18 September 2009

One Hour to Save a Life

There is a very active and informed debate in India about what to do about infant undernutrition. My previous blog gives you an idea of the nature of the malnutrition problem-- all the more stark given it is against a backdrop of dazzling economic growth.

The IDS Bulletin on this issue was the latest opportunity to temporarily intensify the debate. I spent several days in meetings with senior members of the Planning Commission, the Ministry of Women and Child Development, the Ministry of Health and DFID India. The senior policymakers I met in India are very knowledgeable about the extent of the problem, the causes and the consequences.

They are, however, bombarded with a large number of solutions, many of them driven by single-intervention campaigners. There is a real need to focus. But how? Perhaps the first step is to focus by age group. The 0-2 age group is the period when the die is cast in terms of the development of the child, so this is an obvious candidate. But which intervention?

The consensus is that breastfeeding is the most effective behaviour for reducing infant mortality. But “exclusive breastfeeding” for the 6 months is not an easy message to understand and its practice is challenging for a mother who may be malnourished herself and without the support of family, community and employers. So focus more--on promoting breastfeeding within the first hour of life ("one hour to save a life"). For attended birthing, this seems feasible, but perhaps less so for unattended births.

The week was a good example of how a modest research report, with influential backing, can serve to temporarily engage the media and energise the community. It was also a good reminder of how senior policymakers are always looking for the “first thing” to do to navigate through complexity and a reminder of how researchers like me are initially reluctant to make that “first thing” recommendation.

Here is the presentation I made at the IDS Bulletin launch

Launch of Bulletin

Claims and Disclaimers

In Delhi last week I spent a couple of hours at an all day Right to Food Campaign meeting. The Campaign (in which some IDS alumni are participating) is aiming to shape the food security/food entitlements act that the Government is working on, by publishing a list of essential demands.

The draft demands fall into two broad sets: one around entitlements to food, in the spirit of the National Rural Employment Guarantee Scheme, and one around a set of demands on “food first” production and zero food trade. The negotiations within the Campaign members and with the Government will continue for a long time. Social change does not happen quickly.

But whatever the outcome, the focus, strategic vision and drive of the Campaign leaders was an inspiration.

While in India I had an interesting set of email exchanges with one or two of my IDS colleagues, asking me whether readers of this blog thought it represented IDS views or my own. This has prompted me to add the disclaimer under the picture.

IDS speaks with one voice on its goals and values but we try very hard to celebrate a plurality of ideas and to avoid lowest common denominator group think. So readers should be clear that these are my unguarded thoughts, and not necessarily an IDS corporate position.

15 September 2009

Economic Powerhouse or Nutritional Weakling? What India needs to do to “Lift the Curse” of Child Malnutrition

This is an op-ed from me in the Hindu Times today.

Imagine if three thousand Indians died every day from Swine Flu. Actually, the number is closer to 10 a day, and still the malady attracts media attention. But more than three thousand Indians a day die from a different malady. It is called malnutrition. The dead are babies and toddlers. And the press is focused on swine flu. Google News India listed 49,000 stories on Swine Flu on September 9. On the same day there were 2,500 stories on malnutrition.

Economic growth also ignores nutrition. In most countries economic growth and reductions in malnutrition are linked. In India they are ships passing in the night. Real per capita GDP has grown by nearly 4 per cent year on year over the past 15 years. Over the same period, the percentage of malnourished infants barely moved: from 52 to 46 per cent.

At current rates, India will only meet the Millennium Development Goal Targets in 2043, not 2015 as planned. China has already met its 2015 targets. In India, a further generation is condemned to the brain damage, poorer education and early death that result from malnutrition.

A new report published by the Institute of Development Studies (IDS), in partnership with DFID, ‘Lifting the Curse: Overcoming Persistent Undernutrition in India’ argues that this problem reflects a failure of governance at several levels of Indian society. The report contains papers by over 30 Indian authors. It documents a number of problems in nutrition service delivery in India. Services are not provided where they are needed. Some groups of citizens are systematically excluded from services. Services are of low quality. Accountability for service provision is weak. Leadership is fragmented. Awareness of the problem is poor. Year on year nutrition data are not available to monitor any progress. Nutrition, it seems, is nobody’s responsibility. To its great credit the Government is expanding funding to ICDS, the main programme tasked with malnutrition reduction among infants, but without governance reforms this could be a case of “throwing good money after bad”.

So what should be done? The report contains a number of specific recommendations for strengthening governance.

First, fund communities and local governments to undertake social audits of the ICDS services actually delivered. Let the ultimate customers rate the provision and make the results public. This will put pressure on local MPs and local providers.

Second, give the Comptroller General and Auditor Office a bigger role in monitoring Government action on nutrition. Their work is already cited by many, and they should be empowered to do more.

Third, simplify ICDS. There are too many interventions and too many age groups. It is complex to run, especially given the thousands of different contexts it has to adapt to. At the moment it tries to be all things to all people and runs the risk of satisfying none.

Fourth, find an effective cross-ministry mechanism to deliver food, care and health in combinations that work. Efforts to lift the curse of malnutrition must be unified.

Fifth, historically excluded groups must be involved in the design, outreach and delivery of nutrition programmes, reaching out to women from these groups in particular.

Sixth, introduce simpler but more frequent monitoring of nutrition status so that civil society and the media can hold the Government and non-state actors to account for year on year slippage and reward them for progress.

Finally, develop new ways of teaching and doing research on how to improve nutrition. Reducing malnutrition is not just about health, agriculture and economics. It is also about politics, governance and power.

The persistence of extraordinary levels of child malnutrition in the midst of a whirlwind of economic growth – maintained even in the midst of the global recession –must seem like a curse. But the Government of India can act to dramatically change the situation. The IDS report gives many recommendations that we think will help. But September’s National Nutrition Week is not enough. Every day needs to be Nutrition Day if India is to escape the duality of being an economic powerhouse and nutritional weakling. By tackling malnutrition governance, the Indian Government can lift the curse and raise the stature of its children. It will also raise its own standing in the world.

12 September 2009

Aid Under Pressure

As we move into Autumn in the UK, the party conference season is rapidly approaching. All the major political parties will be laying out their stalls for the 2010 General Election. The main topic will be spending cuts. The battle grounds will not be whether they will have to be made (they will if we are to reduce deficits and not store up pressure on interest rates), but how fast and on what? Despite the pledges to maintain the 0.7% pledge (see earlier posts), aid will come under pressure.

I see three major questions being debated right now--all signalling this pressure.

1. What does successful aid spending look like?
2. How do we better assess the impact of aid?
3. When should we get out of aid altogether?

On the first, the UK public is largely supportive of the principle of aid in emergencies, but beyond that the consensus is fragile. Some work we are doing at IDS with the Mass Observation facility at the University of Sussex suggests that the public has a weak picture of what successes in aid look like. DFID has been urged by the International Development Committee to do more to communicate the many good things that come from aid and to not hide the outcomes when things do not work (development is riddled with risks and uncertainty just like any endeavour). The report released last week, Fake Aid, by the International Policy Network (funded by private individuals, businesses and foundations) takes a swipe at DFID's communication efforts. The report is riddled with fundamental errors, but will be taken seriously by some (and you should know that about 45% of IDS activity is funded by various DFID projects).

On the second, there is a lively debate on how to assess the impact of aid in projectised, programme and budget support modes. Budget support channels resources through existing recipient government structures, allowing recipients to pool resources and strengthen their fundamental systems, but it does make it more difficult to demonstrate impact of that aid. See Riddell's 2007 book on this.

On the third, there are the debates about when and how countries should exit from aid, exemplified by Moyo's Dead Aid.

All of these debates would be informed by stronger client-based reporting on whether aid is working. What do users of nutrition centers in India think of the services they are receiving? Are they good quality? are they delivered on time, in the right place, and in a respectful way? (next week I will be blogging from Delhi on these issues). What do farmers in Africa think of large agriculture projects that are supposed to serve them? Do they ask farmers to take on too much risk? Are they gender sensitive? Do they improve the things that farmers care most about?

More client based reporting would generate visions of success (and failure), help develop better measurement systems, and tell us much about when and where aid should be exited from.

08 September 2009

Taking Uncertainty Seriously

I have just finished reading Robert Skidelsky's "Return of the Master" which is about why Keynes is still the most important economic thinker in the world. The book goes though the litany of reasons for the crash: bank institutional failures, China hoarding dollars because of uncertainty, asset bubbles in the UK and US, consumerism and hubris. But behind all of these is a a failure of ideas.

The book has two main arguments.

First, markets cannot price all forms of risk because there are some things we do not know (drumroll Donald Rumsfeld please)--what Skidelsky calls the "irreducible minimum". The models of the Neoclassical and, to a lesser extent, Neo-Keynsian economists however value "beauty over truth" (see Paul Krugman in this week's New York Times magazine). They want to cover all eventualities and the way they do that is to circumscribe all eventualities in a false set, defined by the models themselves. In this way the models don't even entertain the fact that some markets are not self correcting. They assume frictionless markets with cool calculating agents operating with perfect information. As Skidelsy notes, macroeconomics should be built on expectations that are human or conventional, not on those that are rational.

Second, economics should think of itself as a moral not a natural science. It should not be so dominated by market efficiency and the pursuit of money. Money is the "continual stimulator of our imagination creatign a perpetual sense of dissatisfaction".

The solutions?

Economics should have a "more modest role as tutor of governments"
  • A new synthesis of government and market action
  • Build financial models that can cope with irreducible uncertainty and make governments focus on reducing the impact of uncertainty
  • Develop a new global reserve currency that is not influenced by any one country's needs
This will be hard for the freshwater (e.g. Chicago neoclassicals) and the saltwater (the coastal US NeoKeynesians) economists to take but, as a Stanford economist myself, these seem like the right answers to me.

05 September 2009

Grading Research for Development

I just returned from Coleraine and the Development Studies Association Annual Conference. Lots of interesting papers and presentations: Charles Gore on new global paradigms (knowledge-dominated), Santosh Mehotra from the Indian Planning Commision on the impacts of the downturn on India's growth (not too bad) and poverty (not clear but likely to be not good), Mayra Buvinic from the World Bank on what to do to protect women in the downturn (not too many new interventions it seemed to me, mainly intensification of existing ones), the new Director of Research at DFID, Chris Whitty, on a quality graded research evidence base, and DFID DG Andrew Steer reporting on the new DFID White Paper. There were many interesting papers from parallel attended by the 200 participants inlcuding some good IDS sessions on the impacts of the downturn and the implications for development policy. Catch some of the clips at The Broker website.

Chris Whitty's session generated the most heat, and perhaps a little bit of light. Chris shares the same concern I do--research is not fulfilling its potential to reduce poverty. It's hard to prove this. But we do know that there is an accelerating amount of research being generated--much funded by DFID--and that the very volume of it makes it very tough to keep up with. Just think how hard it is to stay on top of developments in one's own field and then imagine how hard it is for generalists in decision making positions either in policy or frontline positions to do so. So how do we systematically organise the material around questions and contexts, separating out the careful from the not so careful, and then communicate that in an accessible way? Outside of the development social sciences this is fairly routine--there is the Cochrane database and the Campbell Collaboration. Inside the development social sciences it is not unknown (see this example from the World Bank) but fairly rare.

The debate at the session revolved, it seemed to me, around which research questions one applies such a mechanism to and what that mechanism looks like, especially who does the grading. On the first issue--which question--one needs questions that decision makers want answers to and questions that lend themselves to comparisons across contexts. One example: when does conditionality of particpant behaviour improve social protection programmes and when not? Even this question is challenging to create an evidence base for--what qualifies as a social protection programme? What does "improve" mean?--but other questions such as: can pro-poor growth be pro-environment? will be more difficult, and more open ended questions such as: how do politics shape the use of knowledge? even more so and potentially counterproductive to even try. On the second issue--grading--it would be good to have peers reviewing, but perhaps in an open wiki-style way. I will keep you posted on this debate as it plays out.