21 November 2017

The State of Nutrition in Nigeria: From Security Threat to Economic Imperative

Last week I spent some time in Lagos and Abuja with the GAIN Nigeria Office. We met with government officials, entrepreneurs, civil society, reporters and development partners. It was a stimulating visit set against the devastating backdrop of a mounting malnutrition crisis, especially in the North East of the country where a famine has been declared. In fact one of the officials I spoke to told me it had gone beyond a crisis to being a clear and present danger to national security.
Nigeria certainly has too much malnutrition. Stunting rates are 33 percent and declining too slowly, wasting rates were 7 percent in 2015 and are now surely significantly higher given the situation in the North East. In addition, anaemia rates and overweight rates for adult woman are, respectively, 49 percent and 55 percent. Unfortunately, the double burden is booming in Nigeria.
It should not be like this. Nigeria has an abundance of natural resources, a vibrant entrepreneurial spirit, and was an early member of the Scaling Up Nutrition (SUN) Movement (2011).  It is true that the economy has been stagnant for the past few years and levels of poverty remain around 50 percent, but you get the feeling that the country has the potential to actually live up to the “economic powerhouse of Africa” tag it once had. The challenge is to enable the dynamism of the South of the country and elsewhere to drive nutrition improvement, livelihood generation, resilience and growth, especially in the more remote and conflict affected North East.
So where are the weak links in the nutrition improvement chain? As the excellent SUN Country Dashboard for Nigeria notes (above), the country does well on enabling environment and on legislation, relative to the other 60 SUN members. But it does less well on scaling of interventions and quality of food supply and on the SDG drivers of nutrition (such as WASH, women’s empowerment and age of marriage).
When we delve further into the aggregate scores and look at all 75 indicators, we can see that some areas of relatively good performance don’t actually look so good. For instance, the relatively good score on finance is due to development partners providing 99 percent of the total nutrition-specific funding. As for government spending, the SUN dashboard says that the Government of Nigeria spends only 0.8 percent of its 2014 budget on nutrition specific interventions. The Global Nutrition Report of 2017presents even more bleak statistics: it says the Government spends only 0.2 percent of its budget on nutrition sensitive AND nutrition specific interventions. Clearly the government needs to step up and invest its own resources in nutrition. Another example of hidden weak performance is the relatively good score for infant and young child feeding, but in absolute terms only 10 percent of infants meet the minimum diet adequacy score; this is shockingly low but only slightly below the SUN member median of 11 percent.
But for me, the most striking gap highlighted by the SUN dashboard is the Government’s apparent lack of appreciation that nutrition is a driver of development. For example, Nigeria’s national development plans barely mention malnutrition (in any of its forms); the orientation of agriculture to nutrition is low, as measured by the SUN dashboard (although there is the promise of some change here); and, of course, there is the low spending on nutrition programs from the Governments own budgets, which is always the firmest test of commitment.
During my trip, I was struck (as in other GAIN country office trips) by how dynamic the small and medium enterprise CEOs are. Take the two partners in the Postharvest Loss Alliance for Nutrition (PLAN).  This programme, conceived of and managed by GAIN and partners supports small and medium businesses that are trying to improve packaging and crating for transport and display, as well as their cold chains in fresh (and nutritious) produce so they can reduce their postharvest waste and grow their businesses.  The two CEOs from Best Foods Nigeria Ltd. and Alyx Ltd. were restless, energetic, driven, focused and in constant problem solving mode. Ironically, they could see the bigger picture better than many policy analysts – because they are a part of that picture.

Alyx Ltd. Mobile cold chain. Abuja, Nigeria
For example, the CEOs noted several ways in which the government could help them better provide low cost fruits and vegetables to low income populations. Specifically, they pointed out that: (a) import tariffs on insulation materials for the portable cold chain collection points (that can be taken out into the fields) are around 30 percent, (b) as are the tariffs for solar panels and batteries that will allow the portable and fixed cold chain points to be off the grid and (c) reused materials (the companies repurpose existing metals and other materials) do not count as collateral when applying for formal finance loans.
So the policies and rules that could make a food system more nutrition sensitive are not always obvious to those working outside the system, that’s why GAIN strives for the duality of being both a participant within, and an analyst of, food systems: it gives us a wealth of insights as to how to work with partners to help fix the systems.  The SUN Business Network which GAIN convenes in Nigeria (and which the World Food Programme convenes in other countries in the region) is also a fantastic platform for the nutrition community to forge new alliances and partnerships with businesses who are acting responsibly to improve nutrition.
In conclusion, there were several things that made me hopeful that more rapid progress on reducing malnutrition in Nigeria can be made: the profile the media is giving nutrition at the moment—this is an opportunity to get the message out that nutrition is an investment in resilience and development; the Dangote Foundation’s new US$100 million commitment to nutrition which should leverage even more external funding for development; the Federal Ministry of Agriculture and Rural Development’s ambition to scale up the availability of biofortified crops; the dynamism and thoughtfulness of the Chair and Vice Chair of the Healthcare Services Committee in the House of Representatives (just like the US system) and their commitment to malnutrition reduction; the development partners we met who were more passionate, informed and action oriented on nutrition than in many other places I have visited; and the enthusiasm of small and medium enterprises to develop their businesses in ways that make nutritious foods more available and affordable.
And the best way to sustain optimism and deliver on it is by strengthening nutrition accountability mechanisms to hold our feet to the fire. For example, I would like to see an annual Nigerian Nutrition Report, similar to the Global Nutrition Report (GNR) or the India Health Report, where outcomes, legislation, policy and investment could be tracked for all 36 states, highlighting successes, bottlenecks and solutions.
GAIN Nigeria will certainly play its part in supporting the government’s efforts to meet the Sustainable Development Goals. During my stay in Abuja, we hosted an event to mark our 15th anniversary (one of 15 events around the world). Fifty or so partners from a range of organisations were present. Together, we explored the malnutrition challenges in the country and the opportunities to make good nutrition a reality for all Nigerians. As Michael Ojo, our strong new Country Director put it: let’s remember who the real “boss” is here: those whose lives, livelihoods and lifecourses are at risk because of malnutrition. Remembering this will make us less likely to be complacent. He also said that working together we are more than the sum of our parts and that together we can accelerate reductions in malnutrition in Nigeria. Exactly.
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13 November 2017

Scaling Up Nutrition (SUN) – the 2017 Global Gathering: Inspiration, Connection, Progress and Love

I just returned from the 2017 SUN Global Gathering (GG) in Abidjan, Cote d’Ivoire. This three day meeting brought together teams from all of the 60 SUN member states, the four Networks (civil society, UN, donors, business—including a few GAIN colleagues), the SUN Movement Secretariat, the SUN Movement Executive Committee (which I am a member of) and the Lead Group (the highest level officials and champions, chaired by UNICEF’s Executive Director, Tony Lake).
This was the first GG since 2015 and the first held in a SUN member country. Its objectives include to energise and inspire, to reconnect and network, and to learn and reflect. The GG did brilliantly on the first two, but we could, in my opinion, improve on the “learn and reflect”.
On the energise and inspire front, the GG was remarkable. For instance, we had the Vice President of Cote D’Ivoire, the former President of Tanzania, many ministers from Africa and many other senior government officials from Africa, Asia and Latin America. Tony Lake was also present for the full three days, testimony to his dedication. These senior politicians and officials (such as Akin Adesina, the President of the African Development Bank) talked with great passion, authenticity and fluency. They knew the core facts: malnutrition affects one in three people, is responsible for nearly half of all under five deaths, leads to losses in GDP of at least 11 percent and investing in preventing it yields benefit cost ratios of 16:1. They weren’t speaking from scripts they were speaking from the heart and from a place of pragmatism (malnutrition is holding our economies back). This was mightily impressive and it is too bad that the top officials from donor agencies were not present to witness it.
But inspiration was not just restricted to these folks: for example, we had a junior Parliamentarian, 15 year old, Spectacular Gumbira from Zimbabwe (a well named, amazing and powerful speaker, completely unfazed by an audience of 900 people), Myriam Sidibe a powerhouse behaviour change advocate from Unilever and Catarina de Albuquerque, Executive Chair of Sanitation and Water For Allmaking connections into the WASH sector.  In addition, a range of inspirational nutrition leaders were honoured by Sight and Life and by SUN, including Ellen Piwoz from the Gates Foundation who won two prizes, both richly deserved.
On the reconnect and network front, the GG did a great job. There were the marketplaces that were set up by all 60-country members, the long breaks in-between sessions, the network meetings and the well-chosen venue with plenty of meeting spaces. Having the meeting in a SUN member country also gave the proceedings a feeling of balance. People like me from European and North American organisations were not able to dominate the proceedings—this was a country first meeting, where egos and logos were checked at the door. The feeling was one of solidarity not hierarchy; one of ideas, not protocol. There was, as David Nabarro (Special Adviser to the UN Secretary General on Agenda 2030 and former SUN coordinator) put it, a lot of love. And I would add solidarity, too.
On the learning and reflection front there was a good session on nutrition in fragile contexts and how SUN could be more relevant, there was some progress on getting civil society and business networks talking to resolve issues around due diligence and accountability of businesses, and there was a short plenary on the new Monitoring, Evaluation, Accountability and Learning (MEAL) resources for guiding us along the SUN theory of change. Despite this, and this is solely my own view, we could have done better on the learning and reflecting front. This really matters greatly, as we know more about the damage malnutrition does, than what works to combat it.
For example, there are some big questions looming which we did not really take on:
  • SUN is scaling well and thinking more about impact, but what about its sustainability beyond 2020, which marks the end of the current funding cycle? Can we really call ourselves a movement if we are so reliant on donor funding? Shouldn’t some of the direct funding for SUN infrastructure come from members (to be fair, I know much of the indirect funding does already come from members)?
  • The double burden of malnutrition is rapidly increasing—the latest Global Nutrition Report (2017) counts 60 percent of countries facing significant burdens of undernutrition (under five growth faltering or adult micronutrient deficiency) as well as overweight/obesity. That percent is likely to grow before it diminishes, so what is the SUN movement’s response? What will we do differently? Can we shy away from the difficult but inevitable discussions which surround curbing some of the unhealthy dietary trends driving this?
  • Urbanisation is growing rapidly in Africa as elsewhere—this presents both an opportunity and a challenge to nutrition—what does the SUN movement need to do adapt? For example, SUN already has Indian States as members, should it also invite cities to be members?
All in all the GG was a great success. The SUN Coordinator, Gerda Verburg, deserves a great deal of credit for her energy and her “telling it like it is” style.  Her team did a superb job of making all the thousands of moving parts mesh together well.
I leave you with one positive and I believe insightful reflection someone shared with me at the end. It was that at the first GG, country members looked a bit bewildered—what is this SUN Movement and what does it mean for me? Country representatives knew what they needed, but were less sure of how to articulate it and to negotiate for it. In Abidjan, they said, it felt as if the country members were in control of the movement: there was a clarity from them about what was needed from others, a confidence on the articulation of those needs and an abundance of know-how on what to do to secure the needed support.
And this country driven approach is essential to Scaling UNutrition. SUN’s ultimate success will be measured in terms of whether it contributed – at the country level – to mobilising additional domestic and external resources to nutrition advancement, whether it contributed to existing resources being spent more effectively and whether it contributed to nutrition being increasingly seen as a core driver of the SDGs. We must never forget that SUN is a global movement.  That means movement the world over as well as movement in more “global” circles. The movement marches on!

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07 November 2017

The 2017 Global Nutrition Report: Nourishing the SDGs

How nice to be asked to write a blog about the 2017 GNR “Nourishing the SDGs” (of course I would have anyway!).
I love the title and the narrative behind this year’s report, which can be summarised as:
1. “Let’s make good nutrition the global social norm”;
2. Disparate communities working on different nutrition outcomes need to come together to have a stronger voice. Implementers, investors and policymakers can do this by looking for double/triple duty actions that address more than one type of malnutrition;
3. Nutrition needs to be made compatible with other sectors – not just what they can do for nutrition, but what nutrition can do for them. Also we need coherence across sectors – even if we can’t convince sector x to do more for nutrition, let’s at least make sure it does not undermine nutrition; and
4. People should be put at the centre of our efforts—no person should be left behind and every voice should count.
I particularly like the sentence near the beginning of the report and repeated towards the end: “The bottom line is that nutrition needs some staying power. While global goal setting and dedicated decades for nutrition are important to spur action, let’s work to mainstream nutrition, so much so that it is considered commonplace to have optimal nutrition.”
Staying power, think about that. “Staying” implies that the good profile nutrition has right now is at risk – it might not stay. “Power” implies that nutrition is the vital “cog” in the SDG machinery.  If it is not working, then things will grind to a halt. We have to find ways to make it stay around; we need to emphasise and enhance its cog-like functions in the SDG juggernaut.
But let’s get to the numbers between the beginning and the end of the report. There are plenty. Here are some facts that made me sit up and take notice:
On the magnitude, location, targets and pace of change of malnutrition outcomes:
  • All 140 countries with data on under five growth, women’s anemia and adult overweight suffer from one of these burdens. All of them.  In previous reports at least we had one or two exceptions.
  • 85 out of 140 countries have serious levels of overweight and one form of undernutrition. That is 61 percent, up from 44 percent in previous reports. The double burden of malnutrition really is the “new normal”.  The challenge now is to make good nutrition the new norm.
  • Women’s anemia rates have increased overall, but more countries seem to be making progress—these are new World Health Organization (WHO) estimates that contain good and bad news.
  • Adolescents: “The nutritional status, behaviours and outcomes of adolescents form a very small part of global monitoring frameworks for nutrition. The only targets that address adolescent nutrition directly are the Maternal, Infant, Young Child Nutrition (MIYCN) target for anemia of 15-49 year olds, but these are not broken out by adolescents.” While the obesity target includes an indicator for adolescent obesity, the anaemia target does not look at anaemia in adolescents separately. Beyond these, indicators are largely missing.”
  • Why does the absence of data on adolescent nutrition matter? “Where estimates are available, from the WHO, these suggest that iron deficiency anaemia is the leading cause of disease burden and disability among adolescents in 2015”. Read that again: anemia is the leading cause of disease burden in adolescents, yet we have very poor data on it.
  • Nutrition specific spending from aid donors as a percentage of total Official Development Assistance (ODA) actually declined from 0.57 percent to 0.5 percent in the past year. What more can we do to support our donor champions to get this number up to at least the 2-3 percent needed to meet the World Health Assembly (WHA) targets?
  • Country budget allocations to nutrition as a percentage of overall national budgets: once again the country estimates of nutrition spend (specific +sensitive) show wild variations. We need some analysis on why some countries are so low (e.g. Nigeria on 0.2 percent and why some are so high e.g. Nepal at 13.1 percent).
  • Of the nutrition sensitive ODA spending, only 11 percent is found in the education sector – are we doing enough here? Is this where we should be focusing much more on double duty actions?
  • ODA spending on obesity and diet related Noncommunicable Diseases (NCDs) constitutes only $25m – about 0.01% of global ODA. Feeble – we know it is difficult, but donors must do better, for example through double duty counting.
  • There are essential calls to improve the way nutrition actions are reported in the ODA Creditor Reporting System (CRS): to better align the nutrition specific codes with actual interventions and to also introduce a nutrition policy code in CRS for nutrition sensitive and policy actions. Donors can change this. But I suspect the nutrition champions within them need some evidence on the consequences of our current miscounting of nutrition spending.
N4G commitments
  • The (self) reporting on the 2013 Nutrition for Growth (N4G) commitments continues in this GNR. This year the no response rate from the 200 or so commitments made in 2013 was 49 percent– worse that the 45 percent in 2016.
  • Businesses were the worst offenders: with a 66-70 percent no response rate. My colleagueJonathan Tench has some great and sophisticated ideas for improving response rates in a panel in the report. My suggestion is less sophisticated. Name the companies. This will get their attention and the attention of their investors.
  • On donor financial commitments I like Fig 5.3, which compares commitments made over the 2013-2020 period versus disbursements made over the 2013-15 period. Most donors seem to be on track.
Away from the numbers
But numbers are not everything. Imagery is important and the report also does well here.
For instance, the language around universality of the SDGs is motivating: we need greater disaggregation of data to ensure no one is left behind and less disaggregation in country groupings—north/south dichotomies are increasingly meaningless in a multiple burden world.
I like the idea of data value chains to help us identify the weak links in the generation, understanding and use of data, but how to get governments and donors more excited to invest in this? We really need a study showing the value added of good data. How do we make the benefits visible to stack up against the very visible costs?
The five areas for action that are illustrated beautifully on the cover are a nice way to reach across the 17 SDGs (roughly, food systems, infrastructure, health systems, equity & women’s empowerment, and peace).
There is the nice quote about “Improved nutrition cannot be a singular set of targets in a silo – rather it is an indispensable cog, without which the SDG machine cannot function smoothly.“
The examples of “double duty” actions introduced in the 2016 GNR are nicely expanded. Examples include paying more attention to NCDs within undernutrition interventions delivered by the health system, and focusing on access to improved water, not only for infection prevention, but also to act as a counterweight to high soda consumption.
The “gatefold sleeve” graphic (I’m really showing my age here) on pages 10-11 is great – stick it on your wall – as a visual story of the report.  Indeed the graphics in the report keep getting clearer and simpler every year.
In general the “call to action” language was downplayed in this GNR but the four sets of actions remain powerful:
  • Build for nutrition while harnessing nutrition’s power across the SDGs.
  • Stand shoulder to should on obesity and diet related NCDs when addressing undernutrition.
  • Be bold in your commitments to nutrition improvement—we will not get the window of another Decade for Action—this is likely to be it, folks.
  • Invest in understanding and strengthening resource data value chains.
So a massive congratulations to the GNR secretariat, the Stakeholder Group, the Independent Expert Group, the funders, the authors, the other partners, the reviewers and, especially, the GNR co-chairs: Corinna HawkesJessica Fanzo and Emorn Udomksemalee. I am proud that GAIN is a member of the report’s stakeholder group.
By nourishing the GNR, they are all nourishing the SDGs.
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23 October 2017

Buoyant in Buenos Aires: the IUNS Conference

Last week, several of the GAIN team were participating in the 2017 International Union of Nutrition Sciences (IUNS) meeting in Buenos Aires. There were thousands of participants from all over the world and hundreds (perhaps thousands) of presentations. Quite a lot of bench science, but also a lot of field and program research, and even some policy research.
All in all the GAIN team made 14 presentations and showcased 12 posters. I was really proud of all of them, but a special mention is reserved for Lynnette Neufeld, GAIN’s Director of Knowledge Leadership. Wonderfully, Lynnette was voted by the Council and country representatives as the new President Elect of the IUNS. This means she has four years to prepare for her tenure, which begins at the 2021 IUNS in Japan. This is an incredible honour, one that is bestowed on her by her peers and the full membership. I know she will do a great job and we will support her all the way.
So what did I make of the Conference?
Obviously I could not go to that many sessions (I gave a talk on nearly every day; there were lots of small group meetings I needed to attend, and many of the formal sessions I wanted to go to ran simultaneously) so, as usual, my views are impressionistic and partial. (And yes I would have made these observations and recommendations even if Lynnette were not the President Elect!)
1. The sessions could have been better aligned so that they aggregated up to answer big questions. There was, of course, some of this (and it must be like n-dimensional chess to get the alignment right), but I felt the presentations somehow did not build on each other enough. Half the world is malnourished, we need science to help find practical solutions, fast.
2. There weren’t enough young people presenting. There were lots of people in their 40s and 50s making great presentations, but I would have liked to have seen more mentoring of younger people. The presentations by our own Djeinam Toure and Corey Luthringer were two of the most interesting I heard. Look at dynamic sectors such as business and IT: they are brimming with young people and benefit accordingly.
3. There was not as much disciplinary diversity as I would have liked to see. I suppose this is the international union of “nutrition sciences” but the “how” is just as important as the what and why, and we need to reach out to other disciplines who are working on nutrition issues to understand these “how” issues better (e.g. the political scientists, the financial analysts, the institutional economists, the behavioural psychologists, the business administrators, the lawyers and the climate scientists). For example, there was not one presentation over the six days including the word “governance” or the phrase “public-private partnership”. Real world solutions desperately need to better link new evidence to stakeholders outside academe.
4. Everyone had to state whether they had a conflict of interest before their presentation, but in none of the sessions I attended did anyone have a conflict to declare. That struck me as odd. In the last of my five talks, I declared an interest. The talk was arguing for more independent evaluations of public-private partnerships in nutrition. This is clearly in GAIN’s interests because we want more independent evaluations to draw on. This will allow us to do better work and attract more resources, so we can have bigger impact. OK, it is not exactly Big Tobacco, but this class of conflict is worth declaring, it seems to me. This is not just about duties, it makes interventions more interesting and real.
But without a doubt the most fun event was the GAIN 15th birthday party organised by Bonnie McClafferty, our Director of Food Value Chains. Bonnie had organised a really interesting session earlier in the day on “Shaping Food Systems”, but the birthday party had better music and dancing.
We had the party because we wanted to thank the folks we asked to give us input into our new strategy, as well as our staff, partners and investors: past, present and future.  We had over a 100 people there and the positivity was fantastic. It was wonderful to be able to celebrate our contributions, standing shoulder to shoulder with our partners, over these past 15 years, and to mark the great year we have just had.
But the birthday party is merely the appetiser for the main course. To mark our 15th birthday a bit more seriously, in the next two months each of our 15 country offices will host a policy roundtable discussion on the future of food systems: in Abuja, Addis Ababa, Copenhagen, Dar es Salaam, Delhi, Dhaka, Geneva, Islamabad, Jakarta, Kabul, London, Maputo, Nairobi, Ottawa, Utrecht and Washington DC.
Watch out for them!

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19 October 2017

Micronutrient Powders: Getting a Grip on Effective Implementation

I had heard of micronutrient powders (MNPs) before I joined GAIN, and, I suspect like many non-experts, I assumed it was a pretty simple intervention.
How wrong I was.
For those of you who are less familiar with the nutrition world, MNPs are sachets of powdered vitamins and minerals that can be added to complementary foods and given to children on a daily basis. They were introduced by Dr. Stanley Zlotkin (who is also a member of GAIN’s Board) in the late 1990s. Easy to use, MNPs do not change children’s dietary habits but can be added to semi-solid foods that are already part of a child’s diet. More importantly, MNPs boost children’s micronutrient intake and reduce their risk of iron deficiency and anaemia.
A just published Supplement of Maternal and Child Nutrition contains a series of papers emerging from a Consultation that summarise the lessons learned from operationalizing MNPs. A subsequent paper which took advantage of the Consultation’s extensive systematic literature search published in Current Developments in Nutrition summarises what is known about factors affecting adherence to MNP recommendations.
The Consultation drew on the reflections of 49 MNP implementers and experts and a review of published and grey literature.
Here are the key points from the overview article by Dhillon et al. and adherence paper by Tumilowicz et al.
1. Iron deficiency anemia (IDA) is the leading cause of years lived with disability among children (I did not know that!)
2. Peak prevalence of IDA occurs at 18 months after which iron requirements decline and iron intake increases through complementary foods (I did not know that either)
3. MNPs have generally replaced iron drops/syrups because they show similar efficacy in reducing IDA (by 51 percent) and anemia (by 31 percent) in children under two years of age, but with higher acceptability and fewer side effects
4. Global scale up has been helped by the fact that MNPs are easy to use and do not require dietary change and, on average, cost USD 0.02 per sachet to produce.
5. Scale up of MNPs has been rapid: from 36 interventions in 22 countries in 2011 to 59 interventions in 50 countries in 2014.
6. Of the 50 countries, nine were implementing national programmes and 20 subnational programmes (I guess the remaining 21 were doing pilots).
7. Despite rapid adoption the extent to which the quality and scalability of MNPs can be maintained is yet to be established. Hence this Consultation.
8. The Consultation looks at 3 dimensions of MNP implementation (1) planning and supply, (2) delivery, social and behaviour change communication, and (3) continuous program improvement
9. Planning and Supply
  • High quality research and data analysis to justify MNP intervention is not always conducted fully
  • Leadership is an important driver of intervention uptake, but so too is the need to find more effective approaches to address childhood anemia
  • Sustainable funding remains a challenge despite evidence of high cost effectiveness – it is good to discuss long term funding early on in implementation. Adding to existing national programmes improves sustainability (e.g. social protection in Mexico and Dominican Republic)
  • Securing reliable and regular supply of MNPs is a challenge for many countries. This means that countries often rely on global suppliers, but this uses valuable foreign exchange, and can lead to long procurement lead in times and problems around local languages and packaging
10. Delivery, Social and Behaviour Change Communication and Training
  • Here the models vary by design feature: (price: free, subsidized or full cost) x (point of distribution: facility health workers, community members, pharmacists) x (sector: health, social protection, agriculture
  • Free distribution through the non-health sector – for example, social protection and early childhood development programs – has shown higher coverage rates than free distribution via health systems
  • Subsidized distribution has achieved a wide variety of coverage rate
  • Whatever the delivery strategy, more and more MNP programmes have been linked to broader infant and young child nutrition objectives
  • Programs are increasingly measuring appropriate use and intake adherence in addition to just coverage
  • Social and behaviour change (SBCC) need to be applied throughout program cycle
  • Regular refresher training of MNP distributors is essential to ensure high quality counselling and messaging
  • Two thirds of all MNP interventions are funded entirely by development partners and this is not really sustainable
11. Continuous Program Improvement
  • Lack of documented MNP experiences, especially those implemented at scale. There are 15 peer reviewed papers and most come from pilots and were externally funded with few examples of them being used to improve implementation
  • Most programmes do not apply a mapping of programme theory to track progress or make course corrections efficiently
12. Factors Affecting Adherence
  • From the perspective of caregivers, positive changes in their children (for example, improved health, increased appetite, increased energy) and acceptance of food mixed with MNP are the main reasons for continuing to use it
  • Caregivers are less likely to stop feeding MNP if they are informed of potential negative side effects (such as changes in stool)
  • In addition to SBCC strategies, administration regimen (fixed or flexible dosage schedule), which may be related to caregivers’ capacity to remember to give MNPs, is frequently cited as a program design feature affecting adherence.
As the papers note, “..implementing MNP programmes effectively remains a complex challenge” and “preparing food with MNP correctly and succeeding in getting a child to eat it depends on a complementary feeding process that requires a complex set of caregiver behaviors and caregiver-child interactions”.
As someone who has spent time outside as well as inside the nutrition world, I’m wondering how complex MNP programs are to implement effectively compared to the program it replaced, namely iron drops/syrups. I’m also wondering how MNPs stack up against other nutrition interventions (e.g. promotion of exclusive breastfeeding, Vitamin A supplementation, biofortification) and against other development interventions (e.g. social protection, WASH, public works programs).  My experience suggests they all require careful planning, linking of supply and demand elements, and learning feedback loops.  They all require sustainable funding.  The impacts of none are resilient to poor design and implementation.
The state of MNP implementation reminds me of the state of conditional cash transfers in the 90’s.  Everyone was jumping on the bandwagon, and many of the transfer programs did not have an impact on nutrition status because of poor design, poor implementation, poor evaluation, or some combination of the three.  But as the good evaluations rolled in, meta-analyses were able to identify the rules of thumb that made positive impact more likely and sustainable at scale, and this was the trigger for governments, such as Ethiopia, to invest their own resources in them.
In sum, there are two things I have learned from the past year at GAIN that speak to these issues: (1) it is harder to design and implement effective programmes than it is to design and implement effective evaluations of them and (2) if you don’t evaluate programmes it is even harder to design and implement them effectively!
The papers in this supplement are a valuable reflection on the MNP experience to date, and I am happy that GAIN was a contributing partner in the endeavour.

11 October 2017

The New Expert Panel Report on Nutrition and Food Systems: What is Different?

The UN Committee on Food Security’s (CFS) High Level Panel of Experts (HLPE) report on “Nutrition and Food Systems” was released at the 44th CFS this week.  The team was led brilliantly by Prof. Jess Fanzo. I was one of the team members.
There have been a number of reports on food systems in the past year – including the Global Panel Report and the IPES report – and next year we have the EATLancet Commission report on sustainable and healthy food systems. This report is specially important as the CFS is the apex body in the international UN system looking at nutrition and food policy.
So what is different about the HLPE report? Here is my take:
First, its main audience is CFS members: governments, UN agencies and other development partners, civil society groups and companies.  This means it has to be couched in the more measured, careful language of diplomacy rather than advocacy.
Second, the report was produced through a very inclusive process. The report team was balanced by geography, disciplinary background and organisation type.  This meant forging compromises that all team members could live with, with the expectation that this will increase the chances of a wider buy in from stakeholders.
Third, it is, subversively, a bit radical. Statements such as “The risks of making well intentioned but inappropriate policy choices are much smaller than the risks of using a lack of evidence as an argument for inaction” are fairly heretical for many nutrition investors guided by Lancet 2008 and 2013. For the more market based interventions within the food system the hard evidence is usually not present and one has to trust educated best guesses and calculated risks as a guide to action. This is an implicit challenge to a trend towards ever more specific searches for evidence to prove interventions are justified.
Fourth, the report gives equal focus to three features of food systems: food supply, food environments and consumer orientation.  Some of the other reports mentioned have not been as balanced and especially do not spend enough time on the creation of the demand for healthy food.
Fifth, the report is very action orientated. For example, there are 26 pages of text on priorities for action in food supply chains, food environments, and in orienting consumer behaviour.  The “investment priority wheels” for the three types of food systems are also useful guides to sequencing action.
Sixth, the report bravely takes on the barriers and enablers for action: bravely because these are all quite context specific and deal with power asymmetries. This kind of political economy analysis needs to be developed further in future HLPE (and other) reports.
Seventh, climate issues are woven throughout the report, not confined to one section or chapter. Other environmental footprint issues could be strengthened in future reports, but to be fair the evidence on the wider environmental footprint of different foods in different countries is sorely lacking.
Finally, the private sector is taken seriously. It is not merely characterised as a malevolent actor.  One of the HLPE team members was even from the private sector –a first, I believe for the HLPE, but brave and necessary.  Given, as the report notes, the public sector is the duty bearer for ensuring food systems enhance food security and nutrition for all, and the private sector is main investor in food systems, it makes sense for the two sides to understand each other better.
I did, however, have quibbles with some of the private sector language (come on, did you expect me to have no quibbles with anything?).  For example, the report states “The private sector is primarily seen as part of the problem, but it can and should also be part of the solution.” Some stakeholders do in fact see the private sector this way, as primarily part of the problem, but many do not.  And the private sector is already part of the solution – it is just that it is also part of the problem (as, incidentally are governments – some of whom have good, some less good policies). Also, the report does little to dispel the notion that the private sector is a multinational monolith.  For example, Small and Medium Income Enterprises (SME) are only mentioned once.
Jessica Fanzo, the Report Team Leader, and Eileen Kennedy, the HLPE member who was our spiritual guide and inspiration, deserve a great deal of credit as do the HLPE secretariat.  They got us through the hard times when it all seemed too overwhelming and when we could not sometimes reach consensus.
All in all, it is a report I’m proud to be associated with. The content, presentation and generation process were all thoughtful, deliberative and inclusive.
So, read it, critique it, share it, but most of all, use it and act on it!

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