Earlier this week I was in Lusaka to help launch a new IDS report that I co-edited with Jody Harris (IFPRI, lead editor) and Silke Seco Grutz (DFID-Zambia) called "Turning Rapid Growth into Meaningful Growth: Sustaining the Commitment to Nutrition in Zambia".
The 11 articles were all prepared by Zambians and authors living in Zambia, so the papers are well rooted in the realities of the Zambian nutrition situation. The papers noted the rather static nature of nutrition indicators in Zambia over the past 20 years (45% stunting rates, 5 % wasting rates, 56% of children under 5 and 42 % of women are anaemic, and overweight among under 5's and adults is increasing).
The papers also noted how the commitment to act has grown dramatically in the past 3-4 years. The papers identify opportunities to act for nutrition in agriculture and social protection and nutrition specific programmes. Gaps were identified in capacity, resources, and evidence. The potential for nutrition action at scale was noted due to the higher tax revenues flowing from Zambia’s minerals fuelled macro growth.
But there are many challenges:
- The myth that “food=nutrition” retains a strong hold. Improvements in food production and consumption are important of course. Increased food production generates more for home consumption or more for sale and income generation—these are often good things for nutrition, although they will not be if newly large diets are not diverse or if increased income is not or cannot be spent on nutrition inputs such as better foods, safer water, improved sanitation, and higher quality health care. Better food production may be helpful to improve nutrition, but it is not automatic that food production=food consumption=good nutrition.
- The doubts persist about whether the international standards apply to Zambians (they do, at least for 0-24 month old children). As long ago as 1974 Habicht et. al. noted that any ethnic differences in heights and weights at similar socioeconomic status were much smaller than differences across socioeconomic strata. It is poverty, not ethnicity, that drives undernutrition.
- The government administrative machinery has not yet caught up with the renewed commitment to nutrition. For example the Demographic and Health Survey conducted in 2011 has not yet been released, and funds that have been committed by development partners to the districts have been held up in a bureaucratic loop for 9 months or so. Bureaucratic bottlenecks have high costs.
- Government spending on interventions with a nutrition focus is low: 0.03% of total government expenditure is allocated to direct nutrition interventions, and 0.31% of the health budget as estimated by the SUN CSO alliance. Spending on direct nutrition interventions (including water and sanitation) per child under the age of 2 is 3 Zambian Kwatcha compared to a recommended level of 190 per under 2 year old from the World Bank. Spending on direct interventions needs to increase--not much can be achieved at these levels. The World Bank (unpublished as yet) estimates the nutrition finance gap as $24 million per year. It is not much is it?
- There are not enough nutritionists in the country. The new University of Zambia undergraduate degree in nutrition has been going for a few years now and if the sharp questions the students asked me during my public lecture (power points here) is anything to go by, the course seems to be a great success. A Master’s programme is in the works, and Hilary Powers (of the Geissler and Powers authoritative textbook fame) has been seconded to the University for 2015. Nutrition cannot be scaled up without qualified and trained people to do it.
- The Government is more focused than ever on nutrition, with a new food and nutrition Act in progress, the strengthening of the National Food and Nutrition Commission, and some progress towards the Nutrition 4 Growth Commitments. The Vice President wrote the foreword to the report, attended the launch and invited us to meet with him the next day for a discussion about nutrition.
- A social cash transfer programme is about to be launched nationwide. The programme is not only targeted to those households with children under the age of 5 or 2 (too difficult politically to give cash to some poor households and ignore other equally poor households in the community) nevertheless an early pilot evaluation (summarised in our Report) found that the cash transfers do improve diet diversity for the household when mothers have higher levels of education. It would be good if some conditionalities were tried (cash if children are immunized, clinic check ups are undertaken, or classes in improved infant and young child feeding practices were attended)
- The Ministry of Agriculture has a unit dedicated to nutrition, and there are plenty of ideas about how nutrition can become more nutrition sensitive, whether reducing aflatoxins in maize or improving the attractiveness of fish farming as a sustainable business.
- The international development partners are investing in nutrition actions, including funding nutrition plans of action in 14 districts, building capacity at the frontlines, and in the universities, with great leadership from Silke Seco Grutz and others.
- Civil society is more and more mobilized, strategic and organized. The CSO SUN Alliance is doing a great job, with great leadership from William Chilufya. For example, they are the ones who estimated the expenditures to nutrition by ploughing through the 2500 page budget document.
- A small but growing group of Parliamentarians are deeply committed to nutrition improvement and there is a public commitment from one of them about getting them organized into a committee, group or caucus, much as in the UK with the influential Select Committee on International Development and the All Party Parliamentary Group on Agriculture and Food for Development
- Some prominent broadcasters are deeply concerned about malnutrition. While I was there I was interviewed by the state broadcasting agency, ZNBC.
- Tax revenues are rising generating more potential fiscal space for nutrition. It was too bad no-one was present form the Ministry of Finance for our launch. We tried. If minerals driven growth in the Zambian economy is to have a positive legacy rather than be a (literal) flash in the pan, those tax revenues will need to be invested in something that yields long term high benefit cost ratios. This is what we meant in the title of the Report by "turning rapid growth into meaningful growth".
- Investments in human infrastructure (i.e. healthy growth) have high economic returns. There is a lot of hard infrastructure investment in Zambia right now. Roads, offices, homes are being built. They have good economic returns and may help improve nutrition somewhat. But investing in proven nutrition interventions generates benefit cost ratios of 16. In other words, invest 100,000 Zambian Kwachas today and watch that grow to 1.6 million Kwachas over the next 25 years. Attention Ministry of Finance officials: that is an annual rate of compound interest of over 11%!
A civil society scorecard for nutrition actions?
As ever, civil society needs to be the lead change maker. Social change comes from concerned and feisty citizens organizing to demand better of their often well intentioned but always busy and distracted governments. It would be great to see a simple scorecard of government commitment that can be tracked.
- % of budget spent on nutrition
- Number of nutritionists on the public payroll
- Number of times nutrition is mentioned in public speeches and policy documents
A Credit Rating for Nutrition?
While I was in the country, the news reported that Zambia has been given a higher than ever credit rating by Fitch due to strong growth and sound macro policies. This was cause for much celebration amongst the economics journalists. Zambian civil society can become the ratings agency for nutrition. How reliable will the government be on nutrition commitments? Any improvement in the nutrition rating would not only be cause for celebration in the nutrition community but also for the economists. We just need to get them to see it!
Undernutrition levels in Zambia are on the cusp of a great decline. For that decline to happen the commitment to nutrition must be sustained--and intensified-- by all stakeholders, but especially by the body that is accountable to its citizens, the Government. All stakeholders need to come together to push, nag, support and applaud the Government in its efforts to do this.