30 November 2015

New paper: India’s Struggle Against Malnutrition—is the ICDS Program the Answer?

A recent paper by Monica Jain (World Development, Vol 67, pp72-89, 2014) “India’s Struggle Against Malnutrition—is the ICDS Program the Answer?” tries to answer this question.

The title promises more than it delivers. The paper only looks at one of the ICDS programme elements—daily supplementary feeding to children 0-2 (actually 6-23 months). 
The paper also does not have the benefit of a true comparison group (which would require matching on observable characteristics and on unobservable characteristics such as maternal priority given to infant nutrition). To match on observable characteristics, the paper uses propensity scoring to adjust outcomes between the two groups (those mothers opting in to receive supplementary feeding for their 0-2 year olds and those who do not).  To match on unobservables the paper assumes that any differences in heights seen between 4-5 year olds whose mothers opt in and those who do not, is linked to unobservable effects.  It is not linked to observables because they have been taken care of and it is not linked to the programme because other studies are cited to show that supplementary feeding for 4-5 year olds is ineffective.  

So treating 0-2 year olds as the treatment group and 4-5 year olds as the control, these unobservables are “differenced” out. There are lots of assumptions here, but the author must have done enough to convince 3 skeptical World Development reviewers to let it through. It must have taken a great deal of perseverance.


The “impact” of daily supplementary feeding in the previous year (the survey is the nationally representative 2005-6 NFHS3) is 1cm, or about 28% of the 3.5cm difference between the height of women in the lowest and highest wealth groups.  The results are less robust for boys, but of similar magnitude.
Despite this potentially positive result, the author reports that only 6% of children 0-2 received supplementary feeding daily in the previous year of the survey. The author suggests this might be because of high private time costs; the lack of appreciation of potential benefit; poor delivery of the program; non-provision of supplementary feeding; and the prioritization of the 3-6 year old group for feeding.  It seems plausible that the potential is there for a much bigger impact of ICDS, not through spending more money but through better targeting of it.

The results in the paper are from 2005-6 data and we think much has been achieved since then in improving ICDS delivery and we also have prioritized the 0-2 age group more.  And open defecation rates will be lower today than in 2005-6. 
So even under the least favourable of circumstances the much maligned ICDS seems to have an effect on the 0-2 age group. If more children 0-2 actually received the supplements on a daily basis the total effect of ICDS would improve even more.  In the absence of randomized controlled trials of ICDS (difficult with universalization, although given uptake rates this low a randomization of encouragement to use the services could be undertaken and an impact estimate derived) the paper represents a valiant effort by the author to estimate impact. 
It would be good to see this analysis done for the new national 2013-14 RSOC data (see Global Nutrition Report). I bet the results would be even more positive.

25 November 2015

Countdown to 2015 is Dead! Long Live Countdown to 2030!

Coverage rates of different interventions from Countdown to 2015

When we were first setting up the Global Nutrition Report we looked to the Countdown to 2015 model.  Countdown to 2015 has been tracking progress for maternal, newborn and child survival for a decade now.  What has been learned?  A paper written by the Countdown to 2015 team (Cesar Victora is lead author) was published in the Lancet October 2015 and takes on this question.
As I said, Countdown to 2015 (CD) has been a big influence on the Global Nutrition Report.  8 months ahead of our first publication, before we even had a team, I was invited to a CD meeting in London in March 2014.  On the one hand I was so impressed by the professionalism and data driven nature of the work they do. On the other hand, I was depressed—how can we even come close to this in 8 months?  We did not do too badly, and that was helped by having 3 of CD’s independent expert group on the GNR’s independent expert group (Jennifer Harris Requjo, Zulfiqar Bhutta and Holly Newby).

The article is a nice summary of why and how CD came into being (from a Lancet 2003 series on child survival with a focus on MDGs 4 and 5) and all the different dimensions it tracks (mortality rates, coverage of programmes, equity, health systems and financing).
Perhaps because I am already familiar with the workings and data behind CD, I found the reflective sections of the paper the most interesting, especially those relating to the SDGs. 

First the focus on data, quality, coverage (especially coverage--I love the picture at the top of this post) and breadth has been really inspirational. The authors note this will get harder in the complex SDG world. In my opinion, too many of the 169 SDG targets focus on outcomes and not enough on coverage and resource allocation.
Second, the focus on inclusivity and collaboration means that CD is more than a report, it is a process that brings people, organisations and ideas together and increases the likelihood that data lead to action. It tries to be an accountability intervention. And, based on the attention it gets, CD is succeeding in this aim.    

Third, the paramount importance of transparency of the data: making it available and highlighting low quality data (and the problem of too much modeled data); while (diplomatically) calling out countries that are not performing that well.
Fourth, the self-accountability has been high—high quality peer reviews in the Lancet and elsewhere. 

Fifth, the reflections on the SMART-ness of the targets set in MDG 4 and 5 were interesting (specific, measurable and time bound, but perhaps not so realistic).   
Sixth, CD has been a champion for the need for better data and a guide on how and where to invest in better data. 

Finally, sticking with it for 11 years, and now thinking about how to adapt to and shape the SDG era is important (Countdown to 2030?).  These folks have shown a remarkable level of staying power and we applaud them for it. 
I look forward to seeing what CD 2.0 looks like and to linking more closely to it via the Global Nutrition Report.

23 November 2015

Attempts to prioritize NCDs: What can nutrition learn?

I really like articles that pose questions that are pretty fundamental.  Here is one from 2012 that I somehow missed.

The paper is “Political priority in the global fight against non-communicable disease” by Anthony Maher and Devi Sridhar in the Journal of Global Health (Vol 2, No 2, 2012). 
The paper asks two fundamental and interrelated questions (1) “Why is there such meagre funding on the table for the prevention and control of NCDs?" And (2) “Why has a global plan of action aimed at halting the spread of NCDs been so difficult to achieve?”  The questions are posed because (a) NCDs are responsible for a large and growing share of the global burden of disease, (b) a number of cost effective “best buys” have been identified by WHO and yet (c) the top donors in global health (the US Government, the World Bank and the Bill and Melinda Gates Foundation are mentioned) allocate less than 2% of their budgets to NCDs.

They use the Shiffman’s political priority tool (Shiffman, Bulletin of the World Health Organisation, 2009) as a way of addressing the questions. Shiffman’s framework identifies 3 variables that are essential to raising the priority of a given issue (a) ideas, (b) institutions, and (c) policy communities.

Using this framework the authors point out things holding back the prioritization of the NCD community:
1.  Labelling something as “non” might mean it is a non-starter or a non issue and it also fails to communicate that NCDs are communicable, not through infection routes, but via social norm routes.

2. The diseases have not been humanized—we cannot put a human face to the suffering as we can to say polio.

3. There is a lack of a short causal chain and so NCD generation cannot be attributed to the “deliberate actions of specific actions” (unlike smoking).

4. The frequent use of the term “epidemic” may stimulate urgency in some policymakers but others consider it a barrier to innovation (ie patents are no longer moral) and a guarantor of ineffectual drugs. 

5. The power of the private sector to frame and set norms must not be ignored and indeed must be taken into account when designing strategies for prioritizing NCDs. Rather than see the private sector as a structural force to be resisted, they argue that social movements begin within communities and so it is important to participate in a process of “socialization through which boundaries between contested and shared ideas are debated, articulated and redefined”.  The authors cite the Pan American Health Organisation’s Forum for Action on Chronic Disease which brings the 32 countries in the region together with business representatives under a clear set of rules on inclusion, admission and removal.

Overarching all of this, the authors make the case that objective evidence is important to convince policymakers, but many more influences are subjective.  All routes need to be pursued, in orchestra, by all stakeholders. 

There are many lessons for malnutrition.

On messaging we are not doing well (stunting, micronutrients, SAM etc). 
We can only humanize the problems when they are very extreme (several acute wasting or obesity and many would argue that the way we do it dehumanizes the victims).
The long causal chain to malnutrition allows bickering between sectors (although multisectoral platforms have helped) and permits ideological divides about personal responsibility and the environmental drivers of individual behavior to rumble on. 
And on the private sector, we are all over the place.  We seem terrified of dialogue-the very thing the article says is the way forward.  I had not read this paper until November 2015 and was pleased to see the alignment with the Global Nutrition Report's 2015’s recommendation for the 4 major UN agencies (call to action 9) to establish a Forum or Commission that formulates norms of participation, conduct and behavior. 

FAO, WHO, UNICEF and WFP—please get going on setting up a structured forum for this dialogue about and with private sector representatives on nutrition.  Divided communities are unattractive propositions for future investors.

21 November 2015

IFPRI 40th anniversary in 40 Tweets

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20 November 2015

IFPRI at 40: not singing along to elevator music

Shenggen Fan, IFPRI DG
When I joined IFPRI as a research assistant in 1984 IFPRI was only 9 years old (I was a bit older).  This past week IFPRI celebrated its 40th birthday: looking back and looking forward.

A quote from an unknown source about being 40 says “At 40, you sing along with the elevator music”.  IFPRI will never be guilty of that—it will always shun bland elevator fare and strive to write vital, original and melodic music.

My 3 stints at IFPRI total 18 years.  It is a great institution, doing cutting edge conceptual and empirical research that aims to be impactful (and frequently is).  What more could a researcher want?

To Date

The successes that stand out for me (and this is very partial—it is only from one of the 4 research divisions and from less than half of IFPRI’s 40 years) include:

*the work on the commercialization of agriculture (it does increase income and food security, but only fitfully improves nutrition status—although it does not reduce it)
*the research on women’s control of resources (greater control is seriously good for women, for their children—and for the whole family)
*the evaluation of Progresa, the first big conditional cash transfer, from Mexico in the late 90s which helped popularize social protection and rigorous impact evaluations
*the careful evaluations of nutrition interventions, not only on the what, but also the how and why
*biofortification of staple crops with iron, zinc and vitamin A through conventional breeding processes (increasing yield as well as bioavailable micronutrients)
Howdy Bouis, HarvestPlus

The biofortification work led by Howdy Bouis (Director of HarvestPlus), is just very impressive. Like all great ideas, it just seems so simple in hindsight: select germplasm for micronutrient content as well as for yield.   Nearly all of the plant breeders said it could not be done, but Howdy refused to take no for an answer and eventually found a plant breeder at Cornell, from outside the CGIAR, who said it could be done.  And it was.  This work may have the biggest legacy of all the work I have seen at IFPRI.  Not only has it changed the way people think, it has led to scalable interventions that will directly improve people’s lives and, in many cases, save them. 

The Future

But what of the future? The 60 + short presentations at the all-day (and not quite all-night) 40th event found it harder to peer into the murky future than to reflect on the warmly remembered past.  This is not surprising—it is always much more difficult to predict what is coming around the bend than to look in the rear view mirror.

I found four things particularly important

* The need to remember that food policy goes beyond agriculture policy and food price policy.  Agriculture will always be a vital component of a food system, but it inevitably will become a smaller part.  In the years to come, what happens between farm and fork will garner more and more energy, money and innovation.  That journey is getting longer and longer, so it needs to be understood and when markets fail, policy needs to step in to guide outcomes toward healthier diets. We need more research on what those policies look like.

* Urbanisation.  So many speakers focused on this--it was striking.  IFPRI tried to get a serious research programme going on this in the late 90s, but there was no real traction from research funders.  Now the time seems right. The urban area is probably more complex than the rural, is certainly less researched, and is possibly more fluid.  Doing research in urban areas will be really valuable because the rapidly growing smaller cities may be able to implement some of the policies equally rapidly and even in big established cities, a small improvement in a policy, because of population size and density, could have a big impact. But, for sure, working in an urban context will challenge the assumptions, biases and experiences of most food and nutrition policy researchers whose formative research experiences were probably largely in rural areas.

Nancy Stetson, US Dept of State

* How to formulate policy in a natural resource constrained world? Most policy research until the last 5 years in food and nutrition acted as if our policies do not use water, or minerals in the soil, or energy. Well they do, and the constraints are increasingly binding. What can be done to give food policy a lighter resource footprint?  As a first step, we need to incorporate these costs in estimates of growth, whether growth of countries or businesses or big NGOs.

 * Understand implementation better.  How to convert plans into high impact actions that are carried out?  On the one hand as the size of governments grow due to increased tax revenues from economic growth, their implementation responsibilities are greater in scope.  On the other hand more and more governments are decentralizing implementation and so the capacity for that is being dispersed.  The why and how of implementation will become more prominent in research, perhaps with more cross learning between low middle and high income countries.

Happy Birthday

40 is a great stage in life—still youthful enough to have lots of energy to try new things without being bashful, but old enough to have the wisdom and experience to understand all the possibilities, how to assess them, and when to expand them. 

That is the place IFPRI needs be in—experimental, but driven by the very serious goal of ending hunger and undernutrition by 2025 (e.g. the new Compact 2025 flagship).  

By working with its hundreds of partners, I have no doubt that IFPRI will rise to the occasion -- now and in the coming years.   

18 November 2015

SLAN-ted: has malnutrition flipped in Latin America?

The SLAN nutrition conference ended last week.  It brings together all the Latin American nutrition societies and is a big deal for the continent and globally.  

So where is malnutrition in Latin America? For a long time we have thought of the countries of Latin America to be the epicenter of the double burden of malnutrition, where countries are grappling with very serious levels of undernutrition and overweight and obesity. 
The latest global data, summarised in the 2015 Global Nutrition Report, suggests that this characterization is no longer valid, at least in terms of under 5 anthropometry.  Consider the following: out of 20 countries in the region for which comparable national data are available, only 5 of them have stunting levels >20% and adult overweight (including obesity) levels >35%: Guatemala, Ecuador, Honduras, Nicaragua and El Salvador.  Using wasting, only 2 countries have levels of wasting >5% and adult overweight (including obesity) levels >35%: Suriname and Guyana.

And it looks like these patterns are stable.  Of the 17 countries where we can assess trends on stunting, the level is falling.  In 7 countries the declines are so rapid that countries will achieve the targets implied by the global WHA 2025 target for stunting reduction.  Meanwhile adult overweight and obesity has increased in all countries between 2010-2104. 

Upon closer inspection, however, we can see that the double burden is very much alive: but rather than a combination of under 5 stunting/wasting and adult overweight/obesity, the enduring combination is primarily one of micronutrient deficiencies and adult overweight/obesity.  For example, 9 countries have rates of anemia in women of reproductive age above 20% and adult overweight/obesity rates above 35%.  

What does this apparent evolution in the nature of the double burden imply for actions to combat malnutrition in the region? It is difficult to say with certainty.  Interventions such as the promotion of exclusive breastfeeding and appropriate complementary feeding will remain central to the avoidance of under-five overweight and obesity as well as the prevention of micronutrient malnutrition. Access to improved water and sanitation will remain central to keeping stunting and wasting rates low.  And of course national averages hide many geographic, income and ethnic inequalities, so the battle against stunting and wasting is not yet being won for significant segments of the population. 

Nevertheless, perhaps the biggest shift in policy will be a greater recognition of the centrality that food systems play in the causation of malnutrition in all its forms.  Globalisation, urbanization and income growth, in tandem with increasing concentration of control of the food system by large national and multinational corporations will make it ever harder for consumers to make healthier food purchase choices.  The introduction and enforcement of financial carrots and sticks to incentivize firms to invest more in healthy foods and less in highly processed foods that are proven disease risks will become ever more important, as will clear and simple labels on all foods.  Of course, these kinds of policy are harder to implement compared to policy intended to reduce undernutrition.  There are vested interests aligned against policies for both forms of malnutrition, but for undernutrition they are not so powerful.  Food systems policies are also harder to evaluate.  They don’t, for example, yield readily to randomization of interventions. 

These changes in the nature of the malnutrition problem in the region pose several challenges for nutrition researchers the world over:

*The need to work across levels as well as across sectors.  We now need to be able to trace food from farm to fork and understand where the possibilities for positive intervention are greatest.

*The need to understand the private sector more.  This does not necessarily mean working with businesses, but it means a greater emphasis on understanding them: what motivates them apart from profit? Are they all the same and if not what drives the differences? Where do they work and how do they actually operate?

*The need to strengthen our ability to undertake policy research.  Not all research can bend to the demands of randomisation of interventions. Nor should it. The nature of the problem and the intervention should determine the evaluation approach.  In particular, governance and political science approaches are likely to add significant value to these efforts given the non-alignment of interests and power imbalances between different food system stakeholders.  

The 2015 Global Nutrition Report puts forward ideas on how we can assess the nutrition friendliness of food systems (in a similar spirit to the baby friendliness of hospitals) and how trust, transparency and enforcement can be strengthened when engaging with businesses. 

The final challenge for nutrition researchers the world over is to get access to high quality data that is comparable over time, and, if possible, globally.  The Global Nutrition Report notes that in 20 Latin American countries only 9 have comparable data to assess progress on the following 6 nutrition indicators: under 5 stunting, wasting and overweight, anemia in women of reproductive age, exclusive breastfeeding and adult overweight/obesity.  Of those 9 countries, none are on course to meet WHA targets for all 6 indicators, and only one (Colombia) is on track to meet 4. 

In the past 20 years Latin America has made enormous strides in reducing under 5 undernutrition. These efforts must continue, but a new set of problems also needs to be taken on; problems that are increasingly rooted in food systems that do not serve vast segments of the population.   To take these emerging problems on, nutrition research teams all over the world will have to reinvent their approaches –and their perceptions.   

(A Spanish language version of this article is on the SLAN 2015 website.)

The Global Action Summit: A new avenue for linking food, health and prosperity?

Earlier this week I participated in the Global Action Platform’s (GAP) annual Summit (see Day 1 recap).  The Global Action Summit is an annual forum held in Nashville, Tennessee, that fosters cross-sector perspectives on food, health, and prosperity.  The CEO is Dr. Scott Massey who is extremely good at bringing together an interesting set of leaders from different corners of society and the economy. There were a lot of folks from the private sector. Fareed Zakaria of CNN is the keynote and active moderator every year.  He was very impressive: combining substance and breadth with superb communication skills.
The aim of the Summit is to create, guide and facilitate leadership initiatives. I was invited, and went because I knew hardly any of the participants, and we in the nutrition community need to talk to people outside of our circles if we are to expand the circle of commitment to nutrition.

I was moderating a panel on SDG2: Ending Hunger and Malnutrition by 2030.  My panelists were Roger Beachy the Director of UC Davis’ World Food Centre, Hugh Welsh, CEO of DSM North America, A.G. Kawamura, former Secretary of State for Food and Agriculture for California, Prabhu Pingali the Director of the Tata-Cornell Initiative on Agriculture and Nutrition and Iftikhar Mostafa from the World Bank.
Our task was to identify actions that would make it more likely to achieve SDG2 by 2030.

I asked the Californian Secretary of State about how he balanced the tradeoffs between agriculture as food producer, as employer, as food safety guarantor, as water user and as a greenhouse gas emitter.  I asked this because in the SDG era these tradeoffs will be taken more seriously than in the MDG era—that is what sustainability is all about.
Iftikhar’s question related to the World Bank’s doubling of lending to agriculture between 2006 and 2013, what has it yielded and what should happen to the level in the next 5 years?

Hugh Welsh from DSM was asked about DSM’s partnership approach.  DSM are one of the more respected companies in the nutrition space—what was their secret?

For Prabhu Pingali I asked what agriculture can do to become more nutrition promoting? Given his work for the CGIAR, the Gates Foundation and now as an academic at Cornell, he was well placed to address this question.

Finally, for Roger Beachy I asked about how we get more actors thinking in the kind of systems way that families have to think about food and nutrition?  The UC Davis centre is renowned for this kind of holisitic analysis—how can it be promoted elsewhere?
Some of the panelists were quite adept at pivoting from the question to what they wanted to talk about anyway, but by and large we stuck to the topic well.

My reflections:
*All panelists talked about infrastructure.  Hugh Welsh (DSM) talked about how businesses had to build the food system in places it did not exist; Prabhu talked about how important it was for the agriculture research infrastructure to begin relaxing its apparent obsession with productivity in 3 staple crops and move into pulses, vegetables and fruits; Iftikhar talked about how important transport infrastructure is to lower transactions costs and improve economic access via lower retail prices; Roger highlighted the need to transform higher education infrastructure from a sole disciplinary basis to a more problem oriented basis.

*Business is still a difficult issue to talk about—in these kinds of panels it seems to be that if you admit anything other than total certainty that business is the solution or the problem then people are not interested.  Who is going to step up and lead on having this dialogue?
*Nutrition was not mentioned much.  It was a rather agriculture focused section.  Prabu mentioned water and sanitation and women’s empowerment, but other than this these sectors did not come up much.  Neither did nutrition-specific programmes, despite the fact that not all of these programmes come from the health sector (e.g. supplementary feeding and the prevention of moderate acute malnutrition).

* The fortification/diet diversity debate rumbles on.  Of course we need both, with emphasis varying by context.  The nutrition community needs to remain unified.
I asked each of the panelists what is the one thing they would like to see happen to make SDG2 more likely to be attained; better metrics that take into account externalities (all), the need to reboot agriculture to explicitly say its goal is to reduce malnutrition (Roger); make climate smarter agriculture (A.G.); communicate more effectively to the general public (Iftikhar); be creative in the search for hunger reduction and profit maximization (Hugh) and the need to retreat from “staple grain fundamentalism” (Prabhu).

My own “one thing” was for civil society to be more active in saying “no” to seemingly persistent hunger and malnutrition. How to do that?  Evidence collections like the Global Nutrition Report help, but people, making things happen, is what leads to change.
And the Global Action Platform? Interesting.  Different people, with different biases.  Some new ideas, some recycled ones.  I think the Platform is a promising way of broadening the debate about how to finally eradicate hunger and malnutrition.