10 May 2017

Making Bangladesh’s rapid economic growth also drive rapid nutrition improvement

I was in Dhaka this week visiting with the great GAIN office team in Bangladesh, well led by Rudaba Khondker.  During the course of several group meetings I heard from GAIN’s current and potential partners about GAIN’s strategic positioning and our value add as a partner.  I learned a lot about our partners and about GAIN.  Thank you to everyone who gave me their time during my stay. 

Rudaba and I wrote the blog below. 

Bangladesh is growing rapidly.  GDP per capita was $1212 in 2015.  The height of under 5’s is growing much more slowly.  While the stunting rate is going down at a pace to meet the 2025 target, the annual GDP growth rate is much more rapid—at 7-8% per year. 

It is pretty clear that the rapid income growth is not translating through to rapid declines in stunting, wasting and women’s anaemia, the latter two being are stuck at high levels.  On the other hand, this income growth, interacting with rapid urbanisation, is pushing up rates of overweight, obesity and non-communicable diseases such as diabetes.  A study cited in the Global Panel’s Foresight report on Food Systems estimates that by 2030 Bangladesh will have more people with diabetes than the much higher income Mexico and Indonesia. These facts should worry Bangladeshi leaders and policymakers at the highest level.  I’m sure they are seriously thinking about it and looking for partners to support them to address the situation.

These leaders and policymakers should be worried: treatments for NCDs are expensive and take health resources away from the prevention of malnutrition in all its forms.  This will act as a heavy brake on Bangladesh’s aspirations to move to a developed country status by 2041.

So we need to make income generation more powerful in reducing undernutrition and less powerful in driving up other forms of malnutrition.  This is not easy.  Here are some ideas:
    With the nutrition peer educators in the garment factory. 
  •   Make one of the most powerful engines of Bangladeshi economic growth--the ready made garment industry—better able to improve nutrition outcomes.  The industry has over a thousand factories with 2,000-5,000 workers in each, mostly women.  GAIN with its partner Business for Social Responsibility (BSR) and Change Associates Ltd. works with 24 of these factories to provide nutrition training to 90 women per factory and each of them then  trains 20 workers.  The aim is to improve business outcomes (piece rate productivity, turnover, absenteeism) and nutrition outcomes (evaluation findings will be out by June this year).  If the evaluations are positive, the potential for scale is large and the goal is to use these results to make the case to the factory buyers and the relevant authorities to undertake workplace nutrition actions by including nutrition as part of the Code of Conduct for the factories 
  •   Strengthen the efforts to improve women’s empowerment.  While in Dhaka I learned about IFPRI’s analyses using their women’s agricultural empowerment index. Women's empowerment is proving to be a powerful lever of a wide range of development outcomes—all at a given level of income. Nothing we did not know, but it is great to have hard quantitative results.
  •  Make food systems more nutrition effective.  Food systems contain large resources flows (along value chains, between consumers and retailers, investments in agricultural inputs): what might be achieved if we put a nutrition lens on these flows? If we did I suspect the food system in Bangladesh would generate more nutrition per unit of income growth. The importance of engagement with business is seen with sceptism by some (and some scepticism makes sense—not all businesses do good things for nutrition) but to attain the SDGs, business resources need to be mobilised. It is noteworthy that Bangladesh has included private sector engagement in the 7th Five Year Plan and in its National Nutrition Policies, Strategies and Plans.

Other observations
  • The unfinished agenda in Bangladesh for fortification is huge, not just large scale, but fortification in small scale mills, biofortification and home fortification.  There is not enough strategic coordination between these different approaches to make sure that between them they cover all segments of the population who suffer from micronutrient malnutrition.  We are working with the government and partners to explore the value added and feasibility of establishing and supporting a government Food Fortification Facility to do just this. 
  • Urban malnutrition is a rapidly growing problem, along with food safety. Slums constitute a large percentage of the country’s urban population and are growing rapidly.  Urban areas heterogeneous and some locations have rates of malnutrition that are frequently worse than those in the rural areas.  Urban areas present challenges for nutrition programming for a variety of complex reasons relating to pollution, land tenure, security and access, infrastructure and mobility.  These challenges need to be addressed.
  •           More than half of the Bangladeshi population is under age 25. Adolescents make up one fifth (27.7 million) of the population. We must be impatient for new solutions for adolescent girls and boys.  Soon they will be the next entrepreneurs, carers, innovators and voters.  They can't afford to wait for solutions.  It is time for new initiatives here.

As usual Bangladesh is inspiring to those who care about progress in development.  It is a country that has been written off from a development perspective many times in the past.  Not so anymore.  The eyebrow raising economic growth rates have investors on alert for economic opportunities.  It is our job to help turn that economic growth into a series of great opportunities to also invest in nutrition—and to drive subsequent economic growth. Remember, nutrition status is a maker and a marker of development.

06 May 2017

Pakistan's malnutrition problem: the need for new capacities and stakeholders

I was in Pakistan last week meeting with the GAIN Pakistan team under the leadership of Qaiser Munir Pasha, and with the government and many of our development partners.

The last time I was in Pakistan, in 2013, it was to launch an IDS Bulletin Seeing the Unseen: Breaking the Logjam of Undernutrition in Pakistan”.  The lead paper by Zulfi Bhutta, Haris Gazdar and me noted the coming together of three events: the massive flooding of 2010 and 2011, which exposed chronic as well as acute undernutrition; with the recent decentralisation of health services to the provinces; and the results from the 2011 National Nutrition Survey, which show an increase in stunting, have created some momentum for nutrition”.

Returning 4 years later it is clear that the momentum is still there, but that it badly needs the oxygen of some new (and hopefully encouraging) nutrition data.  The good news is that there is a new national nutrition survey being planned for 2017-18.  And a new census is also in the works (the first for about 20 years) which is also good news because it opens up the possibility of linking the census with the survey to create very fine grained maps of undernutrition and diet quality (see the GNR 2016 for the possibilities). 

And these maps are needed, because decentralization of health services (including nutrition specific interventions) to the 5 provinces has allowed us “see another unseen” -- that of capacity gaps in the implementation and monitoring of the scaling of these interventions.  Like India, the real energy for improving nutrition is likely to come at the subnational administrative levels, hopefully creating competition between them and forcing the Federal government to do more to help them.  So we need to invest in these capacities.

There is some movement on the nutrition sensitive front with activity around nutrition sensitive WASH given the very high levels of water pollution and open defecation.  And there is a growing urgency around the need to address adolescent nutrition, via schooling, empowerment, and social protection interventions. 

What is desperately missing however is engagement with the private sector on nutrition issues, especially around food value chains.  Pakistan is more urban than most South Asian countries and this means more food purchases from the market.  And that means that businesses are important agents of adding nutrition to the food value chain—and of taking it out.  The potential seems significant for government to mobilise businesses for nutrition improvement. It is true that Pakistan does not do terribly well in the World Bank’s Doing Business ranking for 2016 (138th out of 189 countries) but it is not far behind India. 

What we should be interested in is a ranking of ease of Doing Business to Improve Nutrition.  This can surely be developed—preferably at the provincial level. 

17 April 2017

Which dimensions of household food expenditure are associated with child growth? New paper.

The title of this blog sounds like a really boring question.  But it's not.

We have known for a long time that household food expenditures are associated with child growth outcomes, but how is that association parcelled out: is it quantity or quality or both?

This is the question picked up in a new paper by the Young Lives research team, using data from Ethiopia, India, Peru and Vietnam in the "younger" cohort: pooling 3 rounds (when the kids are 5 years, 8 years and 12 years of age).

To answer the question the team looked for associations between height for age z score and 3 key variables: (a) total household food expenditures per adult equivalent, (b) patterns of household food expenditure (as determined by factor analysis) and (c) child dietary diversity score (number of food groups). Control variable applied included child age and sex and household location (rural/urban).

So why is this question important?   First, we know poor diet quality is the number one risk factor behind the global burden of disease.  Second, diet quality is really difficult to assess: 24 hour recall assessment is costly and often criticised for relying too much on such a short recall period.  Third, there is a LOT of household food expenditure data out there.  The World Bank, in partnership with National Governments collects it routinely in its Living Standards Measurement Surveys (LSMS) and there are plenty of other such surveys out there, typically collected every 3-5 years per country.  Finally, these data are not so difficult to collect: they usually cover 40-60 food types and use a 2 week recall period (covering food from purchase, gifts, in kind payment, own production and outside the home).

If only this commonly collected type of food expenditure data could be used as a credible proxy for the quality of diet.  If an index of food group expenditure diversity could be constructed that is significantly associated with standardised height for age (HAZ), and holds for a number of countries, that would be very useful.

So using ordinary linear regression methods, the authors regress HAZ on total food expenditure per adult equivalent, the household food group expenditure index (HFGEI, derived from a factor analysis of household food expenditure patterns) and child diet diversity scores.

In Ethiopia, India and Vietnam the authors find that HFGEI is significantly and positively associated with HAZ--even after accounting for total food expenditure per adult equivalent and child diet diversity score.  In Ethiopia and India the estimated coefficients on HAZ for a 1 SD change are larger for HFGEI than for child diet diversity. And in Ethiopia and India the estimated coefficient on household food expenditure per adult equivalent becomes insignificant once HFGEI and child diet diversity are introduced.

The authors also do this same exercise for BMI for age (BMI-Z) and find significant (positive)  results, but only for Ethiopia and Vietnam.

There are things I would like to see improved, namely some instrumental variables treatment on the 3 key right hand side variables (e.g. is there some unobserved factor driving HAZ and these 3 variables inducing a fake association?).  I'd also like to see village dummy variables included to take health environment into account. Parental education variables are also missing.  Finally, factor analysis always makes me a bit nervous given its black box propensity, but then again it is no less black box than regression analysis and the authors do a good job of unpacking their factor analysis results.

Nevertheless, this is a careful study which suggests that commonly available household food expenditure data may provide a good proxy for the quality of household food consumption (and perhaps even child food consumption).

In the absence of lots of actual food intake, these food expenditure data sets are likely to prove very valuable to anyone trying to assess their efforts to improve nutrition outcomes through increasing the consumption of nutritious foods.

24 March 2017

Reflections from 2 days at the 3rd International Congress on Hidden Hunger

This week I was at the 3rd International Congress on Hidden Hunger in Stuttgart, organised by the University of Hohenheim.  There were about 300 participants, drawn mostly from nutrition and agriculture; academia, civil society and business.  Hidden hunger means micronutrient malnutrition and we think that at least 2 billion people—in all countries—suffer from these deficiencies and we don’t know much about how quickly they are declining.  Not fast enough for sure.

Chatting with the German Academic Exchange Students (DAAD)
I gave 2 presentations: on food systems and diets and on the role of business in improving the consumption of safe nutritious foods.

Some takeaways from me:

The quality of presentations was high, but it was not always clear who the audience were: researchers or practitioners?  Diversity of audience is good, but not necessarily within the same session.  Often I felt that presentations could not build on each other because of this diversity of audience.

The latest research on RUTF and Home Fortification from Bangladesh is fascinating—and practical. There were two very interesting Bangladesh studies from ICDDR,B: one on ready to use therapeutic foods (RUTF) and one on Home Fortification (HF).  The first, on RUTF, was presented by Dr Tahmeed Ahmed but is not yet published. The conclusion from the study was that the promotion of locally produced RUTF is not in contradiction with efforts to improve infant and young child feeding strategies, do not lead to obesity and do not lead to commercialisation of foods for severely malnourished children.  These are 3 common perceptions about RUTF in Bangladesh and this scientific study provided evidence to the contrary.  The second paper, presented by Haribondhu Sarma, concluded that home fortification (HF) has not been well implemented in Bangladesh. When I asked whether there was something inherent about HF that made it difficult to implement, I was told no.  What is needed is greater care in generating demand for HF and working out how to ensure regular supply of HF to those who most need it.  GAIN works in both these areas and so these findings are really helpful to guide our efforts.

How to prioritise nutrition interventions in a given context?  Rolf Klemm from HKI gave a nice presentation on the challenges of implementing Vitamin A supplementation, Home Fortification and Enhanced Homestead Farming.  He concluded that all of them have implementation challenges, some similar, some unique to the intervention.  We should not be surprised--there are no design-proof nutrition interventions. Rolf presented only 3 interventions and I asked him how governments could prioritise across the dozens and dozens of interventions they could undertake? Which should be done first?  Rolf mentioned the LiST tool (Lives Saved Tool) as one guide but this seems like quite a blunt instrument (for example it does not take into account politics and capacity) and incomplete (it only covers a subset of interventions).  We need something more practical to help governments (and all stakeholders) to prioritise and sequence actions.  

Zero-sum tendencies persist in the micronutrient world.  This tension was simmering below the surface.  The most frequent question was: don’t fortification and bio fortification take away from efforts to generate a diverse diet?  My view on this is that needs, opportunities and capacities have to drive the balance of approaches, with government in the driving seat.  All approaches are important, at different levels, in different contexts, at different times.

There were too many environment-free nutrition papers. There was also a tension between those concerned with the environment and those concerned about nutrition.  For example, are we talking about reducing micronutrient malnutrition at any cost to the environment?  These two communities do not connect easily, but they have to.  They need to because the diet choices that affect nutrition outcomes also affect the use of water and energy and the emission of greenhouse gases.

A company’s BMS poor conduct will take away from the good nutrition work that other parts of that company may be doing.  In a coffee break I had an interesting conversation with an employee of one of the big BMS companies.  I had just presented some ATNI data on how poor the Code compliance of big BMS companies was.  This employee worked in a section of the company that focused on children over 4 years of age and politely made it clear to me that the employee’s team had nothing to do with BMS.  But clearly the failure of the  company’s willingness/ability to comply with the Code was damaging the perception of the work of done by the employee’s team.  Employees who work in companies that violate the Code can be quiet and powerful advocates of change from within.

I am grateful to Prof. Hans Biesalski at the University of Hohenheim, the Chair of the event, for the invitation to participate in the 3rd Congress and I look forward to the 4th in 2019.  I very much hope it focuses more on some of the following issues: environmental trade-offs, double burden issues and how to get hidden hunger higher on the political agenda.

20 March 2017

Universality and the SDGs: transforming development as we know it?

The SDGs have been in place now for 18 months. But already there is some disquiet over the attention that is being paid to them by some countries.  

The BOND Annual Conference took up this theme and one of the sessions, which I chaired, asked the panelists “how do we make the SDGs matter more?” It was framed as how are the SDGs connected and how do we leverage the opportunities they bring?  But really it was about how to make the SDGs matter more.

The SDGs are really different from the MDGs.  The SDGs focus on sustainability, on all people within a country and on all countries.  Many of the SDGs talk about ending a problem e.g. “ending malnutrition” rather than halving its rate. Plus the process of generating the SDGs was much more inclusive than the process that generated  the MDGs. This is all great.

But for the audience and the panel the key distinction was the fact that the SDGs apply to all countries—that they are “universal”. 

This means that it is not DFID that reports on the UK’s performance in meeting its own SDG targets, but the Prime Minister’s Cabinet. 

Universality opens up lots of opportunities:

* An understanding of how difficult it is to achieve lasting change in, say, the UK or the USA or the Netherlands within the strictures of typical 3-4 year funding cycles

* An appreciation of how intrusive and disrespectful the metrics culture can be in terms of naming and shaming high income governments, businesses and NGOs that do not meet their commitments

* Learning across contexts that seemingly have no connection (what about addressing the unaffordability of safe nutritious food in some neighbourhoods of Leeds, Lagos, Lima and Lahore?)

* Connecting and engaging the global and local realities of trying to improve development outcomes.  What do the SDGs mean to someone living in Geneva or Washington DC as well as rural Mozambique and slum dwellers in Dhaka?

But is there a risk from this universality? If those who work on international development perpetuate the divide with domestic development then, I think, yes. If these two worlds remain separate there is a real risk that one will cannibalise the other for attention and resources. If, for example, we draw attention to poor school outcomes in deprived areas of the UK without drawing out commonalities and contrasts with, say, deprived parts of Africa then we run the risk of losing resources for development but we also lose a sense of context and humanity, not to mention opportunities to foster a sense of solidarity.

True universality of the SDGs should challenge international development actors to bridge the easy “us and them” dichotomies. It should disrupt our thinking and organisation sufficiently that we gradually move from international development driven by aid to global development driven sustainably by domestic resources—public and private.

11 March 2017

The Access to Nutrition Spotlight Falls on India: What Does it Reveal?

I'm a big fan of the Access to Nutrition Index (ATNI).

The Index was conceived of at GAIN and partners and became independent a few years ago.  Its first report was in 2013 and I blogged about it favourably then.

Now comes the next logical extension of the Index--a country spotlight index.

The first spotlight is in India, where 1/6th of the world's population lives and are governed by a national and international set of food system regulations.

I really like the spotlight report (although I have only read the 60 page executive summary!).

The report selects the 10 largest Indian food and beverage manufacturers and evaluates them on three key dimensions:

* Corporate profile (company nutrition commitments, policies, practices and disclosure--analysis done by Sustainalytics based on publicly available documents supplemented by information provided by the companies upon request)

* Product profile (assessing nutrition quality of company products, based on food types and labels--analysis done by the George Institute for Global Health in Australia)

* Breastmilk Substitute (BMS) compliance (with The Code and Indian Milk Substitutes/IMS act--done in Mumbai by Westat in partnership with the Delhi Centre for Media Studies)
Indian company scores on product and corporate profiles

Key findings (from my perspective):

1. The Indian companies do well relative to the Indian multinational subsidiaries when it comes to product profiles (they derive larger shares of their sales from more nutritious products based on the Health Star Rating system which accounts for positive components such as fruits and vegetables and more negative ones such as salts, sugars and fats).

2. The Indian multinationals do better on corporate profiles, having access to their parent multinational capacities in this area.

3.  The 8 companies that are assessed on BMS behaviour (only 2 --Nestle India and Amul--overlap with the 10 largest food and beverage companies) comply, in large part, with the Code and IMS.  The exceptions seem to be (1) for products that are "parallel imports", i.e. to be consumed in other countries and (2) in marketing online sites, inviting mothers to sign up to information -- which is not subject to the same level of scrutiny.

As usual the report has clear recommendations for companies and for governments.

As I've noted before I think the overall score adjustment for BMS compliance performance should be multiplicative rather than deductive (because of the multiplier lifetime effects of undermining nutrition in first 1000 days) -- it would be an interesting analysis to see if this changes rankings.

Of course, the true test of ATNI scores is whether they are used to change behaviour.  The most important type of behaviour from a business perspective is whether the ATNI score affects investor/creditor behaviour.

At GAIN we are looking to see if we can work with ATNI to develop scores for companies in some of the key countries we work in.  For example can we use ATNI scores to screen investments in companies from our Marketplace for Nutritious Research and then use ATNI score improvements as one factor in the decision of formal lenders to transact with companies.

The public private space in nutrition desperately needs to become more transparent and accountable.  This is how trust is built up and more effective resource allocation decisions can be made.

ATNI is one important contribution towards doing this--but we need more.

18 February 2017

Can Tanzania emulate Ghana's nutrition achievements? Don't bet against it

Small businesses need support to lower the price of nutritious foods
I was in Tanzania this week to work with our Country Representative, Enock Musinguzi and the rest of the terrific GAIN Team.  We spent a few days talking to the government and its development partners on the country’s nutrition needs and how GAIN’s next generation of projects could help advance agreed priorities. 

It has been about 18 months since I was last in Tanzania and in that time the country’s road map to improved nutrition, the National Multisectoral Nutrition Action Plan (NMNAP—which I can’t find on the net) has been published (October 2016).  

It is an impressive document: compelling in making the case for nutrition, clear about where it wants to get (yes the targets are smart—e.g. 28% stunting by 2021), comprehensive in how it is going to get there, who is going to pay for what, and all evidence based. 

But it is more than a document--all the development partners I met talked about how important a framing it was for their own action.  So it really feels like it is a roadmap for all stakeholders.  My main worry is about priorities—when there is so much to do, where to start?  And there is no study that helps to explain which determinants of undernutrition have, say, driven down stunting rates in the past 6-7 years.  At a pragmatic level we have to act and go where the political energy and the capacity to deliver are, although it would be good to have the confidence of knowing that we were helping to relax a truly binding constraint to improved nutrition. 

Other reflections:

Large scale fortification fatigue has set in, but the fatigue must be shrugged off.  I don’t think one of the development partners we spoke to (with the exception of MI and HKI) were enthusiastic about this.  I found this amazing in a context where effective coverage rates are much lower than anticipated (see the 2015 FACT survey, for example even universal salt iodisation is only at 69% effective coverage levels) and where children and women’s anemia is actually increasing.

Diet related non-communicable disease is being talked about.  Adult overweight and obesity together stand at about 26% and the numbers are rising.  The risk is that treatment for the related diseases such as type 2 diabetes, hypertension and heart disease will divert health system resources away from efforts to reduce undernutrition.  The government has featured NCD reduction in its nutrition plan and clearly some donors are beginning to wonder what they can do to make a contribution (answer: make safe and nutritious foods more affordable, keep promoting exclusive breastfeeding, and work to influence the diet and nutrition choices of adolescents, wherever they are found). They must keep working on this. 

There is an increasing recognition of what businesses can contribute to the national nutrition plan.  Mr. Obey Assery, the key driver of nutrition in the Prime Minister’s Office, has stressed this and the NMNAP counts on businesses for 10% of its budget.  But nutrition development partners are only now beginning to look for ways to engage with businesses.  After brainstorming with each of them for 30 minutes or so, together we can usually identify opportunities within value chains, or in workplace policies, or in behaviour change/demand creation for healthy foods, or in building the capacity of small and medium enterprises to comply with food and nutrition legislation.

Multistakeholder working is strong.  One example was the monthly meeting of development partners for nutrition, to which I was invited to. I was enthused by the energy and commitment of those who support the government in its nutrition plans. It is great for knowledge sharing and action coordination. Moving forward, it would be good to draw in more business knowledge and action through the SUN Business Network to complete the multisectoral loop that the NMNAP champions.

Tanzania clearly wants to be the “next Ghana” a country that halved stunting rates to 19% within a 10 year period. 

After having witnessed the leadership, energy and determination within the country right now, I wouldn’t bet against it happening.