23 June 2017

Innovative funding models to support research innovation in nutrition: The BPNR example

This week I was at an event showcasing nutrition research, held in Ottawa at the Aga Khan Foundation’s Canada headquarters, in partnership with them and the Global Affairs Canada (GAC), the Canadian Government’s Foreign Assistance agency.
So far, so normal, you may think.  But this was no ordinary research programme. It was the GAIN-GAC Business Platform for Nutrition Research (BPNR). And the distinguishing feature of the Platform is that it supports “pre-competitive” research that is useful to business sectors that are hoping to have a positive impact on nutrition status.
Precompetitive research provides answers to questions that all businesses in an industry want an answer to: questions that can be best answered though collective effort rather than by any business trying to go it alone.  The results are available to all, even if they did not collaborate in the research.  Once businesses have the research outcomes they can use them to develop competitive products. This approach tends to support activities where it makes no sense to have multiple answers (e.g. measurement methods and standards development), or where undertaking research requires alliances of stakeholders because of complexity of the issue (e.g. understanding the impact of climate change on food safety).
The BPNR platform works on a matching basis between GAC and the businesses that contribute a documented and certified amount of resources to the project (but not to GAIN).
The current themes under BPNR are:
  • Development of diet quality indicators using the Gallup World Poll as a platform. This work builds on the success of the FAO-Gallup Voices of Hungry work (the indicator was adopted as an official SDG indicator).  The protocol is being developed but it will focus on about 20 different foods.
  • Finding complementary foods (e.g. Lipid-Based Nutrient Supplements) that do not rely on the addition of sugar to increase palatability. This work is designed to find out if we can promote palatability at low levels of sweetness. This will involve Nutriset.
  • Development of mobile phone based markers of Aflatoxin – a blood or urine sample analysed by a small piece of kit in 10 minutes and plugged into a mobile phone to give a detailed quantitative read out. About $1 a test. (Cornell University and Mars).
Watch this space for more news on BPNR research as it generates interesting and useful findings over the next 18 months.
And this is just the beginning, with opportunities for new partners to come together around a range of new research questions that help us all to understand the complexity we are trying to navigate in improving nutrition, and that can shape investments in the demand for and access to nutritious foods, and the legislation and policies that enable these.
There were lots of good questions from the audience, many asking a variant of “what is in it for partners to work with the BPNR?” Answer: for businesses new resources are worth giving up intellectual property rights; for researchers there is a de-risking of the work with companies, because the BPNR platform has collectively agreed on the research question and it guarantees a fair and transparent peer review process.
The Government of Canada deserves a lot of credit for taking a risk on BPNR—it is a new mechanism for nutrition although quite common elsewhere.  It has taken longer than we thought to build relationships between businesses and researchers, and then to identify specific research questions around which there is a consensus, but it feels like the effort will be worth it because the relationships will be enduring, are transparent and will result in open access results in peer reviewed publications.
Several of the researchers present said they would not have pursued their research in the absence of the BPNR. So, if you aim to generate  innovative solutions in the food and nutrition space, think about developing innovative funding sources too.
The innovation in the second might well stimulate innovation in the first.
For more information about BPNR, please contact Lynnette Neufeld at GAIN lneufeld@gainhealth.org

Learn more about GAIN’s work here

18 June 2017

Food Must Fix It: The 2017 EAT Forum

The convening power of Gunhild Stordalen is astonishing.  The Crown Princess of Sweden, the President of Mauritius, Sir Bob Geldof and a large group of other influential leaders, doers, and thinkers.

This was my first visit to the EAT Forum, although I had worked with Gunhild on a joint newspaper article for the Norway launch of the 2015 GNR and knew how committed she was to making a difference.  Her commitment is contagious.

At the Forum, I gave a talk on 3 inequalities at the heart of the food system that generate poor nutrition outcomes. First, our rather conventional public health attempts to stimulate behaviour change in food choice which focus on “wholesomeness” and “good for you” exhortations and worthy messaging—all in comparison to commercial advertising efforts which persuade us to buy certain foods based on their convenience, deliciousness, crave-ability and status. Second, I noted the stark inability of most of the world to afford healthy diets: 52% of household incomes in South Asia would be needed to buy 5 fruits and vegetables a day.  Third, I argued that the lack of information, evidence and data on the impacts of business-government partnerships beyond profits (i.e. on people and the planet) hampers collaboration.

These are three areas where GAIN is working with a wide range of public and private stakeholders to increase the demand for healthy food, to increase the capacity of small and medium and large enterprises to meet that demand and make nutritious food available at a lower price, and to create an environment that enables businesses to do good things for nutrition and discourages them from doing unhelpful things.

My takeaways from the 2 days (disclosure, GAIN is on the EAT Advisory Board):

*As a newcomer to EAT Forum, I found the fact that I only knew about 10% of the participants to be really refreshing.  New organisation, new perspectives, and a fair amount of new thinking. Great.

*Businesses were very present, although mainly European and American ones.  It was great that they were there because, as the African proverb goes, “to change someone’s head they have to be in the room”: no engagement means fewer opportunities to influence.

*But, in general, the event was high income country focused.  Sure, there were people like me focused on low and middle income issues, but still from a European and North American perspective.  If the audience were more geographically diverse it would really accelerate the convergence of the 2 sets of conversations happening in the Forum: the high income and middle/low income ones.  It is clear that the Forum is very much hastening this convergence, but a more rounded and grounded set of perspectives would help us co-create a more unified vision and set of approaches to solution generation.

*A number of the presentations dwelled on the achievements of the presenters and their organisations. This was fine given that were many such fine achievements and the presenters were amazing people and communicators.  But, I wanted a bit more on the challenges they faced and how they overcome them—also, what did not work and why?  For sure there was some of this (and more than you would find at an academic audience!) but more would have been welcome.

*The focus on the links between food, health and the planet were really strong and quite seamless. But I am a data hound and I would have liked a few shamelessly scientific sessions, although perhaps that would have reduced the uniqueness of the meeting.

*The EAT Forum has been disruptive--in a good way.  It has challenged conventional wisdom and now it is rewriting conventional wisdom. So what does it do for a second act?  Bob Geldof reminded us that social change occurs when there is an initial disruption, then an amplification of the message around a set of leaders, followed by consolidation and organisation of the movement, and, underpinning it all, a relentless devotion to a cause.  So what is the future disruption role of the EAT Forum?  Does it just keep going and wait for others to get on the bus, or does it park the bus outside the halls of power and lure them in?  I don’t know.  I suspect the former.   But the disruption question remains. In many ways the EAT Forum could be more unconventional.  It would, for example, be great to get more schoolkids involved to talk about what they think, expect and can do; more journalists talking about what their readers want to read and how that can be influenced; more political activists teaching us about their strategies; and more people from the arts helping us connect outside the policy and business wonkosphere.  Perhaps I am being too demanding, but if so that is because the EAT Forum has raised expectations in a world that is desperately lacking the hope and energy of the period just before the global financial crisis—a world where dreams have been harshly dampened by the austerity our politicians have responded with.

The rallying point for the Forum was “food can fix it” whether health, climate, sustainability or access to a nutritious, safe, affordable and desirable diet.  This simple phrase was deceptively helpful in providing a focal point and, as Johan Rockstrom, the scientific lead for EAT, said at the end, it really should be “food must fix it”.  Agreed.

All in all I found the EAT Forum to be a very refreshing change from the same old meetings where you know everyone and you know what they are going to say well before they say it. Long may it continue to reinvent itself, to keep challenging tired conventional wisdom while catalysing unlikely partnerships that generate ideas and approaches that are truly transformative. 

In short, if the EAT Forum did not exist we would need to invent it.

04 June 2017

No Excuses for Inaction on Adolescent Nutrition

This years World Health Assembly (WHA) meetings (all the Ministers of Health attend) had a big focus on one sixth of the world’s population: adolescents.  The WHA launched the Accelerated Action for the Health of Adolescents (AA-HA!) a major report from all the key UN agencies on why we need to act now to improve adolescent health and what to do. In this context, I participated in two panels on adolescent nutrition.

My key takeaways were:

Adolescents are invisible in nutrition data.  It is ironic because adolescents are typically hard to miss: frequently opinionated, critical and emotional and deafening in their exuberance and silences. Yet in nutrition data, they are absent. Essentially, we don’t collect nutrition data on adolescent boys of 10-19 years of age or on adolescent girls in the 10-14 year age group.  This is extraordinary.  Attitudes and preferences are highly fluid in this 10-14 age group—like liquid concrete waiting to be set for life.  Also, why no interest in boys?  Yes, adolescent girls have higher micronutrient needs due to menstruation, but boys are just as important in shaping attitudes, norms and boundaries in nutrition practices—now and in the future.  This relative invisibility of adolescents to the nutrition community is all the more puzzling because iron deficiency anaemia is the number one cause of adolescent DALYs for girls and boys (see below). 

There are few nutrition interventions that are designed FOR adolescents.  Yes, there are plenty of interventions aimed at the wider population that should benefit adolescents (see here), but none are designed for adolescents particular needs save for iron-folate supplementation (IFA).  IFA seems to work when administered through schools, but not through communities (see here).  This is a problem because only 30% of adolescents in South Asia and Sub-Saharan Africa complete secondary school (see here).  Why do adolescents merit specially designed interventions?  It is primarily because of the plasticity of their attitudes and the rapid velocity with which these attitudes become relatively fixed but also the widening opportunity to act as the gap between biological maturity and social transition to adulthood increases.   The graphic below from the AA-HA! Report summarises things well.

There are even fewer interventions that are designed WITH adolescents.  Adolescents have increasing autonomy and they know what they like and don’t like and I would guess most nutrition intervention and policy wonks don’t have a clue what these likes are and how they can be leveraged and shaped.  Adolescents will have a better idea of where, why and how they can be engaged around nutrition choices.  But adolescents are also more vulnerable to risky food and nutrition options.  Adolescents will help us to think laterally and holistically about their lives, to find opportunities to work with them to influence and shape food and nutrition preferences via sports, clubs, social media, schools, music, film and comics.  Engaging with them will take us outside of our comfort zone and that is where innovation and change happens.

We are paralysed by the lack of evidence.  We are in a “lack of evidence, lack of action, lack of evidence” low level equilibrium when it comes to actions on adolescent nutrition. The consequences of trying something and getting it wrong are not negligible, but these have to be weighted against the consequences of inaction.  The adolescent window is opening and closing without any fresh thinking or action making it through the gap all while nutrition status is eroded throughout the lifecycle. Funders and development agencies need to be braver. They should support (a) the development of new approaches and actions that are grounded in formative adolescent centred research, (b) their implementation, (c) their evaluation, (d) share their results and (e) scale the promising ones.  Adolescents deserve no less.

The private sector has a big role to play, because adolescents are more engaged with the private sector than many other demographic groups: they are tied to their social media platforms (see below from Indonesia—90% of rural adolescents in Indonesia use Facebook!), they buy junk food after school, they buy street food on breaks from their factory work, they listen to commercial radio and watch commercial TV.  For example, how can we combine earnest public sector behaviour change efforts with the more calculated but creative private sector demand shaping efforts.  How can we create hybrid approaches that are greater than the sum of their parts?

The new AA-HA! Initiative from the UN is a great step forward and countries should use it as a guide to raise funds for this agenda and a guide on how to allocate those funds.  GAIN is using the above principles, working in Bangladesh, Pakistan, Indonesia and Mozambique, forming alliances for and with adolescents to generate and implement solutions to accelerate adolescent nutrition.  

Watch this space. 

10 May 2017

Making Bangladesh’s rapid economic growth also drive rapid nutrition improvement

I was in Dhaka this week visiting with the great GAIN office team in Bangladesh, well led by Rudaba Khondker.  During the course of several group meetings I heard from GAIN’s current and potential partners about GAIN’s strategic positioning and our value add as a partner.  I learned a lot about our partners and about GAIN.  Thank you to everyone who gave me their time during my stay. 

Rudaba and I wrote the blog below. 

Bangladesh is growing rapidly.  GDP per capita was $1212 in 2015.  The height of under 5’s is growing much more slowly.  While the stunting rate is going down at a pace to meet the 2025 target, the annual GDP growth rate is much more rapid—at 7-8% per year. 

It is pretty clear that the rapid income growth is not translating through to rapid declines in stunting, wasting and women’s anaemia, the latter two being are stuck at high levels.  On the other hand, this income growth, interacting with rapid urbanisation, is pushing up rates of overweight, obesity and non-communicable diseases such as diabetes.  A study cited in the Global Panel’s Foresight report on Food Systems estimates that by 2030 Bangladesh will have more people with diabetes than the much higher income Mexico and Indonesia. These facts should worry Bangladeshi leaders and policymakers at the highest level.  I’m sure they are seriously thinking about it and looking for partners to support them to address the situation.

These leaders and policymakers should be worried: treatments for NCDs are expensive and take health resources away from the prevention of malnutrition in all its forms.  This will act as a heavy brake on Bangladesh’s aspirations to move to a developed country status by 2041.

So we need to make income generation more powerful in reducing undernutrition and less powerful in driving up other forms of malnutrition.  This is not easy.  Here are some ideas:
    With the nutrition peer educators in the garment factory. 
  •   Make one of the most powerful engines of Bangladeshi economic growth--the ready made garment industry—better able to improve nutrition outcomes.  The industry has over a thousand factories with 2,000-5,000 workers in each, mostly women.  GAIN with its partner Business for Social Responsibility (BSR) and Change Associates Ltd. works with 24 of these factories to provide nutrition training to 90 women per factory and each of them then  trains 20 workers.  The aim is to improve business outcomes (piece rate productivity, turnover, absenteeism) and nutrition outcomes (evaluation findings will be out by June this year).  If the evaluations are positive, the potential for scale is large and the goal is to use these results to make the case to the factory buyers and the relevant authorities to undertake workplace nutrition actions by including nutrition as part of the Code of Conduct for the factories 
  •   Strengthen the efforts to improve women’s empowerment.  While in Dhaka I learned about IFPRI’s analyses using their women’s agricultural empowerment index. Women's empowerment is proving to be a powerful lever of a wide range of development outcomes—all at a given level of income. Nothing we did not know, but it is great to have hard quantitative results.
  •  Make food systems more nutrition effective.  Food systems contain large resources flows (along value chains, between consumers and retailers, investments in agricultural inputs): what might be achieved if we put a nutrition lens on these flows? If we did I suspect the food system in Bangladesh would generate more nutrition per unit of income growth. The importance of engagement with business is seen with sceptism by some (and some scepticism makes sense—not all businesses do good things for nutrition) but to attain the SDGs, business resources need to be mobilised. It is noteworthy that Bangladesh has included private sector engagement in the 7th Five Year Plan and in its National Nutrition Policies, Strategies and Plans.

Other observations
  • The unfinished agenda in Bangladesh for fortification is huge, not just large scale, but fortification in small scale mills, biofortification and home fortification.  There is not enough strategic coordination between these different approaches to make sure that between them they cover all segments of the population who suffer from micronutrient malnutrition.  We are working with the government and partners to explore the value added and feasibility of establishing and supporting a government Food Fortification Facility to do just this. 
  • Urban malnutrition is a rapidly growing problem, along with food safety. Slums constitute a large percentage of the country’s urban population and are growing rapidly.  Urban areas heterogeneous and some locations have rates of malnutrition that are frequently worse than those in the rural areas.  Urban areas present challenges for nutrition programming for a variety of complex reasons relating to pollution, land tenure, security and access, infrastructure and mobility.  These challenges need to be addressed.
  •           More than half of the Bangladeshi population is under age 25. Adolescents make up one fifth (27.7 million) of the population. We must be impatient for new solutions for adolescent girls and boys.  Soon they will be the next entrepreneurs, carers, innovators and voters.  They can't afford to wait for solutions.  It is time for new initiatives here.

As usual Bangladesh is inspiring to those who care about progress in development.  It is a country that has been written off from a development perspective many times in the past.  Not so anymore.  The eyebrow raising economic growth rates have investors on alert for economic opportunities.  It is our job to help turn that economic growth into a series of great opportunities to also invest in nutrition—and to drive subsequent economic growth. Remember, nutrition status is a maker and a marker of development.