26 June 2014

Is a commitment to hunger reduction the same as a commitment to undernutrition reduction? No.

So the new HANCI rankings are out.  As usual the report breaks down commitments into hunger and undernutrition reduction.  My favourite graph is the one above.

The closer a country is to 1, 1 the closer it is to being top ranked in both dimensions.  So Guatemala (GTM) does really well on both counts.  Lesotho (LSO) does well on hunger commitment but relatively poorly on undernutrition commitment, Bangladesh (BGD) does well on undernutrition but less so on hunger reduction.

Several things are worth noting:

  1. Performance in the two dimensions is linked, but weakly (low R-squared) and you can see this just from looking at the (very scattered) scatterplot
  2. Countries below the fitted line are doing better in undernutrition reduction commitment than predicted by their hunger reduction commitment score (e.g. Ethiopia, ETH). Countries above the line are doing worse in undernutrition reduction commitment than their hunger reduction commitment would suggest (e.g. India, IND)
  3. If you draw a 45 degree line through the 0,0 point we can see who has a more balanced (high and low) approach to commitment: Guatemala, Peru, Brazil, Malawi, Ghana, Philippines, Vietnam (high to medium commitment on both counts) and Kenya, Zambia, Nigeria and Guinea Bissau (medium to low commitment on both counts)

The HANCI report also has some really nice in depth primary data collection work on Bangladesh, India, Nepal, Malawi, Tanzania, and Zambia, working with different stakeholder groups in these countries.

The Global Nutrition Report -- What Is It?

Hello everyone.  For the past 2-3 months a group of us have been working feverishly away on the 2014 Global Nutrition Report (#NutritionReport).  

What is it? 

The Report is an attempt to track progress in malnutrition reduction and strengthen accountability in nutrition -- all with the aim of reducing malnutrition faster. 

What will it contain?

It will bring together about 70 nutrition indicators in country-by-country profiles in the following areas: nutrition outcomes, determinants, programme coverage, resources and political commitments.  

It will also track the specific Nutrition for Growth (N4G) commitments made in London in June 2013. 

It will feature a number of short pieces on learning from progress, strengthening system accountability and measurement methods and approaches that are priorities for strengthening. 

Overall, the Report will highlight progress made, bottlenecks experienced, and will make recommendations on where and how progress can be accelerated and how nutrition accountability can be strengthened. 

Why is it needed?

The immediate impetus is provided by the need to follow up on the N4G commitments in an independent way, but there is a sense that while there are many fantastic data collection and progress monitoring efforts going on, that they are a little disparate.  The Report is an attempt to bring those efforts closer together, not to replace them. 

What is different?

In the new post-2015 spirit of solidarity and globality, the Report will look at all countries and will focus on all forms of malnutrition, not just undernutrition. 

We also want the Report to be more than a document -- we want it to be an initiative to improve accountability in nutrition.  We want to contribute to making nutrition everyone's business AND everyone's responsibility. 

We are putting a big effort into country launches.  If this Report is not useful to national nutrition champions, then we have failed.  The launches are not so much launches of the Report, but launches of conversations about how to use the Report to accelerate malnutrition reduction in those countries and regions.  

The country launches are planned for Brazil, Ethiopia, India, Indonesia and Senegal--all in early 2015, with more conventional launches in London, Brussels, Washington and Rome. 

We also try to bring different indicator types together: nutritional, programmatic, economic, political. All data will be made available in one location, in easy-to-use formats (spreadsheets and Stata files). 

Who is it from?

It is from an Independent Expert Group (IEG) of 19 co-chaired by Prof. Srinath Reddy from the Public Health Foundation of India and me.  The IEG were selected by the co-chairs from a wide set of nominated candidates (all of whom were excellent). 

The IEG is responsible for the quality of data and interpretation.  A Stakeholder Group of 22 organisations (Countries, UN, the SUN movement, Donors, CSOs) provide broad strategic advice, but do not have a veto on what the IEG concludes. 

My home organisation, IFPRI, is the convenor of the effort, supported by a team at IDS.  Both organisations are doing an amazing job under pressure and uncertainty -- all with good grace and great humour.  We are all passionate about this effort.  

Who assesses the quality of the Report?

We are working out how to make the draft Report open for short public consultation (we have a very tight timeline).   The Lancet has kindly agreed to run the external blind review process. 

When is it out?

We are frantically working to an ICN2 launch deadline (November 19 or 20).  This means most of the content work will be done by mid September (gulp).   

What are we doing now?

We have been consulting with hundreds of people on the right set of indicators to report on. We have just about finalised the list and will share it on the website soon. 

We are collecting all of the data for the country profiles and these are nearly all in hand. 

We are soliciting responses from the over 90 N4G signatories and they all have July deadlines. 

We are working with 30 or so authors of the short pieces to help them finalise their work.

We are working with the IFPRI team of knowledge managers, designers and comms experts on how to make the data accessible, and how to make the report as useful to users as possible. 

Who is funding this?

To date, six funders have come together to support this effort: the Bill & Melinda Gates Foundation, the Government of Canada, the Children's Investment Fund Foundation,  the European Commission, 1,000 Days, and DFID UK.  We aim to repay their faith in us many times over. 

What can you do? 

We are still working out how to be as open and transparent as possible while meeting our deadlines. Please send us your comments, suggestions, advice in the 'contact us' section of the website.  We will endeavour to respond to all feedback. 

All of the hundreds of  people (and I mean all) we have been interacting with so far have been incredibly helpful and generous with their time, ideas, contacts and data.  We thank them -- they set a great example to us and to others. 

Of course the most important thing you can do is to continue to make noise about the scandal of malnutrition in our world of plenty--and then ramp it up. 

23 June 2014

Indian Nutrition Data: Too Little or Too Much?

People like me complain that the Indian Government does not collect enough data on nutrition outcomes.

The 3rd  National Family Health Survey (NFHS-3) was conducted in 2005-6.  The 4th is labelled as 2014-15 and given its large size (about 568,000 households compared to 109,000 households in 2005-6) we can count on it coming out at the earliest in 2016 and quite possibly 2017.

So, we have some time to wait for new NFHS data.  

But last week, without fanfare, some new Government data on nutrition were released  -- the 4th District Level Household Survey (DLHS IV 2012-2013).  Both NFHS and DLHS are run by the Ministry of Health and Family Welfare.  NFHS-4 will be representative at the District Level for all 640 districts.

The DLHS IV is also representative at district level, but does not cover all States and Territories, notably omitting some of the "low performing" ones (e.g. Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chhattisgarh, Orissa, Rajasthan and Assam).  

These 9 States and Territories are covered in the Annual Health Survey (AHS) which ran for 3 years (and I think has now been discontinued), but these only cover things like IMR, Under 5 Death rates and Maternal Mortality rates--all important, but not nutrition indicators. 

In addition there are (1) the National Nutrition Monitoring Bureau (NNMB), which conducts more specialised surveys on nutrition and diet, (2) the Indian Human Development Survey (IHDS-II) run by NCAER and the University of Maryland  (results on nutrition to be released soon) and (3) a rapid UNICEF national nutrition survey which has been referred to in meetings I have attended in Delhi, but on which I cannot find any references to via the internet. 

What to make of all this?  Well, the AHS data show that modest improvements in IMR, U5M and MMR are being made, but mainly in the districts that show the lowest initial rates.   The IHDS data are rumoured to show not much improvement in stunting and underweight.  The UNICEF rapid assessment survey is rumoured to show dramatic declines in stunting and underweight.  

Forgetting about rumours, it is interesting to note that the DHLS IV shows Maharashtra with a stunting rate for under 5's of 30% (2013) which is down from 46 % using the NFHS-3 (2006, also for under 5's).  That is 16 percentage points in 7 years. This is very good, and is  a similar rate of decline as indicated by a recent Government of Maharashtra/UNICEF survey for under 2's which showed a decline of about 16 percentage points (from 39% in NFHS-3 for under 2's in 2006 to 23% in 2012). This is about the same rate as the all-Bangladesh figures.  That replication of declines across data sets --and the speed of declines--in Maharashtra is very encouraging.  

(Note the above para was changed after helpful comments from Saul Morris at CIFF and Victor Aguayo of UNICEF, who both pointed out errors in what I had reported--thanks!) 

For researchers interested in nutrition in India, this is fascinating.  For policymakers this is either a nightmare or a convenience (i.e. pick your favourite statistic).  Nevertheless, the Government of India badly needs to harmonise it's data collection because the main victims of the data confusion are malnourished people.  

So, too little or too much nutrition data in India? I think there is too much nutrition data because there is not enough of the right kind: regular NFHS rounds every 2-3 years, reported using the same age group. 

20 June 2014

New analysis on how to measure & build political commitment for food and nutrition security

Thanks to Purnima Menon at IFPRI for a shout out about a new paper by Ashley M. Fox, Yarlini Balarajan, Chloe Cheng and Michael R. Reich that develops a new tool (PCOM-RAT) on measuring political commitment for food and nutrition security.  

A version of the paper also appears in the journal Health Policy Planning.  

The paper has lots of links to the Hunger and Nutrition Commitment Index (HANCI) and the Lancet Paper 4, and focuses on primary data collection for 10 countries (curiously none from Africa). 

It conflates food and nutrition security (a problem) but it is a nice theory based scoring system that also tries to identify opportunities for policy influence going forward.  

It criticises HANCI for only being secondary data based (it isn't) but interestingly for the 5 countries that overlap both sets of scores, 4 of them (Guatemala, Philippines, Vietnam and Bangladesh) are ranked in the same order as the secondary data component of HANCI.  Cambodia is the outlier, coming in 3rd out of these 5 countries in PCOM-RAT and 5th in HANCI.

It is great to see more and more interest building on how to assess end build commitment to nutrition, and as a final warning shot the paper quotes

Lancet Paper 4:

“political commitment can be developed in a short time, but commitment must not be squandered—conversion to results needs a different set of strategies and skills.” 


17 June 2014

Of Temples, Toilets and Tendencies: New Survey from RICE

PM Modi has said India must build toilets first, temples later.  Union former Rural Development Minister Jairam Ramesh (picture) made a similar comment before the election.  

But is this diagnosis right?  Will more toilets lead to less open defecation and less ill-health via diarrhoea and other feces-borne diseases?  

A new survey from the Research Institute for Compassionate Economics (RICE) headed up by Dean Spears is reported on in the Indian Press (although I cannot find the results on the RICE website--I'm sure they will be out soon) in this article in The Hindu newspaper.

The results are from 13 districts in 5 states (3600 households) and find:

  • 57% of households have no toilet while 43% do
  • of the 43% who have a toilet (I think they only included working toilets), 40% of them have at least one household member who still defecates in the open
  • less than a quarter of the households with a toilet said they had constructed it for health reasons--protecting the modesty of their daughters in law was the most common reason for building one
  • reasons given for defecating in the open were: convenience, healthier, tradition, pleasure, comfort:  in other words, there is a tendency to do this that is difficult to change
If these findings hold up to further scrutiny, they make it clear that building toilets is a necessary but far from sufficient strategy to end open defecation.  

The link between open defecation and illness (typically via diarrhoea or environmental enteropathy) must be made and communicated and then entrenched. 

14 June 2014

Which wealth groups experience the greatest reductions in stunting? New multi-country paper

When we report stunting rates we tend to focus on the entire population.  

But we know that wealthier households tend to have lower rates of stunting.  This is because higher household wealth can buy more and better food, clean water, improved sanitation and higher quality healthcare.  It is not a perfect relationship by any means, but it is regular. 

But what is happening to this disparity in stunting rates across income groups as overall stunting rates improve?  And the lowest wealth groups reducing stunting more quickly than the highest wealth groups or is the opposite true? A new paper using MICS and DHS datasets and authored by Caryn Bredenkamp and colleagues, published in the International Journal of Epidemiology, answers these questions.

The answers tell us something about the pro-poor sensitivity of nutrition actions.  Countries that do better at reducing stunting in the wealthier rather than the poorer groups have nutrition plans that are geared to addressing the easier cases.  Those that are better at reducing stunting among the lower socio-economic status groups have figured out a way of reaching the poorest children in an effective way.  

Which way is better?  It seems obvious to conclude that the second way is preferable.  And work by Carlos Carrera and his UNICEF team suggests that the benefit cost ratios are higher if we focus on the poorer groups.  But is it so straightforward?  First, every child has a right to avoid stunting.  Second, generating results in the higher wealth groups may generate greater political support for stunting reduction and result in more sustained funding to reach those in the bottom wealth groups.

Anyway, what did the authors find?  Using a concentration index to summarise stunting disparities across different wealth groups, they conclude:

* Out of 53 countries, 31 show no statistical change over the past 10 years or so in the concentration index.  11 countries show a widening in inequality of stunting outcomes (many from South Asia) and 11 countries show a narrowing of inequality of stunting outcomes (the Europe and Central Asia region and the Middle East and North Africa region). 

* Most sub-Saharan African countries show a constant level of stunting inequality
      But the concentration index is a summary statistic.  It can improve for a variety of reasons, for example because the very poor are catching up with the rest, or the middle level wealth groups are catching the wealthier but leaving the poor behind.  

      When we examine the data by wealth quintile the paper shows that for the countries where inequality is increasing, it is because the wealthiest group is doing much better than the rest in reducing stunting (India and Ethiopia are particularly vulnerable in this regard).  

      For countries where inequality is reducing, there are fewer consistent patterns: sometimes it is because the bottom quintile is improving, sometimes the bottom two quintiles and sometimes because the upper quintile is showing a worsening level of stunting.
      What are the policy implications of these findings?  The paper does not draw out any, and that is probably because it is difficult, for the reasons given above.  Ideally we want all groups improving, with public policy geared more to the poorest groups because (in theory) children in the wealthier groups have more private resources to draw on.

      But for me this paper raises the question, yet again, of why we prioritise a stunting rate.  

      The stunting rate simply counts whether a child is above or below the -2 threshold for standardized height for age (i.e. if ZHA <-2) The equivalent in poverty measurement is P0, the poverty rate.  But as any poverty economist will tell you the poverty gap (P1, or the average gap between income and the poverty line) and the poverty gap squared (P2 or the average of the squared poverty gap—even more sensitive to large gaps between income levels and the poverty line)--are more meaningful measures of the poverty sensitivity of policy and programmes.  

      I don’t know why we do not calculate the average ZHA gap (S1) and the average ZHA gap squared (S2) as well as the rate of stunting (S0).  The mortality, morbidity and economic consequences of being at -2.5 ZHA are surely more serious than being at -2.1 ZHA.  We care if a child moves from -2.5 to -2.1, but it would still be classified as stunted.

If we calculated S1 and S2 we could understand more about progress and its distribution than we can with our current stunting measure (S0). I have seen it tried once, by Saul Morris (an excellent addition to the rapidly strengthening nutrition team at the Children's Investment Fund Foundation) but nowhere else.

      Why not

12 June 2014

If the 21st century is to be India’s it has to get rid of undernutrition--fast

We just completed a writer’s workshop for an IDRC supported collection of papers for an upcoming NCAER-IDS book on Indian public policy priorities for nutrition. 

The workshop comes at a good time with Prime Minister Modi's government only a few weeks old.  

Many of the participants felt that the new government generated a new opportunity to put undernutrition prevention higher on the political agenda.  

Why the optimism?

A new government and a new opportunity for undernutrition reduction

First, there was a sense that the Congress Government really failed on undernutrition reduction.  There has been no government funded nutrition survey since 2006.  The PM’s Nutrition Council took over 1000 days to meet after its formation.  There is no focal point for nutrition anywhere in the central government.  India has chosen not to become a member of SUN.  The Total Sanitation Programme focuses on subsidies for hardware rather than on the behaviour change needed to end open defecation.  The list goes on.  New governments like to pick up on things that outgoing government failed to do.  The only way is up.

Second, Prime Minister Modi was a Chief Minister of a state, Gujarat.  States have been the source of inspiration for those of us who care about undernutriton reduction in India.  Maharashtra, Karnataka, Chhattisgarh and Odisha have led the way – reforming seemingly unreformable programmes (e.g. PDS and ICDS).  The space for the states to set higher expectations for the centre will probably expand under Modi’s government.

Third, the ruling BJP party manifesto talked a lot about undernutrition reduction and prevention--and in an informed way.  Manifesto pledges often end up as empty promises, but these pledges were not necessary to win votes, and yet they were made.  Someone seems to care, at least at the moment.

Fourth, the government has also pledged to tackle sanitation, putting a toilet in every home by 2020.  While this may not be the best strategy—as Dean Spears noted, often toilets are not used by some household members even if the toilet is working, preferring the traditional practice of open defecation—it is a step in the right direction and something to build on.

Fifth, resources do not seem to be a strictly binding constraint (we were repeatedly told by participants—official and otherwise).  The commitment in the 12th 5 year Plan is to increase spending on social services. 

Finally, the Government-- emboldened by its large majority-- is seeking “out of the box” thinking on nutrition.  Perhaps some programmes will be radically altered. 

Set against this optimism is a real worry that a “grow the economy now, distribute later” mentality will take over and social programmes will be seen as handouts rather than investments in the future.

Seizing the opportunity

The nutrition community has to seize this opportunity and manage the risks along the way.

First, we must emphasize the notion that undernutrition is a marker of development and that undernutrition reduction is a maker of development.  If you want sustained economic growth, invest in child growth.  If you want the demographic dividend to materialize, invest in infant nutrition now.  If you want to help avert a crisis in diabetes, hypertension and obesity in 25-30 years, invest in the nutrition of adolescent girls and newborns and infants now.  If Modi is to make the 21st century India’s century, he has to get rid of undernutrition -- fast.

Second, we need to support the Government to set out an Indian vision for nutrition.  If the various new (non-Government) all-India surveys (i.e. the Indian Human development Report data and the new UNICEF survey) are to be believed (they are unpublished and I have not seen them), then stunting in 2012-13 is about 35-37%.  This is a decline of about 1.5 percentage points a year since the 48% of 2006.  That is very respectable.  Now push that to 2% (still below what Bangladesh has managed) and India can get to below 20% by 2020. 20% stunting by 2020. That’s a target worth fighting for.  Can India beat this target before its 75th anniversary of Independence in 2022?

Third, there needs to be a high level focal point in the central government. The person should be the public face of the government’s public commitment to undernutrition reduction, preferably in national mission mode.  They would be a respected public figure who transcends political parties and for whom this is their main pursuit. Perhaps an ex-President. Their job would be to inspire and lead all stakeholders, convene and facilitate various initiatives, and report to the public, annually, on what the government has achieved.  Such a person has not been in place for at least the past 10 years.  I don’t even know who to direct this blog to!  Who is responsible for undernutrition reduction in India?  No one can tell me.

Fourth, we need to convince the government that data collection on nutrition is in its interest.  How can you diagnose the problem and prioritize action without a series of comparable data points 3-4 years apart?  In addition to the 2014 NFHS-4 there should be a 2017 NFHS-5 and a 2020 NFHS-6.  If we were talking about economic data collection there would be no discussion about periodicity—annual surveys are automatic.  Nutrition data are just as vital to guide investments in the nation’s destiny.  We would not run an economic policy based on data from 2006 (two World Cups ago!) so why would we do the same for nutrition policy?

Fifth, we need to urge the new Government to invest in Indian researchers working on this topic.  Externally funded research is helpful but it is no substitute for Indian Government funded research.  For the latter, the government has to work out for itself what information it needs and the evidence thus generated will be less easily dismissed if the government supported it.

Finally, there are just some areas which we know need urgent attention, no matter what: efforts to reduce open defecation, ICDS reform to focus it more on 0-3 year olds, efforts to improve the nutrition of adolescent girls, and attention to the price increases of non-staple foods which tend to be higher in micronutrients. 

Undernutrition reduction is everyone’s responsibility

The new Government has a once in a decade opportunity to make its mark on undernutrition and leave an enduring legacy to the nation.  

The rest of us have an opportunity to urge and support it to do so.  Let’s seize the moment: write your MP, write those op-eds, blog like never before, tweet the relevant killer facts and articles, work with filmmakers to make videos about undernutriton, inspire your students to work on it, talk to your doctors about it and convince your influential friends from all walks of life about its existence and importance.  

Undernutrition reduction is everyone’s business and everyone’s responsibility, not just the government’s.

06 June 2014

Nutrition Data: Let the Revolution Begin

by Lawrence Haddad and Jo Lofthouse (Director of Nutrition, Children's Investment Fund Foundation, CIFF)

8000 children die every day from fragility that is driven by their undernutrition. In order to intensify and speed up the world’s efforts to make this statistic become a relic, over 94 stakeholders gathered in London one year ago and collectively and publicly committed to "Preventing at least 20 million children from being stunted and saving at least 1.7 million lives by 2020".  

To help track these commitments they called for an annual Global Nutrition Report.

The recent World Health Assembly (WHA) draft progress report (still undergoing review) reported that business as usual will result in an estimated 130 million stunted children by 2025.  The WHA target is 100 million.  Rates of exclusive breast feeding are increasing, which is good news, but the number of women of reproductive age with anaemia is actually increasing (although the rate is slowly dropping-by about half a percentage point per year), under-5 overweight rates are increasing, we currently lack the data to estimate WHA trends in wasting and no-one places too much faith in the low birth weight figures: in other words, we don't even have reliable estimates of how many children are being born malnourished.  

So, some progress on stunting, but we will fall 30 million children short of our goal.  And for the other indicators?  Apart from exclusive breastfeeding we seem to be standing still, going backwards or fumbling in the dark. 

Everyone who cares about eliminating undernutrition globally should feel encouraged by the current high levels of interest demonstrated by a wide range of key players. But interest is not enough.  In development it is fashionable to say “it's not about the money”.  In this case, talk is cheap and money talks. Less than 1% of development resources are allocated to programmes primarily designed to tackle undernutrition, even though it affects one third of all children under 5 on the planet: this investment needs to increase dramatically.  

More money for programming—from national governments and development partners—is necessary but far from sufficient.  We also we need to invest much more in understanding how to spend the money wisely. Without data, we are flying blind.  We don't know where we are going, where we are or what policy levers we are pulling and not pulling.  Preliminary work on the Global Nutrition Report indicates that data on nutrition outcomes, outputs and inputs are scattered and fragmented.  In some areas – for example domestic government spending on nutrition - they are virtually absent.

The High Level Panel Report on the Post 2015 Development Agenda called for a “Data Revolution”. 

The Global Nutrition Report, to be published in November at the ICN2, will bring together existing data from a wide range of data custodians. 

The team working with me on the Global Nutrition Report has been shocked to see how little is spent on nutrition data collection in various agencies. The data experts in these agencies are absolute heroes—they do so much with so little. To their credit the aid donors have spent hundreds of hours working out their nutrition spend, because their systems – and DAC systems – are not designed to monitor it.  Our systems need to change.  This crucial data cannot be provided on a shoestring, with an annual scrabble for information.

Without comprehensive high quality data, we are all in the dark. Our advocacy, research and policymaking risks being unfocused.  If national governments, donors and CSOs cannot track spending and results properly, none of the rest of us can do our job properly.  

Around 4 children have died from undernutrition whilst you’ve read this post: this is scandalous. Let the data revolution begin at nutrition's door.  Now.