30 September 2015

The Global #NutritionReport Roadshow Begins!

Another year, another round of launches for the Global Nutrition Report.  Why do we do it? Is it some suppressed desire to be doing a world tour with a band?  An attempt to rack up air miles?  Supporting a double life as a hotel inspector?
No, it just seems the best way to communicate the gravity and nuance of the malnutrition situation in a given context and to give added impetus to those who are trying to find solutions.

Showing up equals engagement.  And engagement is essential because the IEG wants the report to be an intervention.
Last year the most media attention and the greatest impact of the report was around the launches.

The launches in the US were geared to lead into SDG week, COP21 in Paris and Davos in early 2016. For the SDG summit the idea was to help keep nutrition in the forefront of those who are negotiating the final indicators for the goals and targets.  For the COP the idea is to get nutrition into some side events to begin building momentum for greater linking of climate modelling to nutrition and greater climate proofing of nutrition interventions. For Davos the idea is to promote dialogue on the role of business and nutrition: not just talking past each other but talking to each other. 
It’s too early to tell if the launches helped with these aims, we will track, but the immediate goal of creating a buzz within the nutrition community and introducing them to the substance of the GNR the events worked well.  Both were full houses of about 160 people.  Both had high level panels.  The DC event worked better because we linked the panel discussion more explicitly to the Report by asking the panelists “what is your favourite number from the report and why?”

The NY event put the panel first in an attempt at scene setting and, while very interesting, was not sufficiently linked to the Report itself.  We will learn from that.
In NY David Miliband was passionate about nutrition and conflict, refugees and internally displaced people.  He pointed out the lack of focus on conflict and nutrition in the report and this is definitely something to consider for future reports.  We will have to see what the Global Hunger Index report –on conflict and hunger--in October 2015 produces.  Joy Phumaphi talked about the importance of country ownership of targets and the fine balance between prodding and embarrassing governments with scorecards.  Graca Machel talked about the centrality of nutrition for central development.  Ertharin Cousin talked about the extensive existing role of business in nutrition and called for more effort in working out the contexts, problems, age groups and products where they might make a positive contribution.  Health Minister Moeloek conveyed the complexity of having to deal with the double burden of nutrition in Indonesia.

The DC event was punchier, perhaps because it was shorter, but also because, as noted above, it had a panel explicitly linked to the report.  Rob Bertram from USAID Food Security Bureau stressed the potential of differently designed agriculture for nutrition.  His favourite number was the large increase in the number of countries, 39--up from 24 last year--that were on course for the WHA stunting target.  Sanjeev Gupta from the IMF was interested in the 16 to 1 economic returns, wondered why that ratio was not more persuasive to Ministers of Finance and was going to look into whether public expenditure reviews could more routinely include nutrition.  Asma Lateef from Bread for the World Institute said her favorite number was 2: SDG 2 on Food and Nutrition, (an achievement to be celebrated), 2 nutrition indicators and 2 months left to get more indicators included.  Clever.  She urged us to get behind the Road to Rio call to spend money better on nutrition, but also for governments and donors to choose to allocate more to nutrition.  

Mike Jacobson from the Centre for Science in the Public Interest told us the scariest number was the 1 in 12 globally suffering from diabetes and told us about the giant threat of big soda moving from the US to the rest of the world as soda consumption declines in America.  He likened it to tobacco companies strategies and feared for populations yet to be subjected to the full blast of soda advertising. Steve Jaffee from the World Bank was interested in the obesity stats (only Nauru, pop 11,000, managed to reduce obesity rates, and then only just) and environmental links between climate, agriculture and nutrition.
The panel facilitators in NY (Leith Greenslade) and DC (Augustin Flory) and my co-presenters Corinna Hawkes and Emorn Udomkesmalee in their different ways did a great job of bringing the calls to action in the report to life for the various audiences. 

As usual it remains a privilege and an energizer to summarise the work of so many great authors and contributors to the report, 70 authors and well over 100 reviewers. 
We now take the report to Africa, South and South East Asia.  We would like to see some Latin America launches too.

If you want to undertake a GNR launch (and they can be small in numbers of audience) then please do contact globalnutritionreport@ids.ac.uk

29 September 2015

The Hunger & Nutrition Commitment Index 2014: The Good, the Bad & the Ugly

I’m currently in Namibia attending a meeting of MPs from the 15 countries in the Southern African Development Community (SADC).  The meeting, co-convened by the Inter-Parliamentary Unit of SADC and UNICEF is intended to support nutrition champions within parliaments to make the case for nutrition to their governments.  I was presenting some of the results from the just released 2015 Global Nutrition Report.

During my presentation I showcased where the SADC countries landed in the 2013 Hunger and Nutrition Commitment Index (HANCI).  Immediately 2 of the countries queried why they were so low in the rankings when they were Nutrition4Growth signatories and members of Scaling UpNutrition movement. I pointed out that the 2015 Global Nutrition Report showed that these countries’ budget allocations to nutrition—something HANCI keys into—were low.  Commitments are only words on a piece of paper until they are backed up by resources.  That’s the beauty of HANCI--it starts conversations about why the country is where it is.  The MPs from those two countries go back to their legislatures armed with information that will help them make the case for nutrition.

This week we see the production of a new set of rankings and scores for 45 countries based on data from 2014. As usual, the 2014 HANCI is based on a set of publicly available data which are fashioned into 20 or so indicators in three buckets—policies, legislation and spending.  The HANCI can also be broken out into a hunger component (HRCI) and a nutrition one (NCI). So what do the new rankings tell us?

From Tables 3.2 and 3.3 we can see that:

* Peru is now number 1 in the HANCI rankings, followed by Guatemala, Malawi, Madagascar and Brazil. What is interesting is that only Peru, Malawi and Brazil do well on the nutrition component, the Nutrition Commitment Index (NCI).  Madagascar is 16th in nutrition rank but 3rd in hunger reduction rank.  India is 7th in hunger but only 30th in nutrition. As I have said many times before, a commitment to reduce hunger is not the same as the commitment to reduce malnutrition.

* Gambia is number 1 in nutrition, followed by Peru, Nepal, Brazil and Malawi

*Guatemala is 1 in hunger reduction, followed by China, Madagascar, Malawi and Rwanda

* The countries at the bottom of the ranking are from fragile and conflict affected contexts and countries where governance is weak: Myanmar 41, Yemen 42, Angola 43, Sudan 44 and Guinea Bissau 45. Nigeria, a country with abundant resources, is 40.

* What about the movers?  Who is up and who is down? For nutrition the biggest jumps are for Mali (up 22 places on the NCI) and South Africa (up 20 places on the NCI). For hunger reduction the biggest jumpers are Benin and DRC (up 10 places on the HRCI) and Cameroon (up 9 places on the HRCI). For nutrition the biggest declines come for Pakistan, Mozambique, Burundi and Cambodia (all 8 places down on NCI). For hunger reduction the biggest declines are Mali, Tanzania and Zambia (all 10 places down on HRCI) and South Africa, Sierra Leone, Senegal and Lesotho (all 9 places down)  

Are there any surprises for me?  Well Ethiopia does well on the HANCI (the combined score) but that is driven by good performance on hunger reduction.  The nutrition ranking is only 31 out of 45, which given nutrition leadership in Ethiopia, is surprising. This is something the Ethiopian policymakers may want to reflect on.

 Where next for HANCI?  In general I would like to see the HANCI expand to more countries: high, middle and low income.  What is the UK government doing to end hunger and malnutrition at home? I would like to know how it fares.  I would also like to see some regression work linking a change in commitment to changes in stunting and wasting over the same period.  This would need HANCI to be constructed for these 45 countries around the turn of the century. 
The main potential for the impact of HANCI is country level briefings with government policymakers. If the HANCI data are out of date then this is a good opportunity to get the fresh data into the public domain. If it is not out of date then responses can be formulated.  Either way, as with the Global Nutrition Report, dialogue is promoted, accountability strengthened and more resources are allocated to hunger reduction and nutrition.  At least that is the theory—this needs to be tested via an evaluation in the next year or two.
As one of the co-founders of HANCI (coming out of the Irish Hunger Task Force) I’m really pleased to see HANCI thriving.  My warm congratulations to the IDS team behind HANCI, led by Dolf Te Lintelo, and to DFID and Irish Aid for supporting it.   Can’t wait for the donor HANCI!

20 September 2015

Someone you know is probably malnourished. What are you going to do about it?

When you ask advocates why they become champions of a cause, it is usually because of some personal wake-up call. They, or someone close to them, has privately suffered from the condition they are now publicly fighting for. By this rule of thumb, we all should be nutrition champions. That is because every country has a serious public health problem and one in every three people is affected worldwide.
What is malnutrition? It's all around you. It's your friend's baby who just won't grow properly through lack of the right kind of feeding and care; it's your exhausted mother who does not have enough vitamins and minerals coursing through her veins; it's your father's blood pressure that is too high because of too much salt; it's your sibling who has diabetes because of too much sugar; it's your friend who cannot walk up the stairs to your apartment because his joints scream out in pain from carrying too much bodyweight because of an imbalanced diet and too little exercise.
It is too many early graves and it is too much lost potential.
It can seem like an intractable problem, but it is not. As the new Global Nutrition Report notes, the number of countries that are on course to meet global targets is rising quickly.

So what can you do to make malnutrition a relic of the past? Obviously, you can help get your friend and family member the support and help they want and need. But you can do a lot more.

First let's think about policymakers. It's pretty clear what they should do:
1. Demonstrate leadership from the very top. Nutrition improvement requires commitment, coherence and cash. Commitment because nutrition does not have a natural bureaucratic home. Is it health, agriculture, social protection, women and child development, education, water, sanitation and hygiene, climate change or food retailing? It is all of these things--a whole of society responsibility. So we need people who can see the bigger picture, who can bring together all the talents. Coherence is important because nutrition efforts will only be as strong as the weakest link and also because when, say, health and agriculture work together, they are more than the sum of their parts. Cash is needed to scale up nutrition actions--it is not sufficient but it is probably necessary.
2. Increase funding to implement nutrition actions at the country level.There is a massive implementation gap in nutrition actions. For undernutrition actions we know that many countries fall far short of 90 percent coverage levels. Not enough of those who need the vitamin A, the breastfeeding promotion, the counseling on infant and young child feeding and treatment for severe acute malnutrition are getting these programs. For overweight, obesity and diabetes, the same holds true--two-thirds of all of the active programs and policies to address these issues are found in high income countries. Funding will be needed to close these gaps. Money won't solve everything--politics and capacity are important too--but it sure helps.
3. Collect data to allow us to judge how well they (the policymakers) are doing. We need data to guide actions and to hold our decision makers accountable for their actions or inaction. My kids are 13 and 14--imagine if I as a parent did not get any data on their performance in school for four years? Think of all the adjustments and support and motivation that everyone would miss out on. Well that is exactly the case with data on nutrition status and programs. We need data every year, not every four years.
Why should these decision makers do this?
Photo: Abbie Trayler-Smith / Panos
First, they should do it for the sheer humanity of it. Malnutrition is agony. It kills. I saw an article about designer babies the other day. In the future, it will be possible to use DNA manipulation to make babies smarter, fitter and stronger. What about the ethics of it all? Well, malnutrition has the reverse effect on these things: babies' brains will develop less well and their bodies will grow more fitfully. What about the ethics of that?
If this does not move them, leaders should do it because business as usual will bankrupt their health systems. Obesity and diabetes are increasing in nearly every country in the world. Estimates of the burden placed on health systems is currently four-to-five percent in middle income countries -- what will it be in 10 years time? 

And if you are an economist, you will be attracted by the returns on scaling up nutrition interventions: 16 to 1. For every rupee, peso, rand or shilling you will get 16 back. What a stellar investment opportunity!
The final reason why decision makers should try to improve nutrition status is that they will succeed. Countries that have done some of these things have seen dramatic declines in some major forms of malnutrition within a generation: Bangladesh, Ethiopia, Brazil, China, Vietnam and some states in India have all shown the way.
But decision makers -- whether in government, the international agencies, big NGOs, or businesses -- are all busy with lots of priorities. You and I may think ignoring nutrition is like trying to build a house on quicksand, building a tower without reinforced concrete, or setting sail with a hole in the ship's hull, but these folks are constantly distracted by events, politics, their bureaucracies and pressure groups. The status quo will inevitably prevail unless it becomes hard to defend it. We have to make it easy for those with power -- at all levels -- to act for nutrition, but also we need to make it hard for them not to do so.
So what can you do?
First, of course, help the ones you love to get what they need to improve nutrition. This is important whatever stage of life they are in but it is particularly so in the first 1000 days after conception when most of the human software and hardware is being laid down. If that is disrupted it is very hard to recover fully later in life.
Second, get political. Think like a decision maker. How can we make it easier for them to do the right thing? How can we make it harder for them to do the wrong thing, or nothing at all? That means speaking to people at schools, community groups and places of worship; writing letters to editors and parliamentarians, signing petitions, using freedom of information mechanisms, creating social media Twitterstorms, joining in peaceful protests, sharing and writing blogs and scientific articles and volunteering time to NGOs. It means educating, organizing and agitating. 

Finally, don't give up. Be relentless. If decision makers make commitments at summits and then fail to implement them or even report on them, call them on it. Encourage them to be specific in what they promise. As the new Global Nutrition Report notes, too many commitments made in the name of nutrition are vague. Fuzziness is a recipe for inaction. Push pledgers to be ambitious: if they are and they fall short, assure them they will have still moved the needle and that their effort will be appreciated. They are just people like you and me. And sustain your effort. Change takes time. How quickly do you learn to do something differently? The successful countries I noted above all have seen big improvements in nutrition within a generation. But a generation means 15-20 years, not three or five. Like policymakers, you also need to think long term, but not be discouraged by that.
We know what we want powerful people to do to improve nutrition. We know where and how they and others should and can do it. We just need to make it one of easiest things they ever get to do and one of the hardest things for them to avoid doing.
If we succeed, by 2025 malnutrition will no longer be viewed as one of the seemingly intractable problem facing our world.

What are you waiting for?
This article originally appeared in the Huffington Post.

16 September 2015

The 2015 Global Nutrition Report in 10 tweets

The 2015 Global #NutritionReport is out.  Here.  I will be blogging about my most interesting facts within it, but here is a quick taster of the report (it is big!) for those of you who are tweeters.

12 September 2015

How do we capture innovations from the field?

I wrote this article for ENN for Field Exchange's 50th birthday.  The original is here

Someone recently asked me: is the nutrition community more fragmented than other development “sectors”? My answer was a firm no. At the Institute of Development Studies (IDS) where I previously worked, I was exposed to communities in climate, health, governance, participation and globalisation. All of them have fault lines and they tend to be very similar across sectors. Some examples? Those who like to plan and manage development processes versus those who prefer organic, emergent processes. Those who favour rights based arguments against those who prefer economics based arguments. Those who like to measure with numbers and those who like to describe with narratives. Those who look to the state first and those who believe market-orientated solutions are the real thing. Those who favour genetic modification if proven safe and those who think it is the devil’s work. All of these are found in nutrition, of course, but they are just mirroring more widespread world-views, often formed at very early ages and very resistant to new evidence. We are pretty much like every group of people trying to contribute to a better world.

Unfortunately we are also like other development areas when it comes to learning from the field. That is, we say it is vital and then we steadfastly refuse to do it. Why should we do so? My own limited experience in the programme world tells me that real problems have to be resolved by health workers, agricultural extension agents, programme staff, farmers, mothers and aid workers They have no option, they have to innovate on the fly, extemporise, roll with the punches and innovate, innovate, innovate.  The tragedy is that no one is around to document the dilemmas and capture the innovations that they spur. The frontline workers are too busy helping people and communities. Their supervisors are too busy managing and raising re- sources and reporting to their donors. Consultants have no strong incentives to share innovations beyond their immediate funders. And researchers? Well, they usually find out about the innovations too late. And even if they were in the right place at the right time, well, it’s not publishable, is it?

Big implementing agencies do some of this documentation and sharing, but they should do more. And even here, the pressure to make their organisations look good can give us only one particular view on an issue. So there is a space for a knowledge exchange that links the relative chaos and improvisation of the frontlines with the more measured but less timely analysis from the backline. Enter Field Exchange (FEx).

FEx has provided those who don’t work at the cutting edge of action a glimpse of the problems, paradoxes, innovations and successes that go hand in hand with an intensity of action driven by the very tangible costs of inaction. We learn about the impracticalities of, say, targeting, of measuring, of working without information, of trying to coordinate, consult and report when communications are difficult, trust is low, roads are destroyed and funds arrive after their peak need. For those working in this context, I would imagine FEx helps them to share their experiences, learn from each other, not reinvent the wheel and be heard. And they need to be heard. The development and humanitarian communities are like ships passing in the night.

I would hope that FEx can help bridge the development-humanitarian divide by bridging the frontline- backline divide. Development practitioners need to understand the role that shocks and crises can play in creating a context in which their models simply don’t work or their assumptions simply don’t hold. Likewise, humanitarian practitioners need to understand that some of the actions they take can set the course of development for many years, sometimes in very unknowing ways.

Many of us in our 40s and 50s were taught about development with a mental model of a rural, fairly stable context. Well, the world is changing. Poverty (and I would guess undernutrition) is increasingly becoming concentrated in fragile contexts and, to a lesser extent, in urban ones. Research in fragile contexts is really difficult. FEX should increasingly inform the development community and the wider nutrition community about scaling up nutrition in fragile contexts. In fact, that would be a great topic for a special issue1. Scaling Up Nutrition (SUN) countries tend to be better governed and less fragile than non-SUN countries at similar income levels. What does scaling up mean in Afghanistan or Syria or in northern Nigeria? What do people working in those contexts have to say about scaling up?  They may simply be trying to avoid scaling down. How can the avoidance of scaling down help us to think about scaling up in those contexts and in less fragile places?

Once when sitting next to Hilary Benn, the then UK Secretary of State for International Development, I pitched the idea of something like YouTube for development. Innovations from the field, captured in 1-2 minute videos, stories told by practitioners, organised and curated by a network of non-governmental organisations (NGOs). It never went anywhere (which is probably just as well) but I think the spirit of this re- mains important. We talk a lot about amplifying the voices of those in poverty or experiencing hunger or malnutrition, but surely hearing from those working closely with them is also important. This is why I will continue to glance at the list of articles in FEx, why I think it should broaden its reach into the nutrition “development sector” and why it should consider going beyond the printed word to the spoken word. Life begins at 50 (believe me). Viva FEx! 

03 September 2015

7 Ways to "Sell" Nutrition

Ugh, I hear some of you say.  Sell nutrition?

Well, it is not doing such a great job of selling itself: 1 in 3 world wide are malnourished in one form or another.

And just as we begin to reduce one form of malnutrition (stunting), another begins to pop up all over the place (obesity).

So, it needs selling.  But how? I was recently asked by a leading marketing and advertising company what was the one thing to emphasise.  Of course I said it depends on the audience.

There are at least 7 approaches any budding nutrition champion can take:

1.  Human Rights.  This argument really appeals to those with strong first principles about justice and morality. This could be the right to food or water or the rights of women or child rights.  I personally favour the rights of the child route--I find it more powerful to talk about the rights of those who are least able to claim their rights.

2. Child survival.  We know that 45% of under 5 mortality is linked to poor nutrition status.  For those whose buttons are pushed by mortality rates, this is the fact to emphasise.  This tends to appeal to the general public and those who work in the health field.

3. Early Child Development.  For those in the education field this is the most important period--getting ready for school entry. And remember we care about stunting because it is a marker for impaired brain development.  

4. Economic returns.  We know that for every $1 invested in scaling up high impact nutrition programmes we get $16 back.  That is some return!  Economists are interested in this.

5. Poverty.  We know that kids that avoid stunting or who are breastfed for over 12 months are much more likely to avoid poverty as adults.  This appeals to the social development policy wonks.

6. Intergenerational justice.  This may be powerful with the environmentalists.  What is this generation leaving the next generation to work with?  That's not just natural resources but the human resources needed to manage those natural resources.

7. National narratives. This is the most unorthodox and most under-explored of motivations, but how can a country portray itself as dynamic and emerging if 40% of its kids are stunted and probably less that half of its kids are growing healthily?  It can't, at least not for long  For national leaders who want their country to be seen as a leading light in their region, the coexistence of malnutrition and the banners seen at airports proclaiming their country's emergence will become very uncomfortable.

Having so many reasons for investing in nutrition action may be seen as a weakness (why can't you just focus?) but I think having many tools in your toolbox is far more preferable.

You just have to know when and how to use each of them.

19 August 2015

5 personal reflections on the GNR 2015 report-writing process

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.