23 April 2015

What the Different UK Political Parties Really Think about DFID

14 days to go to the closest UK General Election in recent history and we have not heard much about DFID/UKAid/Overseas spending, except from UKIP which is not keen at all.

This lack of election fever debate is good in the short run and reflects a consensus that having a sizable international development budget is the right and smart thing to do.

But in the medium run it would be good to have a discussion of when and how the aid budget changes and evolves. An election is exactly the wrong time to do this because everything in the discourse becomes binary, simplistic and shrill.

However, we do need a debate on the long term future of UK Aid and I hope the new Government starts thinking and consulting about it.

In any case, a friend asked me if I was going to do a blog on the different parties' views on DFID--as I did back in 2010.  I told him I thought there was not enough grist for a decent blog.

But behind the harmony of the public positions, what are the UK political parties really thinking about DFID?

Here is my entirely non-serious attempt to read their minds (apologies to non UK readers for the in-jokes):

Conservatives: well, that was a real vote winner!

Greens: we'll double the 0.7% to 1.0%. Er, hold on..

Labour: blimey, I hope we're not supporting zero hours jobs overseas

Plaid Cymru (Welsh Nationalists): it already sounds like a Welsh town & Wales is international, right?

Scottish Nationalist Party: it supports strong national governments all over the world ;)

UK Independence Party: nuke it, nuke it, and then nuke it again

Liberal Democrats: what they said...

Needed: Nutrition Behaviour Change Communication for the Powerful

This week I was invited to give a keynote on the global nutrition situation in the context of a book launch on Development and Nutrition: The Role of Social Norms by the excellent Elaina La Ferrera and Annamaria Milazzo of Bocconi University with the support of the Fondazione Romeo and Enrica Invernizzi, one of the supporters of the Milan Expo 2015 which starts next month.

The book reviews norms around inheritance, intrahousehold resource allocation and beliefs around diet and nutrition. The authors report on some interesting issues such as what happens to diets when people move to different states or countries (sometimes good for nutrition, sometimes not) , the differences in nutrition status across religions controlling for all other factors (e.g. Hindus with stronger son preference compared to Muslims in India), the strengthening of inheritance rights for women (good for infant nutrition), the delineation of certain crops as being grown by women or men and the brake that puts on household food security. 

This is a fascinating review, but it tends to focus on norms that affect the household.  But these norms also affect powerful decision-makers in the public and private sectors. And these individuals are perhaps better positioned to change the norms. 
Consider the following social norms I commonly encounter in policy circles:

*Income growth will take care of nutrition status. It will take care about half of undernutrition—in the long term.  Kids don’t have the luxury of waiting.  Keynes said in the long run we are all dead, but for young children, they are more likely to die in the short run without adequate nutrition.

*Food security is the same as nutrition. Food security is one of the 3 legs of the nutrition table.  Care and health environments are the other 2.  Food security is necessary but not sufficient for good nutrition. 

*Children 0-2 grow differently in different countries.  The WHO growth standards study shows definitely that they do not.  After the age of 2 maybe, but until then, no.

*Women’s time is less valuable than men’s.  While women tend to have less access to resources, control and authority, asking them to do more things may be even more disempowering.  They need to have more control over the priceless commodity of time.  

All of these norms need to be challenged and updated.  As any good community behavior change communication initiatives will know, information and evidence are vital, but not nearly enough.
Engagement, mobilization, ownership and collective action are all vital for changing norms at the community and household levels. They are vital in policy circles too.   

18 April 2015

Why Has Stunting Declined So Fast in Tanzania? Poverty Reduction & Nutrition Spending Increases Matter

I just returned from a week in Tanzania, exploring options for evaluating the impact of m-nutrition initiatives on nutrition behaviours and status.  More on that as it develops.

During the trip I found out about a recently released 2014 SMART national nutrition survey that shows under 5 stunting rates at 34.7% in 2014, down from 42% in 2010.  That is 7.3 percentage points in 4 years. Good news.  This is an annual average rate of reduction of nearly 5% -- well above the nearly 4% required to meet the World Health Assembly targets.  If this can be maintained then this is even better news.  But there seems to be no consensus as to what is driving the decline.

I don't know of a study that looks into this for Tanzania (my IFPRI colleague Derek Headey has done these kinds of studies in Ethiopia, Bangladesh and Nepal), so I went to the Global Nutrition Report's Tanzania Nutrition Country Profile.  The profile shows that the rates of food security, improved water and improved sanitation are all increasing, but very slowly.  Unimproved sanitation + open defecation rates remain very high (79% in 2012).  Economic growth is steady but not spectacular.  The big change seems to be $1.25 a day poverty rates which have almost halved in 12 years: 85% in 2000 to 43% in 2012. 

As you can see from the link to the 2014 survey results, infant and young child feeding has not improved and for exclusive breastfeeding rates have actually decreased.  Iron Folate supplementation rates have increased, Vitamin A supplementation rates for under 5's have increased and women's thinness has declined:  but none of these positive changes are huge.

The Government of Tanzania's health expenditure has increased substantially between 2008 ($383 million) and 2014 ($622 million).  The 2014 Nutrition Public Expenditure Review is even more revealing. As the picture below shows, the total budget for the nutrition sector has increased rapidly.  Equally important the share of the government in that expenditure, although quite low at about 30%, has held steady, so real GoT expenditure on nutrition is also increasing rapidly.

This is the really good news story--an increasing government commitment to nutrition, not only in words, but also in cold hard cash that has multiple alternative uses.  Of course, money is not the only important resource, and it has to be spent on things that can improve nutrition, but scale up of programmes is impossible without it.

So, while we need a proper study to confirm it, maybe, just maybe, it is the declining poverty rate combined with increased nutrition spending by government and external partners, that is responsible for the decline in stunting in Tanzania.  And more good news: there is plenty of room for improvement in water, sanitation and infant and young child feeding programme coverage rates. 

Can Tanzania meet its WHA targets? If these trends are maintained the situation seems very positive. 

11 April 2015

Measuring Women's Empowerment: Is it worth it? Yes.

There are two things about empowerment.  First it is a process: a process of increasing power.  Second it is about "power".   As a process it is perhaps not that easy to quantify.  As for "power", well, the ways in which that is exercised are highly context specific and difficult to recognise.  Trying to quantify women's empowerment in a cross-region context is a task for brave souls.  

And yet this is exactly what my IFPRI colleagues Hazel Malapit and Agnes Quisumbing have attempted to do with the Women's Empowerment in Agriculture Index (WEAI), working with colleagues from OPHI and USAID's Feed the Future. Malapit and Quisumbing's latest paper --on Ghana--has just come out in the journal Food Policy.  

Why is it even worth attempting to measure women's empowerment?  Well we know that various measures of women's power to control resources, their own bodies and their own mobility are associated with a range of food security and nutrition status outcomes and we know that women are routinely denied access to the same kinds of agricultural inputs that men take for granted.  So if we can identify domains or geographical areas where their power relative to men is low, then we can better try to take the power imbalance into account --and even contribute to eifforts to change it--thereby improving a range of food security and nutrition status outcomes (as well as a range of other outcomes and of course women's status to control decisions is a vitally important outcome in and of itself). 

As the authors note, the WEAI is a survey based index that “directly assesses women’s empowerment across five domains in agriculture, namely, agricultural production, access to and control over productive resources, control over the use of income, leadership in the community, and time allocation. The women’s empowerment score reflects the extent to which women are empowered in these domains. Comparing women’s and men’s empowerment scores enables us to assess the inequality between the achievements of women relative to the men in their households.”  

There are 10 indicators across the 5 domains (see picture at top of post).  One domain has one indicator (e.g. sole or joint control over income and expenditures) and it is weighted as 1/5 of the index.  One domain (resources) has 3 indicators and each of them are weighted as 1/15 of the index.  The overall index is useful as a headline, but the real value is that the WEAI can be broken down into the 5 domains of empowerment: production resources, income, leadership and time.

This paper asks: in Northern Ghana, which domains of empowerment are associated with (a) infant and young child feeding practices AND (b) child and women nutrition status.  Ordinary least squares are used to assess associations between various domains of WEAI and these nutrition related outcomes, controlling for a wide range of individual and household characteristics.  The authors also test whether the associations between WEAI components and child nutrition status differ for boys and girls.  The IYCF outcomes are exclusive breastfeeding up until 6 months of age, minimum diet diversity and minimum adequate diet scores for children 6-24 months of age, stunting wasting and underweight and for women the indicators relate to diet diversity, underweight and BMI.

For the sample of women in northern Ghana all 10 indicators have significant deficits in terms of women’s empowerment, with access to and control over assets, credit and income being the most important.

The results show:

* On IYCF practices, WEAI index and component domain scores show a few statistically significant associations (p less than 0.05) but they are mixed (some positively associated with practices, some negatively)

* No significant associations (p less than 0.05) between WEAI or components and child nutrition status measures

* No significant associations (p less than 0.05) between WEAI or components and women’s BMI, but positive and significant association between women’s control of credit decisions and women’s diet diversity

These results are interesting, but raise more questions than they answer.  The authors are not surprised by the complexity of the findings and acknowledge that context is everything; that not all domains of empowerment will be associated with all manner of nutrition practices and outcomes;  and when they are associated, the direction of association may be counter intuitive. 

The WEAI is available for 18 countries.  It should be used by policymakers who care about nutrition—to identify bottlenecks to improved nutrition practices and outcomes (such as access to and control over credit decisions and the strong positive associations with women’s diet diversity in northern Ghana)—but also because gender parity is a right and women’s empowerment has many benefits to women, families and society that just cannot be measured in a quantitative way.

20 March 2015

Nutrition Happiness is…

On International Happiness Day, here are my 10 tweets on Nutrition Happiness

18 March 2015

What has sanitation done for nutrition lately? Not enough. New paper

Today sees the launch of IFPRI's 2014 Global Food Policy Report.

Dean Spears and I have a chapter in it on sanitation and nutrition (actually, Dean did most of the work).

The paper looks at the links between WASH (mostly sanitation) and nutrition through different types of evidence, research implications and implications for policy.

* observational evidence: noting (among other things) that kids in West Bengal, just across the border from Bangladesh, come from higher income households than their Bangladeshi counterparts but have lower height for age scores.  We cite evidence that suggests (it is observational after all) the rapid decline in open defecation in Bangladesh (from 34% in 1990 to 2.5% in 2012) has something to do with the fairly rapid decline in stunting in Bangladesh.

* impact evaluations: here we note, with the exception of a study in Mali, that sanitation interventions have not shown much impact on child stunting (or other nutrition status outcomes).  The main reason is that the interventions were not effective in changing behaviour around open defecation.  No change in behaviour, no change in nutrition status. So we need to design better interventions.

This is the challenging first stage of WASH interventions (see below).

* research priorities:  these include, obviously, research that will help construct interventions that will change WASH behaviours.  Simply providing household toilets is not sufficient and in some case may not even be necessary (communal might be OK).  Behaviour change in this domain (pretty much like in most domains) is complex and varied partly because it is so wrapped up in diverse cultural norms.

* policy implications: First, invest in (and evaluate) pilots that attempt to change behaviours around open defecation and other practices that we think negatively affects nutrition status.  Second, be careful in wanting to make WASH nutrition sensitive.  It may help WASH become more effective at reducing nutrition by emphasising the consequences of current WASH behaviours, but it might also overload frontline workers and the bureaucracies behind (or on top of) them.

Is breastfeeding associated with increased earning later in life? New paper by Victora et al. from Brazil

It is not every day that a study based on a 30 year prospective cohort is published, and when it is led by Cesar Victora, in Lancet Global Health, we had better pay attention.

The study was trying to become the first to directly explore the association between duration of breast-feeding and earnings.  There had been much suggestive work showing indirect links between earnings and breastfeeding (via things like child IQ and school enrolment), but nothing directly linking breastfeeding to adult earnings.

The study tracked 5914 newborns from 1982, born in 5 maternity hospitals in Pelotas, Brazil.  In 2012-13 the authors were able to do follow up analyses on 3493 members (some could not be traced, some had died, some had incomplete information on IQ and breastfeeding).

The study measured the duration of breastfeeding (21% of sample less than 1 month; up to 17% of sample greater than or equal to 12 months) and the duration of predominant breastfeeding (26% of sample less than 1 month; up to 12% of the sample greater than or equal to 4 months;  defined as "the age when foods other than breast milk, teas or water were introduced". The authors say that exclusive breastfeeding was "seldom practised at the time", hence they did not analyse it).  

The study controlled for potential confounders such as monthly family income, household assets, maternal education, maternal age, pre-pregnancy body mass index of mother, type of birth delivery,  gestational age, birthweight and, interestingly, genomic ancestry (based on DNA samples).

The study found that adult IQ was significantly increased by duration of breastfeeding and by duration of predominant breastfeeding, as were educational attainment and adult income.

For duration of breastfeeding and IQ the key results are in the figure below.  Note the association between family income at birth and subsequent IQ (this shows the importance of controlling for confounders such as income at birth).  Even controlling for family income at birth (and the other confounders), you can see how IQ increases with duration of breastfeeding, with a bigger effect for the higher income group (the red triangles)

The results are even more striking, I think, for predominant breastfeeding. Predominant breastfeeding covers a shorter period and is associated with a monthly increase in income that is over 80% of the income increase associated with longer durations of (not necessarily predominant) breastfeeding.  It is too bad the exclusive breast-feeding data were not suitable for analysis.

The increases in IQ and educational attainment are associated with increases in monthly income (IQ is responsible for 72% of the "effect" of breastfeeding on income).

How big are the income changes?  For the difference between lowest and highest duration of breastfeeding the effects are big: nearly one year of additional education, 4 points in IQ and about an additional one third of the average income.  How many education and income generation programmes would like to show that size of effect? A lot.

Is the methodology good enough?  The authors are careful to emphasise this is an associational study--for causation you would have to randomly assign babies to breastfeeding and non breast-feeding groups and of course that is not ethical.

The authors check on attrition (are the people they found in 2012-13 sufficiently representative of the original set of newborns?) Yes.

They control for confounding variables using regression analysis (although unlike economic journals, medical journals never seem to give much detail on the regression methods used--hey at least they still publish these kinds of associational studies, but that is another point).

There is some recall data on duration of breastfeeding for 4% of the sample, and  this is found to be of reasonable accuracy.  Seasonality of monthly income is not a major issue in this urban population. IQ tests were not done for parents, but educational attainment was included as a proxy.

The study also notes that the breast-feeding mechanism (is it the content of the breast milk or is it the bonding) cannot be determined, and admits the possibility of influence of unmeasured confounders such as intellectual stimulation or simply the woman's motivation to be a good mother.

In all cases the authors do more than enough to assure me (if I had been a reviewer) that they are cognizant of the study limitations, have done all they can to address them, and that they do not undermine the fundamental finding of the paper.

This is a carefully done study that finds large and significant associations between breastfeeding, IQ, education and income.  Can we be definitive that the findings are causal? No. Can we be confident that they are? Yes.

Economic policymakers, I hope you are listening.