History

UNICEF was established for a limited period by the General Assembly of the UN in December 1946 as the United Nations International Children's Emergency Fund to provide assistance to children in Europe and China suffering from the devastations of World War II. In 1950, its life was extended for an additional 3 years, with a mandate covering all developing countries, and in 1953 the General

Assembly gave it permanent status in recognition of the chronic and continuing needs of children. Its name was changed to that by which it is known today: 'International' was dropped as being redundant and 'Emergency' as too restrictive, but the familiar acronym was retained.

Early Days

In its early days, UNICEF gave priority to relief and rehabilitation and the provision of material assistance, laying the foundations for its reputation as an efficient supply agency. UNICEF needed people 'in the field' to ensure supplies reached those for whom they were intended; this was the origin of UNICEF's network of country offices. The 'specialized agencies'—the Food and Agriculture Organization of the United Nation (FAO) and the World Health Organization (WHO)—provided technical advice from a regional or headquarters base.

In the year after it was created, UNICEF requested FAO and the WHO Interim Commission (WHO itself not formally having been established) for technical advice on child nutrition. A joint committee of specialists in nutrition and pediatrics was established, and its advisory report provided basic information on such matters as the energy and protein needs of different age groups, the importance of breast feeding, the negative effects of infections on nutritional status, and the consequences of deficiencies of micronutrients such as iodine, iron, and vitamin A. These remain major issues in public nutrition, although understanding has increased of how to address them successfully. UNICEF has developed its own technical capacity and has become recognized as primarily a developmental rather than a humanitarian organization, dealing in ideas as well as supplies.

During its early years, UNICEF's work on nutrition concentrated on support to direct child feeding through schools, especially through provision of dried skim milk, which was in plentiful supply. This was sometimes coupled with the development of local dairy industries. Fortification of milk powder with vitamin A was an issue—and sometimes still is today. Later, following the common scientific perception of the day, and guided by the Protein Advisory Group (PAG) of the UN system, UNICEF shifted attention from school to preschool feeding and to commercial production of low-cost, highprotein supplementary foods for children. However, costs could not be kept so low that those for whom they were chiefly designed could afford them, and although a frequent condition for UNICEF provision of plant was that the government should subsidize the product for the poor, this commitment could not be maintained.

Applied Nutrition and Nutrition Planning

During the 1960s, UNICEF provided support, with FAO technical inputs, to so-called applied nutrition programs (ANPs), which were essentially educational programs at the local level encouraging the production and consumption of 'nutritious foods.' Emphasis was placed on horticulture and raising of small animals; kitchen, school, and community gardens; and use of appropriate technology to store, preserve, and prepare foods and conserve fuel. Nutrition education was always a component and such programs were often linked to provision of health services, such as immunization, potable water, and environmental sanitation. Although some of these programs attempted to be responsive to local needs and to mobilize local resources, insufficient attention was given in practice to these critical matters, and ANPs tended to be regarded as of peripheral significance. Nevertheless, in some countries they were acknowledged to have laid the groundwork for national nutrition policies, to have provided the first practical experience of intersec-toral cooperation at various levels, and to have increased recognition of the need to involve local people in community programs.

The 1970s saw attempts to introduce nutrition strategies into regional and national development planning. In 1971, the UNICEF executive board declared that ''the best action was through the establishment of national food and nutrition policies.'' Governments were asked to consider specific measures designed to improve nutritional conditions of mothers and children of low-income families. However, these were primarily food based, and the insight of the Mixed Committee of the League of Nations, with its call in 1937 for multisectoral approaches to problems of hunger and malnutrition with a ''marriage of agriculture and medicine,'' seemed to have been lost. Many found it difficult to accept that malnutrition could result either from infection or from an inadequate diet, or often from some combination of the two. Meanwhile, UNICEF continued to try to deal with poor child nutrition through interventions of various complementary kinds, including public health, small-scale agriculture, and the promotion of women's groups.

During this period, experience of program delivery and coverage and better understanding of the development process led to the formulation of concepts that have had a profound effect on the operational approach to improving nutrition. One of these was the basic services concept, first presented by UNICEF to the World Food Conference in 1974 but accepted as policy by the executive board and endorsed by the General Assembly of the UN in 1976. The essence of this holistic approach lies in promoting and responding to community initiatives, the involvement of local community or village-level workers, appropriate technology, and effective support, technical supervision, and referral services. The objective is to foster self-reliance. Similar principles are behind the primary health care (PHC) approach, endorsed by the WHO/UNICEF jointly sponsored international conference on PHC in Alma Ata in 1978. The PHC strategy involves shifting the focus of attention to the primary level of health care, involving the community in its establishment and management, and recognizing the many different sectoral activities that contribute to improved health, among which the Declaration of Alma Ata included the ''promotion of food supply and proper nutrition.'' Experience of these approaches has demonstrated the difficulty of generating community participation and the generally inadequate attention given to training and support of village-level workers. More fundamentally, problems have been encountered in the comprehension and acceptance of the philosophy of the approaches, indicating the importance of effective communication. Often, nongovernmental organizations (NGOs) are able to overcome these handicaps: The challenge then is to expand their local successes into the national scene.

Child Survival and Development

In 1982, UNICEF launched a new initiative, known as the Child Survival and Development Revolution, which focused on the young child and emphasized low-cost actions appropriate for the family but suitable for national application. This was characterized by some as selective PHC. Key components (all reflecting the synergism between nutrition and infection) were the protection and promotion of breastfeeding, immunization against the six EPI (WHO's Expanded Programme of Immunization) diseases, oral rehydration therapy in the control of diarrhea, and regular growth monitoring of the child primarily to help the mother promote optimal growth. Sometimes referred to as the GOBI strategy, it relied heavily on mass communication and social mobilization. The component that received most support was immunization, and in 1991 the UN recognized the attainment of the 1990 goal toward universal child immunization (UCI): 80% of all infants immunized against tuberculosis, polio, diphtheria, pertussis, tetanus, and measles.

UNICEF had become concerned by the erosion of breast-feeding consequent on urbanization and encouraged by aggressive marketing of breast milk substitutes, and it was actively involved with WHO and NGOs in steps that led to the adoption in 1981 by the World Health Assembly of the International Code of Marketing of Breast-Milk Substitutes. In 1990, UNICEF convened with WHO, with the cosponsorship of the US Agency for International Development and the Swedish International Development Authority, an international conference on the protection, promotion, and support of breastfeeding. This conference issued the Innocenti Declaration (named for its venue at the historic Spe-dale degli Innocenti in Florence, home of UNICEF's International Child Development Centre), which called for the reinforcement of a 'breast-feeding culture' and its vigorous defence against incursions of a 'bottle-feeding culture.'

Growth monitoring was perceived as a useful tool for promoting satisfactory growth of children, which itself represented the outcome of influences of diet and disease. Furthermore, child growth was held to be a sensitive and reliable indicator of overall development, and UNICEF advocated that nutritional status should be considered along with more conventional economic indicators in assessing situations and determining policy, in the context of its advocacy of 'structural adjustment with a human face.' Growth charts and weighing scales were widely distributed, but the approach came into some disrepute when it was recognized that too often it was perceived as an end in itself, a sort of technological fix, with little attention to how monitoring should be done and how the results should be used.

Aware of the importance of communication and concerned about identifying simple messages about survival and development of universal validity, although often requiring local adaptation or addition of specificity, UNICEF in 1989 published with WHO and the United Nations Educational, Scientific and Cultural Organization Facts for Life: What Every Family and Community Has a Right to Know. More than 15 million copies are in use in 215 languages. The third edition, published in 2002 by UNICEF and seven other UN agencies including the World Bank, covers 13 topics, including safe motherhood, breast feeding, nutrition and growth, diarrhea, and HIV/AIDS.

Nutrition Strategy and the World Summit for Children Goals

In 1990, the UNICEF executive board approved a new strategy for improving nutrition of children and women in developing countries. The strategy stemmed from the Convention on the Rights of the Child: freedom from hunger and malnutrition are recognized as basic human rights, and continued malnutrition is unacceptable. The strategy proposed a methodology for the identification of appropriate actions through situation assessment and analysis rather than through a predetermined set of technical interventions. This so-called triple A cycle (assessment, analysis, and action, followed by reassessment, etc.) is applicable at household, district, and national levels.

Nutrition status is seen as an outcome. Immediate determinants are dietary intake and infectious disease. Underlying influences can be grouped into three major clusters: household food security, health services coupled with a healthy environment, and care for children and women. The degree to which the three conditions necessary for good nutrition are fulfilled depends on the availability and control of human, economic, and organizational resources at different levels of society: household, community, national, and international. Education has an important role, against a background of political, economic, cultural, and ideological factors. The conceptual framework advocated by the strategy for analyzing the nutrition situation is shown in Figure 1.

The strategy proposed a number of nutrition goals for the 1990s, shared with WHO. As endorsed by heads of government at the World Summit for Children in 1990, the goals were

• reduction of severe and moderate malnutrition among under-fives by half of 1990 levels;

• reduction of the rate of low birth weight (less than 2.5 kg) to less than 10%;

• virtual elimination of iodine deficiency disorders (IDD);

• virtual elimination of vitamin A deficiency (VAD) and its consequences, including blindness;

• reduction of iron deficiency anemia (IDA) in women by one-third of 1990 levels; and

• empowerment of all women to exclusively breastfeed their children for 4-6 months (later changed to 6 months) and to continue breast feeding with complementary food for up to 2 years of age or beyond.

The summit endorsed a number of other goals related to women's health and education, child health and sanitation, and basic education, all of which are relevant to the attainment of the goals for nutrition. Governments committed themselves to prepare and execute national plans of action to implement the summit goals. In 1992, the FAO/ WHO International Conference on Nutrition in Rome included in its World Declaration and Plan of Action for Nutrition a commitment to the nutritional goals of the World Summit for Children.

In 1991, the first meeting on a global scale to pursue summit goals was held in Montreal,

Manifestations (nutritional status)

Immediate determinants

Underlying determinants

Education

Resources and Control Human, economic and organizational

Manifestations (nutritional status)

Immediate determinants

Underlying determinants

Basic determinants

Figure 1 Determinants of child survival and development and nutritional status.

Canada: it was a policy conference on overcoming micronutrient malnutrition titled Ending Hidden Hunger. The strategy to control the three micronu-trient deficiencies was to involve a country-specific combination of short-term and long-term measures, including dietary diversification, food fortification, and nutrient supplementation. In 1991, UNICEF also launched with WHO the Baby-Friendly Hospital Initiative, which formally recognizes maternity facilities that follow specified practices that enable mothers to make an informed choice about how to feed their babies and that helps them to establish and maintain lactation.

By 1993, UNICEF and WHO adopted mid-decade goals, which included goals for IDD, VAD, and breast-feeding, as a way to ensure early progress toward achieving the end-decade goals. The mid-decade goals were the more doable 'top down' goals that could be verified by coverage surveys. For IDD, it was Universal Salt Iodisation (USI), to be verified by the coverage of iodized salt at the household level. For VAD, it was the coverage of children aged 6-59 months consuming high-dose vitamin A capsules in the previous 6 months, and for breast-feeding it was the extent of exclusive breast-feeding at 4 months and the coverage of baby-friendly hospitals. The mid-decade push and prioritization ensured real progress toward these goals by the end of the decade.

By 2000, most children in more than 40 countries were receiving at least one high-dose vitamin A capsule yearly. Between 1998 and 2000, an estimated 1 million child deaths were prevented by vitamin A supplementation. USI was also a great success. Whereas in 1990 less than 20% of households were consuming iodized salt, by 2000 this was 90% or more in 24 countries, with a further 21 achieving 70-90%. The exclusive breast-feeding rates also increased by 10% during the decade, and by 2001 more than 15,000 hospitals in 136 countries had been certified as baby-friendly. These large increases in coverage of iodized salt, and also of vitamin A capsule distribution, and exclusive breastfeeding, can be translated into millions of child lives saved, and child disabilities prevented, and improvement in children's development improved.

Nutrition in the World Fit for Children

At the Special Session on Children held at the UN General Assembly in May 2002, the nations of the world committed to building a world fit for children and adopted a resolution that includes the World Fit for Children (WFFC) goals for 2010. Among the WFFC goals are the reduction of child malnutrition among children younger than 5 years of age by at least one-third, with special attention to children younger than 2 years of age, and reduction of the rate of low birth weight by at least one-third.

UNICEF has adopted in its medium-term strategic plan for 2002-2005 five priorities that derive from emphasis on the rights of the child: integrated early childhood development (IECD); immunization 'plus' (signifying services that can utilize the same delivery system, for example, vitamin A supplementation); girls' education; improved protection of children from violence, abuse, exploitation and discrimination; and fighting HIV/AIDS.

The IECD approach is a holistic one that looks at the whole child and starts from before birth to preschool age, with the emphasis on children younger than 3 years of age. IECD is where nutrition now resides in terms of UNICEF programs. Reduction of protein energy malnutrition (PEM) through implementation of the nutrition strategy requires what have been called diagonal approaches—those that respect both vertical goal orientation and horizontal community process capacity building. IECD should facilitate the tackling of PEM since it is about understanding how to deliver a set of integrated services to children in their community. UNICEF's capacity to do this alone is limited, and partnerships are sought with others, including the World Bank.

With regard to emergencies, UNICEF continues to be responsive to natural and man-made disasters within the constraints of its mandate and resources, and in close cooperation with other parts of the UN system. Thus, UNICEF would not normally provide food aid, this being the province of the World Food Programme (WFP), but may provide supplementary or therapeutic foods for children, health supplies, blankets and tents, fuel for heating, water purifiers, cash assistance, and logistical support.

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