21 July 2014

Why Worry About the Politics of Nutrition? New Paper

So, why worry about the politics of nutrition?

In a new (open access) paper in World Development by Nicholas Nisbett, Stuart Gillespie, Jody Harris and me, we argue that nutrition is inherently political.

First, there are the multiple sectors, power bases, alliances and aims. This entails negotiation, contestation, alliances and compromise. In short, politics.

Second, there are information asymmetries. Nutrition is highly technical.  Are complex services being delivered in a good enough way?  Are nutrition-related products being marketed responsibly?  Information asymmetries allow power to be exercised in the shadows. And that is not typically a good thing.

Finally, there is the invisibility of malnutrition: stunting is hard to see, what is being spent is difficult to track across sectors, and micronutrient malnutrition is largely hidden. Being out of the public eye means that no-one is going to be blamed if things don't improve.  Invisibility undermines accountability.

We then go on to suggest that nutrition can learn a lot from other sectors in terms of power analysis (the power to but also  power over and the power within), governmentality (moving from the conduct of government to the governance of conduct -- of all actors) and hybrid governance (moving from simple state-society interactions to mash ups or hybrids of these two types of institutions).

We also argue that governance research can learn from the challenges of nutrition and its current dynamism.  For instance where else can you see a global movement such as SUN rise in a period of 5 years or so?  The SUN movement on its own is a potential source-- and beneficiary -- of hundreds of political science PhD's.

There are of course research gaps. Can communities hold governments and other service providers to account for quality of delivery?  What are the effects of capacity gaps on nutrition outcomes --which types of capacity and at what levels?  Can commitment really be measured?  When does more timely data lead to more timely action?  Check out the Transform Nutrition RPC site for on-going attempts to fill those gaps.

So don't worry about the politics of nutrition, just recognise they exist, navigate them -- and maybe even influence them.

20 July 2014

IDS-IFPRI Transforming Nutrition Summer School: Nutrition Has Moved On

Well, another fun and intense week of learning, sharing, inspiration and laughing has finished.  Once again the Brighton weather over performed, as did the participants.

We had about 30 participants from Africa, Asia, Europe and the Americas. We were national policymakers, programme managers, UN agencies, donors and researchers --all learning together.

One key part of the programme is for participants to break into working groups and develop an action plan for a problem they have identified in their country, state or organisation (e.g. how to increase uptake of nutrition services?  How to move nutrition up the political agenda? How to get a budget line established for nutrition?)

On the final day of the course the plans were presented to a panel who gave feedback.  This year we had 7 groups: Ethiopia, Odisha, Madhya Pradesh/Bihar, Malawi/Zambia, Ghana/Tanzania, Nepal/Timor Leste/Lao PDR (or NeTiLao!) and a global group.

Some reflections from me on their presentations:

1.  The chicken and egg dilemma. Several of the plans noted that it takes resources to make the case for increased resources.  We reflected that change usually takes sacrifice of committed people to push for change even while they already have day jobs.  It helps if you can plausibly show that increased resources will lead to improved outcomes

2. Focusing on a problem does not necessarily lead to a narrow plan of action.  Even the most focused problem identified by the groups required a broad range of alliances, actions and capacities to overcome.  Consider the increased uptake of antenatal services:  is it low demand or poor quality supply?  On the demand side is it discrimination or universal norms that need changing? On the supply side is it front line worker capacity or capacity elsewhere in the system?

3.  Who is going to do this?  Often brilliant plans were put in place about what, when, where and how of actions.  But the "who" was much more difficult.  Related to point 1, who is going to go beyond their job description?  Changing job descriptions is hard--it requires taking on vested interests, has resource implications and is a big change to take on for an unproven set of actions.

4. Learning from other country experiences. As usual, much of the learning was from reviewing other country experiences, especially from near neighbours. We will use more and more case studies as the course evolves.

5. Be explicit about what's in it for me?  If we want multiple sectors to work on and with nutrition we have to be strategic about figuring out what is in it for them. Some of the country plans were very strategic--focusing on 2 or 3 ministries where alliances could really pay off rather than worrying about all 12 potential ministries they could work with.

6. The importance of creating "forcing moments".  Some of the plans presented were focused on creating "forcing moments" where it is difficult or embarrassing to avoid making a pledge. And if you make a pledge it makes you look good--perhaps around the launch of a new policy, or a new survey or a new crisis, or a visit of an outside group.

7. Accountability is rising up the agenda. The plans focused on accountability, things like: budget transparency, community feedback, real time monitoring of outcomes.  This felt different to previous years' plans.  It was not enough to formulate the plans but how would we monitor implementation of them?

8.  It is not all about financial resources.  Often we have a knee-jerk reaction to throwing more money at the problem.  These plans had some of that but were more focused on capacity gaps.

9.  The capacity debate is getting more sophisticated.  On capacity, there was a great deal of emphasis on building capacity to scale up implementation.  Capacity audits were to be instigated and ways of upgrading skills, strengthening incentives and improving the system as a whole were highlighted.

10.  Finally there was a sense that nutrition had moved on.  One of the panelists who had served the same role in 2012, our first year, said that she felt the plans were very different from her previous engagement.  Back then it was about getting someone to pay attention to nutrition.  Now it is about delivering under their gaze.   If our composed and steely participants are anything to go by I have no doubt this will happen in many places.

We will be running the course in Brighton in July 2015.  Watch out for our call in January.

07 July 2014

Are the SDGs really like fairytales?

Last week Richard Horton, the formidable editor in chief of the Lancet wrote a piece in the journal entitled " Why the Sustainable Development Goals will fail".   

Based on his reading of the latest zero draft (rev 1)  of the "Proposed Goals and Targets on Sustainable Development for the Post-2015 Development Agenda" he states:

"The SDGs are fairy tales, dressed in the bureaucratese of intergovernmental narcissism, adorned with the robes of multilateral paralysis, and poisoned by the acid of nation-state failure. Yet this is served up as our future."

My reading of his critique is that it centres on 2 related things (1) there is little attempt to think about what sustainability really means and how it should shape the SDGs (Horton's list:  intergenerational equity , externalities, resilience, wellbeing, capabilities, and the strength of our civilisations) and (2) many of the goals are "negotiated wish lists" that focus on business as usual. 

At first when I saw the title of his piece I thought he was going to complain that the SDG process was thinking big impractical thoughts.  But on reading the SDG zero draft and his review, it is clear that he thinks the SDG process is not doing this.  I agree with him.  The SDG process does not seem to have started with ideals and worked towards a result.  Rather, like some of the teams at the World Cup, the process is being ruthlessly pragmatic, wishing not to fail than daring to succeed.   

However I am not quite as pessimistic as Horton about what the SDGs may look like.  There is still time for a really good SDG outcome.  The deadlines will focus the minds.  The process is too open for mediocrity to prevail.  We may not get the expansive and symphonic vision that Horton calls for but we might just get what we need: a set of goals that balances the needs of the current generation with those of the future ones, one that balances outcomes and accountable choices and one that injects a little more poetry into the, so far, rather dull prose.  

Thanks to Richard for injecting some poetry into the debate. 

02 July 2014

Leadership in Nutrition: Some New Findings

Leadership has been identified as a key factor in supporting action on nutrition in countries experiencing a high burden of childhood undernutrition, but there have been very few systematic studies of what supports or constrains leadership in nutrition.

A new IDS Working Paper by Nicholas Nisbett (I'm one of 3 co-authors) was just published on what supports or constrains effective leadership in nutrition.  It is based on a 4 country set of interviews under the Transform Nutrition Research programme. A summary of the 4  questions posed, the key findings and  the implications are listed below.

It is a study of individuals identified as influential within nutrition in Bangladesh, Ethiopia, Kenya and India (through a NetMap and follow up analysis) and it examines why particular individuals champion nutrition policy, and how they operate in the wider policy and political environments of their countries.

Based on analysis of 89 interviews, the paper considers how individual (adult development) capacities, knowledge and motivations, and wider political economy considerations structure the ability of these leaders to think and act. 

The paper argues that only by locating individuals within this wider political economy can we begin to appreciate the range of strategies and avenues for influence (or constraints to that influence) that individual leaders employ and face. We review the literature in this area and suggest a number of ways in which we may support, nurture and develop nutrition leadership in future. 

The bottom line is that leaders are important for reaching outside of the nutrition community to influence those with power, influence and resources. And while the fortuitous emergence of nutrition leaders is wonderful, we cannot wait for leaders to emerge randomly, we must nurture their emergence and development.  

More emphasis needs to be given to leadership development in nutrition--to help bridge sectors, disciplines and generations. Efforts to build leadership such as the UN’s REACH, the SUN movement and regional initiatives such as the African Nutrition Leadership Programme and Action Against Hunger’s support for Nutrition Champions in West Africa need to be supported and nurtured. 

     Summary of Study Findings

26 June 2014

Is a commitment to hunger reduction the same as a commitment to undernutrition reduction? No.

So the new HANCI rankings are out.  As usual the report breaks down commitments into hunger and undernutrition reduction.  My favourite graph is the one above.

The closer a country is to 1, 1 the closer it is to being top ranked in both dimensions.  So Guatemala (GTM) does really well on both counts.  Lesotho (LSO) does well on hunger commitment but relatively poorly on undernutrition commitment, Bangladesh (BGD) does well on undernutrition but less so on hunger reduction.

Several things are worth noting:

  1. Performance in the two dimensions is linked, but weakly (low R-squared) and you can see this just from looking at the (very scattered) scatterplot
  2. Countries below the fitted line are doing better in undernutrition reduction commitment than predicted by their hunger reduction commitment score (e.g. Ethiopia, ETH). Countries above the line are doing worse in undernutrition reduction commitment than their hunger reduction commitment would suggest (e.g. India, IND)
  3. If you draw a 45 degree line through the 0,0 point we can see who has a more balanced (high and low) approach to commitment: Guatemala, Peru, Brazil, Malawi, Ghana, Philippines, Vietnam (high to medium commitment on both counts) and Kenya, Zambia, Nigeria and Guinea Bissau (medium to low commitment on both counts)

The HANCI report also has some really nice in depth primary data collection work on Bangladesh, India, Nepal, Malawi, Tanzania, and Zambia, working with different stakeholder groups in these countries.

The Global Nutrition Report -- What Is It?

Hello everyone.  For the past 2-3 months a group of us have been working feverishly away on the 2014 Global Nutrition Report (#NutritionReport).  

What is it? 

The Report is an attempt to track progress in malnutrition reduction and strengthen accountability in nutrition -- all with the aim of reducing malnutrition faster. 

What will it contain?

It will bring together about 70 nutrition indicators in country-by-country profiles in the following areas: nutrition outcomes, determinants, programme coverage, resources and political commitments.  

It will also track the specific Nutrition for Growth (N4G) commitments made in London in June 2013. 

It will feature a number of short pieces on learning from progress, strengthening system accountability and measurement methods and approaches that are priorities for strengthening. 

Overall, the Report will highlight progress made, bottlenecks experienced, and will make recommendations on where and how progress can be accelerated and how nutrition accountability can be strengthened. 

Why is it needed?

The immediate impetus is provided by the need to follow up on the N4G commitments in an independent way, but there is a sense that while there are many fantastic data collection and progress monitoring efforts going on, that they are a little disparate.  The Report is an attempt to bring those efforts closer together, not to replace them. 

What is different?

In the new post-2015 spirit of solidarity and globality, the Report will look at all countries and will focus on all forms of malnutrition, not just undernutrition. 

We also want the Report to be more than a document -- we want it to be an initiative to improve accountability in nutrition.  We want to contribute to making nutrition everyone's business AND everyone's responsibility. 

We are putting a big effort into country launches.  If this Report is not useful to national nutrition champions, then we have failed.  The launches are not so much launches of the Report, but launches of conversations about how to use the Report to accelerate malnutrition reduction in those countries and regions.  

The country launches are planned for Brazil, Ethiopia, India, Indonesia and Senegal--all in early 2015, with more conventional launches in London, Brussels, Washington and Rome. 

We also try to bring different indicator types together: nutritional, programmatic, economic, political. All data will be made available in one location, in easy-to-use formats (spreadsheets and Stata files). 

Who is it from?

It is from an Independent Expert Group (IEG) of 19 co-chaired by Prof. Srinath Reddy from the Public Health Foundation of India and me.  The IEG were selected by the co-chairs from a wide set of nominated candidates (all of whom were excellent). 

The IEG is responsible for the quality of data and interpretation.  A Stakeholder Group of 22 organisations (Countries, UN, the SUN movement, Donors, CSOs) provide broad strategic advice, but do not have a veto on what the IEG concludes. 

My home organisation, IFPRI, is the convenor of the effort, supported by a team at IDS.  Both organisations are doing an amazing job under pressure and uncertainty -- all with good grace and great humour.  We are all passionate about this effort.  

Who assesses the quality of the Report?

We are working out how to make the draft Report open for short public consultation (we have a very tight timeline).   The Lancet has kindly agreed to run the external blind review process. 

When is it out?

We are frantically working to an ICN2 launch deadline (November 19 or 20).  This means most of the content work will be done by mid September (gulp).   

What are we doing now?

We have been consulting with hundreds of people on the right set of indicators to report on. We have just about finalised the list and will share it on the website soon. 

We are collecting all of the data for the country profiles and these are nearly all in hand. 

We are soliciting responses from the over 90 N4G signatories and they all have July deadlines. 

We are working with 30 or so authors of the short pieces to help them finalise their work.

We are working with the IFPRI team of knowledge managers, designers and comms experts on how to make the data accessible, and how to make the report as useful to users as possible. 

Who is funding this?

To date, six funders have come together to support this effort: the Bill & Melinda Gates Foundation, the Government of Canada, the Children's Investment Fund Foundation,  the European Commission, 1,000 Days, and DFID UK.  We aim to repay their faith in us many times over. 

What can you do? 

We are still working out how to be as open and transparent as possible while meeting our deadlines. Please send us your comments, suggestions, advice in the 'contact us' section of the website.  We will endeavour to respond to all feedback. 

All of the hundreds of  people (and I mean all) we have been interacting with so far have been incredibly helpful and generous with their time, ideas, contacts and data.  We thank them -- they set a great example to us and to others. 

Of course the most important thing you can do is to continue to make noise about the scandal of malnutrition in our world of plenty--and then ramp it up. 

23 June 2014

Indian Nutrition Data: Too Little or Too Much?

People like me complain that the Indian Government does not collect enough data on nutrition outcomes.

The 3rd  National Family Health Survey (NFHS-3) was conducted in 2005-6.  The 4th is labelled as 2014-15 and given its large size (about 568,000 households compared to 109,000 households in 2005-6) we can count on it coming out at the earliest in 2016 and quite possibly 2017.

So, we have some time to wait for new NFHS data.  

But last week, without fanfare, some new Government data on nutrition were released  -- the 4th District Level Household Survey (DLHS IV 2012-2013).  Both NFHS and DLHS are run by the Ministry of Health and Family Welfare.  NFHS-4 will be representative at the District Level for all 640 districts.

The DLHS IV is also representative at district level, but does not cover all States and Territories, notably omitting some of the "low performing" ones (e.g. Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chhattisgarh, Orissa, Rajasthan and Assam).  

These 9 States and Territories are covered in the Annual Health Survey (AHS) which ran for 3 years (and I think has now been discontinued), but these only cover things like IMR, Under 5 Death rates and Maternal Mortality rates--all important, but not nutrition indicators. 

In addition there are (1) the National Nutrition Monitoring Bureau (NNMB), which conducts more specialised surveys on nutrition and diet, (2) the Indian Human Development Survey (IHDS-II) run by NCAER and the University of Maryland  (results on nutrition to be released soon) and (3) a rapid UNICEF national nutrition survey which has been referred to in meetings I have attended in Delhi, but on which I cannot find any references to via the internet. 

What to make of all this?  Well, the AHS data show that modest improvements in IMR, U5M and MMR are being made, but mainly in the districts that show the lowest initial rates.   The IHDS data are rumoured to show not much improvement in stunting and underweight.  The UNICEF rapid assessment survey is rumoured to show dramatic declines in stunting and underweight.  

Forgetting about rumours, it is interesting to note that the DHLS IV shows Maharashtra with a stunting rate for under 5's of 30% (2013) which is down from 46 % using the NFHS-3 (2006, also for under 5's).  That is 16 percentage points in 7 years. This is very good, and is  a similar rate of decline as indicated by a recent Government of Maharashtra/UNICEF survey for under 2's which showed a decline of about 16 percentage points (from 39% in NFHS-3 for under 2's in 2006 to 23% in 2012). This is about the same rate as the all-Bangladesh figures.  That replication of declines across data sets --and the speed of declines--in Maharashtra is very encouraging.  

(Note the above para was changed after helpful comments from Saul Morris at CIFF and Victor Aguayo of UNICEF, who both pointed out errors in what I had reported--thanks!) 

For researchers interested in nutrition in India, this is fascinating.  For policymakers this is either a nightmare or a convenience (i.e. pick your favourite statistic).  Nevertheless, the Government of India badly needs to harmonise it's data collection because the main victims of the data confusion are malnourished people.  

So, too little or too much nutrition data in India? I think there is too much nutrition data because there is not enough of the right kind: regular NFHS rounds every 2-3 years, reported using the same age group.