SOME THOUGHTS ON THE SETTING OF GOALS AND TARGETS: HAVE THEY HELPED PROGRESS OR NOT?
SCN News, No.22, Gva., July 2001.
The big hype
The outcome-process riddle
Being realistic
On convergence
The Human Rights twist
The equity factor
On accusations of dependency and top-down implementation
Donors (and we ourselves) touch some projects more than others
The poverty alleviation connection
Some thoughts on the setting of goals and targets in nutrition:
Have they helped progress or not?
The big hype:
There is a big difference between the excitement and the expectations generated while preparing for a big international gathering to set or to monitor the status of time-bound, monitorable global goals and targets, and saying that the same will be or are being really useful. Keep in mind that setting these goals is the result of a process in which public admission of dissent is difficult. Therefore, countries pledge, but do not really embark and comply.
The real challenge, therefore, comes after the (usually expensive) international gathering. It comes during the process of preparing, finding the funding and executing down-to-earth action plans. Unfortunately, this process is rarely participatory. And for this process, the international conference, more often than not, is not too helpful, because the respective strategies to achieve the targets are left a bit in the air (or in the paper).
The outcome-process riddle:
Getting to where we want to go requires not so much knowing and quantifying where we want to be at a given time, but more so the process(es) through which we are going to get there. Goals and targets address the former. Processes are left to the planners and implementers to decide/execute –often excluding community representation. But it is the process that carries in it the seed of sustainability. Unfortunately, as nutrition professionals, we fear prescribing processes (or denouncing processes we know do not work or are not working). We also have not spent the time to arrive at universally acceptable indicators that can measure sustainable progress in processes such as participation, mobilisation and empowerment. Instead, we have spend time and money choosing and monitoring outcome goals and targets that have unduly over-medicalised the nutrition problem. Think about it.
Being realistic:
With a pinch of self-criticism, some goals and targets set in the 90s called for a number of pretty unrealistic measures, unaffordable to most developing countries’ state coffers. With low resources, one cannot but get low coverages –and this is by definition, not only ineffective, but also wasteful. The danger I see is that we may be doing it again for goals to 2015. At the moment, we have no assurances that the new set of goals will mobilise leaders, the media and members of civil society any more than before. Business as usual will not get us there for anaemia, stunting and underweight: at present rates, it will take us decades to halve the prevalence of child malnutrition.
Moreover, three serious concerns arise here.
One is on who the judges should be of what is realistic. Certainly not only us the technicians. And certainly, realism can no longer be based on global, across-the-board targets.
Another related concern is that being realistic also has to do with the quality of the data we use to monitor progress towards achieving the respective goals. If the latter is poor, the intrinsic value of the number reflecting how far one is from achieving the target can certainly be misleading. This comes out clearly in the responses we received to the questionnaire sent out to field workers which you can find in the next section.
The third concern is that I still find colleagues saying that this or that goal may be ambitious. I think the time has passed for ‘maybe’ positions. [I am reminded of a small poster hanging on the wall of my office which reads “I said maybe, and that’s final!”]. The facts are out. After democratic consultation, we are expected to endorse concrete advice on directions and finish lines.
On convergence:
An issue not often touched is the convergence of some of the goals and targets set in the 90s.
Even if they branch out to achieve different primary outcomes, actions to overcome more specific aspects of malnutrition can be additive.
For example, improvements in vitamin A status positively affect nutritional anaemia; improvements in iron status can positively affect the appetite of a child. Quite a few other examples can be found. Our actions to address micronutrient deficiencies and chronic malnutrition are thus complementary and impact on the overall well-being of individuals.
But these individuals live in imperfect societies that cause them to suffer from the different forms of malnutrition.
I guess what I want to highlight is the centrality of the individual with her/his multifaceted problems. With a goals and targets mindset, we tend to forget and de-personlise the individual, especially the fact the s/he lives in an adverse environment. Yes, we can get the retinol levels of a child up to normal, but the child goes on to die very anaemic from malaria. So, to what avail our efforts? We simply cannot afford to miss the big picture.
When it comes to processes, it behooves us to jointly embark on the processes needed to make change sustainable. The processes still in need of much more convergence are those related to tackling the underlying and basic causes of malnutrition. Much more needs to be done on this, perhaps starting with the de-medicalisation of our goals, as well as with focusing more on these processes than mostly on outcomes. And this applies to all of us.
The Human Rights twist:
As members of institutions and/or as individuals, many of us are moving towards a change in the paradigm giving direction to our work. What we may not have thought enough about is that goals and targets –many of them intermediate in nature– are, in a way, antithetical to the Human Rights paradigm. This, because it rests on the principle that we cannot rest until the rights of all are restored or instated, i.e. a target of 100% …not ten years down the road, but the soonest possible. Consequently –and being realistic– we should be talking of steps to be achieved in the process of fulfilling the Human Rights of all claim holders. In our case, the issue is nutrition rights and food as a right. And, for most of us, this is a whole new approach.
A complementary compromise position could be to start working on goals and targets in reverse. We could express targets as an expected decrease in the number of malnourished (or what it will still take to close the gap and uphold the right of 100% of them).
The equity factor:
Reaching targets (usually followed by a congratulatory stage) can be misleading. Applying all prescribed interventions primarily to the easier-to-reach near poor –say the second lowest income quintile– can, eventually, get us to achieve national targets on schedule. I do not need to tell you what this means to equity… Here, I just want to bring to your attention what some are calling the distributional concerns of (sometimes short-cut) actions (imposed) to achieve goals.
On accusations of dependency and top-down implementation:
The achievement of micronutrient goals has created dependency. How? Not only are many iodine deficiency disorders (IDD) and vitamin A deficiency disorders (VADD) schemes top-down –with an element of dependency there– but supplies and other resources are, more often than not, donor provided. In the long run, in terms of sustainability, what worries some of us is the ‘ownership-donorship’ interplay. At the end of the day, it is a zero sum game.
On this issue of top-down, I do disagree with what some colleagues imply when they tell us that solutions lie in a continuum from vertical micronutrient interventions to those addressing stunting and underweight so that the former call for vertical goals which need little action at community level and only the latter need active community involvement; I disagree with them when they say that it is only when goals need action at community level that actionable levels must be consulted with community representatives.
To me, the idea of ‘some amount of community action’ is nonsensical. Implying that for child chronic malnutrition most actions are to be devised and carried out by the community implies shifting the responsibility for having so many malnourished children among them to the community itself –so they better deal with it…
Donors (and we ourselves) touch some projects more than others:
What are the reasons for a lack of commensurate donor support for iron deficiency anaemia (IDA) and for the reduction of child malnutrition? Does it have something to do with donor fatigue or with targets for these two having been set at unreasonable levels? (Remember that, justifiably or not, UNICEF dropped the monitoring of the underweight goal from its mid-decade review). Are we then in part responsible for having set ourselves up for failure? I tend to think that the response to the latter two questions is no. In the eyes of donors (…and many among us) IDA and chronic malnutrition are more messy to deal with than IDD and VADD. There is all this bottom-up, community action, poverty alleviation, equity and other such involved in them, as well as longer time horizons. Donors pay plenty of lip service to these more than, so far, embarking head-on on working on solutions for them. That is not fatigue; it is not a lack of will, it is a political choice. Internal and external resources allocated to IDA and under five malnutrition have thus remained a pittance, unmatched to the challenge. And there is nothing in sight that tells me that this is changing soon.
Again, it is in the process of selecting the strategies and the steps to progressively achieve them where donors and many among us have been and continue to be undemocratic and where we have failed 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 should consider ourselves part of the problem and not the solution.
The poverty alleviation connection:
Will the new global shift of all donor agencies towards poverty alleviation strategies happen? and will it change what has been said above? The reduction of child malnutrition has now been selected as a key outcome indicator to measure progress in poverty alleviation. But, alas, this does not automatically translate into greater advocacy, more actions and more donor resources going for the prevention of malnutrition. Being an indicator does not translate into being the object of concerted new efforts and investments directed at halving malnutrition. We have a lot more to do here. Improved socioeconomic status will improve nutrition, but we know that is only part of the story –although quite a big one.
To sum up, the take-home message perhaps is that there is probably no such thing as across-the-board realistic targets. At most, they can be proposed by us on some technical grounds. But consensus must be painstakingly built for them in many, many places with both bottom-up and top-down inputs. There simply are no short-cuts. Goals or no goals, for people to gain control over the resources they need to overcome all aspects of malnutrition remains the key. Remember UNICEF’s conceptual framework of the causes of malnutrition and the bottom-centred (top-down and bottom-up) AAA (assessment-analysis and action) process…
Claudio Schuftan, SAIGON
schuftan@gmail.com