]
largely insensitive to clients, treating them as objects to be manipulated
for their own good' is overly strong, it is now clear that in the early days
the ultimate clients did not receive the attention they deserved.
But lessons have been learned and improvements have been made. 10
In some instances, the promise has been greater than the delivery; in
others, complicated methodological devices have fallen of their own
weight. Those working in nutrition have learned from experience that
they have to take smaller bites, that they cannot do everything at once,
that there have to be priorities and phasing. The Tamil Nadu project,
for example, is a culmination of that kind of experience. The project,
which appears to have reduced severe malnutrition by about 50%, 11
enjoys strong support in the responsible Department of Social Welfare
and in the state government. It pays a great deal of attention to training,
motivation and support for local workers. According to David Dapice,
10
Alan Berg, Ma/nutrition: What Can Be
who is completing an economic evaluation of that programme, it is well
Done? Lessons from World Bank Experi- focused, modest in cost and effective. It appears to reach and engage
ence, Johns Hopkins University Press, villagers. Perhaps Professor Field owes multisectoral nutrition planning
Baltimore, MD, 1987.
''Reynaldo Martorell, 'Impact evaluation
a better judgement than he gives it.
of the Tamil Nadu integrated nutrition
project', Consultant's Report to the Gov- Political agendas
ernment, 19 June 1987; and Berg, op cit,
Ref 10. Professor Field reports that nutrition planning appealed to basically
FOOD POLICY November 1987 371
Rejoinder: m11ri1io11 pla1111ing is affre and well, thank you
conservative governments and was used by them as an excuse for
inaction. What is the evidence that its use was limited to such
governments? It is true that over the years nutrition planning has tended
to be done somewhat more by less progressive governments than others.
But some very interesting nutrition planning work has gone on in places
like Allende's Chile, Tanzania, the Yemen Arab Republic, Rwanda,
Nicaragua, China, India, Colombia (under the Liberal Party regime),
and Cuba.
Even in countries where the political climate is not receptive to social
change, it is usually possible to identify government officials or staff who
can be trained and helped to carry out experiments so that when the day
comes that political leaders are more receptive, the country will be in a
better position to do something. Just as disciplines such as nutrition
planning are not monolithic, neither are government bureaucracies. In
Brazil, for example, under the military regime there was no illusion that
nutrition planning and modest-scale nutrition projects were going to
solve the country's nutrition problems. But pilot efforts were planned
and carried out to determine what worked better than what else and, on
the return of civilian rule, there were experienced people in positions
where they could make a difference.
Even in the Philippines, where a national food and nutrition plan
developed during the Marcos regime received largely lip service,
nutrition planning helped foster an experiment in consumer food
subsidies. The experience (and the plan in general) is now getting
considerable attention from the Aquino government.
Is the notion that malnutrition is 'morally unconscionable' so
preposterous a banner to work under as Professor Field infers? Do not
those in a position to help the poor, even in repressive regimes, have a
moral obligation to do what they can? Should professionals, officials
and agencies whose work carries some potential for alleviating the
effects of poverty refuse to proceed with their second- or third-best
solutions because the governments they are advising will not undertake
basic reforms?
The role of planners
Professor Field's article resonates with disenchantment with develop-
ment economists and detailed, top-down planning. There is much to
agree with in this argument, but not Professor Field's conclusion that
'national planners have limited political influence, no operational
authority and only an indirect relationship to how funds are spent'. This
is 'an extraordinary generalization for the Third World as a whole', says
Robert Muscat (economic adviser to NSDB, the planning body of the
government of Thailand), 'and is so inapplicable to the countries in
which I have worked that it suddenly, at the end of a well-written
article, raises serious question as to Field's knowledge of the role of
government bureaucracies in developing countries.' Perhaps he is drawn
into this mistake by confusing plans with planning. Most plans over the
years have had much less impact than Hollis Chenery and other early
development planners had expected. And probably plans have even less
impact in this decade, as unpredictable external shocks in many
countries render last month's policies inadequate. But planners, once
the ink of their plans is dry, spend most of their time on the continuous
policy process. Their contribution comes (it is hoped) from their
372 FOOD POLICY November 1987
Rejoinder: nutrition planning is alive and well, thank you
capacity to inject a logical process and rationality into policy making,
including analysis of the indirect effects of individual policies on
realizing general policy objectives,
The basic issue to be addressed by nutrition planning (and in all
planning) is how resources are to be allocated among sectors when
human and financial resources are limited. Where should resources be
put to reach an objective most cost-effectively? If the goal is to have
nutritionally healthy people, what is the best way to move towards it?
Given limited resources, there has to be some process for allocating
them. What tools are needed to do that? Might the synergistic effect
from doing things together be more productive than doing things
separately? What is the context, what are the priorities, what phasing
and sequencing are needed? Without nutrition planning, or planning
under some guise, what will be the new strategies? How can they be
developed if not through planning?
Not only is it important for a particular government to understand the
context within which to plan its actions, it is also important to
understand the culture of foreign assistance organizations and the
constraints within which they work. There also are competing needs for
their limited resources.
In short, though there may not be a need for what were called
nutrition planners, there most certainly is a need for people who
appreciate the importance of nutrition and know something about it -
and who can plan.
An integral part of agriculture and health
Professor Field's punchline is that we should get 'on with the job of
making nutrition an integral part of agricultural development and
primary health care'. But his buildup far exceeds his answer to how this
can be done.
The agriculture and health approaches are important, and strenuous
efforts should be made to use them. Even within these sectors, however,
nutrition planning will be needed. Without the tools provided by
nutrition planning, the kind of building of nutrition into health and
agriculture that Professor Field supports would not have been possible.
But to improve nutrition significantly will require more than working
within the health and agriculture sectors - even if those sectors were to
give high priority to nutrition, which they mostly do not. To confine
nutrition - and nutrition planning - in this way ignores the reality that
malnutrition is a problem that escapes all the standard programmes. An
earnest attempt must be made to discover why and how nutrition
concerns so often fall through the cracks. There is still a need to
understand what the linkages are.
Seemingly unrelated policy decisions - on exchange rates, trade, fiscal
cutbacks on government services, wages and prices - impinge on
nutrition in ways that might never occur to decision makers. Field
workers in health and agriculture are generally powerless to affect these
decisions. All they can do is mop up after them, using up limited
resources to do so. Those who can affect these decisions must be made
aware of their relation to nutrition concerns. Where is the impetus going
to come from to do this kind of work?
It is not enough to take scattered shots at malnutrition. Efforts in the
health and agriculture sectors are necessary but they are not sufficient.
FOOD POLICY November 1987 373
Rejoinder: nutrition planning is alive and well, thank you
Nutrition planning ambitions may, as Professor Field suggests, have
been naive, but to expect agriculture and health to carry nutrition's flag
reflects a naivety about values, drives, inclinations and reward systems
of people working in those fields. Health officials, for example,
commonly believe the solution to malnutrition falls outside the ministry
of health's jurisdiction, or that including nutrition in health programmes
makes them unmanageable or that their preoccupation with family
planning or immunization or, now, AIDS regrettably robs nutrition of
the attention it deserves. Agricultural specialists generally assume that
the way to address malnutrition is to increase food supply; they regard
more complex nutrition issues as social welfare problems outside their
domain. Or they claim that they do not have the expertise, or because of
pressing priorities the time, to deal with nutrition issues.
Agriculture and health cannot do the whole job. Those concerned
about nutrition should not attempt to supplant them but to help them do
better what they can do and then to do those things that health and
agriculture cannot do. Professor Field advocates an 'intrasectoral
approach'. But an 'intrasectoral approach' does not deal forcefully with
poverty.
Finally, Professor Field makes a strong pitch for bottom-up planning,
in contrast to top-down planning. This is not the either/or situation he
makes it out to be. Clearly local-level planning and action are important
and should not be overshadowed by top-down planning. But it would be
planning myopia to assume that local-level planners can affect changes
in consumer prices, buffer stocks, export and import policies, cash crop
versus subsistence crop issues, and so on. The best-laid plans at the local
level can go awry because of higher-level policy changes. Balance is
needed, just as in the issue of intersectoral versus intrasectoral planning.
Both are important. Again, each can do only part of the job.
Post mortem to a post mortem
Professor Field's description of what he sees as a botched-up romance
with nutrition planning or multisectoral nutrition planning is at places
anorexically thin.
Many of us who were involved in nutrition planning did at times
become entangled in our own schemes; our zeal sometimes outran our
judgement, and delivery fell considerably short of the intention and the
potential. But to say that 'a little critical thinking' would have set a
different course is unfair. There was a lot of critical thinking by a lot of
concerned people in a lot of countries. And there still is. To suggest that
nutrition planners 'moved blindly' is to ignore much of the literature. A
number of cautions - some of them very early - make it clear that
practitioners were not oblivious to the bureaucratic constraints and
political realities Professor Field now identifies.
And it would be cruelly wrong to suggest that no progress has been
made. The legacy is more than, as Professor Field states, 'a series of
diagrams and flow charts'. Years ago planners started moving away
from that whole business. Nutrition planning may have borne fruit of a
different sort than some of its early advocates envisioned, but there is no
question that it bore fruit.
The issue is whether nutrition planning has influenced the way people
think about nutrition and the way they analyse problems. And about
this there can be no doubt. Nutrition has come a long way from the days
374 FOOD POLICY November 1987
Rejoinder: nutrition planning is alive and well, thank you
of fish protein concentrate and lysine fortification as miracle solutions.
Nutrition planners did create the recognition that there were inter-
dependent relationships. This was an important advance, which
broadened the vision of many who were thinking only in one dimension.
Before this, who ever heard of nutritionists talking of commodity prices
and consumer food subsidies? In the process, the nutrition planning
effort has created a new cadre of people working at country and regional
levels, with a different view of nutrition problems and how to solve
them.
Finally, as Sol Chafkin reminds us, Professor Field practically sweeps
aside the history of the consequences of inattention to adequate
food-nutrient intakes, especially for vulnerable groups. He should
know better than to throw out the baby because he doesn't like the bath
water.
Nutrition is an unruly topic and not an easy subject for planning and
policy-making officials to grasp. This problem is exacerbated by a lack
of consensus in the nutrition community. ranging all the way from
whether certain foods have good or bad effects to the way that nutrition
interventions can best be undertaken. Slowly, with the advent of
nutrition planning, respect for nutrition has grown in some development
circles and it has become a legitimate subject for inclusion in the policy
discussions of planning councils of many governments. What is not
needed at this stage is yet another change in signals, particularly if the
signals are based on out-of-date and incomplete information. Perhaps
these responses to Professor Field's article will help to tow back to shore
and to resuscitate those about to drown in the sea of doubts he has
raised.
Nutrition before nutrition planning was largely confined to laboratory
research, local-level demonstration projects, home economists' four-
food-group type of education run out of extension departments, and
miracle technological fixes. None of these efforts had much prospect of
solving the major nutrition problems or reducing child mortality.
Nutrition planning established the utility of a more systematic approach.
It made sense to map the types of malnutrition and of people suffering
from them. It made sense to isolate the major causes of malnutrition
and examine policies that might attack them, even when actions would
cut across sectors. It made sense to take nutrition issues to a national
level, both for the required sophistication of the analysis and the
magnitude of resources or types of policy changes needed. All of these
elements of multisectoral nutrition planning remain intact.
So, Professor Field, nutrition planning is alive and well. It is true that
there were mistakes, some of them significant. But they were
recognized long ago, and changes were made. Prophecy is a risky
business but it would not surprise me, once the air clears, to find those
who are truly interested in nutrition hailing the folks who rode in and
raised all that ruckus that put nutrition on national agendas.
FOOD POLICY November 1987 375
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