As the PDF proofs are being finalized before the 2015 Global Nutrition Report goes off to the printers next week, I wanted to jot down some personal reflections on the process before I forget them. In doing so, I will hopefully whet your appetite for what is in the report itself (September 22 release).
I should add, these views are wholly mine--I'm not speaking for anyone else.
My reflections fall under 5 points
1. The report is really ambitious
Consider, we have:
(a) reached out to potential new stakeholders in climate, food systems and businesses. This required understanding their views and trying to not only suggest when it was in nutrition's interests to engage them, but also why it is in their interests
(b) tried hard to get a better balance between undernutrition and overweight/obesity/nutrition related NCDs. We have monitored more indicators (including exclusive breastfeeding and adult obesity), looked for convergence and tradeoff points between the two worlds, developed more unifying concepts and reached out to more stakeholders in the latter community. It has not been easy. The worlds are quite separate and sometimes highlighting one set of issues can diminish the perceived importance of the other
(c) developed more nuanced assessments of progress (not just on and off course) and expanded the set of assessments to all N4G business commitments and all donor financial commitments
(d) worked with SUN country governments to bring new data to the table on domestic budget allocations to nutrition
(e) walked a tightrope between publishing the new State level India data and having them officially released (luckily they were, although the Economist had already leaked them)
(f) reached out beyond the usual (important) suspects to get endorsements from those in climate, finance, sports and popular culture
As a result the report is about a third longer than the first.
During one of our stakeholder group meetings in February in Addis, one of the stakeholders said "the report is ambitious--too ambitious perhaps?". I understood the sentiment--more can be less--but my own view was, in 2015, when the world is reshaping development, nutrition has to be in the mix, it has to be relevant and it has to be ambitious for itself.
2. The production of report has been more closely followed this year
Version 0 was produced on April 15, version1 on May 13, version 2 on June 15 and the final version on July 26. At each stage we had over 100 pages of comments and then many hundreds more in track changes.
We also had about 30 pages of comments from 4 anonymous Lancet reviewers.
Some of our key stakeholders gave us many more comments this year than last.
In addition, many more partners have given us advice on communications and messaging than last year.
One could interpret this negatively I suppose--we are less trusted than before--but I think it reflects a sense that the report matters and therefore we need to get it right. And the report quality improved tremendously between version 0 and 3.
3. It is hard to begin writing a second report 4 months after the first has been published
As we were launching the first report we had to begin thinking about the second. Content was guided by an open consultation process in Dec/Jan, but finding the sheer willpower to being thinking about the next report when you are still digesting the first was a real challenge.
One of our stakeholders said, is it worth doing a new report in 2015? We felt it was--new data, new issues, new opportunities. All presented themselves.
4. The balance between technical soundness and usefulness for advocacy is as fine as ever
This was one of the hardest things to balance. Getting the technical language right in a way that people outside the nutrition bubble can understand. We did not always succeed. We erred on the technical side, figuring that a number of sharable content products could be generated (a 12 pager, infographics, tweets, blogs, op-eds etc). But getting the big picture and the fine grain to line up was really hard.
5. It has been great to broaden the GNR team out
One of the things the Dalberg evaluation of GNR 2014 (soon to be posted on the GNR website) pointed out was that it was too dependent on me. This is a very fair comment, and we expanded the co-chair team by adding Corinna Hawkes and Emorn Wasantwisut. They have been brilliant--sharing the workloads, making joint decisions, liaising with the IEG and generally bringing different perspectives to bear. (And keeping my excesses in check, just about.)
We also developed a more coherent communications strategy this time around (now that we know what the report looks like!), involving our partners much more.
Finally, I want to share a question that one of our partners asked me and what I said to them: is the GNR a mirror or a beacon? I said "both": it tells us where we are on outcomes and actions (mirror) and it offers pointers on how to get to our goal (beacon)--ending malnutrition in all its forms.
Being involved in the report remains a privilege. A blast. A thrill. We hope you enjoy it when it comes out on September 22.
19 August 2015
13 August 2015
Communicating clearly to non nutrition folks is difficult for nutrition folks because the topic is so laden with jargon and the technicalities actually matter. But that is no excuse.
So I thought I would try to help my IFPRI colleague out (and maybe a few others) with some thoughts about how to communicate complex ideas in nutrition to lay people. (And remember I am no expert).
1. Understand the complex idea. You have to really understand the complexity before you can simplify. This may seem counterintuitive, but I have found it much easier to simplify from understanding than from ignorance. As Director of IDS I often had to be a 2 minute expert on stuff I had not actually done any research on. I found it much harder to simplify without being simplistic. Even if you have not done research on the topic you are trying to communicate, be sure you understand the nuances--talk to people who are experts.
2. Get to the core issue. Don't be distracted by second order issues. How to identify the core issue? Is it descriptive (e.g. there is more poverty in low-middle income countries than in low income countries)? Is it associative (e.g. are certain types of diets more linked with disease than others?) Or is it causal (does this intervention affect that indicator)? What is the centre of gravity of the piece of research? Work hard at finding this story. If you are lucky it will also be counterintuitive.
3. Use simple language. Instead of utilize, try use. Instead of scale up, try "getting programs to people that need them". Instead of stunting, try kids who are short for their age. Instead of micronutrients try vitamins and minerals.
4. Never over-claim. This does not mean focus on every caveat. I would only focus on the first order caveats. For example, this program only works in this population. This indicator is only linked with this indicator under these conditions. Make sure people know where to go to have access to the full report and in that report make clear all the limitations of your report. But never claim something the research does not show.
5. Have a relentless focus on the "so what?" If a relationship is statistically significant, is it significant in terms of magnitude? If the effect of a price rise of 10% in sweetened sodas on obesity rates is statistically significant but results in a decrease in purchases of 0.25% then it is important to make this clear. If the "so what" is only of interest to other researchers, then don't bother trying to communicate it to anyone else.
6. Understand your audience. Lay audiences are heterogeneous (and don't use THAT term)--are they businesspeople, civil servants, doctors, media, constituents, villagers, parents or schoolkids? Talk to some of them ahead of time if possible. Have a look at their newspapers or websites to see how they think, speak, communicate.
7. Read around your subject as much as possible. Don't just focus on your narrow sub-sub field. Try to find big picture books, views and blogs to see how your work fits in a wider context (especially for people starting out in research careers).
8. Try it out on your friends and family (if they are outside your field). I do this a lot. I started talk about the MDGs once and got only blank looks. Same with economic development. Find language that they can access and that does not bore them stiff.
9. Powerpoints? Use all the space on the slide! Use simple but memorable pictures that convey the messages that are laid over them. Never use text below 32 point. Use as few words as possible. Write the text for the audience, not for yourself! Have no more than one per minute of your presentation, preferably less.
10. Hone your communication skills. You may not believe Malcolm Gladwell's 10,000 hour idea, but he is right: practice gets you closer to perfect. Also learn from those who do it well. Personally I continue to marvel at the communication skills of people like Paul Collier, Simon Maxwell and Jeff Sachs. You don't have to agree with what they say, but learn from how they say it--their memorable use of images, metaphors and sticky phrases.
Posted by Lawrence Haddad at 18:13
29 July 2015
Nutrition needs leaders more than most other issues. Why? Well, nutrition has no obvious institutional home (no Ministries of nutrition), it cuts across disciplines and sectors and so requires leaders who can work across boundaries, it is invisible--it needs people who can stand up for it, and it affects those who are most vulnerable and have least voice--the poorest, the youngest and the most marginalised.
Where are these leaders? They are everywhere. Some are in the spotlight, some are behind the scenes. Some are at the frontlines, some are working at headquarters. Some are technicians, some are implementers. Some see themselves as leaders, others would never recognize themselves as such. Some are recognized, some are unsung. In short there are many types and forms of leadership. The important thing they all share is people taking responsibility and doing things that might be inconvenient for them but make things better for others. Lead from where you are, is the motto, and it is a good one.
Do we do a good enough job of celebrating leaders in nutrition? No. One of my former bosses always used to say its a shame we don't recognize contributions of people before they leave a job or before they pass on.
So I'm really pleased about the Transform Nutrition Champions awards from Transform Nutrition and Save the Children UK. It recognizes unsung heroes and by doing so gives them a little more belief and fortitude and, more importantly, gives the rest of us their story to inspire us and help energize the leaders of the future.
Nominate someone. Do it today.
Posted by Lawrence Haddad at 20:31
19 July 2015
We just finished the fourth one week course on Transforming Nutrition. We had 25 fantastic participants and the three course convenors (me, Purnima Menon and Nick Nisbett) shared with a series of presentations and discussions on the causes and consequences of malnutrition and the actions to overcome it. The course is based on the best evidence and helps participants think about strategies to overcome malnutrition in their contexts. We had great faculty to help us out: Stuart Gillespie, Richard Longhurst, Mdu Mbuya, Namukolo Covic, Jodie Harris, Inka Barnett, Dolf te Lintelo and guest presentations from Corinna Hawkes, Emily Mates (ENN), Jessie White and Susan Elden (DFID), with fabulous after dinner speeches from Richard Jolly and Simon Maxwell.
1. The cohorts coming through are getting more assured, confident and demanding about nutrition and what they want out of the course. In the first year or two participants were more tentative about what they could achieve in nutrition in their context, now the sense I get is that they know exactly what to do and they want advice on how to strategise about that and make it happen.
2. The cohorts are getting more and more dominated by country leaders from government, UN agencies based in country and civil society. There were about 5 participants from development partners, and they provided a valuable perspective, but the 20 country based participants ran the show, and it was refreshing.
3. We talked about overweight, obesity and nutrition related chronic diseases more than ever before. This probably reflects the presenters growing knowledge on the issues, but the discussions and questions were very focused on how to sequence action on undernutrition on top of all the other malnutrition issues manifesting themselves. These two worlds are slowly converging, and that is a good thing.
4. The group presentations at the end of the week were simply amazing. The Nigeria team was large, determined, and impressive. The Tanzania team was small in numbers but very thoughtful. The Mozambique and Bangladesh teams innovated in their group presentations, using role play and film to communicate their problem, what they would do to overcome it and who they would influence to make it happen. The calibre of all participants was exceptional. I was struggling to keep up at times.
5. I remain amazed at how few country or state level case studies there are of change. Why did stunting go down in this country? Why is wasting static? Why is overweight declining? Why is anaemia static? Why is exclusive breastfeeding rates going backward in country x? The nutrition journals currently disincentivise this kind of study, presumably because it is not methodologically pure enough. This is a real shame. Slicing and dicing research may help researchers get published, but who is going to weave all the strands back together again?
It is really gratifying to see how strong the demand for this course remains. We have had over 130 people go throughout the programme now. They have energised us and we hope we have energised them. We need all the energy going. The force may be with us in nutrition right now, but we (yes, you, reader) have to be the force to sustain it and turn it into action that reduces malnutrition. Nothing less will do.
Posted by Lawrence Haddad at 23:13
06 July 2015
Guest blog from Stuart Gillespie: From the politics of commitment building to the politics of delivery
Guest blog from my IFPRI colleague, Stuart Gillespie, with some reflections on enabling environments for nutrition.
“The microbe is nothing, the terrain everything” (Louis Pasteur, 1895)
“The microbe is nothing, the terrain everything” (Louis Pasteur, 1895)
"The objective of development is to create an enabling environment for people to enjoy long, healthy and creative lives." (Mahbub ul Haq, 1990)
We have learnt a lot about “enabling environments” in nutrition over the last few years -- about what they are, and why they’re important. In broad brush, an enabling environment is one in which there is a political commitment to address malnutrition, backed up by institutional commitment in the form of pro-nutrition policies, incentives and accountability. Nutrition-relevant data are generated, shared widely, and they inform action. Different elements of nutrition-relevant capacity are understood and strategies are pursued to address gaps and weaknesses. Nutrition champions build alliances and they work across sectoral boundaries to make the case for nutrition. The growing priority attached to nutrition is reflected in financing that is adequate, stable and flexible.
Such enabling environments (EEs) lie at the base of the Lancet (2013) conceptual framework, and they have opened the door to a more politically nuanced analysis of nutrition in recent years. EEs may be foundational but they are also dynamic. They can change….for better or worse. In tracking countries’ progress against four indicators, the SUN movement is monitoring the development of EEs at the national level.
This is clearly important, but it’s not enough. Between Pasteur and ul Haq, environments operate at different levels. Think of the layers of an onion. At the core, a child’s nutritional status represents an enabling (or disabling) environment for her/his growth and well-being, Pasteur, and his compatriot Claude Bernard, did not explicitly refer to nutritional status the “milieu intérieurthat was believed to be “the condition for a free and independent life”. Nearly a century later, when he launched the first Human Development Report, Mahbub ul Haq was building on Amartya Sen’s capability approach. Enabling environments were those that preserved the future capability to act, that kept an individual’s set of life choices open. Human development was about expanding the richness of human life, not the richness of the economy.
Between the outer and innermost layers of the onion – between macro and micro – there are district-level bureaucracies. A supportive policy climate does not automatically guarantee effective subnational implementation of nutrition-relevant programs. We need to move below the national level to better understand meso-level environments for nutrition. We need to pay more attention to vertical coherence (national to community) and go beyond the politics of commitment-building to the politics of delivery.
Creating and sustaining EEs is not easy, and it takes time. There are many moving parts, and there is no gold standard. Future research and action needs to recognize such complexity. One way to do this, and to foster sharing and learning across contexts, is to document real-world experiences in developing EEs at different levels. Such “stories of change” – focusing as they do on the lived experience of key actors -- can be powerful. Stories inform, but they also inspire.
Posted by Lawrence Haddad at 08:34
24 June 2015
One of my favourite book reviews (as long as it never applies to me) is: “This book fills a much needed gap” (think about it). Those who advocate for more nutrition data need to ask themselves the same thing: do these data simply fill a much needed gap? In other words, do we really need to fill any given data gap?
Yesterday I participated in a brainstorming meeting at WHO on data gaps that matter for scaling up nutrition interventions. Data are needed at the subnational, national and global levels to guide action, to assess progress, to help advocacy and to strengthen accountability.
We spent the whole day (a) identifying gaps that need filling, (b) mapping ways forward on data gaps that can be filled relatively straightforwardly and (c) brainstorming on the more difficult or “gnarly” data gap issues.
The participants work mostly at the “global” level—and it showed. It was important to keep in mind the constraints faced by people working with data in the domestic nutrition system. There was a tension between framing things as “what do we need to do to get more domestic data into the international system?” and “what do countries want/need to move their nutrition agendas forward?” Another tension was around framing that said “what additional data would be useful to countries?” and “what do countries need to make existing data more useful?” All of the framings are valid, it seems to me, it is about listening to countries while also meeting global accountability and advocacy needs. But how to “listen to countries” without burdening countries, while doing it in a demand driven way that is not patronising? And then how to aggregate up? Perhaps via country typologies in terms of the nutrition problems they face and the capacity they have to collect and use data.
The parlous state of food consumption data. This was mentioned by nearly everyone as a problem. Food intake is vital to address undernutrition, but also other forms of malnutrition driven by unbalanced diets. How can countries formulate a strategy to address undernutrition in a balanced way if they do not know what their population eats? There are a number of initiatives in process to strengthen food intake data, but there was a general sense that data collection in this area needs to step up a gear.
Coverage data. As the GNR 2014 pointed out, of 10 Lancet nutrition specific interventions, only 4 have internationally comparable data on coverage for more than a handful of data (vitamin A supplementation of under 5’s, iodized salt intake, zinc treatment of under 5’s with diarrhea and iron folate capsule intake during pregnancy).
But what to do about nutrition specific intervention coverage? Why is it not more routinely embedded in on going data collection activities such as DHS/MICS/SMART surveys? One reason is that we do not have a set of agreed on and easily implemented coverage indicators that can be embedded in surveys or, indeed, in facility-based data collection. We need such a set.
And what to do about nutrition sensitive programmes? How do we know if they are nutrition sensitive and how do we figure out who they reach? No answers I’m afraid, just prioritizing unknowns.
Cost data for nutrition interventions. If we want to know how much reducing malnutrition costs—and try to make action more cost effective--cost information is essential. What can we do to make sure these are always collected? And how can these data be curated and made available to a wider audience?
So more questions than answers, but a list of follow up actions was drawn up, and different people committed to deliver on these actions. Many were process actions, but that is OK it seems to me. The costs of data collection are high and the costs of collecting the wrong data are even higher. Doing data things in a deliberate and coordinated way is important.
Surprises? There were 2-3 strong advocates for better micronutrient surveys but not as many arguing for it as I would have thought given the large numbers of people affectedly them, the lack of specificity about who they are and the lack of progress in addressing the burdens. We did not talk much about indicators for capacity (beyond the number of front line health workers) although this is an important issue. We talked about the need for better data on preventing severe acute malnutrition and on the coverage of treatment, but not as much as the issue perhaps deserves. As usual, the issues raised depend on who is in the room, no matter how objective they are trying to be.
In the context of the broader dialogue, the group is aiming to write a more considered piece for public consumption to contribute to the wider discussion about which data to invest in. And why that investment would fill a gap that is not much needed.
Posted by Lawrence Haddad at 07:54
01 June 2015
I was invited to the annual meeting of UNICEF nutrition leaders from around the world. It was a bit like an episode of Marvel's "Avengers Assembled" -- I had met so many of these great professionals at various stages in my own working journey. It was great to see them assembled in one place.
I had been asked by Werner Schultink, UNICEF Nutrition Chief, to speak to the topic of "What does the global community expect of UNICEF? How should it respond? My powerpoints are here.
What do I expect of UNICEF on nutrition?
1. Leadership. Nutrition is flavor of the month right now, but leadership is speaking up for nutrition when no-one else is doing so and UNICEF has been very good at doing that pre-2008. Keep doing it, even if everyone else is. More importantly, help us keep our feet on the ground.
2. Innovation. As Michael Anderson said at the IFPRI Forman Lecture last year, one can get carried away with innovation. Many times we just want people to do their job. But UNICEF has been a pioneer in so many areas: from the conceptual framework, to rights based programming, to using mobile phones and to being involved with the Power of Nutrition and UNIT LIFE financing facilities for nutrition. Keep asking yourselves and the rest of us: "what's next?" in nutrition.
3. Measurement. While I don't believe what gets measured always matters, we need to measure what does matter, and UNICEF is a fantastic fundraiser for surveys: from the regular MICS to one-off surveys in Maharashtra and the Indian nationwide Rapid Survey on Children. The GNR tells us that 40% of countries have anthropometry data that is at least 5 years old. Imagine what that statistic would look like without UNICEF.
4. Documenting stories. In an era when research fashions have sliced and diced the change landscape, we need organisations like UNICEF to commission comprehensive stories of change or stasis. If Kenya has just generated impressive declines in stunting, what has generated them? There will be a self serving element here--the commissioned work can tell UNICEF about their role (and if good, provide some promotional material) but the wider service to the field is to describe, analyse, inform and inspire everyone else. More please.
5. Support to countries. I have seen the invaluable long term support UNICEF has provided to Maharashtra, Uttar Pradesh and Ethiopia. They do it in a way that respects country leadership. Changing nutrition outcomes does not take as long as we sometimes think, but it does require 7-10 years of constant support--and this is an eternity for some governments and donors. UNICEF is patient.
6. OK before you wonder if I have been paid by UNICEF to write this blog (nope), what could they do better?
* work across sectors better. UNICEF is in a privileged position--they are not constrained by sector . So can they make the most of this liberty? Some of the UNICEF staff were very open--they could do better, but this would require support from UNICEF Res. Reps. Hey, if UNICEF cannot do it within their organization, how can the rest of us do it across organizations?
* help us all chart a pathway through the double burden terrain. More and more countries are struggling with the realities of the coexistence of under and overnutrition. What should they do? Be blind to it or blinded by it? Neither. We need a clear eyed vision, and UNICEF with their focus on health systems and schools can help.
* help us navigate another rocky terrain--business involvement in nutrition. When to stick or twist? And how to minimize the risks with doing either? Because much of the controversy surrounds the role of business in marketing products to infants and young children, UNICEF has to speak up and help develop some norms of behavior. Get more involved in the private sector debate.
* help us lock in the current high commitment to nutrition. This means making more noise about the lack of nutrition in the SDGs. UNICEF is a stone's throw (literally) from those haggling over the SDGs. Sharpen those elbows.
* help us make SMARTER commitments on nutrition. There is a big pledging moment coming up in Rio in August 2016. With a few exceptions, the nutrition community is not brilliant at making pledges that we can be held accountable for, so UNICEF maker your own commitments water tight and then help the rest of us to.
In many ways UNICEF is our moral compass on nutrition. Its influence and size are increasing: nearly $0.5 billion of spending on nutrition, 500 nutrition professionals world wide. These are numbers that we could only have dreamed of 10 years ago. But with power comes responsibility. In 3-5 years UNICEF will need to show what is has accomplished with this strong wind at its back. The time to start measuring is now. I have no doubt that the organization will rise to the challenge.
Posted by Lawrence Haddad at 22:56