Growth charts don't cure malnutrition.

PIP: Growth chart monitoring developed as a technique designed to decrease infant and child morbidty. In order for similar techniques to reach those who need them most, special emphasis must be placed on the question of how services and information will be delivered. This problem of implementation, often neglected by primary health planners, becomes the linchpin of success or failure when small-scale projects with limited coverage are scaled up to large regional or national programs. Supervision is most often the weakest aspect of growth monitoring programs. This frequently results in improper use of the growth charts and insufficient attention to follow-up of the children at risk. Large scale schemes employing monitoring techniques have tended to spend an inordinate amount of time considering mechanics and technical questions at the expense of analyzing results. Thus, the time consumed by the weighing and the charting is so considerable that little time or energy remains to do what is really important, that is, to analyze individual charts and provide services to those whose growth is faltering. Until the focus shifts away from the numbers of children weighted to the follow-up activities undertaken, programs utilizing growth charts will continue to have limited results. Also, in order to make a successful leap from small-scale project to improved national health, careful planning is necessary when applying any health intervention.^ieng

Nutrition interventions: problems associated with expanding pilot/demonstration projects into national-level programs.

PIP: It is necessary to determine what makes the small-scale nutrition projects successful and what are the constraints precluding effective implementation of project-developed interventions on a large scale. Research in the Western Indian state of Maharashtra suggests that a process can be identified and isolated which helps explain how small-scale projects achieve their impact. During the 1970s, 7 community-based projects operated within Maharashtra delivering an integrated package of nutrition and health services. 6 of these were voluntary agency managed, and all but 1 was operated exclusively by the government. All 7 were similar in that they recruited, trained and utilized villagers as outreach workers. The services delivered differed from project to project but generally included nutrition, primary health care, and some fertility control services. Several projects were able to demonstrate impressive impact. The percentage of eligible couples practicing contraception was particularly impressive. After studying each project and identifying those factors responsible for impact, it is possible to construct a composite or "ideal type" project from the joint experience. The primarily management-related features provide a standard to which the implementation process of the expanded program can be compared. The underlying orientation of a project or program can help to explain how results are achieved. The 2nd factor was good staff morale. The Maharashtra projects held both staff and community accountable for their actions. The 4th and 5th factors were flexibility and community participation. In 1977 the new Janata Government launched the Community Health Worker Program (CHWP). This provided an opportunity to study what happens in the process of project expansion and why. 3 perspectives or sets of conceptual lenses were necessary to identify and analyze problems arising in the expansion of the project-developed intervention: rational actor analysis; organizational analysis; and political analysis. These are reviewed. Policy makers and program designers need to be aware of the constraints facing them when expanding a project-developed intervention. Thus far the technical, scientific, and economic aspects have taken precedence over the human elements. This time has come to focus more on the process or what makes an intervention effective.^ieng