12 November 2014

The Teeth Behind ICN2 Commitments & Recommendations: Will They Bite or Merely Chatter?

Do have a read of the ICN2 Outcome Documents: (1) Rome Declaration on Nutrition and (2) Framework for Action.

They are very sensible: a good balance of nutrition status outcomes, programmes, sectors and policies.

These documents were very food focused 6-9 months ago, so FAO and WHO deserve a lot of credit for listening and responding to concerns.

The one section that worries me is the accountability section. Accountability is covered in 3 out of 60 recommendations in the Framework for Action.

Recommendation 58 says that "national governments are encouraged to establish nutrition targets and intermediate milestones, consistent with the timeframe for implementation (2016-2025).... they are invited to include" indicators for nutrition outcomes and policy.  "Encouraged" and "invited":  I understand that this is diplomatic speak, but couldn't  "strongly" or "urged" have featured?

Recommendation 59 says that reports on the implementation of the commitments of the Rome Declaration  on Nutrition will be compiled jointly by FAO and WHO drawing on country self reporting and other mechanisms (and it mentions the Global Nutrition Report).  But will these reports identity commitments, link them to responsible parties, assess delivery and make assessments publicly available?  There is silence on this when there needs to be clarity.

Recommendation 60 is really odd, saying that the governing bodies of FAO and WHO and other relevant organisations are "requested to consider the inclusion of reports on the overall follow up to ICN2 on the agendas of the regular FAO and WHO governing body meetings"  Requested to consider?  How about a commitment from the governing bodies to demand such reports?

Finally, two big omissions from the ICN2 documents:

* there is some complacency on the eventual prominence of nutrition in the SDG framework.  As the Global Nutrition Report notes, nutrition is only mentioned in one of the 169 SDG targets.  4 of the 6 WHA indicators are not in the SDG framework.  This is not good enough.  The best thing to come out of ICN2 would be a realistic plan to get nutrition more prominent within the SDGs.  The SDGs, after all, will be the main accountability mechanism for development over the next 15 years.

* what about an ICN3?  Will we have to wait another 22 years for an ICN? What about an ICN3 in 5 or 10 years?  One that focuses clearly on what has happened in the proposed Decade of Action for Nutrition.

So the ICN documents are good, but do the teeth behind the ICN2 have bite or do they merely chatter?

10 November 2014

ICN2: Time for Leadership -- in Nutrition and in Accountability

Well, the final week's build up for the Second International Conference on Nutrition (ICN2) has begun.

Panelists are being briefed,  speeches polished, press releases honed, op-eds hawked, social media plans finalised.

But ICN2 is about much more than these rituals, important as they are.

ICN2 is an opportunity for real leadership.

The kind of leadership that is permanent, not just for this week until the next podium comes along.

The kind that challenges conventional wisdom rather than bowing to it.

The kind that is far reaching and wide ranging, not focussed on short term parochial gains.

The kind that inspires as well as informs.

Most importantly it is a chance for leaders to demonstrate their accountability.

How clear will their commitments be?  How supportive will they be of efforts to track those commitments?  And will they be spurred on by assessments of their progress against commitments or will they stick their heads in the sand?

We need our nutrition leaders to be accountability leaders.

The Global Nutrition Report is one contribution to strengthening accountability in the nutrition system.

The Report will be made available on Thursday November 13, at 1400 UK time, on the website.

Further online materials will be available in the days leading up to the Rome launch:

* 193 Nutrition Country Profiles (2 pagers with 80+ indicators)
* 12 Technical Notes on analyses and measurement issues
* 30 or so Panels (shorter versions of some are in the Report, some are not in the Report)
* the detailed Nutrition for Growth (N4G) Tracking Tables that provide the evidence for the N4G assessments

The Report does the following things
  1. Notes the truly global nature of malnutrition--nearly every country has crossed the red line on nutrition
  2. Argues that multiple burdens of undernutrition and overweight/obesity are the "new normal"
  3. Documents global and country progress--who is on course for what and why
  4. Argues for stronger nutrition representation in the SDGs and more ambition on SDG targets for 2030
  5. Makes recommendations on actions to accelerate malnutrition reduction
  6. Evaluates progress on the N4G commitments--who is on course and who is not?
  7. Identifies key data gaps that need to be filled
  8. Makes recommendations on how nutrition accountability can be strengthened
We are presenting at the SUN Global Gathering on November 17 at WFP and formally launching at the ICN2 on Nov 20 at FAO, 18.30-20.00

Further Roundtable events are scheduled (in chronological order)

London (Dec 2), New York (Dec 8), Washington DC (Dec 9), Geneva (Jan), Delhi (Feb 4), Bhubaneswar, Odisha (Feb 6), Addis (Feb 24), Lusaka (Feb 26), Brussels (Feb/March), Mexico City (March 2), Jakarta (March).  More details to follow here

They will be advertised in each location--please watch out for them and we look forward to your participation.

06 November 2014

Undernutrition in India: Is the “Curse” Finally Lifting?

Five years ago Sushila Zeitlyn and I co-edited a collection of papers by Indian authors on why undernutrition was so persistent in India and why the government seemed so disinterested in making tackling it a priority.  At that time the Prime Minister called undernutrition a “curse”.  It must have seemed like that—rapid economic growth and high and stubborn levels of stunting, wasting and micronutrient deficiencies.

I just returned from a trip to Delhi and Lucknow and I have never been more encouraged.  Is the curse finally lifting?

First there was the Together for Nutrition Conference organized by two consortia, both convened by IFPRI: POSHAN and Transform Nutrition.   The conference explored different forms of collaboration in nutrition: from alignment to coordination to cooperation to integration.   What was so encouraging here was the participation from 14 different states.  The nutrition champions were everywhere.  We had great research papers and inspiring stories from a range of Indian and international practitioners and researchers.  Once again, there was the prevalent feeling that dynamism, innovation and commitment are coming from the States, not the central Government.   
Second, there was the Coalition for Food and Nutrition Security, chaired by M.S. Swaminathan, still driving the agenda with a razor sharp intellect and turn of phrase.  The Coalition is a group of civil society, government and research organisations and individuals who are fighting for nutrition.  I attended the launch of their Action Agenda. The Coalition outlines 5 urgent areas of action; coverage of evidence informed nutrition interventions, equitable access to services provided by sectors related to nutrition, adequate financing, nutrition as a development indicator with regular data collected every 3-5 years and institutional leadership within the offices of the Prime Minister and state Chief Ministers.  I like this set of 5, especially the last two as I think they set the tone.  

Speaking of Chief Ministers who take the lead, I next went to Lucknow in Uttar Pradesh (UP), to speak at the launch of the new State Nutrition Mission.  UP is the biggest state in India at 200 million people (the 6th largest country in the world, if it were one) and has the highest rate of stunting at about 56%.  That is about 13 million stunted children or about 8% of the world’s total.  8%.  The Chief Minister and his wife, an MP, spoke passionately about the need to reduce malnutrition.  The Citizen Alliance, a group of MPs and civil society featured strongly at the podium and are clearly powerful.  UP was strongly influenced by the Maharashtra experience (hence my invitation to present this report) and there were many officials from that state also present.  If things can get moving in UP it could be a real global game changer.
Finally, I returned to Delhi to co-teach in the Transforming Nutrition short course co-hosted by PHFI and IFPRI.  The quality of the participants was really excellent and it was inspiring to be around so many experienced and knowledgeable experts on nutrition.  Aryeh Stein from Emory University was a great addition to the PHFI/IFPRI faculty, especially with his knowledge of the double burden and developmental origins of health and disease.

There’s a real energy and excitement about the Indian nutrition scene: a sense that progress is being made.  Causes for optimism include:
* New headline figures from the yet to be released Rapid Survey on Children (Government of India and UNICEF)—under 5 stunting declines from 48% to 38%
* UP’s Nutrition Mission
* The new Government’s preparation of a National Nutrition Mission
* The new Government focus on sanitation
* The active role civil society is playing: the Citizen’s Alliance, the Coalition and Naandi’s Hungama 2
* Maharashtra, Odisha and Kanartaka’s leadership on nutrition at the state level
* A PDS system that seems to be lurching into life in terms of promoting food security
* UNICEF’s strong partnership of the States

Challenges remain: the promise needs to be delivered on and there are some very difficult hurdles to overcome (open defecation, caste barriers, sluggish agricultural development). But the sense I took away—perhaps for the first time in 20 years—is one of optimism.  People kept saying that they were “waking up to malnutrition”. 
Maybe the curse really is lifting.  Maybe India will join SUN.  Maybe India will hit the WHA targets by 2025 or even exceed them.  We shall see. 

21 October 2014

Catch up growth? Yes, but what does it signify? New paper from Young Lives

A new study by Young Lives researchers measures height for age of a cohort of children at  ages 1, 5 and 8 years, in 4  countries: Ethiopia, India, Peru and Vietnam.

The study uses WHO multicentre growth study standards at age 1 and WHO NCHS standards for ages 5 and 8 to generate normalised height for age z-scores (HAZ).

An HAZ of less than -2  means a child is stunted.  

The results?

Ethiopia, mean HAZ: -1.51 (age 1), -1.46 (age 5), -1.21 (age 8)
India, mean HAZ:       -1.30 (age 1), -1.63 (age 5), -1.43 (age 8)
Peru, mean HAZ:        -1.29 (age 1), -1.51 (age 5), -1.13 (age 8)
Vietnam, mean HAZ: -1.08 (age 1), -1.33 (age 5), -1.09 (age 8)

Notice the declines from age 1 to age 8 in Ethiopia and Peru and the declines in all 4 countries between ages 5 and 8 (when the growth standards are strictly comparable, i.e. both NCHS).

The authors conclude:

"Our data demonstrate that while child growth trajectories throughout the pre-school and early school-age years are predicted in part by size at age 1 year, there is significant variation in growth after 1 year of age. This includes catch- up growth in some children and faltering in others. These results suggest that while prevention of early-life stunting must continue to be a top priority, programme planners and implementers should consider identifying and targeting for further nutritional interventions children who nevertheless become stunted during infancy, as well as children at risk for later growth faltering. An important area for future research is identifying the factors that contribute to these later variations in growth."

I do think it is important to find out why some kids catch up in growth and others do not (since, as the authors report, 40-74% of HAZ at year 5 is not predicted by HAZ at year 1). 

I think it is also important to work out what is catching up.  Is it more than height?  Cognitive functioning, for example? 

We're interested in height not because it is intrinsically important but because it is a marker for other things that are stunted in the first 1000 days of life.  

An interesting study that reminds us not to give up on kids after the first 1000 days, but does not detract from the focus on this time period, it seems to me.  Interested in your thoughts. 

Evidence on the impact of research on international development? New DFID literature review.

A new DFID literature review hit the streets in July: 

"What is the evidence on the impact of research on international development?  New DFID literature review". 

It is written by DFID staff, reviewed by 7 external experts.   

This is the concluding chapter in full:

"Investment in research activities can lead to development impacts. However, research is not a panacea; Investments in some research projects will lead to large development gains while investment in some activities will lead to little or no impact.

Having said that, it is possible to consider the general theory of change by which we expect research to lead to impacts and to draw some conclusions on what type of research activity we should invest in to achieve different outcomes.

Key findings

This literature review reveals some general principals regarding investment in research:
  • Investment in public research in low-income countries is unlikely to lead to substantial levels of direct commercialisation of research outputs in the short to medium term. Informal academic engagement with industry may be more economically important but some activities (particularly consultancy contracts) may have negative impacts on research capacity. While the generation of new innovations within low-income countries is unlikely to be a major driver of growth, the absorptive capacity of industry (i.e. the ability to adapt and make use of existing research knowledge) will be a vital driver of growth and interventions which would increase this absorptive capacity (e.g. strengthening of tertiary education) are likely to have large impacts.

  • Research from developed economies reveals that, in contrast to the beliefs of most academics, there is no strong link between the research outputs and teaching quality of tertiary education establishments. As yet there is no evidence to indicate if such a link exists in low-income countries so efforts to improve tertiary education through investment in research should be treated with caution. The human capital developed through investment in research and research capacity building can have multiple positive impacts on development including via the spill-over of former researchers into government and industry and the generation of research experts who can act as policy advisors. Research suggests that investment in doing research in low-income countries on its own will not lead to improved research capacity and that an effective and explicit capacity building strategy must be developed.

  • Investment from both developed and low-income countries in research in public institutions and/or public-private partnerships can generate pro-poor products and technologies. Some of these products and technologies have had dramatic impacts on development. However, there are also multiple products and technologies which have not had the expected impact. When investing in the development of products and technologies, it is vital to carry out research to ensure there is a demand for it and that there are no barriers which will prevent it from having positive impacts. 

    Using evidence to inform policy and practice decisions can help ensure policies and practice achieve their desired impact. Two categories of decisions can be informed by evidence. Firstly, research to understand what works and why can be used to inform decisions on specific interventions. Secondly, evidence which describes the existing context can inform general theories of change. Major barriers to use of evidence are the low capacity of policy makers and practitioners to understand and use research evidence, and the absence of incentives to drive research usage. Interventions which succeed in increasing use of evidence by policy makers and practitioners may lead to important impacts. 

    There are a number of methods which have been used to quantify the economic benefits of investment in research. All methods suggest positive rates of return to research however individual figures are highly sensitive to the assumptions used in the calculations and therefore need to be interpreted cautiously."
A few observations:

1.  For such an important question it is surprising that this was not a systematic review.  The search strategy is listed in Chapter 8, and it seems quite partial.  Key literature like S. Fan et. al. on the impact of investments in agricultural R&D (compared to other investments) on poverty in India, China and Africa is missing.

2. The report would have been much more helpful if it could have said more about the features and attributes of research that give it more of an impact. Some research will have an impact, some won't. No surprise there.  The reasons for impact may relate to relevance, rigour,  originality, timing, sheer luck or some combination of these.  Also, what does the evidence say about the timescales over which we should expect to see impacts?

3. Barriers to use of research.  Good points on the barriers to research uptake although with an over-focus on capacity.  Of course the most relevant, brilliant and accessible research might be ignored if it gives an inconvenient political answer.  So this is more than a capacity issue, it is also a governance issue.  It is not just about demand but about a balance of (sometimes) competing interests (within the public and private sector spheres).

4. The comment that "all methods suggest positive rates of return to research however individual figures are highly sensitive to the assumptions used in the calculations and therefore need to be interpreted cautiously" seems to vaguely cast aspersions on the research community--i.e. we have a vested interest in a certain outcome and we cannot be trusted to assess returns to our work (perhaps why DFID chose to do this review themselves).  Maybe I am misinterpreting, but that is how it reads to me. 

Overall, an interesting and intriguing study.  I wonder what impact it will have? 

Who has Coverage covered? Learning from the SAM side of the big tent

This might just be me catching up with the rest of the nutrition community.  But the more I find out about SAM (severe acute malnutrition) coverage thinking, the more I think the rest of the nutrition community--so concerned with scaling up--has a thing or two to learn from our SAM colleagues.

I'm just reading the latest Coverage Matters report from the Coverage Monitoring Network and ENN.   There are several articles which interrogate the naive assumption of serene coverage increases over time.

The articles are short and accessible and cover things like:

* the Tanahashi coverage diagram (from availability coverage, accessibility coverage, acceptability coverage, contact coverage, to effectiveness)  

* active outreach to generate early admissions--the context is SAM prevention and treatment, but the principle obviously extends to early trimester and early childhood interventions on the chronic side

* the role of audits (programme and social) to identify barriers to coverage scale up and to generate solutions for overcoming them

* reasons for non-attendance: from lack of awareness of the programme or the problem, to family members barring participation

* the relationship between coverage and effectiveness (don't assume effectiveness stays constant)

* the SQUEAC (semi-quantitative evaluation of access and coverage) tools (e.g. for creating "mind maps" of assumptions about how programmes work and people engage with them) seem to have usefulness beyond the SAM programmes

Just another reason to close the "chronic" - "emergency" divide.

17 October 2014

Ebola means there should be a greater focus on nutrition, not less

The Second International Conference on Nutrition (ICN2) is scheduled for Nov 19-21.

I have heard some people talk about how Ebola may take the focus away from nutrition, but I think it strengthens (unfortunately) the case for more attention to nutrition.

First, people with poor malnutrition will have weaker immune systems and so--all other things being equal--it is plausible that they will be more likely to contract the disease given the same exposures (note, as a number of you have pointed out since I originally published this, it is hard to find any actual evidence to support this statement, it just seems plausible--but if you have seen any evidence supporting or refuting this, please let me know and I will edit the blog).

Second, health systems are going to be decimated because health workers are most at risk and the health system will be working overtime to deal with Ebola in countries with high levels of infection (see this harrowing account in the New England Journal of Medicine from an MSF staff member).  This means fewer resources to prevent malnutrition to stifle infection.

Third, because the infection is spread through touching, it becomes more difficult to give very young children the care they need for healthy growth, even without the virus.

Fourth, agriculture is going to suffer, just as it did with HIV/AIDS.  There will be a labour shortage effect, but perhaps the bigger effect will be an inability to transport food due to curfews and lockdowns -- hence the very real risk of food price spikes.

Of course, much more investment is needed NOW to deal with the infection.  But once the case loads have peaked, more attention is needed to building resilience to future outbreaks-and that means better nutrition and stronger health systems.