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.


21 July 2014

Why Worry About the Politics of Nutrition? New Paper

So, why worry about the politics of nutrition?

In a new (open access) paper in World Development by Nicholas Nisbett, Stuart Gillespie, Jody Harris and me, we argue that nutrition is inherently political.

First, there are the multiple sectors, power bases, alliances and aims. This entails negotiation, contestation, alliances and compromise. In short, politics.

Second, there are information asymmetries. Nutrition is highly technical.  Are complex services being delivered in a good enough way?  Are nutrition-related products being marketed responsibly?  Information asymmetries allow power to be exercised in the shadows. And that is not typically a good thing.

Finally, there is the invisibility of malnutrition: stunting is hard to see, what is being spent is difficult to track across sectors, and micronutrient malnutrition is largely hidden. Being out of the public eye means that no-one is going to be blamed if things don't improve.  Invisibility undermines accountability.

We then go on to suggest that nutrition can learn a lot from other sectors in terms of power analysis (the power to but also  power over and the power within), governmentality (moving from the conduct of government to the governance of conduct -- of all actors) and hybrid governance (moving from simple state-society interactions to mash ups or hybrids of these two types of institutions).

We also argue that governance research can learn from the challenges of nutrition and its current dynamism.  For instance where else can you see a global movement such as SUN rise in a period of 5 years or so?  The SUN movement on its own is a potential source-- and beneficiary -- of hundreds of political science PhD's.

There are of course research gaps. Can communities hold governments and other service providers to account for quality of delivery?  What are the effects of capacity gaps on nutrition outcomes --which types of capacity and at what levels?  Can commitment really be measured?  When does more timely data lead to more timely action?  Check out the Transform Nutrition RPC site for on-going attempts to fill those gaps.

So don't worry about the politics of nutrition, just recognise they exist, navigate them -- and maybe even influence them.

20 July 2014

IDS-IFPRI Transforming Nutrition Summer School: Nutrition Has Moved On


Well, another fun and intense week of learning, sharing, inspiration and laughing has finished.  Once again the Brighton weather over performed, as did the participants.

We had about 30 participants from Africa, Asia, Europe and the Americas. We were national policymakers, programme managers, UN agencies, donors and researchers --all learning together.

One key part of the programme is for participants to break into working groups and develop an action plan for a problem they have identified in their country, state or organisation (e.g. how to increase uptake of nutrition services?  How to move nutrition up the political agenda? How to get a budget line established for nutrition?)

On the final day of the course the plans were presented to a panel who gave feedback.  This year we had 7 groups: Ethiopia, Odisha, Madhya Pradesh/Bihar, Malawi/Zambia, Ghana/Tanzania, Nepal/Timor Leste/Lao PDR (or NeTiLao!) and a global group.

Some reflections from me on their presentations:

1.  The chicken and egg dilemma. Several of the plans noted that it takes resources to make the case for increased resources.  We reflected that change usually takes sacrifice of committed people to push for change even while they already have day jobs.  It helps if you can plausibly show that increased resources will lead to improved outcomes

2. Focusing on a problem does not necessarily lead to a narrow plan of action.  Even the most focused problem identified by the groups required a broad range of alliances, actions and capacities to overcome.  Consider the increased uptake of antenatal services:  is it low demand or poor quality supply?  On the demand side is it discrimination or universal norms that need changing? On the supply side is it front line worker capacity or capacity elsewhere in the system?

3.  Who is going to do this?  Often brilliant plans were put in place about what, when, where and how of actions.  But the "who" was much more difficult.  Related to point 1, who is going to go beyond their job description?  Changing job descriptions is hard--it requires taking on vested interests, has resource implications and is a big change to take on for an unproven set of actions.

4. Learning from other country experiences. As usual, much of the learning was from reviewing other country experiences, especially from near neighbours. We will use more and more case studies as the course evolves.

5. Be explicit about what's in it for me?  If we want multiple sectors to work on and with nutrition we have to be strategic about figuring out what is in it for them. Some of the country plans were very strategic--focusing on 2 or 3 ministries where alliances could really pay off rather than worrying about all 12 potential ministries they could work with.

6. The importance of creating "forcing moments".  Some of the plans presented were focused on creating "forcing moments" where it is difficult or embarrassing to avoid making a pledge. And if you make a pledge it makes you look good--perhaps around the launch of a new policy, or a new survey or a new crisis, or a visit of an outside group.

7. Accountability is rising up the agenda. The plans focused on accountability, things like: budget transparency, community feedback, real time monitoring of outcomes.  This felt different to previous years' plans.  It was not enough to formulate the plans but how would we monitor implementation of them?

8.  It is not all about financial resources.  Often we have a knee-jerk reaction to throwing more money at the problem.  These plans had some of that but were more focused on capacity gaps.

9.  The capacity debate is getting more sophisticated.  On capacity, there was a great deal of emphasis on building capacity to scale up implementation.  Capacity audits were to be instigated and ways of upgrading skills, strengthening incentives and improving the system as a whole were highlighted.

10.  Finally there was a sense that nutrition had moved on.  One of the panelists who had served the same role in 2012, our first year, said that she felt the plans were very different from her previous engagement.  Back then it was about getting someone to pay attention to nutrition.  Now it is about delivering under their gaze.   If our composed and steely participants are anything to go by I have no doubt this will happen in many places.

We will be running the course in Brighton in July 2015.  Watch out for our call in January.

07 July 2014

Are the SDGs really like fairytales?

Last week Richard Horton, the formidable editor in chief of the Lancet wrote a piece in the journal entitled " Why the Sustainable Development Goals will fail".   

Based on his reading of the latest zero draft (rev 1)  of the "Proposed Goals and Targets on Sustainable Development for the Post-2015 Development Agenda" he states:

"The SDGs are fairy tales, dressed in the bureaucratese of intergovernmental narcissism, adorned with the robes of multilateral paralysis, and poisoned by the acid of nation-state failure. Yet this is served up as our future."

My reading of his critique is that it centres on 2 related things (1) there is little attempt to think about what sustainability really means and how it should shape the SDGs (Horton's list:  intergenerational equity , externalities, resilience, wellbeing, capabilities, and the strength of our civilisations) and (2) many of the goals are "negotiated wish lists" that focus on business as usual. 

At first when I saw the title of his piece I thought he was going to complain that the SDG process was thinking big impractical thoughts.  But on reading the SDG zero draft and his review, it is clear that he thinks the SDG process is not doing this.  I agree with him.  The SDG process does not seem to have started with ideals and worked towards a result.  Rather, like some of the teams at the World Cup, the process is being ruthlessly pragmatic, wishing not to fail than daring to succeed.   

However I am not quite as pessimistic as Horton about what the SDGs may look like.  There is still time for a really good SDG outcome.  The deadlines will focus the minds.  The process is too open for mediocrity to prevail.  We may not get the expansive and symphonic vision that Horton calls for but we might just get what we need: a set of goals that balances the needs of the current generation with those of the future ones, one that balances outcomes and accountable choices and one that injects a little more poetry into the, so far, rather dull prose.  

Thanks to Richard for injecting some poetry into the debate. 

02 July 2014

Leadership in Nutrition: Some New Findings

Leadership has been identified as a key factor in supporting action on nutrition in countries experiencing a high burden of childhood undernutrition, but there have been very few systematic studies of what supports or constrains leadership in nutrition.

A new IDS Working Paper by Nicholas Nisbett (I'm one of 3 co-authors) was just published on what supports or constrains effective leadership in nutrition.  It is based on a 4 country set of interviews under the Transform Nutrition Research programme. A summary of the 4  questions posed, the key findings and  the implications are listed below.

It is a study of individuals identified as influential within nutrition in Bangladesh, Ethiopia, Kenya and India (through a NetMap and follow up analysis) and it examines why particular individuals champion nutrition policy, and how they operate in the wider policy and political environments of their countries.


Based on analysis of 89 interviews, the paper considers how individual (adult development) capacities, knowledge and motivations, and wider political economy considerations structure the ability of these leaders to think and act. 

The paper argues that only by locating individuals within this wider political economy can we begin to appreciate the range of strategies and avenues for influence (or constraints to that influence) that individual leaders employ and face. We review the literature in this area and suggest a number of ways in which we may support, nurture and develop nutrition leadership in future. 

The bottom line is that leaders are important for reaching outside of the nutrition community to influence those with power, influence and resources. And while the fortuitous emergence of nutrition leaders is wonderful, we cannot wait for leaders to emerge randomly, we must nurture their emergence and development.  

More emphasis needs to be given to leadership development in nutrition--to help bridge sectors, disciplines and generations. Efforts to build leadership such as the UN’s REACH, the SUN movement and regional initiatives such as the African Nutrition Leadership Programme and Action Against Hunger’s support for Nutrition Champions in West Africa need to be supported and nurtured. 

     Summary of Study Findings