11 October 2017

The New Expert Panel Report on Nutrition and Food Systems: What is Different?

The UN Committee on Food Security’s (CFS) High Level Panel of Experts (HLPE) report on “Nutrition and Food Systems” was released at the 44th CFS this week.  The team was led brilliantly by Prof. Jess Fanzo. I was one of the team members.
There have been a number of reports on food systems in the past year – including the Global Panel Report and the IPES report – and next year we have the EATLancet Commission report on sustainable and healthy food systems. This report is specially important as the CFS is the apex body in the international UN system looking at nutrition and food policy.
So what is different about the HLPE report? Here is my take:
First, its main audience is CFS members: governments, UN agencies and other development partners, civil society groups and companies.  This means it has to be couched in the more measured, careful language of diplomacy rather than advocacy.
Second, the report was produced through a very inclusive process. The report team was balanced by geography, disciplinary background and organisation type.  This meant forging compromises that all team members could live with, with the expectation that this will increase the chances of a wider buy in from stakeholders.
Third, it is, subversively, a bit radical. Statements such as “The risks of making well intentioned but inappropriate policy choices are much smaller than the risks of using a lack of evidence as an argument for inaction” are fairly heretical for many nutrition investors guided by Lancet 2008 and 2013. For the more market based interventions within the food system the hard evidence is usually not present and one has to trust educated best guesses and calculated risks as a guide to action. This is an implicit challenge to a trend towards ever more specific searches for evidence to prove interventions are justified.
Fourth, the report gives equal focus to three features of food systems: food supply, food environments and consumer orientation.  Some of the other reports mentioned have not been as balanced and especially do not spend enough time on the creation of the demand for healthy food.
Fifth, the report is very action orientated. For example, there are 26 pages of text on priorities for action in food supply chains, food environments, and in orienting consumer behaviour.  The “investment priority wheels” for the three types of food systems are also useful guides to sequencing action.
Sixth, the report bravely takes on the barriers and enablers for action: bravely because these are all quite context specific and deal with power asymmetries. This kind of political economy analysis needs to be developed further in future HLPE (and other) reports.
Seventh, climate issues are woven throughout the report, not confined to one section or chapter. Other environmental footprint issues could be strengthened in future reports, but to be fair the evidence on the wider environmental footprint of different foods in different countries is sorely lacking.
Finally, the private sector is taken seriously. It is not merely characterised as a malevolent actor.  One of the HLPE team members was even from the private sector –a first, I believe for the HLPE, but brave and necessary.  Given, as the report notes, the public sector is the duty bearer for ensuring food systems enhance food security and nutrition for all, and the private sector is main investor in food systems, it makes sense for the two sides to understand each other better.
I did, however, have quibbles with some of the private sector language (come on, did you expect me to have no quibbles with anything?).  For example, the report states “The private sector is primarily seen as part of the problem, but it can and should also be part of the solution.” Some stakeholders do in fact see the private sector this way, as primarily part of the problem, but many do not.  And the private sector is already part of the solution – it is just that it is also part of the problem (as, incidentally are governments – some of whom have good, some less good policies). Also, the report does little to dispel the notion that the private sector is a multinational monolith.  For example, Small and Medium Income Enterprises (SME) are only mentioned once.
Jessica Fanzo, the Report Team Leader, and Eileen Kennedy, the HLPE member who was our spiritual guide and inspiration, deserve a great deal of credit as do the HLPE secretariat.  They got us through the hard times when it all seemed too overwhelming and when we could not sometimes reach consensus.
All in all, it is a report I’m proud to be associated with. The content, presentation and generation process were all thoughtful, deliberative and inclusive.
So, read it, critique it, share it, but most of all, use it and act on it!

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09 October 2017

Overcoming the Data Roadblocks to Public Private Engagement to Improve Nutrition

I am sorry if this sound like a rather techy title, but I believe it touches on some of the most sensitive issues holding back progress on the Sustainable Development Goals (SDGs). Why?
At a recent meeting of public and private sector organisations I was asked to share some thoughts on the data gaps that inhibit productive engagement between the public and the private spheres to advance nutrition. The meeting was addressing how to push food systems to both feed AND nourish the world, and for this market actors (private sector) and policy setters (governments, development actors) simply have to work together for meaningful change. We are far from this.
My sense is that the data gaps that are inhibiting us all fall into at least five categories: 
1.Having a joint goal. If you don’t know what you want to achieve, no partnership will succeed, no matter the partners.  What is the common objective?
2. Lack of a sense of opportunities. In the public private space in nutrition we tend to get blinded by the hotspots of breastmilk substitute marketing and products high in added sugar. These are of course vital issues to address, but there are many other issues too.
3. Demonstrated benefits from engagement. The perceived costs of engagement – exclusion, criticism, reputation – are very visible and quickly felt, but the potential benefits are less clear because they are rarely validated by independent and careful evaluations. PR is no substitute for evidence.
4. Lack of a data mechanism for building trust and ensuring transparency. This type of mechanism is important in any relationship. The Access to Nutrition Index (ATNI) does this well for major food and beverage companies every two years, but we need additional mechanisms which are lighter, can cover the major part of the food system, namely the farmers, entrepreneurs and local companies, and can be collected in real time.
5. Lack of a mechanism for sharing data and evidence. This is important because it provides examples to spur action. This could be a register of public private partnerships or a web portal that screens, curates and mobilises evidence in the public private domain on what works.

The table below provides more examples and detail.  These are issues we are working on at GAIN as one contribution to making it easier to engage across the public private divide to improve nutrition for all, especially the most vulnerable. Stay tuned, or better, share your ideas!
Roadblock to public private engagement to improve nutrition
How can data help overcome roadblock
1. Lack of a joint goal
- Identify key groups and dimensions of malnutrition where little progress is being made
- Accelerating reductions in Anemia in women and children

- Improving adolescent nutrition
2. Lack of a sense of the breadth of opportunities
- Collect data on firms by sector and product—who is doing what?

- Collect data on sales of different foods and food products—how is demand changing?
- Screening and segmenting SMEs that have nutritious foods at the heart of their business model

- Collecting data on the sales of packaged foods in low income countries
3. Lack of sense of benefits to a particular type of engagement
- Independent evaluations of process and impact of public private engagements: by product type, market segment, engagement type
- More independent evaluations commissioned and published

- Public research programmes on PPPs in nutrition
4. Lack of mechanism for assessing conduct and building trust
- Evaluations of company performance

- Indicators of government efforts to create nutrition friendly enabling environment for food and which tracks businesses who want to do the right thing for nutrition.
- Initiatives like ATNI, SDG2 Scorecard

- Indicators to characterize the strength of the ecosystem support for businesses who are working in areas that could advance nutrition outcomes
5. Lack of a mechanism for sharing data, knowledge and evidence
- Knowledge mobilization around what works to advance nutrition in the government-business sphere (and the types of benefits) and what does not work (and the risks and how avoided)
- Establish a Knowledge Hub on Markets for Nutrition

This blog is also available on the GAIN website
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Published 9 October 2017

04 October 2017

Discussing how to make food systems deliver more nutrition with the European Commission

Last week I presented on the role of business in food systems to improve the consumption of nutritious safe foods.
I focused on the need to develop innovative ways to create the demand for healthy food, ways of supporting businesses and governments to meet and shape that demand, and what governments can do to make it easier for businesses to do the right thing for nutrition and harder to do the wrong thing. I highlighted each of the three points with impact examples from GAIN’s own work. The slides are here.
It was an audience of European Commission (EC) officials and the Brussels NGO community and I got some good questions:
  • What data are missing in the public-private space?
A: One example is that businesses in low-income-countries have very little public (or for purchase) market information data to draw on.
  • What is the impact on farmers of more affordable foods?
A: Farmers are also businesses, so they have to get fair prices, and they set their prices to maximise sales revenue. But lower prices further along the value chain need to generate good demand linkages for their products.
  • How can we guarantee the foods that are supposed to be fortified, actually are at the point of consumption?
A: GAIN regularly undertakes Fortification Assessment Coverage Toolkit (FACT) surveys which measure the coverage (was fortified food actually consumed?), coverage of adequately fortified foods (was the food properly fortified?) and effective overage (is enough fortified food consumed to close a nutrient gap?). Through our ENABLE Platform and country teams we work with businesses and governments to help them, comply with and monitor, respectively, the national laws and standards.
  • What about the environmental impacts of different “healthy” foods?
A: The evidence base on the trade-offs with water, soil and energy of producing more nutritious foods is not there right now so we have to be very careful to do no environmental harm.
A: Where animal source food consumption is low, the requirements per kg are high and there are few alternatives for getting the nutrients in the right concentration then animal source food consumption is justified on nutritional grounds. If you eat high levels, you should consider reducing your consumption—this is essentially the advice from WHO and national food based dietary guidelines.
  • What are the implications for research?
A: More research needs to be done to increase the productivity of, for example, fruits, vegetables, pulses, eggs and dairy. In addition we need a dedicated research programme on the nutrition impacts of public-private collaboration—there is too little evidence on whether the private sector collaborations actually add nutrition value.
  • Do you consider ultra-processed fortified foods to be nutritious foods?
A: No. The science around these foods is not settled but we are taking a precautionary approach and not including these as part of our definition of nutritious foods.
  • Food is important, but what about the other determinants of malnutrition?
A: Absolutely, the aim is to work where poor diet is one of the key limiting factors.  That is why we do contextual and formative research ahead of programme development.
The External Investment Plan
As Commissioner Mimica stated at the Scaling Up Nutrition (SUN) Lead Group meeting in New York last week, the European Union (EU) wants to do more to engage the private-sector intelligently to bring in new capacities, resources and opportunities to advance nutrition while not doing anything to endanger the advances of the past 10 years.
Although it is a general development facility (EUR€ 3.5billion) to engage the private-sector, the new External Investment Plan represents a good opportunity for nutrition given its triple objectives of (1) mobilising resources, (2) providing technical assistance to businesses, governments and civil society and (3) a focus on the enabling environment for businesses that want to do good things for nutrition.
We should all stand ready to help nutrition champions within the EU to leverage this facility to transform markets to make them more pro-nutrition.

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25 September 2017

Gaga for UNGA?

This past week I have been at the annual UN General Assembly (UNGA) meetings in New York.  This is when more than 100 Heads of State and Government come to the UN HQ, setting off a scramble to meet senior leaders from governments, development agencies, NGOs and businesses.  It has been described by the New York Times as “speed dating from hell” and “the world’s most tedious cocktail party”.
I found it neither of these things.  The speed dating bit is true, but if you organise it well enough (thanks to Laure Walsh in my office!), it is speed dating with who you really want to meet rather than with people you have to put up with.  Hell can be avoided.  And the need to connect on a human level, explore an alliance, or close a deal within 15-20 minutes is quite exhilarating.
And as for cocktail parties, for a boundary introvert/extrovert like me they were easy to avoid.
All in all I had “bilateral” meetings with about 30 people and went to 6-7 events. I even bumped into a member of Nigerian royalty in an elevator in my very modest midtown hotel.
So what were the takeaway points for me?  As usual these are my views, not GAIN’s, and they are partial based on who I talked to, and are coloured by my own experiences and biases.
  1. Hunger, Hidden. Five UN agencies had just released the State of Food Security and Nutrition in the World (by the way, kudos to FAOWFP and IFAD for welcoming UNICEF and WHO to join the report writing, and congratulations to those two for embracing food issues more strongly than ever before). Despite the report showing an increase in the numbers of “undernourished people” (the hunger numbers which are based on food balance sheets, shaped by income distribution data)–the first such rise since 2007-8, there was really very little mention of this in any meetings or events. Is the rise real? What is causing it? What do we need to do about it? I found the lack of urgency on this to be alarming. Perhaps I went to the wrong meetings, but even in my bilateral meetings few people mentioned it. Greater leadership is needed. I know the Secretary General has a lot to deal with, but what is more profound than not having enough to eat?
  2. Communicating non-communicable diseases. Prior to UNGA week there had been an announcement of the Bloomberg, Zuckerman, Gates USD 225 million initiative, Resolve, to address the leading risk factors (e.g. poor diet) linked to non communicable diseases (NCDs) such as coronary heath disease, diabetes and strokes. Perhaps this led to a buzz, perhaps the consciousness around obesity is reaching a tipping point, but there was a lot more talk about these issues than I expected.
  3. Business is no longer a dirty word in nutrition circles. Everywhere I went (and even in the most unlikely places) I heard about the need to engage critically with business if we want to make a serious dent in malnutrition in all its forms.  The world has moved on a lot in the last 10-15 years on this issue. Now there is an increased recognition by those in the public sector that business is deeply involved in nutrition through food markets and the wider economy. Conclusion: if we want them to do better things for nutrition and stop doing bad things, the best thing is to engage. And you don’t change someone’s head unless they are in the room, as the African saying goes. But big food businesses are also reeling from, and sometimes driving, the rapidity with which consumer food tastes are changing, in most of North America and Europe and increasingly worldwide.  Poor diet is one of the main  causes of poor health. And they don’t want to be seen as the next Big Tobacco.  We should engage, inform, and find alignment of interests. And if there are none, let’s be clear about it and not engage until there is.
  4. Islands in the stream. In light of a recent blog on the need to build on past commitments, I was disappointed not to hear more about the Decade of Action for NutritionNutrition for Growth, the Global Nutrition Report or the ICN2 Framework for Action.  Call me old fashioned, but if the stepping stones are laid down, we should make sure they are close together and actually lead to where we want to get to.  At the moment they are simply islands in the stream. And this gets back to first point in this blog.  We need more and stronger leadership in nutrition to build on a decade of remarkable progress.  But from where?  I have my views, but that is for another blog!
So am I gaga for UNGA? I found it helpful, and that was because GAIN colleagues, more organised than me, created a large and excellent set of bilateral meetings, interspersed with a few interesting events—not the other way around.
And the member of Nigerian royalty? She gave me her business card and said see you next year. Let’s see.
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04 September 2017

Connecting the Dots to Set Up a Decade of Impact for Nutrition

BLawrence Haddad, Global Alliance for Improved Nutrition (GAIN) and Francesco Branca, World Health Organization (WHO)

The Challenge and the Opportunity
In its first year, the Decade of Action for Nutrition has helped to generate a series of glorious opportunities for stakeholders from all walks of life to expand and deepen their commitments to advancing nutrition status.  These opportunities will play out across the world in the eight months between September 2017 and April 2018.

Citizens of all countries would benefit from this intensification of intent and action. As the Global Nutrition Report (GNR) 2016 notes, three billion people are suffering from malnutrition in at least one of its forms. Put simply, undernutrition is not declining fast enough while other manifestations of malnutrition such as obesity and diabetes are rising rapidly.

Each of the opportunities crystallises around an event designed to make it more impossible than ever to ignore the challenge of malnutrition and more possible than ever to meet it.  The events are listed below. Each of these events will no doubt be inspiring and illuminating. But will they amount to less or more than the sum of their parts?

Stepping Stone to A Decade of Impact for Nutrition
Key audience
Interest in nutrition
United Nations General Assembly (UNGA) NY, September
UN Member Governments (mainly Foreign ministries; some Health & Development ministries), UN agencies
CFS Rome, October
UN Member Governments (mainly Agricultural ministries)
IUNS Buenos Aires, October
G7 Milan, November
G7 Donors, WB, EU (head of government level)
SUN GG Abidjan, November
SUN governments & networks
World Economic Forum (WEF) Davos, January 2018
Businesses & media & government (some heads of government)
World Bank Spring Meetings DC, April 2018
IFIs, ministries of Finance
EAT Forum Stockholm, June 2018
G20 Summit; Buenos Aires; June or July 2018
Heads of Government
Probably Direct
UN High Level Political Forum; July 2018
Foreign, Development, some other ministries
Not clear

These opportunities have to compound the gains that each one makes along the way. There needs to be a steady and deliberate gathering of momentum for meaningful action. The need to reduce the suffering of billions of people demands it.

What To Do?

The question is, how to create stepping-stones out of these islands of engagement so that the Decade of Action for Nutrition becomes a Decade of Maximum Impact for Nutrition?
The meetings are too well defined to accommodate changes in themes at this stage, even if there was a willingness to do so.
So what can be done to maximise the impacts for nutrition? Imagine if the organisers of the meetings could agree to do the following:

  • Build momentum for action in three-four key topics by picking up where the previous event left off on a given topic. Candidates for topics? The G7 meeting will focus on food systems, women’s empowerment and cities, and the Scaling Up Nutrition (SUN) gathering will have a focus on complex emergencies. These issues will no doubt be raised at other fora—let’s link the debates.
  • Work with stakeholders across these fora to make commitments to act in these and other areas, guided by the 60 or so action areas in the Decade of Action’s Framework for Action. The commitments need not be the SMARTest at first, these can be honed later on—they key is to get public statements of intent on the table, to see what there is energy for and what is missing.  These commitments could kick start the Decade for Action, with pledges to act.
This building of momentum for action and the making of commitments for action would provide a template for each year in the Decade of Action.  Not every year will have 2017’s alignment of events – the Nutrition for Growth (N4G) and International Union of Nutritional Sciences (IUNS) events only happen once every three-four years-, but they will have a set that can be built on at the global level.  While the imperative is to convert energy at the global level into national and subnational action, it is also important to maintain the global energy. One way of feeding that energy is to provide many examples of where actions are taking place on the ground and the effects they are having.

How To Do It?

Who should do this? There is no overarching lead group for nutrition—this is sometimes a strength as it allows nutrition actions not to get stuck in top-down bureaucracy, but in this case it is a weakness as no one group is worried about weaving together all these golden strands of energy into a dazzling fabric that can support and catapult nutrition efforts upwards.

A two track process could be followed: (1) the organisers of each of these events could, this year and every year, get together and coordinate some elements of their meetings and (2) a light touch task force for the Decade of Action could be established under the leadership of, say, the UN Deputy Secretary General to provide a focal point for the efforts of all 193 UN members and to stimulate greater coordination across major events within a year and also across years to build dialogue and action to ensure the Decade of Action for Nutrition delivers a Decade of Impact.  Three billion people are owed that much—and more.

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Published 4 September 2017

31 August 2017

Starting life strong in slums: the role of engaging vulnerable groups on sanitation and nutrition

Crowded slums, poor sanitation and unhealthy diets.  It’s a potent cocktail and for too many families across the world, a daily reality.  Right now, an estimated one billion people live in slums and that number is expected to double by 2030. Slums are where the many deprivations facing the urban poor collide, including lack of access to clean drinking water, sanitation, safe and nutritious foods, sufficient living space, durable housing and secure tenure (UN Habitat).  They’re where human waste is routinely emptied into streets, canals, and garbage dumps. And where overcrowding and low rates of immunization and breastfeeding combine to exacerbate the already perilous problems children face.
Children growing up in these surroundings are at a higher risk of death and disease and are more likely to be chronically malnourished (Ezeh et al. 2017). For example, forthcoming World Bank research from Bangladesh shows that children living in slums are 50 percent more likely to be stunted than children living in other urban areas. This doesn’t just have implications for today – children who are stunted early in life go on to learn and earn less, and face a higher risk of chronic disease as they grow older. Tragically, these effects are often passed on to offspring, trapping families in poverty and malnutrition for generations, as per findings in a forthcoming World Bank report called Uncharted Waters.
So it is crucial that the response is commensurate to the challenge.  In the sanitation sector a ‘radical shift’ is underway to deliver Citywide Inclusive Sanitation, with a focus on ensuring sustained service delivery rather than focusing solely on building infrastructure. The end goal is to eliminate fecal contamination from the urban environment, providing the conditions for children to grow up strong, healthy and prosperous.
Improvements in sanitation are a necessary but insufficient contribution to eliminate stunting and malnutrition among the urban poor. They have to go hand in hand with creating food systems that are better able to promote healthy diets. Following the recommendations of the just launched report on WASH Poverty Diagnostic, the water, sanitation, health and nutrition sectors need to work jointly to ensure that improvements in WASH services and nutritious food systems translate into improvements in child health. We recommend the following three actions:
Firstly, nutrition and WASH services need to be inclusive of all groups to have the greatest impact on child nutrition.Women and children are most vulnerable to the effects of poor nutrition, but traditionally lack the political voice needed to secure services. Poor urban households and those living in slums are often in a similar position – bearing the high health costs of poor service while being ignored by decision makers. These groups can be effectively targeted and engaged using community and social outreach workers.
In Ethiopia, a new Urban Water Supply and Sanitation Project includes support to slum areas and uses urban health extension workers to carry out sanitation and hygiene behavior change. These extension workers are a potential channel to reach groups not just in need of WASH, but other social and health services.
In Indonesia, the Global Alliance for Improved Nutrition (GAIN) is working in partnership with the Ministry of Health and Nazava Water Filters to improve nutrition in East Java under the Baduta Program. One of the key components of this program is the establishment of a sustainable supply chain of household drinking water filters that help households to filter their tap, well or rain water without the need to boil or use electricity. Filtering water is three times cheaper than boiling it and nine times cheaper than buying water. As part of this project, partners are piloting a micro-entrepreneurship model for women entrepreneurs for the distribution of community water filters.
Secondly, behavior change remains crucial.  Research in Ghana shows that uncooked vegetables, grown in areas surrounding slum households and irrigated with wastewater from open drains, are the main way young children are exposed to fecal contamination (Robb et al. 2017). This suggests that a range of actors, including those from agriculture, nutrition and WASH, are needed to influence household behaviors around wastewater reuse, food safety, food safety, feeding practices, and handwashing with soap.  Educating those who care for small children is particularly important.
Another key component of the Baduta project in Indonesia is a behavior change campaign called Rumpi Sehat (Healthy Gossip), designed to promote exclusive breastfeeding, optimal complementary feeding and safe WASH practices. As part of this campaign, village volunteers in East Java conduct various Emo-Demos (emotional-demonstrations) that are 20 to 40 minute highly interactive, game-like sessions with mothers that aim to create surprise, grab attention, spark emotion and challenge social norms. The village volunteers ensure a consistent experience in order to engage and motivate mothers to participate, giving them the confidence to practice the right feeding and hygiene behaviors. GAIN’s team worked closely with the London School of Hygiene and Tropical Medicine to develop the various props and simple discussion guides used for the Emo Demos.
Ultimately, behavior change also plays a key role in helping create demand for nutritious foods and health services, turning communities into active participants in the fight against malnutrition and poor WASH.
Finally, slum households that are counted are better served. Governments are sometimes reluctant to recognize the existence of informal settlements or include them in official statistics – and they can face technical difficulties doing so. But their inclusion is vital to adequately assess needs, obtain budgets, and get services like health, nutrition, housing, water and sanitation to the places where they are needed most. Convergence of these critical services is the first step to a strong start and bright future for every child born into a slum.
Today, at Stockholm World Water Week, stakeholders from the water and nutrition sectors are coming together to discuss the evidence, policy and practice examples of how we can effectively address stunting in slums and informal settlements. We can no longer afford to overlook the complex problems faced by urban slums residents. By working together, we have the power to find sustainable solutions to improve their futures and help to build healthy communities and nutritious food systems.

Follow the discussion @WorldBankWater with #NutritionMeetsWASH and check back here next week for a post-event interview with participants.  
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