Reaction from Ireland to the Lancet Series and to HANCI

Yesterday I was in Dublin at Trinity College presenting on the Hunger and Nutrition Index (HANCI) at a morning symposium jointly arranged by Concern, Trinity, Irish Aid and the Development Studies Association of Ireland.

Bob Black started the morning session with an overview of the Lancet series on nutrition and then I continued with HANCI.

One of the nice things about the way it was organised was the ample time for discussants and questions from the audience.

There were some good questions, here are some I noted down:

On the Lancet Series:

•        The small for gestational age data are new and important—essentially one fifth to one quarter of all children are born stunted—how do we prevent this? We don’t know enough
•        Is the cognitive damage really irreversible after 1000 days?  Well, it is irreversible in the sense that the early cognitive loss cannot fully be made up even if there is a concerted effort to do so--although this does not mean that learning does not happen throughout childhood, just that it is starting from a lower base than it has to.
•        Are the messages sharp enough coming out of paper 4 (enabling environment)?. What, for example, would you invest in to get that environment? Capacity, new forms of resource mobilisation, accountability mechanisms, intersectoral coordination, and more real time data on nutrition outcomes and programme coverage
•        What do you invest in first in a given context—I noted the idea that investing in nutrition is more like constructing a barrel with vertical planks—the barrel only holds as much water as the shortest plank.  But we in nutrition tend to think of the barrel as being built with horizontal planks—where every new investment must increase the capacity of the barrel and the order of the planks does not matter
•        What about capacity—what do we know about the payoffs to investments in different types (e.g. the number, quality and presence in post of front line workers)? ‘Not much’ is the answer—research funders and researchers tragically do not find this a sexy topic.  
•        Does the term enabling environment imply a roll back of the state?  Not at all—it just means the state cannot do it all, but what it can do can make a huge difference to the motivations and incentives of everyone else
•        Should the series have done more on HIV/AIDS? Probably yes, because of the important interactions of food, nutrition and HIV/AIDS.  One important point that Bob Black made—the scale up of anti retroviral drugs has put paid to the myth that scaling up nutrition, a less complex set of interventions, is too difficult
•        The series said a lot on what to do but less on how to do it.  I think this is OK personally, as much of the how is context specific. I would like to see a Lancet series on the 7-8 highest burden countries, where all the evidence on that country is brought together and reconciled—the current Lancet series, for all its strengths, does tend to decontextualize nutrition actions.

      On HANCI (the Hunger and Nutrition Commitment Index) there was a lot of positive feedback and some tough questions

•        How do you deal with the quality of policies and spending?
•        How do you deal with the fact that some of the data are 18 months out of date?
•        What has been the traction at the country level?
•        Isn’t the real value in countries developing this themselves and making it their own?
•        How will you combine HANCI with other indicators such as Global Hunger Index?
•        We presented a list of indicators that we did NOT include in HANCI and a couple we had concluded were too indirect were challenged: why not education spending (empowerment of women) and why not community health worker coverage?  We will look again at these for the next version.
•        How will you evaluate whether HANCI contributes to action to reduce malnutrition and hunger?
•        What does it mean if the HANCI score is different from one’s own perception of how well the country is doing? Well, you may be wrong, HANCI may be wrong or both may be wrong—but the point is it gets you to challenge your priors and have a fresh look.

All good questions and I do not have an immediate answer to many but these are questions we will take on in the next round of HANCI published in 2014. 

It was interesting and encouraging to talk to the Irish government colleagues who were saying what can we do in Ireland to improve our ranking (already a good 5 out of 23).  And we were told that HANCI has provided a useful starting point in conversations between government and civil society on the nutrition landscape in Zambia and Tanzania.  Clearly we have to do a better job of capturing these uses.

The quality of the debate in the Trinity College audience was very high indeed.  Ireland is a relatively small country but it is punching well above its weight in terms of fighting malnutrition and hunger. It is a real leader and long may that continue.