29 September 2014

The New Hunger Figures: What Do They Tell Us?

The 2014 State of Food Insecurity in the World (SOFI) was released recently by FAO, IFAD and WFP, the three Rome-based UN agencies tasked with supporting efforts to reduce food insecurity and hunger.

SOFI centres on "undernourishment" estimates.  These are generated by estimated calories from food supply (production and net imports), divided by population to get a mean per capita value.  Undernourishment is the percent of a population below a minimum energy cutoff.  To estimate this percent, a log normal distribution is assumed for calories, then a coefficient of variation is assigned (which measures the spread of the distribution) by drawing on occasional income or food consumption surveys either from the region or the country.

Undernourishment is a rough estimate of hunger.  FAO is working on making it better through the use of more surveys to test assumptions and through working with Gallup on the new experiential hunger estimate, but for now this is the best we have.  (We need a Global Database on Food Security where all the food availability/food consumption surveys are vetted, reworked and housed, but that is another story.)

So what does the latest SOFI say?

* Globally 805 million people are estimated to be undernourished in 2012-14.  This is down from 1015 million in 1990-92, a decline of about 10 million a year.   Good news, although at this rate we will only have Zero Hunger in 2084 rather than 2030.

* China is responsible for 138 million of the 210 million decline over the past two decades.  Take China's extraordinary performance out and the rest of the world does not look so great.

* The less good news is that the numbers of undernourished in sub-Saharan Africa are increasing: 176 million in 1990-92 to 214 million in 2012-14, about 2 million a year.  (See picture above for all Africa.)

* Numbers undernourished in Western Asia (Iraq and Yemen are the 2 countries accounting for most of the regional numbers) have increased from 8 to 18.5 million in the past 20 years.  A reflection of the instability and conflict in the region.

* At the country level, there are some very odd numbers in there.  For instance, Zambia is 48% undernourished, and Lesotho  is 12% and yet they have similar Gross National Income per capita at purchasing power parity ($3070 in Zambia, $3320 in Lesotho) and in terms of inequality the poorest 20% of the population captures about the same proportion of income in each country (3.6% in Zambia and 3.0% in Lesotho).

* The report picks up on the idea of "enabling environments" which has been promoted by the DFID supported Transform Nutrition research programme (IFPRI, ICDDRB, IDS, PHFI) although it does not say much about how to construct them.

* The 7-8 country vignettes are nice because they show some of the complexity involved in attempting to reduce hunger,  but we need more than the box at the end of the vignettes to draw some cross-cutting conclusions.

* The report says the MDG hunger target is within reach, but does not say what "greater efforts" needed to reach it actually means.

Given the flawed nature of the data, and the fact that there is nothing better out there, these SOFI Reports do a good job of giving us a rough sense of the direction of travel different regions are making in the fight against hunger.   But their effectiveness simply masks the need for a Global Database on Food Security.  Someone needs to step up and fund that.

25 September 2014

Turning Rapid Growth into Meaningful Growth: Nutrition on the Cusp in Zambia

Earlier this week I was in Lusaka to help launch a new IDS report that I co-edited with Jody Harris (IFPRI, lead editor) and Silke Seco Grutz (DFID-Zambia) called "Turning Rapid Growth into Meaningful Growth: Sustaining the Commitment to Nutrition in Zambia".

The 11 articles were all prepared by Zambians and authors living in Zambia, so the papers are well rooted in the realities of the Zambian nutrition situation.  The papers noted the rather static nature of nutrition indicators in Zambia over the past 20 years (45% stunting rates, 5 % wasting rates, 56% of children under 5 and 42 % of women are anaemic, and overweight among under 5's and adults is increasing). 

The papers also noted how the commitment to act has grown dramatically in the past 3-4 years.  The papers identify opportunities to act for nutrition in agriculture and social protection and nutrition specific programmes.  Gaps were identified in capacity, resources, and evidence.  The potential for nutrition action at scale was noted due to the higher tax revenues flowing from Zambia’s minerals fuelled macro growth.  

But there are many challenges: 
  • The myth that “food=nutrition” retains a strong hold.  Improvements in food production and consumption are important of course.   Increased food production generates more for home consumption or more for sale and income generation—these are often good things for nutrition, although they will not be if newly large diets are not diverse or if increased income is not or cannot be spent on nutrition inputs such as better foods, safer water, improved sanitation, and higher quality health care.  Better food production may be helpful to improve nutrition, but it is not automatic that food production=food consumption=good nutrition.
  • The doubts persist about whether the international standards apply to Zambians (they do, at least for 0-24 month old children).  As long ago as 1974 Habicht et. al. noted that any ethnic differences in heights and weights at similar socioeconomic status were much smaller than differences across socioeconomic strata.  It is poverty, not ethnicity, that drives undernutrition.
  • The government administrative machinery has not yet caught up with the renewed commitment to nutrition.  For example the Demographic and Health Survey conducted in 2011 has not yet been released, and funds that have been committed by development partners to the districts have been held up in a bureaucratic loop for 9 months or so.  Bureaucratic bottlenecks have high costs.  
  • Government spending on interventions with a nutrition focus is low: 0.03% of total government expenditure is allocated to direct nutrition interventions, and 0.31% of the health budget as estimated by the SUN CSO alliance.  Spending on direct nutrition interventions (including water and sanitation) per child under the age of 2 is 3 Zambian Kwatcha compared to a recommended level of 190 per under 2 year old from the World Bank. Spending on direct interventions needs to increase--not much can be achieved at these levels.  The World Bank (unpublished as yet) estimates the nutrition finance gap as $24 million per year.  It is not much is it?  
  • There are not enough nutritionists in the country.  The new University of Zambia undergraduate degree in nutrition has been going for a few years now and if the sharp questions the students asked me during my public lecture (power points here) is anything to go by, the course seems to be a great success. A Master’s programme is in the works, and Hilary Powers (of the Geissler and Powers authoritative textbook fame) has been seconded to the University for 2015.  Nutrition cannot be scaled up without qualified and trained people to do it.   
However, there are plenty of causes for optimism:

  • The Government is more focused than ever on nutrition, with a new food and nutrition Act in progress, the strengthening of the National Food and Nutrition Commission, and some progress towards the Nutrition 4 Growth Commitments.  The Vice President wrote the foreword to the report, attended the launch and invited us to meet with him the next day for a discussion about nutrition.
  • A social cash transfer programme is about to be launched nationwide.  The programme is not only targeted to those households with children under the age of 5 or 2 (too difficult politically to give cash to some poor households and ignore other equally poor households in the community) nevertheless an early pilot evaluation (summarised in our Report) found that the cash transfers do improve diet diversity for the household when mothers have higher levels of education.  It would be good if some conditionalities were tried (cash if children are immunized, clinic check ups are undertaken, or classes in improved infant and young child feeding practices were attended)
  • The Ministry of Agriculture has a unit dedicated to nutrition, and there are plenty of ideas about how nutrition can become more nutrition sensitive, whether reducing aflatoxins in maize or improving the attractiveness of fish farming as a sustainable business.
  • The international development partners are investing in nutrition actions, including funding nutrition plans of action in 14 districts, building capacity at the frontlines, and in the universities, with great leadership from Silke Seco Grutz and others.
  • Civil society is more and more mobilized, strategic and organized. The CSO SUN Alliance is doing a great job, with great leadership from William Chilufya.  For example, they are the ones who estimated the expenditures to nutrition by ploughing through the 2500 page budget document.
  • A small but growing group of Parliamentarians are deeply committed to nutrition improvement and there is a public commitment from one of them about getting them organized into a committee, group or caucus, much as in the UK with the influential Select Committee on International Development and the All Party Parliamentary Group on Agriculture and Food for Development
  • Some prominent broadcasters are deeply concerned about malnutrition. While I was there I was interviewed by the state broadcasting agency, ZNBC.
  • Tax revenues are rising generating more potential fiscal space for nutrition.  It was too bad no-one was present form the Ministry of Finance for our launch.  We tried.  If minerals driven growth in the Zambian economy is to have a positive legacy rather than be a (literal) flash in the  pan,  those tax revenues will need to be invested in something that yields long term high benefit cost ratios. This is what we meant in the title of the Report by "turning rapid growth into meaningful growth". 
  • Investments in human infrastructure (i.e. healthy growth) have high economic returns. There is a lot of hard infrastructure investment in Zambia right now.  Roads, offices, homes are being built.  They have good economic returns and may help improve nutrition somewhat.  But investing in proven nutrition interventions generates benefit cost ratios of 16.  In other words, invest 100,000 Zambian Kwachas today and watch that grow to 1.6 million Kwachas over the next 25 years. Attention Ministry of Finance officials: that is an annual rate of compound interest of over 11%!

A civil society scorecard for nutrition actions?

As ever, civil society needs to be the lead change maker.  Social change comes from concerned and feisty citizens organizing to demand better of their often well intentioned but always busy and distracted governments.  It would be great to see a simple scorecard of government commitment that can be tracked. 

Candidates include
  • % of budget spent on nutrition
  • Number of nutritionists on the public payroll
  • Number of times nutrition is mentioned in public speeches and policy documents

A Credit Rating for Nutrition?

While I was in the country, the news reported that Zambia has been given a higher than ever credit rating by Fitch due to strong growth and sound macro policies.  This was cause for much celebration amongst the economics journalists.  Zambian civil society can become the ratings agency for nutrition.  How reliable will the government be on nutrition commitments?  Any improvement in the nutrition rating would not only be cause for celebration in the nutrition community but also for the economists.  We just need to get them to see it! 

Undernutrition levels in Zambia are on the cusp of a great decline.  For that decline to happen the commitment to nutrition must be sustained--and intensified-- by all stakeholders, but especially by the body that is accountable to its citizens, the Government.  All stakeholders need to come together to push, nag, support and applaud the  Government in its efforts to do this. 

16 September 2014

Global Nutrition Report 2014 - Update

If I have been quiet on the blog front these past few months, it has been because we have been working hard on the first Global Nutrition Report.

We have now completed a draft that is ready for copyediting and formatting.  It has been through 4 versions, has received countless sets of excellent comments from a wide range of stakeholders (no doubt many of you reading this) and has involved interaction with a wide range of authors (there are over 40 panels and 80 panel authors).

The outputs include:

  • The Report (print and online)
  • 40 longer Panels (online)
  • 3 longer Technical Notes (online)
  • 193 Nutrition Country Profiles (online)
  • Powerpoints with key messages
  • A 4 page Issue Brief

We are also working on a summary article for the Lancet.

The launch of the Report will be at the Second International Conference on Nutrition (ICN2) in Rome on November 19-20.

We will be using the Report to initiate a number of roundtables in Belgium, Ethiopia, India, Indonesia, Latin America, Senegal, Switzerland, US, and the UK.  They will take place between December and March.

I just wanted to acknowledge the broader nutrition community's contribution.  You have been generous with your ideas, energy, time, and constructive criticism.  Thank you.

We also have an amazing Independent Expert Group and an immense Secretariat team at IDS and IFPRI. The former determined the content, shape and flow of the Report and assured its quality and the latter did much of the analysis and writing. I would like to thank both groups.  Finally, our Stakeholder Group (including 7 funders) also deserves a lot of thanks--they have been tremendously supportive and encouraging.

Anyway, enough of that, no rest for the wicked--work on the 2015 Report starts soon!

14 September 2014

Fitting the Evaluation Design to the Intervention: New paper on nutrition and mobile phones in Indonesia

It is not often that you see a paper that outlines the process of how an intervention design was created to fit the context and features of the programme and the outcomes of interest.

Often the impact assessment method is fixed and the researchers only take on impact questions that fit the method they prefer, hence there is little effort expended in figuring out what is the right way to evaluate a given programme.

Here is a new paper from Inka Barnett and colleagues at IDS that bucks this trend.  The researchers from IDS were looking for a mobile phone intervention in nutrition to evaluate.  They found a willing partner (World Vision) in Indonesia who said this is what the intervention looks like (mobile phones in nutrition growth monitoring, counselling and service delivery) and this is the flexibility there is to adjust the intervention to permit better evaluation (not much).  The question all parties wanted the answer to was whether mobile phones are better than paper based methods for generating more accurate and timely information on nutrition outcomes and behaviours, leading to more timely and more effective action.  And if so, why?

The study is just starting, but the care with which the impact evaluation design has been created is different.  For example, for various reasons it was not possible to randomise the mobile phone versus paper method of recording, so there can be no treatment and control group.  Undeterred the evaluators scoured the evaluation toolbox and came up with a Mill's Method of Difference design (circa 1843!) which identifies the net effect of mobile phones by looking at the difference of the two methods used simultaneously by the same set of clinics and households.

I recommend the paper--a good example of how to rummage around in the big evaluation tool box for the right tool for the most important job, rather than only picking the jobs that yield to the tool you are most comfortable with using.

05 August 2014

So What Drove Maharashtra's Stunting Declines 2006-2012? New Study

Today a new report from IDS-UNICEF (written by me, Nick Nisbett, Inka Barnett and Elsa Valli) on the reasons for the rapid declines in stunting in Maharashtra between 2006 and 2012.

Report is here.  Video is here.  Powerpoints are here.

We used three approaches to tell the story: a review of reports and studies; primary stakeholder interviews and a comparison of two the surveys from 2006 and 2012.

We found improvements in stunting were across the board in all groups.  There were many improvements in determinants at many levels and in many sectors, but they were not amazingly large--they were just wide-ranging.

The conclusions were that if stunting cannot decline in Maharashtra where lots of things were moving in the right direction then stunting will not decline anywhere.

On the other hand there were still things that did not improve much--food security, sanitation, and PDS leakage.   So Maharashtra is not such a perfect scenario that these results cannot be replicated elsewhere (and probably are in many Indian states).

Finally we noted that these declines took 10 years of public commitment and quiet hard work from governments, civil society and researchers --all working together.

Undernutrition can come down quickly, it just takes a lot of people working together with a strong and enduring focus.

01 August 2014

Nutrition for the Next Generation: what the US - Africa Summit should really focus on

“Investing in the Next Generation” is the powerful theme for next week’s US-Africa Summit in Washington DC.

It’s a big moment. Convened by Barack Obama and spanning three days with around 50 heads of state, a range of African and US businesses leaders, civil society, youth leaders and politicians. No doubt there will be plenty of announcements, handshakes, deals, pledges and rhetoric.

I hope that one issue has the attention it deserves. Good nutrition is one of the best investments political leaders can make in the next generation. If you want your countries’ kids to maximise their potential in life and to supercharge your demographic dividend, you should invest in child nutrition in the womb and in their early years. The right nutrition at the right time will not only  give your children a head start in life, it will slow down the onset of non-communicable diseases that are now dominating health burdens throughout the world—diabetes, hypertension, coronary heart disease and obesity.  Well-nourished mothers are more likely to give birth to well-nourished babies.  This is an investment in the next generation, and the next: the investment returns are remarkable.

Ten years ago, these points were not well known. Now there is widespread recognition that sustainable economic growth and child growth are inextricably linked. I have written about the economic impact of undernutrition, which may cost African countries on average 11% of GDP[1].  Given the enormous potential GDP win, you would think all government leaders and economic planners would have their eyes on their undernutrition rates and make massive budget allocations to fix the problem. But the data is not available.

Can you imagine running an economy with data that is 5-10 years out of date?  Week in week out, Ministers of Finance and political leaders sweat the decimal points over inflation rates, interest rates, employment rates and the rate of GDP growth.  Up to date data is critical to make informed economic course corrections and to prevent or recover from crises. But up to date nutrition rates or data on nutrition spend?  Not so.

There are many initiatives to try to fill these data gaps. 

The Global Nutrition Report, an initiative of a wide range of stakeholders from national governments, the UN, civil society and donors, is attempting to bring all of the data together and make it widely available and easy to use.  The idea is to help measure progress, strengthen accountability and reduce malnutrition faster.  The Report will be launched in November at the Second International Conference on Nutrition in Rome. We are working hard on a first draft, but some things are already clear:
  • Few countries have the data to even tell if they are on target for more than 3 of the 6 World Health Assembly nutrition goals.
  • Hardly any data is available on what governments actually spend on nutrition.
  • The 70 or so nutrition relevant indicators the Report has collected (on outcomes, programmes, determinants and inputs) are not consistently available.
This is not the fault of the organisations tasked with collecting these data—they are doing heroic things on modest budgets.  They want the data to be good quality, relevant, timely and used.  But too often, organisational decisions on budget allocations assume that data collection can be done on the cheap, when even low quality data is expensive to collect. Many organisations also think that data collection does not bring enough direct benefits. Even worse, some think that the data is not valuable enough, assuming wrongly that we will not be able to respond effectively to what the data is telling us.

We would not think that way in economics. Constructing household income is a devilishly difficult thing to do with a huge number of challenging assumptions about prices, consumption baskets, the costing of in-kind consumption, self-reporting accuracy etc.   For child growth you have to collect age, weight and height.  Easier said than done, but just like you can train an economist to measure prices per common unit of weight or volume, you can train for collection of good nutrition data.   In economics we would invest in surveys, enumerators, supervisors, data processors, data checking routines, analysts and smart ways  to communicate the data.  Governments would then tell us how they were going to react.  Conversations and debate would ensue.  Action would be demanded.   

Economics matter to politicians.  But politicians should care as much about child growth as they do about economic growth because they are inextricably linked. We need a data revolution in nutrition and we need it now.  Without investments in good data for nutrition, we are less likely to have good nutrition.  And that really is bad for the economy.

I hope that during the three days of talks at the US-Africa Summit, the leaders are not content to settle for the world as it is. They should have the courage to remake the world as it should be. Invest in good nutrition for the next generation.

(Note, this article first appeared on the Devex website

[1] Child Growth=Sustainable Economic Growth: Why we should invest in Nutrition, Haddad 2013, [include weblink] 

31 July 2014

Latest Proposed SDGs: What are the links with nutrition?

The latest proposal for 17 Sustainable Development Goals (SDGs) came out on July 19.

What are their links with nutrition and what contributions can nutrition make to them?

Here is a quick analysis (here and below).  Out of 126 sub goals, nutrition is mentioned in 2.

I'm still digesting it, but let me know if you disagree or if I have missed anything.

As the SDGs are potentially the  major accountability mechanism for the post 2015 era we are particularly interested in this for the Global Nutrition Report which aims to promote accountability in nutrition.