Scaling Up, Scaling Down: Overcoming Malnutrition in Developing Countries

Thomas J. Marchione, Editor
Gordon and Breach. 1999. Hardcover, paperback. ISBN: 9057005476

Reviewed by Steve Hansch
This book may be ordered online through Hunger Notes’ bookstore.

Many non-governmental organization (NGO) projects are first established as “pilot” efforts in order to test and learn about what works best, both in terms of an optimum package of deliverables and in terms of what can succeed in the particular local environment. Often, though, in pilot projects that are successful, that success turns out to be dependent on an intensity of attention and inputs that can be managed for small pilot projects but are not feasible when the approach is taken from a particular village to a whole region or country. This challenge has in past years defined the challenge of “scaling up” from proven, effective narrow interventions to larger regional or countrywide programs. At the other extreme, some programs focus on working through the international arena or through national governments, and need to be “scaled down” to become practical and to deploy scarce resources (for example, food aid) to those most in need– i.e., “targeting.”

This text is the best contribution to date in describing how these challenges can be met. Each chapter explores the ways that aid and development organizations are learning to grapple with hunger and nutrition issues by replicating programs that work, and also by devolving control to grassroots level ownership. As such, it makes excellent reading for NGO staff or in courses on program intervention, nutrition planning, or NGO organizational development.

Several parts of the book’s focus analyze trends in malnutrition in developing countries. Peter Uvin looks at global food trends, observing that overall, “the world produces enough food to feed its entire population on a basic diet, and has sufficient stocks to protect itself against disasters. However, the margins seem to be slim.”
Because of WTO/GATT and because of the decline in subsidized agriculture in wealthier countries, Uvin expects “as world food prices rise, food production in the Third World should increase, as should Third World food exports: local farmers would not suffer anymore from artificially low-priced, subsidized, import competition, and would thus be able to increase their own production.”

David Pelletier’s chapter summarizes current knowledge about the public health consequences of malnutrition in large populations: “mortality is elevated even among children with mild-to-moderate malnutrition (and) is not due simply to the confounding effects of socioeconomic factors and inter-current illness.” Applying the latest epidemiological formula to the poorest countries, Pelletier finds that “malnutrition, through its potentiating effects on infectious diseases, contributes to 56 percent of all child deaths.”

Editor Marchione’s chapter reviews the evolution of concepts in food security, comparing, for example, vertical (technique-specific) with horizontal (integrating with general health care) approaches. Unfortunately, food aid has decreased in recent years. Marchione refers to the U.S. government’s international contribution which “has decreased its commitment… its food aid resources have declined from 7.9 million metric tons in 1993 to a projected 2.7 million metric tons in 1997. Marchione calls on food aid programmers to recognize the changing environment, including the proliferation of democratic regimes that claim to acknowledge international conventions such as the Convention on the Rights of the Children, reaffirmed in the 1992 International Conference on Nutrition. Marchione finds that “civil society has begun to flourish, opening development activities to NGOs.” Marchione projects that “planning and control is coming more under the influence of grassroots communities, local governments, and local NGOs.”

Much of the book deals with the process of finding approaches that are feasible for large populations. For example, such is the case in Togo, West Africa, where a community sense of ownership was the goal for the programs that promoted a regional store of essential drugs to improve household access to basic health services.

Peter Uvin, in a separate chapter, elaborates a typology of different ways that an effort can be “scaled up,” including, for example, 1) quantitative, whereby a program increases its membership or geographic spread, 2) functional, whereby a program expands to types of activities it includes, or, 3) political, whereby organizations take on activities beyond service delivery and advocate for policy change at higher levels. Drawing on a review of key developing country-based NGOs that have won the Feinstein Hunger Awards in the past, Uvin also identifies how NGOs undergo “organizational scaling up” in which they improve their strength, effectiveness, and sustainability, largely through improving their financial base, through expanded partnerships and enhanced management skills.

An excellent example of how one project was first tested in a small area and then replicated much more broadly (or “scaled up”) to a number of regions is given in a chapter about Save the Children’s work in Vietnam to help reduce malnutrition in poor rural families. Save The Children’s “Poverty Alleviation and Nutrition Program” was begun in the coastal/delta Thanh Hoa Province, focusing on growth monitoring, mother education and social marketing of nutrition and hygiene messages, supported also with a targeted revolving loan fund that provided egg-laying hens. Conceptually, Save used the “positive deviance” concept to identify what feeding practices seemed to work among those mothers whose children were well nourished (had high growth attainment). The positive deviance approach led to an emphasis which led the program to encourage mothers to feed their young children shrimp, crabs, and green vegetables, inexpensively available in the local area.

Although the pilot Save the Children program was very successful in reducing malnutrition, many visitors doubted its ability to be scaled up, given how much administrative attention Save had injected into the small pilot project. Nevertheless, in 1993, Save the Children successfully expanded the program to 10 more communes, adapting key components, and eventually reached over 200 communes and over 1 million poor Vietnamese. “Save the Children made a strategic decision to minimize the number of interventions required to… impact nutritional status. Although it is clear that water and sanitation projects, increased agricultural productivity and income generation would certainly further enhance nutritional impact, the cost of these additional components would militate against broad program replication. Hence, Save the Children placed replicability above optimum impact in prioritizing ultimate program objectives.” The Save experience in Vietnam could represent a best-case example, given that “classless, casteless Vietnamese may be easy to mobilize because of their discipline and reverence for education and training.”

Another successful example is provided about a cost-efficient program to provide nutrition education to poor mothers in Haiti, following the “Heath model” which uses local foods and builds on the positive deviance approach. The intervention, described by G Berggren et al., reached out to mothers in poor communities with a two-week intervention including training of mothers in the use of inexpensive local foods, referral care of sick children, growth monitoring and deworming. Mothers learned by doing. Because of extensive community involvement, the program was able to scale up to the district level and was adopted in other regions.

The case study from Bangladesh is very valuable reading because it so clearly explains the roles of various regional, domestic and international NGOs, various donors, and how different nutritional goals were attacked one by one. The main organization involved, the Worldview International Foundation (WIF), is headquartered in Sri Lanka, but has been at the forefront of promoting programs to combat vitamin-A deficiency through different routes than the standard capsule distribution approach that had been strongly supported by UNICEF and the Swedish government, though without ever reaching more than 65 percent coverage of the population. WIF’s approach was built from the grassroots up, educating families, by means of various traditional and mass media, including billboards, folk singers, schools, and trained women volunteers, about the importance of obtaining and including vitamin A-rich foods in the diet. The program scaled up geographically, to include increasing districts, and also functionally, to address iron and iodine deficiencies as well as parasitic Helminth infections and infant feeding practices. By devolving ownership and communication channels to the community level, WIF found that the impacts were long lasting: “When adequate knowledge, changes in dietary patterns and the desire to grow nutrition crops have been achieved, the people themselves, supported mainly by commercial markets (but also to some extent the educational system and agricultural extension) will sustain the necessary behaviors.” In addition to encouraging cooperation among NGOs, the case recommends attention to the balancing act between the size and the management needs of successful new programs: “If they are too large in scale, then the many changes required in design, training and management result in debilitating shifts in project routines and high costs for retraining. If the scale of pilot projects is too small, then the lessons learned may not be applicable to the wider society. Failure to find mid-level managers with vision and motivation may explain the failure of most pilot projects to go to scale successfully.”

The last part of the book reviews field methods of inquiry into food insecurity. Ellen Messer gives a historical review of rapid rural appraisal techniques– originally developed by anthropologists and now used extensively by nutritionists and project planners. Building on this is the example by CARE’s food specialists, Tim Frankenberger and Cathy McCaston about the recent development of CARE’s “rapid food and livelihood security assessment,” which involves at least six randomly chosen villages and takes up to four weeks, using a multi-pronged approach that examines livelihood security of households and the community in a way that informs program design and targeting. Large group interviews, which tease out general community facilities, consumption and common resources, are followed by smaller focus groups on livelihoods. These are complemented by semi-structured household surveys as well as by nutrition and health surveys. CARE’s surveys have now been completed for many poor countries and other organizations should benefit from learning more about their findings and their approach.

Several further chapters round out this text that addresses, better than any other, the subtle planning aspects of growing an intervention, which is successful in technical terms, into something that can sustainably reach a sizeable population. As Marchione concludes, “this book puts to rest the notion that scaling up a nutrition program is only a matter of increasing its size… the programs that were most cost-effective were found to work in small settings that were replicated by governments and NGOs with careful consideration of the particularities of new coverage areas. …Critical to all scaling up is how to make a grassroots nutrition organization financially sustainable. Given the scarcity of resources, managers must become ever more adept at project self-financing and competition for scarce donor funding.”

Hansch consults widely on refugee issues and is an editor of Hunger Notes.