Hunger-Undernutrition Blog

Renormalizing “normal”

By Cara George, with Humanitas Global Development

Genetics influence everything about how we are created –from our eye color, to whether we can roll our tongues, even our ability to smell. But what about height? Sure, genetics play a role in that as well. But a recent entry The Global Crisis You Never Heard Of: Stunting on the 1,000 Days Blog points to stunting, or stunted growth, as a dangerous phenomenon, linked to horrifying statistics on impaired brain development and mortality resulting from diarrhea, due to chronic nutritional deficiencies.

Development work consists so heavily of creating a “new normal”. One idea we’re developing here at Humanitas Global Development is how to promote behavior change in a current nutrition project underway in Central America, where the target population does not even understand that they are stunted because everyone else around them is short too. Having served as a Peace Corps Volunteer in  Guatemala, I experienced this firsthand. At 5'6" tall, I always felt at average height in the US, and once in Guatemala, it took some getting used to the feeling of towering above everyone in my town - even the men. 

How do you “convince” a population of chronically malnourished individuals that genes are not solely responsible for their height, and encourage a new way of perceiving “normal”? And how does one work to establish fresh ideas around what is healthy and normal, especially when it means working in a cultural context that does not see the problem or issue in the same way?

Since our readers work in such a variety of areas and geographical/cultural contexts, we want to know your successes and challenges in working towards a “new normal”!

Working Together is Critical for Success

Guest blog post by Robert Baldwin with the Flour Fortification Initiative

In October I was in Albania on a joint mission between the Flour Fortification Initiative and UNICEF to advance flour fortification in that Balkan nation. Throughout the week, our team met in small groups with more than 35 decision and policy makers and policy shapers in the public, private and civic sectors. We were impressed with their willingness to work together to make it happen. The Ministry of Health, acknowledged by all as the entity to lead the effort, was confident that it could embrace and engage all other sectors in working together to achieve the goal.

Albanian leaders proved once before that they could work together to fortify a staple food when in 2008 they successfully undertook a salt iodization program. At week’s end our team was confident that these folks were on the right path toward fortifying flour. While there are a number of ways to decrease micronutrient deficiencies, the Albanians recognized that flour fortification is a cost efficient, technologically simple way to improve the nutrition status of a great number of people in a short timeframe.

Their commitment to work together to accomplish that goal shows that they understand micronutrient malnutrition is a multi-sector problem that demands a multi-sector response.

Oftentimes, when speaking to a group about micronutrient malnutrition, I ask the question “Do you think that micronutrient deficiencies are primarily a health sector problem?” Invariably, more than half respond with a “Yes” answer.

My response is that it is not exclusively a public health problem, but more of a societal problem. This issue of hidden hunger impacts almost all aspects of a society’s lifecycle:

• It impacts the education sector—the intellectual development of children is impaired, creativity is diminished, inventiveness is stifled.
• It affects the labor sector—nutritionally impoverished adults can’t perform at full capacity, lose time from the job, and thus are not a productive as they can be.
• It impacts the economic sector—lost productivity leads to lower wages which restrict purchasing power— these and other factors contribute to lowering a country’s GDP.
• It does affect the health sector by contributing to blindness, lowering immunity to disease, contributing to childhood morbidity and maternal mortality, increasing the incidence of debilitating birth defects, while contributing to the overall increased cost of health care.

If you buy the argument that this is a problem across society, then it is unreasonable to expect the health sector alone to deal with and solve the problem. The public health sector often provides the leadership necessary to alleviate the problem. Yet to effectively combat micronutrient malnutrition, it must muster the collaboration of other agencies within the public sector, as well as involving, from the start, the energies, experience and skills of the private and civic sectors.

This formula soon becomes apparent to those engaged in the effort to achieve national-scale flour fortification in a country. Collaboration among representatives from multiple sectors is not easy to accomplish at first and requires great effort on the part of all involved. Working together, however, they have greater strength than any one partner working alone.

 

Bread for the World Calls for Updates to US Food & Farm Policies

A guest blog by Todd Post, Bread for the World Institute

Bread for the World Institute unveiled today its 2012 edition of the Hunger Report, Rebalancing Act: Updating U.S. Food and Farm Policies. The 2012 Report picks up where the 2011 report left off, arguing for a stronger focus on U.S. food security programming on the 1,000 days window from pregnancy to age two.

The 2011 Hunger Report, Our Common Interest: Ending Hunger and Malnutrition, introduced Feed the Future, the U.S. global hunger and food security initiative, which is one of the Obama Administration's signature foreign aid programs. The 2012 report proposes ways for Feed the Future to be better coordinated with the U.S. emergency food aid program, P.L.480.

Feed the Future and P.L. 480 represent a very distinct division of labor in U.S. food security programming. The 2012 Hunger Report aims to bring both more into alignment. Feed the Future presents the U.S. government with an opportunity to test ways of coordinating agricultural development assistance and food aid, making U.S. foreign aid both more efficient and effective.

For example, Feed the Future supports improvements in agricultural infrastructure. Why not direct some of the resources for improving infrastructure to help countries build their capacity to do more local and regional purchase of food aid? Critics often say that developing countries don't have the infrastructure to mill and fortify food aid up to U.S. standards. Well, here's an opportunity to address that problem. This would achieve development objectives as well as strengthen parts of the agriculture and food production value chain.

In 2011 two impressive reports by U.S. government agencies examined the nutritional quality of food aid shipped from the United States. Nutritional quality matters most when targeting certain groups, such as young children, pregnant and lactating women, and those with compromised immune systems. A USAID/Tufts University report and a GAO report considered the feasibility of improving nutritional quality of food aid. The bottom line is it will cost more to provide more nutritious food aid.

The prospect of Congress committing new resources to improve the nutritional quality of food aid appears unlikely. In lieu of that, the 2012 Hunger Report argues for phasing out practices of monetizing food aid and using those savings to improve nutritional quality of food aid.

Monetizing food aid is a practice NGOs use to run agricultural development projects mostly. It goes back decades and became popular as agricultural development assistance fell out of favor with donors.

Monetization has always been controversial. It is widely understood to distort markets, hurting the same smallholder farmers that agricultural projects aim to help. Moreover, monetizing food aid is an extremely inefficient way to provide development assistance. Over a recent three-year period, GAO found that close to one-third of resources set aside for monetizing food aid, more than USD$200 million, was lost to development projects due to inefficiency.

Monetization may have been justified in some sense before Feed the Future, but now that the U.S. has stepped up investments in agricultural programming again, there may no longer be a compelling reason to continue this practice. NGOs may push back, but given when we know about the importance of early childhood nutrition, Bread for the World Institute thinks it makes good sense to eliminate monetization and divert those resources to improving the quality of food aid.

Fortifying Flour Where People Eat Rice

Guest Post by Scott J. Montgomery, Director of the Flour Fortification Initiative

One of the projects underway at the Flour Fortification Initiative is developing a strategy for fortifying wheat flour in Asia. When I describe this, people’s initial response is always some variation of: “Don’t they just eat rice there?”

Yes, the main cereal grain consumed in Asia is rice. But in many regions, wheat consumption is also high enough that fortifying wheat flour has the potential to deliver essential vitamins and minerals to millions of people.

Consider Malaysia, a country of 28 million people. The daily food supply quantity of rice is 314 grams per person, according to the Food and Agriculture Organization of the United Nations (FAO). That is high, as expected, but the amount of wheat in the daily food supply is also high at 181 grams per person per day.

The following table shows the rice and wheat daily food supply quantity for eight other Asian countries where the wheat in the daily food supply is more than 75 grams per person, based on FAO data.

Daily Food Supply (grams per capita per day)
Country	Rice	Wheat
Brunei Darussalam	1006	100
China	315	185
India	291	164
Japan	233	122
Maldives	178	180
Nepal	321	104
Republic of Korea	312	139
Sri Lanka	400	121
Source: Food and Agriculture Organization of the United Nations, 2007

These countries would be wise to use a multi-faceted approach to improve the nutritional status of their people. And the amount of wheat in their food supply is high enough that flour fortification should be considered in their approach. Flour can be fortified with iron, zinc, vitamin A, vitamin D, folic acid, and other B vitamins such as niacin and riboflavin. Together these vitamins and minerals increase productivity, reduce neural tube birth defects, improve maternal health, and strengthen immune systems.

Some may counter that rice fortification would be more appropriate in these countries. Currently the technology for rice fortification is evolving and is not widely practiced. Flour fortification has been practiced for decades, and modern mills already have the technology to implement the process. In countries where wheat flour is frequently consumed as a secondary cereal, flour fortification could make a health impact now while the technology to fortify rice is being developed and adopted.

Another reason we encourage flour fortification in Asian countries is that wheat consumption is increasing throughout the region. Instant noodles, made with wheat flour, are so popular that a cup noodle museum recently opened in Japan.

A study of wheat flour consumption in Indonesia shows that people are eating more flour products such as instant noodles, sweet bread and biscuits. Average national consumption of flour increased from a 15-year low of 45 grams per capita per day to 51.5 grams per capita per day in 2008. The study concluded: “This trend in increased consumption of wheat flour is accompanied by a decline in rice consumption as Indonesian’s diversify their diet as a result of economic development.”

If flour fortification becomes standard milling practice now throughout Asia, then the addition of vitamins and mineral to flour will be routine business as people diversify their traditional rice-based diets with more flour-based foods.

In Nepal, flour fortification had been voluntary, but in August this year the government made it mandatory for industrial mills to add iron, folic acid, and vitamin A to wheat flour. Now three countries in Asia – Nepal, Indonesia, and the Philippines – require fortification of wheat flour. The strategy we are developing with our partners in the public, private, and civic sectors will help provide the advocacy and technical resources needed for other countries in Asia to follow these examples.

Nutrition Takes Center Stage in the Battle Against Non-Communicable Diseases

 
Secretary-General Ban Ki-moon addresses high-level meeting on the prevention and control of non-communicable diseases.

Guest blog post by Fokko Wientjes, with DSM

Will history judge last week’s United Nations Summit on Non Communicable Diseases as a watershed moment in the battle against malnutrition?

Quite possibly, yes. The fact that the summit took place is an achievement that should not be underestimated. As this blog reported last week, this year represented only the second time in its history that the UN has discussed a health issue at its General Assembly, yet the resulting discourse between the political, non-governmental and business worlds has led to an unprecedented consensus forming around the role nutrition can play in reducing the burden of NCDs and spurring development.

This consensus is built on the understanding that a child’s diet in the first thousand days (between pregnancy and age two) is crucial. Crucial because, with the right kind of nutrition, it is possible to reduce the risk of an NCD, such as diabetes, heart disease, obesity and certain cancers, later in life. Crucial because essential nutrients early in a child's life allow the brain to develop, giving children a chance to grow to their economic and social potential.

These benefits are so acute that the Copenhagen Consensus, the think tank, has calculated that making sure a population has the right kinds of micronutrients could increase a country’s GDP by 2%.  This analysis reinforces that micronutrients are among the most cost-effective interventions a government could make in terms of generating an economic return on investment.

We have known this for some time, which is why we at DSM have been involved in a number of initiatives aimed at making sure some of the world’s most hard-pressed populations have access to adequate nutrition. We underlined this commitment in New York last week, when we launched Future Fortified, a program aimed at delivering food fortification to nutrition black spots in the Nile Delta and elsewhere, along with our partners GAIN and Herbalife.

Future Fortified is just one of a number of ambitious and worthy projects aiming to alleviate nutrition deficiency and improve food security in the developing and developed world. The UN’s Scaling Up Nutrition (SUN) program and the 1,000 days campaign, launched last year at the tenth anniversary of the Millennium Development Goals, received wide-scale backing from UN Secretary General Ban Ki-moon, U.S. Secretary of State Hillary Rodham Clinton and others last week. We continue to work with our partners in the private and public sectors on other initiatives, including Project Laser Beam, a US$50 million, five-year partnership to tackle child malnutrition.

A second, and perhaps equally critical, consensus also developed in New York last year. This was the acceptance that the private sector can and should play a role in providing the solution. Business must engage in this challenge, together with stakeholders in the public sector. We believe that only through such a cross-fertilization of know-how, innovation, experience and resources, a lasting solution can ever be achieved.

This Rubicon has now been crossed and there now pervades a real belief that, beyond providing short term remedies, the goal of long term, sustainable nutrition security for all is a genuine possibility. These are inspirational times and all of us involved in this quest are united in a commitment that we will not let this opportunity pass.

United Nations High-Level Meeting on Non-Communicable Diseases: Visible Opportunity for the Nutrition Community

World leaders are meeting today to kick off the first of a two-day United Nations General Assembly Special Session on Non-communicable Diseases (NCDs). The high-level meeting takes place in New York September 19 - 20.

NCDs, or "lifestyle" diseases, have not only taken their toll on the health and productivity of those living in rich countries, but are spreading rapidly in poor and middle-income countries. Diabetes, heart disease and stroke, cancers and chronic respiratory disease top the list. According to the World Health Organisation (WHO), NCDs are a leading cause of death worldwide with 36 million dying each year - many of these deaths are preventable.

This is the United Nations second high-level meeting on a health issue. The first was the UNGASS on HIV/AIDS in 2001. The high-level meeting will address the prevention, control and reduction of NCDs worldwide, with a special emphasis on the broad health, social and economic development challenges that have surfaced as a result.

Secretary -General of the United Nations, Ban ki-Moon is pushing for NCDs to become a global priority and expects countries to come up with workable action plans to reduce the toll of NCDs.

"The summit in September in New York is our chance to broker an international commitment that puts non communicable diseases high on the development agenda, where they belong, " said Ban Ki-moon.

Tobacco, unhealthy diets, inactive lifetsyles and alcohol abuse all increase the risk of NCDs. The NCD high-level meeting will give the important role of nutrition during the life cycle another boost, but it also reinforces the fact that countries can't look at nutrition or other interventions in a silo. We know that NCDs can be managed, and in most cases prevented, but they require collective efforts across sectors. Combating NCDs also require action plans that set specific, realistic goals to spur communities onto a path where nutrition, fitness, preventative health interventions, healthy habits and other actions all converge.

This week, governments, civil society and the private sector will be hosting side events to support the UN calls to action around NCDs and incorporate evidence-based efforts that can be deployed. The Humanitas Global Development team will be attending many of these meetings and events, and will report back.

The nutrition community needs to be demonstrate where nutrition fits in to these country action plans. The nutrition community must bring the best programs and evidence (not just clinical, but also programmatic) to the table, along with a clearly outlined path that empowers country-leaders to activate smart and effective nutrition programs within the context of their broader NCD plans.

More to come this week!

Nutrition Education in Guatemala

Guest post by Cara George, a Peace Corps Volunteer in Guatemala

When invited to serve as a Peace Corps Volunteer, one can never really imagine what two years in a different country may bring. In August 2009, I stepped off the plane in Guatemala, as an eager Municipal Development Volunteer, hopeful that my efforts would strengthen the local government, civil society groups, and women’s rights. I never expected to focus on nutrition, but in a country that is ranked highest for malnutrition in the entire Western Hemisphere, it was difficult not to. In this post, I’d like to share some of my experiences working on nutrition in rural Guatemala.

Like many places in the Western Highlands of Guatemala, my beautiful pueblo has a huge market where one can buy fresh fruits and vegetables daily. But it is very common that families consume artificial, packaged foods, like consommé, fruit juice mixes, and horrendously unhealthy, yet embarrassingly addictive chips “bolsitas” for their children’s snack time. They also eat food they grow themselves, which in the colder regions, sometimes only include beans, potatoes, and corn – foods that mostly make children grow bellies instead of grow tall. In addition, Guatemalans love their food either super salty or super sugary – trust me, after two years of living here, I have four cavities to prove it.

The lack of education around nutrition and healthy eating habits doesn’t help. A woman once came into our Municipal Women’s Office seeking help to purchase milk powder and sugar for her infant, as she was no longer able to nurse. I understood her using milk powder, knowing how expensive baby formula is, but felt completely defeated when she refused to understand that she should not add sugar to her baby’s bottle.

But, when visiting communities where the women are eager to learn about nutrition, I always think of ways to explain important concepts using dynamic and visual methods, given that 85% of women here are illiterate. I show a huge drawing of milpa and ask what the cornstalks need to grow tall and strong. “Water!” “sun!” “land!” “air!” “compost!” are among the enthusiastic answers. And then I explain that milpa could grow with just a few of those essentials, but will not grow well without all of them – thus my intro to the different food groups.

I divide the food groups into a “pot” instead of the traditional pyramid, and ask the women if they think that the section with margarine, oil, and sugar is healthy. I was once dumbfounded by the answer I received: “Yes, sugar is healthy, because the package says, ‘Fortificada con Vitamina A.’”

After discussing proteins vs. carbohydrates vs. vitamins and minerals, I hold in each hand a different item: in the left, a bolsita of Tortrix, and in the right, a banana. I dramatically examine the corn chips bag, pointing out that it has ingredients like, “Rojo #40” and ask the women what they think that ingredient might be. And then I examine the banana, and “surprisingly” find that there is no ingredient list. The conversation usually goes as follows:

Cara: “Where does Tortrix come from?”

Women: “The factory!”

Cara: “And where does the banana come from?”

Women: “God!”

Cara: “And who cares more about our families’ health – the factory, or God?”

One can imagine the women’s response. And while I can’t expect changes to happen quickly, I still smile when I see a mother handing her child a piece of fruit instead of a quetzal coin to buy Tortrix from the store.

Youth Feed the World

Guest blog post by Lazarus Lynch

Today, we live in the face of abject hunger and poverty. Every day, almost 16,000 children die from hunger-related causes. That is one child every five seconds. Proper feeding practices such as breast-feeding for children in their first six months is a vital component for early childhood nutrition. Still, many children lack these fundamental resources around the world. Because the allocation of resources is unjustly distributed, the need for change is crucial.

As a culinary arts high school student and a teenage aspiring dietician/chef, these statistics affect me deeply. However, I realize that action will go where sympathy cannot. It compels me, along with other young people that we have a responsibility to respond to the crises of hunger by using our skills and resources to help feed the world.

It never occurred to me how that statistical child could have been me until a year ago. I think many people have forgotten the ethics of our basic humanity- our responsibility in jointly responding to the fundamental needs and people of our world.

Last year I attended the World Food Prize Global Youth Institute in Iowa; a conference that has changed my life. I attended the conference along with my friend Ariana and was inclined to take back what we had learned about food insecurity to both educate and inspire other young people to become actively engaged in the fight against hunger. We were determined to become an integral part of the solution and soon many others were too. For example, she held a hunger-banquet at her school to demonstrate the levels of poverty that existed amid struggling families and served their typical daily diet. I, on the other hand, noticed the need for an educational multimedia platform and decided to launch a website to raise awareness. Many young people across the world, like Ariana and me are meeting the challenges of hunger and are becoming activists for ending hunger.

Young people becoming more politically active are also important. While participating in charitable organizations may contribute to eradicating hunger, by neglecting to address the structure of failing governments that do not secure food, we ultimately sabotage our overall efforts. Hunger is an issue that has been an inconsistent priority for world governments. As poverty is the leading cause of hunger, focusing political energies on combating hunger at its root is where real change begins.

I believe that the hands of committed food fighters, both young and old, who desire to see change will deliver this change! It is imperative that young people begin to get involved in changing the politics of hunger through action. As the change-makers of today and tomorrow, we are to be a voice for the voiceless, seekers of justice and equality, and pursuers of peace.

Lazarus Lynch is a rising senior at Food & Finance High School in New York City.  You can visit his website on food, hunger and nutrition at www.keeping-it-healthy.com.

Investing in the Food Security Challenge - Now and in the Future

Guest blog post by Mark Rosegrant, International Food Policy Research Insitute (IFPRI)

The complex challenge of feeding the hungry now—but especially in the future—has recently dominated headlines. But recent IFPRI research shows that this issue and its very real impacts on the world’s poor won’t disappear anytime soon if policymakers in developing countries don’t make strategic investments now.

In the future, a cocktail of factors—climate change, high and volatile food and energy prices (recently discussed by G20 farm ministers), population and income growth, changing diets, and increased urbanization—will put intense pressure on land and water, challenging global food security as never before. If agricultural production and policymaking continues down its present course, there could be severe consequences for many poor people in developing countries. These myriad threats to food and nutrition security are very real, but IFPRI research shows that these outcomes are not inevitable.

The division that I lead at IFPRI uses state-of-the-art economic modeling (based on alternative future scenarios for agricultural supply and demand that take the impact of climate change into account) to project crop yields, food prices, and child malnutrition through 2050 and beyond.  We used this innovative tool to determine that even without climate change, the prices of rice, maize, and wheat are projected to increase by 25 percent, 48 percent, and 75 percent, respectively, by 2050 if current policies continue. We also found that per capita meat consumption will increase in many developing regions, leading to a doubling of total meat consumption by 2050. At the same time, growth in the production of staple foods is expected to decline significantly in most of the world. Climate change will further slow productivity growth, increasing staple food prices and reducing progress on food security and childhood malnutrition.

Based on this modeling work, we concluded that strategic investments can lessen the brunt of these challenges. We determined that US$7 billion of additional annual investments in research to improve crop and livestock productivity will result in nearly 25 million less malnourished children in developing countries (compared to a business-as-usual scenario).  If investments in agricultural research are increased—along with greater spending on irrigation, rural roads, safe drinking water, and girls’ education, for a total additional increase of US$22 billion per year—the number of malnourished children in the developing world, currently projected to be 103 million in 2050, would drop to 45 million. 

Spending in these areas would particularly help farmers to boost their yields, improve their market access, increase their incomes, and improve the health and wellbeing of their families.  Greater crop productivity also means that more of the growing demand for food could be satisfied from existing land, limiting environmental damage and ensuring that progress in the fight against hunger and poverty is sustainable.

Mark W. Rosegrant is the Director of the Environment and Production Technology Division at the International Food Policy Research Institute (IFPRI) in Washington, DC.

 

Finding the Path Forward: The Case of Grameen Danone

By Priya Bapat, Humanitas Global Development

What should implementers do when a celebrated development project turns out not to be as successful as originally hoped?  Or better yet, what can they do to prevent the project from failing in the first place?

  In my previous blog post, I described the issues that Grameen Danone faced during their roll out of the Shokti Doi product.  When Grameen Danone became aware that their initial project design was not working, they had to make a choice on how to proceed.  In the previous post, I also described how the Case Foundation responded when confronted with the problems of the Play Pump system.  Jean Case, CEO of the Case Foundation outlined three options for an organization with a non-functioning program:

1. To ignore the evidence and continue on,

2. To stop the program and channel resources into more effective programs, or

3. To reassess the project and make changes in hopes of improved outcomes

Despite operating under losses, Grameen Danone appears committed to making this project work.   In 2009, in order to maintain subsidized prices in the rural areas, the company began to sell the yogurt in urban markets at a higher price.  They also began to offer diversified products such as mango yogurt and marketed their products through mass media.  The company also sought to stabilize prices by developing their own dairy storage facilities in Bangladesh.

In rural communities, Grameen Danone held promotional events to increase awareness and demand for the yogurt.  The company later reintroduced the sales lady component of the program with a redesigned approach.  Grameen Danone is also developing an additional product for the rural market – a plant-based yogurt product called Shokti +pocket that is less expensive than full-milk yogurt and does not require refrigeration.  A second yogurt production factory is slated to be built this year, despite reports that the current factory in Bogra is operating well below capacity.  The company aims to earn profits on its operations by 2013.

While we all hope that the Grameen Danone joint venture will turn out to be successful in the end, it is clear that there were some major challenges in the conceptualization of the project.  The most obvious obstacle was that Grameen Danone failed to design their intervention based on end-user needs. 

A thoughtful blog post examining the case of the PlayPump highlights how it is essential to integrate end users in the design phase of development projects.  A recent paper points out that the Grameen-Danone venture designed their interventions around the strengths of the implementing organizations, rather than the particularities of the problem of rural malnutrition. 

Despite Danone’s knowledge and capacity for yogurt production and consumer research, yogurt was not the wisest choice for a fortified food product given its need for refrigeration and consumer habits.  The famed Grameen ladies may have been a successful distribution channel for other Grameen initiatives (such as microloans and phone services), but the “Shokti ladies” scheme did not generate enough profit to support the yogurt business.  Because they did not take these issues into account, Grameen Danone faced the unnecessary challenge of distributing highly perishable dairy products in areas without refrigeration.  An alternative product, such as biscuits or powdered milk, may have been a more appropriate choice.

A second issue is that Grameen Danone did not sufficiently inform rural consumers about Shokti Doi before the product was released.  Although yogurt was not regularly consumed in rural areas, marketing campaigns carried out in conjunction with the campaign could have helped boost awareness and demand for the product during the initial phase of the project.   An awareness campaign would have prepared the community for the yogurt product and would have most likely boosted rural sales.

The changes implemented by Grameen Danone greatly improve the program’s likelihood for success.  However, by neglecting a few key steps initially, the company created a number of problems that could have been avoided.  The importance of designing interventions based on end-user needs and preparing them for the interventions prior to project roll-out cannot be understated.   It is essential that donor and project design communities keep in mind the lessons learned from the Grameen Danone case.

Photo Credits: http://www.flickr.com/photos/danone-communities/1543902034/sizes/m/in/set-72157602368737535/