Evaluating the Impact of Nutrition and Health Programs

Evaluating the Impact of Nutrition and Health Programs

Evaluating the Impact of Nutrition and Health Programs Edited by Robert E. Klein Pan American Health Organization/Institute of Nutrition of Central America and Panama Guatemala, Guatemala Merrill S. Read Pan American Health Organization Washington, D.C. Henry W Riecken University of Pennsylvania Philadelphia, Pennsylvania James A. Brown, Ir. u.s. Agency for International Development Washington, D.C. Alberto Pradilla Foundation for Higher Education Cali, Colombia and Carlos H Daza Pan American Health Organization Washington, D.C. PLENUM PRESS. NEW YORK AND LONDON

Library of Congress Cataloging in Publication Data Pan American Health Organization International Conference on the Assessment of the Impact of Nutrition and Related Health Programs, Panama, 1977. Evaluating the impact of nutrition and health programs. Includes index. 1. Public health-evaluation-congresses. 2. Nutrition-Evaluation-Congresses. 3. Evaluation research (Social action programs)-congresses. 4. Malnutrition-Latin America-Prevention-Congresses. I. Klein, Robert E. II. Pan American Health Organization. III. Title. IV. Title: Impact evaluation. [DNLM: 1. Nutrition-Standards-Congresses. 2. Nutrition disorders-congresses. 3. Evaluation studies-congresses. 4. Public health America-Congresses. QU145 C747p 1977] RA427.P2161977 614 79-11321 ISBN 978-1-4684-3491-0 001 10.1007/978-1-4684-3489-7 ISBN 978-1-4684-3489-7 (ebook) Based on the proceedings of the P AHO International Conference on the Assessment of the Impact of Nutrition and Related Health Programs, held in Isla Contadora, Panama, August 1-4, 1977 1979 Plenum Press, New York Softcover reprint of the hardcover 15t edition 1979 A Division of Plenum Publishing Corporation 227 West 17th Street, New York, N.Y. 10011 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

Preparation of this volume has been a joint effort of Plenum Press and the Pan American Health Organization, Regional Office of the World Health Organization. This volume also is to be published in Spanish for distribution through the Pan American Health Organization, Washington, D.C. 20037

Foreword As is noted in the opening chapter of this volume, nutrition and public health programs have been important throughout Latin America and the Caribbean for many years. This is due to the special concerns of those responsible for setting national policies, the program experience and leadership in public health developed by the national governments, and the stimulus and cooperation of the Pan American Health Organization (PARO), including its twelve associated centers which focus on research, training and program development. The need for a coordinated hemisphere-wide attack on malnutrition and other health problems was expressed clearly in the "Ten Year Health Plan for the Americas" (1). This plan established specific targets for reducing the prevalence of the major nutritional diseases and other health problems for the decade 1971-1980. It was noted at that time that very few countries had formulated adequate comprehensive national food and nutrition policies and plans, nor had they developed strategies for combating the nutritional deficiencies known to affect large numbers of people throughout the Region. Following a review of the available data on a country by country basis in 1975, the PARO Directing Council endorsed recommendations for formulating the necessary national policies and strategies for the intersectorial execution of food, nutrition and health programs (2). This report also summarized the available national data related to nutritional status, existing programs such as food fortification, and the human resources available for services as well as for research and education. The nutritional problems in the Americas are varied. The most frequently encountered deficiency is protein-energy malnutrition (PEM). It affects the growth and health of large numbers of young children and also contributes importantly to low birth weight of infants born to inadequately nourished mothers. PEM is seen most often among the rural populations and the marginal urban vii

viii FOREWORD poor in rapidly expanding cities. It is seen much less frequently in those areas and countries where health and community services have been extended to provide adequate coverage or in those areas where extremes of wealth or poverty are not great. In nearly all its forms under-nutrition is associated with higher incidence of gastroenteritis and other childhood diseases, either as a result of decreased food intake during illness or because malnutrition adversely affects the development of immunologic defense mechanisms. Therefore the development of appropriate national programs, and their evaluation, must be approached on a multisectorial and multi-disciplinary basis. Several of the countries in the Western Hemisphere have developed extensive national food and nutrition plans. In these countries a variety of program activities have been projected or implemented. These include food stamps or food supplements for target populations, nutritional fortification of commonly eaten foods, extension of primary health care coupled with nutrition and health education, agricultural reform, and income maintenance. Information systems, (i.e., health and nutritional surveillance) are being implemented in several countries to determine where problems lie, what services are being delivered, and what may be the impact of national programs as they are implemented (3,4). Frequently these efforts are centered in the health ministries (5). However, a multisectorial approach to impact evaluation will obviously be required if serious attention is to be given to the well-being of the needy populations. Papers in this volume make this point abundantly clear. It is clear that evaluation of the impact of nutrition and health programs will become increasingly more important as co~atries throughout the world seek to provide services to meet the needs of their populations. We believe that this volume will stimulate new and innovative approaches to this end. The Pan American Health Organization wishes to express its appreciation to the United States Agency for International Development for financial support of the conference and preparation of this volume. Hector R. Acuna Director, Pan American Health Organization

FOREWORD ix REFERENCES 1. Pan American Health Organization. Ten Year HeaZth PZan for the Ameriaas. PAHO Official Document No. 118, Washington 1973 2. Organiazcion Panamericana de la Salud. PoZ!tiaas NaaionaZes de AZimentaai6n y Nutriai6n. Publ. Cientif. No. 328. Washington 1976. 3. Joint FAO/UNICEF/WHO Expert Committee. MethodoZogy of NutritionaZ SurveiZZanae, Technical Report Series #593. Geneva: World Health Organization 1976. 4. Coloquio sobre Sistemas de Vigilancia Epidemiologica Nutricional, IV Congreso Latino Americano de Nutricion, Caracas, Venezuela, November 1976. Published in Arah. Latinoamer. Nutr. 27 (2)., Supplement, June 1977. (English translation: Pan American Health Organization 1978. In preparation). 5. Daza, C. H. and M. S. Read. Health-related Components of a Nutritional Surveillance System. Paper presented at Plenary Session of IX International Con(J!'est! on Nutrition, Rio de Janeiro, August 1978.

Contents I. INTRODUCTION Rationale for the Conference and Organization of the Volume Determinants of Health and Nutritional Status John A. Daly, Joe H. Davis, and Robert L. Robertson 1 7 Comments by H~ctor General Discussion Correa 34 35 II. APPROACHES TO IMPACT EVALUATION Recent United States Experiences in Evaluation Research with Implications for Latin America Thomas D. Cook and Emile G. McAnany Comments by Robinson G. Hollister Special Issues for the Measurement of Program Impact in Developing Countries John W. Townsend, W. Timothy Farrell, and Robert E. Klein Comments by Guillermo Herrera General Discussion for Section II 39 76 99 123 127 xi

III. ASSESSING SPECIFIC OUTCOMES OF INTERVENTIONS Measurement of Health and Nutrition Effects of Large-Scale Intervention Projects Jean-Pierre Habicht and William P. Butz Comments by Alberto Pradilla, L.F. Fajardo, and G. Acciarri General Discussion Family Composition and Structure in Relation to Nutrition and Health Programs Susan C. M. Scrimshaw and Gretel H. Pelto Comments by Nelson Amaro General Discussion The Economic Theory of the Household and Impact Measurement of Nutrition and Related Health Programs Dov Chernichovsky Comments by Sebastian Pinera General Discussion Educational Outcomes and Nutrition Selma J. Mushkin Comments by Ernesto Pollitt General Discussion 133 170 179 183 218 224 227 258 261 269 302 306 IV. IMPLEMENTING AND USING EVALUATIONS Political and Organizational Issues in Assessing Health and Nutrition Interventions Antonio Ugalde and Robert Emrey Comments by Adolfo Chavez Some Suggestions for Improving the Applicability and Utilization of Evaluation Assessments Jerome S. Stromberg Comments by Ricardo Galan Morera 309 331 339 356

CONTENTS xiii V. PRACTICE AND PROBLEMS OF IMPACT EVALUATION Practice and Problems of Evaluation: A Conference Synthesis Henry W. Riecken Clarification of Concepts and Terms Commonly Used in Evaluative Research Karen M. Hennigan, Brian R. Flay, and Richard A. Haag Participants Index..'. 363 387 433 441