20 July 2016

So, Why Did I Join GAIN?

My warm thanks to the hundreds of you who have sent me messages of congratulations about my recent appointment to the Global Alliance for Improved Nutrition (GAIN).  So, why did I decide to apply for the GAIN Executive Director position and why did I accept the Board’s offer to join (I begin on October 1)? 

First, much of GAIN’s work revolves around improving access to food that is safe, nutritious and affordable.  Poor quality diets and diet related conditions represent the largest set of risk factors for the global burden of disease -- greater than unsafe sex, alcohol, drug and tobacco use combined.  These poor quality diets have massive economic consequences – equivalent to a having a global financial crisis every year, according to the 2016 Global Nutrition Report.  This state of affairs reflects enormous food system failures.  

The food environments that consumers make decisions in are not helping them make food choices that support high quality diets.  That is because these diet choices are unaffordable, not available, or are not framed by businesses and governments as desirable.  This makes improving the food environment, and the food system that underlies it, such an important challenge for the achievement of a wide range of Sustainable Development Goals. Food is not the only thing that is important for nutrition status—we all know that—but it is the thing that is least easy to change through public action alone (unlike say water and sanitation, health facilities and schools) and it is important for all forms of malnutrition. Public sector leadership on setting priorities and on establishing and enforcing regulatory frameworks is essential if businesses and NGOs are to play a positive role in nutrition, but the public sector cannot do it on its own.

That brings me to the second reason: food systems are not mainly populated by bureaucrats, but by consumers and businesses.  Some of the businesses—whether small, medium, large or very large--act positively for nutrition, some act negatively and some do both.  By working with businesses that have positive track records in nutrition –and evaluating those efforts independently--we can begin to change the food system to work harder to give consumers choices that support the pursuit of improved diets.  For businesses that do not have a good track record, we should be able to explain to them—with evidence--why what they do is negative for nutrition and what they can do to change that.  In this way GAIN and other organizations can make it easier for everyone to understand when, why and how it makes sense to engage businesses in efforts to accelerate malnutrition reduction.  Changing norms about businesses and nutrition away from “business=good” and “business=bad” towards something more nuanced and which helps identify and manage conflicts of interest, would be a major contribution. 

Third, it seems to me that there are not enough people and organisations working in this space, namely on how to make food systems more nutrition friendly.  There are lots of reports available now on what to do, but few have credibly evaluated attempts to actually innovate for change in the system.  GAIN and others have the opportunity to really populate this space with examples of things that were tried and worked (or did not).  The key is to learn and share the learning with others.  Hence the alliance- building role of GAIN is absolutely essential to moving forwards.  We all know that to end malnutrition we have to form alliances that are powerful enough to counteract the powerful forces that generate malnutrition.  In part this means people and organisations getting on with their jobs and doing them well, but in part it is about the strategic and tactical joining of forces to accomplish things that single organisations cannot do on their own.  GAIN, if it does this sensitively, carefully and wisely, can help build new positive alliances to end malnutrition, identifying ways of conducting due diligence on potential partners--whether from the public or private sector--and documenting behavior that is essential if nutrition status is to be improved and not diminished.   

Finally, I have been really impressed by the quality of the GAIN Board and staff that I have met.  They are clearly driven by a vision of ending malnutrition.  And they have brought GAIN a long way forward in a short space of time (GAIN is only 15 next year).  I really look forward to working with them to take GAIN to the next level.  What does success look like?  It is too early to tell, and this is just my opinion as of now, but in 10 years time I would like to see GAIN contribute to a handful of widely scaled innovations (systems, institutional, governance, technological) that have made it easier for those who are malnourished to claim sustainable access to food that is nutritious, safe and affordable. 

GAIN and the entire nutrition community have a fantastic chance to change the way we think and act about how food systems--and the actors within them--can work better for good nutrition.

Come and work with us to make it a reality.

16 July 2016

Three quick reflections from the 2016 IDS-IFPRI Nutrition Summer School

We just completed another IDS-IFPRI-Transform Nutrition Summer School.  I co-convene this with Nick Nisbett from IDS and Purnima Menon from IFPRI.

We had another great cohort of knowledgeable, committed and hardworking participants, drawn largely from the policy and programme world, who worked with the convenors of the 5 day course to go through the causes, consequences and solutions to ending malnutrition.

The Transforming Nutrition Class of 2016
As usual the course was a lot of fun and involved a lot of learning on all sides.  Here are a few quick reactions.

1. The participants were looking beyond the usual sectors for solutions that might be useful for nutrition

Where was the work on climate change (impacts of and strategies for mitigation)?  Where was the work on education (keeping girls in school, delaying age of first birth, teaching kids about high quality diets)?  We did expand the food systems section of the course, but the participants wanted more.  Maybe we will have to have parallel sessions next year. 

2.  There was a real thirst for how to put solutions together

So if you are in a region that experiences this kind of a malnutrition problem, and we can identify 30 things to do to improve the situation, how do you decide which are the priorities and how to sequence those?  We noted that there are precious few tools to help with this and one of our group suggested we use more systems thinking next time around to do this.  Good idea.  We also need to develop new tools. 

the participants working hard on their nutrition plans
3.  Finally, I was struck by how few of these courses there are throughout the world

I don't get it. Maybe it is as simple as not being able to demonstrate the benefit of the course in terms of cold hard cash to prospective investors.

But surely this problem bedevils most education initiatives.  And the participant evaluations of the course are great, and demand--the ultimate judge of value added-- is strong for the course (we can only accept 1 in 3 applicants).
our World Bank alumnus from 2014 

One qualitative indicator of benefit was the presentation of a class of 2014 participant who reached out to us to present at the course. He is a World Bank staffer working on nutrition in Lao.

He gave a great presentation that showed very clearly how the course has helped him and his team develop diagnostics with the Lao colleagues to really zero in on the key links in the Lao nutrition chain that need to be addressed.
Purnima (IFPRI) and Adam (TFNC, Tanzania) 

me, reaching for the data
When I move to GAIN on October 1,  I will certainly be working with GAIN colleagues to look at whether these immersions that bring together practitioners and evidence are a useful thing to do for our mission.

And get ready for the 2017 IDS-IFPRI course, held in July 2017.  Applications will be accepted early in 2017.  Check out this webpage early in 2017.

06 July 2016

Data: What India needs to end malnutrition by 2030

It may seem like a no-brainer to say that we need data to guide efforts to end malnutrition. 

Would you run an economy without a regular stream of credible data? You'd be flying blind if you did, and we know what happens if you try to do that. And yet this is precisely the situation that those trying to end malnutrition in India find themselves in.

Until the Rapid Survey on Children (RSOC) data from 2013-14, seven years had elapsed since the last nationally representative nutrition survey, the third National Family Health Survey (NFHS 3). We hear that NFHS 4, the next big government survey, is in the field and we very much hope it will be out by 2018. If it is, that will be a gap of five years since the RSOC.
Why is data important?

As the 2016 Global Nutrition Report reminds us, it is important because it tells us which types of malnutrition are being reduced and how fast that is happening. If we know this we can adjust efforts and reallocate resources before it is too late. It is also important for accountability: We need to know how resources have been allocated and the effect they are having if we are to assess the performance of key stakeholders, whether from the government, civil society, the development agencies or businesses.

What type of data is critical? There are at least five.

First, we need to know the extent of malnutrition: Where it is and how fast it is (hopefully) decreasing. In India, based on the RSOC data and the Global Nutrition Report, the speed of decline in stunting rates has improved as has the speed of improvement in exclusive breastfeeding rates and this is great news. But the rate of wasting of under-five's remains high at 15.1 per cent, adult diabetes rates are increasing and are currently 9.5 per cent and women's anaemia rates are essentially static at 48.1 per cent, one of the world's worst (170th out of 185; China and Brazil are under 20 per cent, Sri Lanka is 26 per cent and Nepal is 36 per cent). Data tells us where to apply the accelerator, where to try to apply the brakes and when to turn to different priorities.

Second, we need to know whether high-impact nutrition interventions are reaching the people they are supposed to reach. Interventions cannot work if they do not reach families at risk of malnutrition. India has a patchy record on coverage: Some interventions and practices such as exclusive breastfeeding have high rates of coverage but the coverage of infant and young child complementary feeding programmes is poor, with these infants and young children showing very poor diet adequacy and diversity. Coverage is where the rubber hits the road for nutrition action. We need to know whether the roads are seeing any rubber-and whether they are the right roads.

Third, we need to know more about how well certain sectors are doing in supporting nutrition improvement. Public distribution systems that use micronutrient-rich foods are more nutrition-sensitive than ones that do not. Water and sanitation programmes that have a child-centred focus are more nutrition-sensitive than those that do not. Cash-transfer programmes that incorporate some behaviour change communication work around nutrition will be more nutrition-sensitive than those that do not. The only way to assess the nutrition-sensitivity of these sectors is to go through the national and state and district budgets - as NITI Aayog member Bibek Debroy recently said - line by line, and designate certain line items, say, 0, 25, 50, 75 and 100 per cent allocations to nutrition. If they are fully nutrition-sensitive they will be given a 100 per cent weight. If they are not nutrition-sensitive at all they will score zero per cent. The challenge is to increase the overall percentage allocated to nutrition. To meet that challenge, we need data.

Fourth, we need the first three types of data at the state and sub-state levels. As the India Health Report clearly shows, different states and different districts have different nutrition problems, have different capacities to address them and show different levels of political commitment and leadership. Moreover, the distance between people and their leaders narrows as we move towards the district and community levels, and so, accountability is easier to build. To guide action and promote everyday accountability, we need more disaggregated data.

Fifth, we need to know what works. If we don't know whether a nutrition programme actually works, where it works, for whom it works, why it works and how it works, then we are, again, flying blind, wasting resources and acting irresponsibly. More research funding inside and outside India needs to be directed towards making Indian nutrition interventions more effective and more easily scaled up. Innovations need to be developed, piloted, tested and, if cost effective, scaled up. While the costs of evaluating interventions are not trivial, as the 2014 Global Nutrition Report showed, the benefit-cost ratios of identifying and scaling up the interventions that work to prevent malnutrition are huge: Over 34 to 1 for India. The implementation of a national, state or district economic strategy without reliable and regular data would not be attempted-investors simply would not take any such strategy seriously. And yet this is tolerated for a nutrition strategy.

The signing of the Sustainable Development Goals by the Indian government provides the perfect opportunity for India to develop its own dashboard of nutrition indicators-one that is linked to specific, measurable, achievable, relevant and time-bound (SMART) targets. The hardest thing for any government to do is to put in place measures for its people to hold it accountable. But all governments need to act confidently and match the bravery exhibited by the mothers, fathers and families that struggle to prevent and cope with the malnutrition that affects too many of the world's next generation. 

A government that stands up and allows itself to be counted on nutrition is a government whose bravery will be rewarded by an incredible legacy-the ending of malnutrition by 2030.

03 June 2016

Guest blog: Investing in civil society is the ultimate commitment to sustaining momentum for nutrition

It is not often that I have guest bloggers on Development Horizons, but I feel so strongly about this topic that this was a no-brainer. 

Dear governments and donors: investing in civil society is the ultimate commitment to sustaining the momentum for nutrition.  Your Presidents, Prime Ministers and Ministers will sooner or later enough fixate on another issue.  But once you light a fire in the hearts and minds of citizens about malnutrition, that fire will burn on--it just needs enough oxygen to make sure it lights the way to effective advocacy, implementation and accountability.  Claire Blanchard's blog will help you make your case for funding CSOs so they can help end malnutrition by 2030.  

Dr Claire Blanchard, SUN CSN coordinator, makes the case for supporting civil society
Civil society plays an essential role within the Scaling Up Nutrition Movement, making the link between communities and the national and international platforms where governments, donors, agencies and others meet. In 39 high-burden countries, local, national and international organisations working on nutrition have come together into civil society alliances (CSAs). These CSAs occupy a unique position in the nutrition movement with many now being a recognised counterpart to government, with a place at the table and influence on nutrition policy and implementation.
Why are these alliances important in nutrition improvement?
They coordinate civil society to speak with one voice, raise the profile of nutrition, enrich nutrition policies by channelling the voices of those directly suffering from malnutrition, highlight the gender needs, promote and ‘walk the talk’ of accountability, strengthen local capacity, build sustainability of all nutrition efforts and are a real added value for money.
So what can civil society do that others can’t
Civil society operates at ground level in the communities most affected by the impact of poverty and poor nutrition – making these organisations ideally placed to design, deliver and monitor programmes, track nutrition-related spending, and verify that governments are delivering on commitments.
Civil society can:
ü  Share community knowledge of the needs of those directly suffering from malnutrition – as well as what works - to shape policies.
ü  Contribute to implementing nutrition actions and monitoring progress and impact.
ü  Raise community awareness of the importance of good nutrition and support them in understanding how to change behaviour.
ü  Help champions and citizens advocate for action and investment – and help people hold governments accountable for their commitments.
Investing in civil society can have significant impact
ü  In Peru, chronic infant malnutrition has been halved in less than a decade. Civil society advocacy has been a key driver of this progress sustaining prioritisation of nutrition.
ü  In Zambia, the CSA used public awareness and media campaigns to ignite national debate and convinced MPs to form All Party Parliamentary Caucus on food and nutrition
ü  In Guatemala, the CSA have 22 youth groups auditing the implementation of - and flag gaps in - the national 1,000 days strategy in ‘hard to reach communities’ – some suffering from as high as 90% malnutrition rates.
ü  In Zimbabwe, the Nyazhou Garden Project aiming at improving household income, food and nutrition security of vulnerable women in poor communities have changed the lives of 60 villagers. Sekai Tembo, a 72 year old widow said the project had completely changed her life.
“When my husband died, I had no choice but to carry on with life, though it was hard. I had no cattle, and you know the importance of draught animal power in our lives, but since I joined this project I now have two goats. Before, I used to do gardening but it would only sustain me and my family but now the produce is feeding me, my two grandchildren and I sell the surplus to surrounding villages. I get $15 dollars per week, which is $30 per month because the other two weeks the vegetables would be sprayed. Previously, it was hard to get hold of only $2,” Sekai Tembo, Uzumba Maramba Pfungwe, Zimbabwe
ü  Kenya’s CSA successfully advocated for revision of National Health Policy to include a stronger nutrition component.
ü  In Nepal, the CSA helped secure a directive that local level governments must include a nutrition program in their work plans.
ü  Budget tracking and advocacy efforts at decentralised level have shown increased nutrition investments by local authorities in Nigeria and Tanzania
Sustainability threatened by funding insecurity
Securing funding beyond 2016 is crucial for CSAs, with the SUN Multi Partner Trust Fund now coming to an end. Most CSAs are supported by their members through significant financial and in kind contributions and are seeking national funding as a priority.  Funding is also needed for the SUN Civil Society Network - the fastest growing network in the SUN movement with a combined membership of over 2,500 local, national and international organisations. SUN CSN is an accelerator– a fast-start mechanism enabling new national CSAs to quickly build capacity, set up appropriate governance and systems, and learn about effective advocacy from their well-established peers.
The recent independent evaluation of SUN’s Multi Partner Trust Fund praised the role of civil society in taking the SUN Movement into places it otherwise wouldn’t reach.
Donors want to see the best value for their investment, improved integration and innovation to ensure at scaled impactful and sustainable efforts.
We need more money for nutrition but more important a better use of existing moneys as highlighted by the recent World Bank estimates. However we also need to earmark some of these moneys to ensure civil society keeps doing what no one else can. We need existing and new donors investing but we also need to think of innovative and sustainable funding models, diversifying our funding sources and ensuring we are as effective with existing resources as possible.
Momentum is critical in any attempt to bring about a significant, lasting change. The momentum created by the SUN Civil Society Network over the last three years is significant – but is now in danger of being lost.
As Tom Arnold, Interim coordinator for the SUN Movement puts it: “Civil society has an absolutely pivotal role to play in the next phase of SUN. In order to build on investments to date and sustain its work, civil society needs funding to ensure that joint efforts are long-lasting and to ensure progress is accelerated.”

28 April 2016

Now is Japan's Time to Shine for Nutrition

Food and nutrition are high on the agenda in Japan policymaking circles right now.  The G7 meeting in a month, hosted by Japan, the passing of the N4G torch in Rio in early August, the TICAD (the Tokyo International Conference on  African Development) conference in late August—all are stoking interest. 
In this context it was great to be invited to Japan to launch the 2015 GNR in Tokyo earlier this week.  The launch was hosted by Save Japan, Results, World Vision and the Network for Action on Malnutrition.  Officials from the Japanese government were present: from the Ministry of Foreign Affairs (the Food Security Working Group), the Japanese International Cooperation Agency (JICA), the Ministry of Agriculture and some key parliamentarians.  Over 200 people attended.

In addition to the launch we met with JICA officials working on a new initiative to be launched at the G7, and with the G7 reps doing the background work for their government’s representatives to the G7.
In my presentation I urged the government to do the things in the slide below.  Japan is one of the most important donors for nutrition specific interventions at about $60m in 2014, but this is down from over $100m in 2013, so the first order of business is to get this back to over $100m in 2015 and then in 2016 to $150m, at least doubling over the 2016-2020 period compared to the 2010-2015 period.  

I also urged the government to estimate how much it is currently spending on nutrition sensitive actions.  I suspect it is quite a large amount, but Japan has not estimated this.  If they did it would help the government to assess where it is strong and where it could strengthen the nutrition impact of current resources.  We will invite them to do so for the 2017 GNR.
But Japan can play a bigger role than this. It can improve the enabling environment for nutrition in Asia and the Pacific -- and beyond.  Japan was a founder member of the SUN donor network, so it has shown vision and ambition on nutrition.  But Japan can play an expanded nutrition leadership role in the following ways.

Over 200 people attended the event in Tokyo
*As the 2020 hosts, Japan can really energize the N4G process after Rio through a 3-4 year series of stepping stones including making some ambitious and SMART pledges at the TICAD conference, pledges aligned with the aims of the recently announced Decade for Action on Nutrition. 
* As a leading practitioner in working with the private sector in development, Japan can bring some learning to the nutrition arena about the opportunities and pitfalls of working with business and how the former can be maximized and the latter minimized. 

*As the perennial holder of the Asian Development Bank brief, Japan should work hard to get them as interested in nutrition as the African Development Bank, under Akin Adesina’s leadership and the World Bank under Jim Kim, seem to be.  I still remember giving a talk with Stuart Gillespie in 2000 at ADB HQ on a project, funded by the ADB, looking at opportunities for advancing nutrition in the Asia Pacific Region.  In a large auditorium, the audience was 10!  Most malnutrition is in Asia.  If the ADB bankers want high and secure returns on their investments they need to invest in nutrition.

* In a country that has a high diet quality, Japan should lead the G7, N4G, TICAD and ADB towards this overlooked dimension of food security, one that is equally important for the prevention of malnutrition in all its forms.  Poor diet quality is now the number one risk factor in the global burden of disease, but food systems choices are not influenced by this fact.  Japan can be a leader in how to develop food systems that deliver more affordable diet quality.

I left Tokyo full of optimism that Japan will enhance its nutrition leadership over the next 4 years.  Japan’s leaders now have a once in a decade opportunity to inspire the entire world of nutrition. A great first step would be a breathtaking SMART commitment launched in August, either at the N4G or TICAD events. 

15 March 2016

The SDGs: A Great Gift to Nutrition Accountability – If We Accept It

Today I was at a workshop organized by the SDG2 Accountability Group, convened by ONE.

My presentation made 6 points about the gift that the SDGs represent to strengthen nutrition accountability.

1.  The 17 SDGs are said to be indivisible.  For nutrition this is certainly the case.  In the 2016 GNR (to be released on June 14) we analyse the 230 brand new SDG indicators and we identify over 50 that are highly relevant to nutrition, coming from 12 SDGs.  And SDG2 is not the Goal that contains the most of these indicators!  SDG2 is a starting point, not an end point for accountability on nutrition.

2.   The SDGs refer to malnutrition in all its forms.  This means overweight, obesity, high blood sugar etc as well as stunting, wasting anemia etc.  Bringing in stakeholders who care about accountability in these manifestations of malnutrition does not represent a distraction, but an opportunity.  The NCD Alliance, the Food Foundation and Jamie Oliver’s Food Foundation—to name a few—can strengthen accountability for all of us by bringing in citizens and others who would not normally focus on undernutrition.

3.   End Malnutrition.  Ending as opposed to halving (as in the MDGs) malnutrition means that we have to prevent and end malnutrition wherever it may happen.  High hanging fruit are no longer safe.  This means getting more disaggregated data.  In the 2016 GNR we conduct an analysis that compares stunting levels at the sub national level within 60 countries and find extraordinary differences between regions with the highest and lowest rates within each country.

4.   By 2030.  Having an endpoint is really helpful.  The MDGs obviously had this, but somehow the end date feels more meaningful when the goal is to end rather than halve malnutrition.  In terms of business as usual estimations, how long would it take for us to end anemia in women?  Never mind a Decade of Action, more like a Century of Action.

5.    Be SMART.  Too few countries (and other stakeholders) make SMART commitments.  As the 2016 GNR will show, only a small percentage of commitments made by governments are SMART.

6.    Collect more data.  Four of the WHA indicators rely on regular survey data like DHS and MICs: under 5 stunting, wasting and overweight and exclusive breastfeeding rates.  For these indicators across the 193 countries, we can only make on/off course country assessments for about half of the country-indicator pairs.  Targets without assessments are about as useful as an iPod Classic without headphones.

These SDG gifts need to be accepted and then used. 

A few quick reflections on the first 3 hours of the workshop (I couldn’t stay longer).

* It is great to see ONE back in the nutrition fold after a brief hiatus.  Welcome home.

* SDG 2 Accountability is a welcome initiative.  As I noted above, accountability in nutrition is weak.  More attention to it is welcome, especially as the initiative is trying to align with other accountability efforts such as the GNR.  

* The big value added of SDG2 Accountability (I think) is bringing in new and innovate ideas about (a) how to use existing data better, improving interoperability and user interfaces, (b) how to tweak existing data collection initiatives that are not motivated by nutrition but could work well for it, and (c) how to collect nutrition data in completely new ways.  Interestingly the 3 presentations I caught on “big data” were from companies.  Keeping my skepticism in check (e.g. data quality, data representativeness, the limits of interoperability etc.) I found the presentations intriguing.  I want to find out more.  We all should. 

I wish the SDG2 Accountability initiative well.

10 March 2016

Urban Jonsson: a towering figure in the world of nutrition and human rights

The late, great Urban Jonsson
We learnt yesterday that one of the giants of nutrition and of human rights, Urban Jonsson, had passed away.

If ever there was a better proponent of Neil Young's famous line "it's better to burn out than to fade away" I can't think of one.  Urban went down swinging, for nutrition, for rights, for humanity.

Why was he so great?

Well, for starters, he was a conceptual thinker.  Want to know where the UNICEF framework came from?  What the Lancet framework was inspired by?  Answer: Urban Jonsson.

He understood the importance of politics in nutrition. He had a stint as a politician in Sweden.  He was a master communicator and he understood how to do deals for nutrition.

He was practical yet idealistic.  He popularised the triple A cycle within UNICEF (assessment, analysis, action) and he popularised (with others) the importance of rights in nutrition and in development more broadly--he was eloquent in explaining how people had to have support to claim rights and how duty bearers often needed support to deliver on those claims.

He was fearless.  He basically said whatever he thought, no matter the consequences for himself (and sometimes for others).  This got him into trouble quite often.  Sometimes it made him unnecessarily controversial.  And while he often sucked the oxygen from a room, he usually substituted that with boundless energy and passion.  Read about him here, in his own words.

The first time I ever spoke to him was on the phone in 1994 while I was working in South Africa.  He called me up out of the blue to "summon" me to give a presentation at the UNSCN meetings that year.  It took me about 20 minutes to convince him I would not attend -- because I would be on honeymoon!

He was that kind of a person--he wouldn't take no for an answer when it came to nutrition.  We need more people like that.

I will miss him, as will thousands of others.