06 July 2015

Guest blog from Stuart Gillespie: From the politics of commitment building to the politics of delivery

Guest blog from my IFPRI colleague, Stuart Gillespie, with some reflections on enabling environments for nutrition.  

“The microbe is nothing, the terrain everything” (Louis Pasteur, 1895)

"The objective of development is to create an enabling environment for people to enjoy long, healthy and creative lives." (Mahbub ul Haq, 1990)

We have learnt a lot about “enabling environments” in nutrition over the last few years -- about what they are, and why they’re important. In broad brush, an enabling environment is one in which there is a political commitment to address malnutrition, backed up by institutional commitment in the form of pro-nutrition policies, incentives and accountability. Nutrition-relevant data are generated, shared widely, and they inform action. Different elements of nutrition-relevant capacity are understood and strategies are pursued to address gaps and weaknesses. Nutrition champions build alliances and they work across sectoral boundaries to make the case for nutrition. The growing priority attached to nutrition is reflected in financing that is adequate, stable and flexible.

Such enabling environments (EEs) lie at the base of the Lancet (2013) conceptual framework, and they have opened the door to a more politically nuanced analysis of nutrition in recent years. EEs may be foundational but they are also dynamic. They can change….for better or worse. In tracking countries’ progress against four indicators, the SUN movement is monitoring the development of EEs at the national level.

This is clearly important, but it’s not enough. Between Pasteur and ul Haq, environments operate at different levels. Think of the layers of an onion. At the core, a child’s nutritional status represents an enabling (or disabling) environment for her/his growth and well-being, Pasteur, and his compatriot Claude Bernard, did not explicitly refer to nutritional status but it was the stability of the milieu intérieurthat was believed to be “the condition for a free and independent life”. Nearly a century later, when he launched the first Human Development Report, Mahbub ul Haq was building on Amartya Sen’s capability approach. Enabling environments were those that preserved the future capability to act, that kept an individual’s set of life choices open. Human development was about expanding the richness of human life, not the richness of the economy.

Between the outer and innermost layers of the onion – between macro and micro – there are district-level bureaucracies. A supportive policy climate does not automatically guarantee effective subnational implementation of nutrition-relevant programs. We need to move below the national level to better understand meso-level environments for nutrition. We need to pay more attention to vertical coherence (national to community) and go beyond the politics of commitment-building to the politics of delivery.

Creating and sustaining EEs is not easy, and it takes time. There are many moving parts, and there is no gold standard. Future research and action needs to recognize such complexity. One way to do this, and to foster sharing and learning across contexts, is to document real-world experiences in developing EEs at different levels.  Such “stories of change” – focusing as they do on the lived experience of key actors -- can be powerful.  Stories inform, but they also inspire.

24 June 2015

You say you want a nutrition data revolution? Well, you know, we’d all love to see the plan

One of my favourite book reviews (as long as it never applies to me) is: “This book fills a much needed gap” (think about it).  Those who advocate for more nutrition data need to ask themselves the same thing: do these data simply fill a much needed gap?  In other words, do we really need to fill any given data gap?

Yesterday I participated in a brainstorming meeting at WHO on data gaps that matter for scaling up nutrition interventions.  Data are needed at the subnational, national and global levels to guide action, to assess progress, to help advocacy and to strengthen accountability. 

We spent the whole day (a) identifying gaps that need filling, (b) mapping ways forward on data gaps that can be filled relatively straightforwardly and (c) brainstorming on the more difficult or “gnarly” data gap issues.

Some reflections:

The participants work mostly at the “global” level—and it showed.  It was important to keep in mind the constraints faced by people working with data in the domestic nutrition system.  There was a tension between framing things as “what do we need to do to get more domestic data into the international system?” and “what do countries want/need to move their nutrition agendas forward?”  Another tension was around framing that said “what additional data would be useful to countries?” and “what do countries need to make existing data more useful?”  All of the framings are valid, it seems to me, it is about listening to countries while also meeting global accountability and advocacy needs.  But how to “listen to countries” without burdening countries, while doing it in a demand driven way that is not patronising?  And then how to aggregate up?  Perhaps via country typologies in terms of the nutrition problems they face and the capacity they have to collect and use data.  

The parlous state of food consumption data. This was mentioned by nearly everyone as a problem.  Food intake is vital to address undernutrition, but also other forms of malnutrition driven by unbalanced diets.  How can countries formulate a strategy to address undernutrition in a balanced way if they do not know what their population eats? There are a number of initiatives in process to strengthen food intake data, but there was a general sense that data collection in this area needs to step up a gear.

Coverage data.  As the GNR 2014 pointed out, of 10 Lancet nutrition specific interventions, only 4 have internationally comparable data on coverage for more than a handful of data (vitamin A supplementation of under 5’s, iodized salt intake, zinc treatment of under 5’s with diarrhea and iron folate capsule intake during pregnancy). 

But what to do about nutrition specific intervention coverage?  Why is it not more routinely embedded in on going data collection activities such as DHS/MICS/SMART surveys?  One reason is that we do not have a set of agreed on and easily implemented coverage indicators that can be embedded in surveys or, indeed, in facility-based data collection.  We need such a set. 

And what to do about nutrition sensitive programmes? How do we know if they are nutrition sensitive and how do we figure out who they reach?  No answers I’m afraid, just prioritizing unknowns.

Cost data for nutrition interventions.  If we want to know how much reducing malnutrition costs—and try to make action more cost effective--cost information is essential.  What can we do to make sure these are always collected?  And how can these data be curated and made available to a wider audience?

So more questions than answers, but a list of follow up actions was drawn up, and different people committed to deliver on these actions.  Many were process actions, but that is OK it seems to me.  The costs of data collection are high and the costs of collecting the wrong data are even higher.  Doing data things in a deliberate and coordinated way is important.  

Surprises?  There were 2-3 strong advocates for better micronutrient surveys but not as many arguing for it as I would have thought given the large numbers of people affectedly them, the lack of specificity about who they are and the lack of progress in addressing the burdens.  We did not talk much about indicators for capacity (beyond the number of front line health workers) although this is an important issue.  We talked about the need for better data on preventing severe acute malnutrition and on the coverage of treatment, but not as much as the issue perhaps deserves.  As usual, the issues raised depend on who is in the room, no matter how objective they are trying to be. 

In the context of the broader dialogue, the group is aiming to write a more considered piece for public consumption to contribute to the wider discussion about which data to invest in.  And why that investment would fill a gap that is not much needed.  

01 June 2015

UNICEF and Nutrition: What Do We Want From It?

I was invited to the annual meeting of UNICEF nutrition leaders from around the world.  It was a bit like an episode of Marvel's "Avengers Assembled"  -- I had met so many of these great professionals at various stages in my own working journey. It was great to see them assembled in one place.

I had been asked by Werner Schultink, UNICEF Nutrition Chief, to speak to the topic of "What does the global community expect of UNICEF? How should it respond?  My powerpoints are here.

What do I expect of UNICEF on nutrition?

1. Leadership.  Nutrition is flavor of the month right now, but leadership is speaking up for nutrition when no-one else is doing so and UNICEF has been very good at doing that pre-2008.  Keep doing it, even if everyone else is. More importantly, help us keep our feet on the ground.

2. Innovation.  As Michael Anderson said at the IFPRI Forman Lecture last year, one can get carried away with innovation.  Many times we just want people to do their job.  But UNICEF has been a pioneer in so many areas: from the conceptual framework, to rights based programming, to using mobile phones and to being involved with the Power of Nutrition and UNIT LIFE financing facilities for nutrition.  Keep asking yourselves and the rest of us: "what's next?" in nutrition.

3. Measurement.  While I don't believe what gets measured always matters, we need to measure what does matter, and UNICEF is a fantastic fundraiser for surveys: from the regular MICS to one-off surveys in Maharashtra and the Indian nationwide Rapid Survey on Children.  The GNR tells us that 40% of countries have anthropometry data that is at least 5 years old.  Imagine what that statistic would look like without UNICEF.

4. Documenting stories.  In an era when research fashions have sliced and diced the change landscape, we need organisations like UNICEF to commission comprehensive stories of change or stasis.  If Kenya has just generated impressive declines in stunting, what has generated them?  There will be a self serving element here--the commissioned work can tell UNICEF about their role (and if good, provide some promotional material) but the wider service to the field is to describe, analyse, inform and inspire everyone else.  More please.

5. Support to countries.  I have seen the invaluable long term support UNICEF has provided to Maharashtra, Uttar Pradesh and Ethiopia.  They do it in a way that respects country leadership.  Changing nutrition outcomes does not take as long as we sometimes think, but it does require 7-10 years of constant support--and this is an eternity for some governments and donors.  UNICEF is patient.

6.  OK before you wonder if I have been paid by UNICEF to write this blog (nope), what could they do better?

* work across sectors better.  UNICEF is in a privileged position--they are not constrained by sector . So can they make the most of this liberty?  Some of the UNICEF staff were very open--they could do better, but this would require support from UNICEF Res. Reps.  Hey, if UNICEF cannot do it within their organization, how can the rest of us do it across organizations?

* help us all chart a pathway through the double burden terrain.  More and more countries are struggling with the realities of the coexistence of under and overnutrition.  What should they do?  Be blind to it or blinded by it? Neither.  We need a clear eyed vision, and UNICEF with their focus on health systems and schools can help.

* help us navigate another rocky terrain--business involvement in nutrition.  When to stick or twist?  And how to minimize the risks with doing either?  Because much of the controversy surrounds the role of business in marketing products to infants and young children, UNICEF has to speak up and help develop some norms of behavior. Get more involved in the private sector debate. 

* help us lock in the current high commitment to nutrition.  This means making more noise about the lack of nutrition in the SDGs.  UNICEF is a stone's throw (literally) from those haggling over the SDGs.  Sharpen those elbows. 

* help us make SMARTER commitments on nutrition.  There is a big pledging moment coming up in Rio in August 2016.  With a few exceptions, the nutrition community is not brilliant at making pledges that we can be held accountable for, so UNICEF maker your own commitments water tight and then help the rest of us to.

In many ways UNICEF is our moral compass on nutrition.  Its influence and size are increasing: nearly $0.5 billion of spending on nutrition, 500 nutrition professionals world wide.  These are numbers that we could only have dreamed of 10 years ago.  But with power comes responsibility.  In 3-5 years UNICEF will need to show what is has accomplished with this strong wind at its back.  The time to start measuring is now.  I have no doubt that the organization will rise to the challenge.

27 May 2015

The FANUS 2015 conference: highlights and a lowlight

I just left the FANUS conference after 3 days of presentations and discussions.

There were plenty of highlights:
Isatou Jallow at NEPAD presenting on the key role of women in nutrition-an impassioned and evidence based presentation; Martha Ayagaya the new Africa Nutrition Director at CIFF gave a great talk on governance and accountability;  Ferew Lemma and Anne Bossuyt presented carefully but passionately on the new PSNP4, designed to be more nutrition-sensitive;  Lindewe Sibanda, FANRPAN, presented ATONU, a new initiative for integrating nutrition into agriculture programmes; Prof Amadeus Kamagenge on Tanzania’s promising new safety net programme; Prof Tola Atinmo on human rights and nutrition; Prof. Joyce Kinabo on Agri-Diet, the Irish Aid funded project on agriculture and nutrition; and Suneetha Kadiyala on Agriculture Nutrition Health Academy, launched on June 3 at the LCIRAH conference.  The academy aims to establish a global network of researchers to work on agriculture and nutrition linkages and how to strengthen them.  I hope they focus on the academy bit in particular and contribute to a new generation of researchers and practitioners for who linkage comes naturally.

And the odd lowlight….
One of the large pharmaceutical companies announced the introduction of a website billed as a one stop shop for nutrition.  Very unfortunately the information given was incorrect.  Under the “0-6 month baby feeding guide” it says that breastfeeding exclusively for the first 6 months is “suggested” and that “if you want to bottlefeed your baby start with …”.  Well, either the company was incredibly sloppy, or deliberately misleading, or both.  Either way they need to get their printed facts right and then put in place a set of scientists that are named and widely respected to validate the accuracy of their website so that it does not become a one stop shop of misinformation and harm.  This kind of thing spills over to more responsible companies, giving them all a bad name.  They should not tolerate it and nor should we.  

Perhaps the presentation that took me most out of my comfort zone, in terms of methods and biochemistry was that by Prof Andrew Prentice on the epigenetics of embryo development.  His work in the Gambia on this has been published in Nature and widely reported on but this was the first time I had heard it in person. 
Engaging as ever, Andrew took us through the research step by step.  He and colleagues found that babies conceived of in the hungry season, when preconception nutrition status of women was worse, had more methylated DNA (how cells lock genes in the “off” position) and there is some indication that the genes involved relate to immune system development in the early embryo.  One of the implications is that pre-conception nutrition status might be even more important than previously thought.  If this all holds true with another 18 months of research to check robustness then the strong implication is that we need to find practical programmatic ways of improving adolescent nutrition status (girls, but also boys).  Andrew was careful not to frame this as a challenge to the 1000 day window from conception to 2 years old, rather talking about the importance of getting ready for 1000 days.  So what would those practical programmatic interventions be?  Good question.   

There were some really talented African researchers at the Conference.  There needed to be more external support, however, as not many external agencies and not many researchers from outside Africa attended. 

Big thanks to Joyce Kinabo, Bjorn Lundqvist and the team--and Tanzania--for being such great hosts.

26 May 2015

FANUS 2015: African Nutrition at the Crossroads. But which one?

For the past day I have been attending the Federation of African Nutrition Society  (FANUS) conference in Arusha, Tanzania.  

The Conference is called “African nutrition at the crossroads”.  The question is, what does that mean?

Here are some potential meanings:

*Just as progress is being made on reducing stunting rates, overweight and obesity are increasing rapidly on the continent.   Africa’s choice?  How much effort to expend on preventing overweight, obesity and the related NCDs at risk of diluting the effort to reduce undernutrition? This is somewhat of a false (budget) choice because many of the nutrition related NCD choices are about policy rather than spending.  And the rise of nutrition related NCDs means an even greater focus on African food systems - they are at the heart of all forms of malnutrition reduction.  Again, no tradeoff there, just a strengthening of emphasis on health and nutrition.

*The commitment to reduce undernutrition on the continent is high—but will this be translated into actions and impact?  This will be harder than building commitment (which was not easy!)—the temptation to give up in the face of difficulties must be resisted. Budget allocations to nutrition need to be increased.  Frontline nutrition workers need to be hired.  The coverage of programmes needs to be expanded and monitored.  
*Economic growth is strong in many African countries.  Their Ministers of Finance face a decision: invest in the productivity of the next generation so that the coming demographic transition can be a demographic dividend or invest in unsustainable short term fixes that are electorally attractive?

*The MDGs applied to all low and middle income countries, but were mainly focused on Africa.  This will not be the case for the Sustainable Development Goals.  Africa’s voice will be diluted in the SDGs unless the countries become more active in shaping the agenda, and nutrition--represented so poorly in the latest publicly available SDG drafts—desperately needs African outrage to move nutrition higher up that agenda.

Many other regions are at these crossroads, but it seems to me that the consequences of taking the wrong paths are intensified in Africa.  Africa has more time than Asia to deal with nutrition related NCDs and it needs to use that time well.  Africa faces more challenges than other regions in terms of low nutrition budget allocations and the low number of frontline nutrition workers, but these are also opportunities—the case for increasing the allocations has never been stronger, especially from such a low base.  Tax revenues are growing more rapidly in Africa than elsewhere, partly because from low levels, and decisions made around how to spend those taxes will be difficult to undo in later years.  Finally, Africa has a lot of moral authority to exert its influence over the SGDs—African countries are affected more than other regions by the actions of the high income countries (think climate) so African countries can use that authority to raise the profile of nutrition within the SDGs.

All of these crossroads are presenting themselves to African decision-makers—those within and outside nutrition. The consequences of getting it wrong have never been higher.  But so too the benefits of getting it right. 

22 May 2015

Stunting? Not a LoL matter

Today I gave a talk on malnutrition at my daughter's school.  An audience of ninety 14 year olds.  Scary.

I spent quite a lot of time on the presentation (here).

(Apologies to those whose infographics I stole. I was particularly shameless is stealing Generation Nutrition's We Can End It logo, which I love).

Key takeaways:

1.  Preparing for an audience of 14 year olds is a great exercise in communication. 

Not to say I nailed it, but the kids seemed engaged, did not throw anything at me and  did not giggle once. I had to use really plain English (Utilise, Food Security, Social Protection?  Waaay too complex.).  I just about got away with "stunting" although my daughter warned me it means practical joking (with accompanying LoLs) in their world.

2.  Infographics are great for this kind of audience.

BUT, there is no central repository of info graphics, categorised, for us all to use AND there are some pretty terrible infographics out there as well as the good.

3.  Katy Perry helped out.  (Actually 2 of her videos for UNICEF did.)  

Her videos were great--kept the kids' attention and had great messages (her leveraging of the spotlight on her for the kids, unconditional love for the kids from the communities despite their deprivation, and the first hand viewing of the conditions that convinced her to work with UNICEF).

4.  The Power of Nutrition video is great.  

I used this too.  It is very nice--simple without being simplistic.  It is also great because while it promotes the Power of Nutrition initiative it also deliberately promotes the power of nutrition, period.

5.  14 year olds can ask great questions. 

How is climate change affecting malnutrition?  Does preventing malnutrition increase population growth?  How long does it take to treat a malnourished child?  What do you do after the first 1000 days?

So, if you ever get a chance to communicate to a group of children, do it.

And my daughter?  She said she was proud.  Melt.

19 May 2015

Pearls, Bread and Iron: biofortified millet reduces iron deficiency in Indian schoolkids

Biofortification is one of those ideas that seems too simple to be true--good nutrition for crops is good nutrition for people.  But it also seems to face many hurdles to bring it to fruition.  For example, is it really possible to find or breed varieties of staple crops using conventional breeding methods, that are high in key micronutrients, that improve yields (or at least do not lower them), that don’t affect the appearance, texture or taste of the food, and can be afforded and consumed by micronutrient deficient populations in sufficient quantities (with their micronutrient content remaining bioavailable)--to make a difference to their micronutrient status?  I make that about 10 hurdles to overcome.  Well, for Pearl Millet in India, the race seems to have been won.  The answer to the multipart question is “yes”.

What is the evidence?  Well, a new paper in the Journal of Nutrition reports on a randomized trial of iron-fortified pearl millet in school children of 12-16 years of age in the Indian state of Maharashtra.  The trial, overseen by the highly experienced Cornell nutritionist, Jere Haas, finds that the consumption of biofortified Pearl Millet (eaten in the form of Bhakri bread) for 4 months by the 12-16 year old children resulted in them being 1.6 times as likely to be iron-replete as the children eating non-biofortified Pearl Millet.
The study has limitations.  It was done in a boarding school setting and so the school meals provided more structure than family meals.  Also 28% of the study population was anemic, which is lower than many such populations.   These factors limit the external validity of the study (i.e. how likely is it to be generalizable?).  The authors recognize these limitations and outline how future studies should deal with these issues.
Nevertheless this is a big step forward for biofortification and the HarvestPlus programme behind it. This is the first such trial to show such strong effects on iron deficiency.  With over 2 billion people deficient in one or more micronutrients, we should be looking for all potential pathways—diet diversity, supplementation, fortification, and biofortification—to perform at high levels to eliminate this hidden form of malnutrition.

Biofortication seems to be charting one clear pathway to improved nutrient status, but they are all important.  I very much hope we get many more of these biofortification efficacy (and effectiveness) studies and that as many as possible show positive impacts.  
If the pearl is the oyster’s autobiography, as the saying goes, then this study may be the midpoint of biofortification’s biography.