2011 August blog
My column this month comes in two parts linked by one word. This is 'target' in two of its meanings. These are 'targetry' and also 'setting targets'. The concepts that I want to get across to you are self-evident as you read along.
In the name of greater equity, many currently proposed approaches to resolve the problems of nutrition still very often favour and select actions covering, for the most part, strategies that target services to the disadvantaged and malnourished, such as the measurements of weight and height of little children as shown above. This strategic approach, it is purported, represents a move towards equity. But is it really? Many of us rather think that what is needed is to mobilise a strong popular movement that demands a comprehensive, truly equity-oriented nutrition policy (1).
TARGETRY AND EQUITY
'FIXING THE WORST CASES' DOES NOT
AND CANNOT ADDRESS THE BASIC ISSUES'
Many of us also think it is wrong to propose targeting as an alternative to making nutrition an integral part of primary health care – applied in its full Alma Ata spirit. Individual targeting is a variant of the ill-reputed 'selective primary health care' approach we all saw rise after Alma Ata. Its motto was: 'Go for the worst cases, fix them, and improve the statistics'. But this does not and cannot stop recurrence of the same problems.
Unfortunately, individual targeting is now seen as a central option by the World Bank and other major funding agencies, together with geographical and other types of targeting.How can this be fair? In an era of fee-for-service delivery systems promoted by free-market proponents, one of the key issues for individual targeting – to keep a semblance of equity – seems to be the exemption from user fees for the poor. Unfortunately, these waiver schemes, in all their variants worldwide, have proven to be mostly catastrophes. They simply do not work. Perhaps they are meant not to work. They are often implemented insincerely, only as a political manoeuvre to make user fees more palatable to the population when first introduced.
In my view, and that of many others, individual targeting cannot be made to work equitably. Nor is it effective. Weeding-out and providing the needed services that actually do target individuals or groups is a time-consuming and costly administrative process.
Geographical targeting, for instance of the most impoverished districts probably has more potential, and the more so if being made part of a comprehensive primary health care approach. But impoverished communities usually have little political clout to fight for their share. But even at somewhat higher cost, this type of focus on the poorest clusters of poor people makes sense in terms of equity – and of human rights.
Throwing crusts to the hungry
Individual targeting is a dangerous path to follow. It pursues a 'mirage of equity' that basically leaves the perennial determinants of the rich-poor gap untouched. It is like throwing a crust of bread to the hungry.
What's needed now is to compare the effects on long-term equity and on nutrition indicators of selected individual targeting interventions with a host of already tried direct poverty alleviation measures. The data for this may already be there or may be still missing.
Overall poverty reduction (or better, disparity reduction) is a theme yet again getting growing attention these days. So nutrition colleagues have a golden opportunity to work harder to influence overall development strategies towards equity in health and nutrition. We should not miss the opportunity. All the more so, because the health/nutrition sector cannot, by technical actions alone, make significant improvements in the health/nutrition conditions of impoverished populations.
The limits of data
Breaking down health and nutrition data by income quintiles, by gender and by ethnic background, as is now proposed by some donors, is a welcome first move. This can be used to consolidate credible national and international databases and thus track equity issues. Results of analysis of these data could usefully be published annually in a publication with the stature of the annual UN Development Programme World Development Report. Countries could be ranked according to their respective performance. Such a publication could further analyse existing gaps, and minimum performance objectives could be set for improvements for the immediately following years.
Using such data to tackle the inequities at sub-national and especially local level is where the real challenge lies. Donor agencies will have to be more forceful in advocating equity-promoting, human rights-based, participatory, bottom-centred interventions. They will also need to be more responsive to government-initiated requests from low-income countries for funding to prepare and execute policies specifically addressing what is the fundamental issue of equity.
Governments and donors will need to enter into binding commitments, perhaps with signed memoranda of understanding, in order to move in the direction of disparity reduction and greater equity. Close monitoring of progress will also be needed. These binding commitments should be a precondition for continued support. Funds could then be released in tranches based on the achievement of negotiated verifiable indicators of progress along the line of project implementation. At the same time, donors should develop formal relations with national and local civil society organisations. In the case of non-responsive or non-performing governments, donor funding should be progressively reallocated to what by that stage should be known to be a competent and trustworthy civil society organisation network.
All this may only add up to a start --and from the top at that. But it is a start.
HEY DIDDLE DIDDLE, THE HYPE AND THE RIDDLE:
THE GAP BETWEEN WISHING AND DOING
Here are some targets shown in graphic form above: those of the Millennium Development Goals, which are also quantified in the MDG text. There is though, a big difference between the excitement and the expectations generated by setting goals and targets, on the one hand, and on the other hand, being able to claim that they actually work. Setting targets is typically not a participatory a process, and usually does not admit of public expressions of dissent. Further, in affirming goals and targets like those of the MDGs, countries pledge, but whether they really commit and comply is a whole different matter (2).More often than not, the processes to achieve the targets are left in the air (or only on paper).
Getting from where we are to where we want to be, requires quantifying where we want to be at a given time, and also requires specifying the process we are going to get there. Targets address the former. Processes are typically left to planners and implementers, and usually exclude any representation of those who are supposed to benefit. But it is the processes that contain the seeds of sustainability. Unfortunately, we nutritionists are good at setting targets, but not much good at prescribing sustainable processes – let alone denouncing processes we know do not work or are not working. Nor do we spend much time and energy on considering and agreeing what measurements can gauge progress towards fulfilling the right to nutrition. such as people's participation, mobilisation and empowerment. Instead, we spend so much time and money proposing and monitoring outcome targets that medicalise the nutrition problem. Think about it.
The need to get real
Some targets we set before and during the 1990s called for a number of pretty unrealistic measures. These could not be afforded by most lower-income countries, let alone by impoverished communities. The result has been low coverage rates and low compliance – ineffective and also wasteful.
It seems to me and many others that this basic mistake has been and is being made with the MDGs. Already in 2011, we have no assurance that the goals are really mobilising national governments beyond lip service. And to repeat what I have said in previous columns, political and economic 'business as usual' will not and cannot achieve targets for anaemia, stunting and underweight, and at present rates, it will take way beyond 2015 to halve the prevalence of child malnutrition.
Moreover, three serious concerns arise here.
One is on who should be the judges of what is realistic. Certainly these should not be only us, the technicians. Also, realism can no longer be based on targets set at national levels. National averages hide huge disparities.
Two is the quality of the data used to monitor progress towards achieving targets. If progress seems to be poor, this may reflect poor quality of the numbers from which the goals are derived.
Three, I keep hearing colleagues say that this or that target 'may be' too ambitious. The time has passed for 'maybe'. (A poster hanging on the wall of my office reads 'I said maybe, and that's final'). It is only through setting up processes of democratic consultation that we can expect to get realistic bases for concrete, feasible goals.
An issue not often considered is the convergence of the various goals and targets we technicians set, from the top down.
Actions to overcome specific aspects of malnutrition can be and are additive. For example, improvements in vitamin A status positively affect nutritional anaemia; improvements in iron status can positively affect the appetite of a child. Our actions to address micronutrient deficiencies and chronic malnutrition are thus complementary and impact on overall well-being of populations and families. But we need always to remember that they live in imperfect societies that ultimately cause them to suffer from the different forms of malnutrition. Yes, we can get the retinol levels of a child up to normal, but then the child may go on to die from malaria. So, to what avail our efforts?
BACK TO TARGETS AND RIGHTS
HO SHOULD SET TARGETS, AND FOR WHAT?
HOW CAN WE REALLY BE PART OF THE SOLUTION?
How can we make change sustainable? As always, we need to address the underlying and basic causes of malnutrition. We can start by de-medicalising our goals and targets, and by focusing both on processes and on outcomes.
The whole process of setting targets is, in a way, antithetical to human rights. The human rights principle is that we cannot rest until the rights of all are restored or instated, not 15 years ahead (and then another 15 years ahead), but in the present. We should be setting progressive, verifiable targets to be achieved year by year, in the process of progressive step by step fulfilment of human rights for all. A compromise position is to start working on targets in reverse. We could express targets as an expected year on year decrease in the number of malnourished at all including sub-national levels. Also, applying all specified interventions firstly to the easier to reach near poor – say, the second lowest income quintile – can move towards achievement of national average targets on schedule and also to reduction of inequity.
I disagree with colleagues when they say that consultation with beneficiaries (claim-holders) need to begin only when targets requiring direct action at community level begin to be achieved. To me, the idea of 'just some amount of community action' being needed is wrong. It implies a shift in the responsibility for doing something for the malnourished children in the community to the community itself. This victimises people who have been historically marginalised.
Donors. Fatigue or bad attitude?
More generally, why is donation of support for reduction of maternal and child malnutrition not working well?
Is this because of 'donor fatigue? Or have targets for reduction of malnutrition having been set too high? And if so, are we responsible for having set ourselves up for failure? On the whole I think that the answer to these questions is, no.
In the eyes of donors. and also of many among us, chronic malnutrition is more messy to deal with than iodine deficiency disorders or vitamin A deficiency disorders. With bigger issues such as protein-energy malnutrition (and perhaps also iron deficiency anaemia), it is obvious that bottom-up, community-driven action is needed, and that issues of equity are involved, as well as longer time horizons. Donors pay plenty more lip-service to what needs to be done than, so far, working hard on solutions for these bigger and broader issues.
This is not fatigue, it is not a lack of will. It is a political choice. Internal and external resources allocated to under 5 malnutrition have thus remained a pitiable and disgraceful pittance. And there is nothing in sight that tells me that this is changing soon, notwithstanding the World Bank inspired SUN Initiative.
In the selection of targets and processes, and in the steps needed progressively to achieve them, donors and many among us have been and continue to be undemocratic. Thus we fail those whose nutrition rights are being violated. As long as we consider the strategies needed to tackle the basic causes of malnutrition to be outside the realm of our professional scope of work, we are part of the problem and not of the solution.
The poverty alleviation connection
Will a global shift of donor agencies towards strategies that really are design to alleviate poverty and reduce inequity, ever happen? I have my doubts.
Reduction of maternal and child malnutrition is selected in the MDGs as a key outcome indicator to measure progress in poverty alleviation. Yes, a decrease in poverty will improve nutrition. But, this does not automatically translate into greater advocacy, more actions and more donor resources for the prevention of malnutrition. Being an 'indicator' does not translate into anything much, let alone being the object of concerted new efforts and investments directed at halving malnutrition.
Finally, perhaps there is no such thing as realistic across the board targets. Perhaps targets can be proposed by us for participatory consideration, based on some technical grounds, together with an outline of possible processes to attain them. Rational and realistic onsensus for targets and processes must be painstakingly built in many, many places with both bottom-up and top-down inputs. There are no short-cuts.
- Schuftan C. Can significant major equity be achieved through targeting? abstract, Health Action, CHAI, India, 13, 12, December 2000.
- Schuftan C. Aiming at the target: What's left for the devil to advocate?, SCN News 22, July 2001.
Acknowledgement and request
You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.
Please cite as: : Schuftan C. Targetry and equity. [Column] Website of the World Public Health Nutrition Association, August 2011. Obtainable at www.wphna.org
The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.
This column is reviewed by Geoffrey Cannon.