11 March 2015

Does the World Bank care enough about malnutrition?


The title of this blog may seem strange to some.  The World Bank has made some very important intellectual and policy contributions to nutrition over the years, from Alan Berg to Judy McGuire, Harold Alderman, Meera Shekar and Leslie Elder.  But it feels, to me at least, as if nutrition is not quite the priority it should be at present within the Bank. 

If true, this lack of focus comes at a bad time.  The SDGs are being set in quick drying concrete and there is only a month or so to affect the contours.   The Spring meetings of the Bank/IMF might be the last throw of the dice to embed nutrition more firmly within the post 2015 framework.  

So what am I basing this concern on?  Admittedly as an outsider my evidence base is thin.  I have to rely on the following pieces of “evidence”: (1) of 71 World Bank Press Releases in February 2015, only one was on nutrition, (2) out of 925 Topics in the Open Knowledge Repository of publications only 1 Topic heading is on nutrition (“Nutrition and Population”).  Within the 232 publications in that Topic heading I could only find 23 that were actually on nutrition (under and overnutrition), and (3) the crudest of all measures, a Google search on “Jim Kim nutrition”, does not exactly turn up a treasure trove of statements (try it).

Words and publications are nice but surely, you say, money talks.  Well, data provided by the Bank to the Global Nutrition Report shows that its commitments to direct nutrition programmes (“nutrition specific” interventions in the jargon) have increased dramatically between 2010 and 2012, from $55 million to $248 million.  Commitments to indirect programmes (known as “nutrition sensitive” interventions, such as certain types of agriculture, cash transfer programmes and water and sanitation programmes) were estimated to be about $2 billion in 2010 and $1 billion in 2012 (the commitments are lumpy by nature, being large and multiyear).  Nevertheless, in 2012 the World Bank was the second largest provider of ODA to nutrition, after the US Government. 

So what am I complaining about?  Well, the financial picture is far from clear—disbursement figures are lower than commitment figures and hard to interpret, for example.  But my main plea is not about money, it is about ideas. 

I want the Bank to become an intellectual leader in nutrition once again.  

This is important because the Bank is the leading shaper of development thinking and nutrition is the quintessential post 2015 sustainable development issue.  Consider the following 3 features of a post 2015 development issue: (a) it affects nearly all countries, (b) it affects intergenerational equity and (c) it is best addressed through collective action.  Nutrition has all three features.  On the first, the Global Nutrition Report finds that nearly every country has a serious public health problem with nutrition. On the second, we know that malnourished mothers are more likely to give birth to malnourished babies, and that they are more at risk of growing up to be malnourished adults and, if women, the cycle continues.  Finally, because there are so many sectors involved in the production of good nutrition, all stakeholders have to work in harmony and sometimes collectively (as in the Scaling Up Nutrition movement).  Even at the level of nations, international standards on healthy diets will do more to drive the food system towards good health for people (and for the planet) than national standards alone.

To this the Bank might say, hey, all we really care about is eliminating extreme poverty.  Now extreme poverty is pretty sensitive to increases in GDP per capita.  But stunting, the preferred measure of chronic malnutrition, is much less so.  And yet it is hard to think of a more complete, if grisly, composite indicator of deprivation than the height of a child for its age. Every insult in the area of food, care, infection and neglect is captured and accumulated in a kind of negative rate of return, observed as height, which is a mere marker for the things we really care about: mortality and neurological and cognitive development.  Society needs to make it easier for parents to make the right choices for their babies and infants.  Stunting should be the indispensable complement to money metric poverty.  If both of these can be eliminated we have conquered poverty today and tomorrow.


So nutrition needs the Bank to re-energise its interest in nutrition.  The Bank is the premier development institution and nutrition is a key development issue.  The Bank can help to make development decision-makers recognize that.  But perhaps equally importantly, the Bank needs nutrition: to ensure that when poverty rates decline, they do so for this and for the next generation.

11 comments:

DialogueSmut (Aaron B) said...

Thanks kindly for these thoughts and goading, Lawrence. You might be interested in joining a tri-partite webinar between the SecureNutrition Knowledge Platform (World Bank), USAID SPRING project, and independent Ag2Nut community of practice on March 25th. We'll be delving into the history of nutrition-sensitive (specifically, ag + nutrition) development at the Bank since the 1960's. Official announcement should be up shortly, so I'll try to circle back and leave a registration link here. Best - Aaron

DialogueSmut (Aaron B) said...
This comment has been removed by the author.
Anonymous said...

Another opportunity that stands ready to be missed, is whether the forthcoming Bank-Led Global Financing Facility for "Every Woman Every Child" (http://www.worldbank.org/content/dam/Worldbank/document/HDN/Health/ConceptNote-AGlobalFinancingFacilitySupportEveryWomanEveryChild.pdf) will have any relevance to nutrition, or have any reach outside the narrow borders of the the health sector and its specific interventions.

It is hard to conceive of any initiative focussed on improving MNCH not putting nutrition high on the agenda, but I fear that may be the case here.

Admittedly Health Sector / specific interventions are hugely important(and it would be welcome to see Health Systems Strengthening projects judged by increases in breastfeeding) but it is not where most impact is still to be had.

Given the scope of dialogue the Bank has with partner countries, it could play a valuable role in ensuring that nutrition progress and impact becomes a deliverable across government, and the extra resources from the GFF could be used to influence health and nutrition determinants, and leverage outcomes from non-health sectors.

But who in the international community is asking them to step up to this role?

Lawrence Haddad said...

I agree--who is doing this? Several nutrition champions are on the working group--Michael Anderson, Jane Edmonson, Joanne Carter, Diane Jacovella, Tim Evans.. we should reach out to them...

Meera Shekar said...

Hi Lawrence,

Great to see you prodding on nutrition again! As you know, the World Bank was the first to say that nutrition is central to development in our paper “Repositioning Nutrition as central to development, 2006” and we agree fully that it fits front and center in the post 2015 sustainable development agenda.

As you note, the Bank is among the largest investors in nutrition. And we are expanding our investments, not just for nutrition-specific investments through the health sector, but also making our investments in agriculture, social protection and WASH more “nutrition sensitive” so we can achieve our twin goals of ending poverty and boosting shared prosperity – with a special focus on reaching the bottom 40%. That is why, apart from the dramatic increase in financing that you highlighted over the last few years, we are also working with countries to develop evidence-based, costed scale-up plans; to then support the financing of these plans.

The Bank has continued to put nutrition on the development agenda. We have been a leading partner in initiating the Scaling-Up Nutrition (SUN) movement since 2010 that is now supported by over 55 client countries and several hundred development partners. We did this because we believe that nutrition is indeed central to development, including the SDGs, and that collective action is key.

The other latest news is that we are working with partners like the Children’s Investment Fund Foundation, and UBS’s Optimus Foundation to put in place a catalytic financing facility to make this financing more sustainable, including leveraging domestic resources where feasible. You will be hearing more on that very soon. We want to keep our focus on the longer term horizon, and on results, not just publications or research. Research institutions like IPFRI are crucial here. But, we are also working with key partners such as the Gates Foundation to help estimate the cost of achieving the nutrition targets embedded in the SDGs.

And as we move to identifying key development areas for “Global Solutions” that the Bank will prioritize to address poverty, nutrition is already in there…up front and center, as it should be. Our focus now is on action and on results and we have seen great progress already in Senegal and Ethiopia.

So we are still very energized about nutrition! Hope your readers can join us in person or via webcast for our Spring Meetings Nutrition event – details to come soon…..

Meera Shekar
Lead Health and Nutrition Specialist
The World Bank

Monique Vledder said...

Dear Anonymous and Lawrence,

Please rest assured that the Business Plan for the Global Financing Facility in support of Every Woman Every Child - which is still being finalized – makes it clear that the GFF will support nutrition.

And there is strong support among the members of the Planning Team (which includes CSOs, Foundations, governments, private sector) to include nutrition as part of the GFF's comprehensive approach.

For the latest information on the GFF please go to:http://www.worldbank.org/en/topic/health/brief/global-financing-facility-in-support-of-every-woman-every-child

Monique Vledder, Senior Health Specialist and GFF Coordinator
The World Bank

Monique Vledder said...

Dear Anonymous and Lawrence,

Please rest assured that the Business Plan for the Global Financing Facility in support of Every Woman Every Child - which is still being finalized – makes it clear that the GFF will support nutrition.

And there is strong support among the members of the Planning Team (which includes CSOs, Foundations, governments, private sector) to include nutrition as part of the GFF's comprehensive approach.

For the latest information on the GFF please go to:http://www.worldbank.org/en/topic/health/brief/global-financing-facility-in-support-of-every-woman-every-child

Monique Vledder, Senior Health Specialist and GFF Coordinator
The World Bank

Lawrence Haddad said...

Hi Meera, thanks for this comment. Of course the Bank has played a very important role in repositioning nutrition, but it's leadership has been relatively silent these past 2-3 years just when we need to hear from them the most. Great to hear about these on-going projects and initiatives, but they are still quite below the radar. Be great if the Bank could speak up more on nutrition. Actions speak louder than words, of course, but words matter too because they inspire others. Best

Lawrence Haddad said...

Hi Monique, thank you for your comment. Great to hear that the GFF Business plan will highlight nutrition. This is of course where the rules of resource allocation between sectors and between countries take place and we know how easy it is to forget about nutrition, which strangely always seems to be low in the pecking order of health sector priorities. The RMNCAH GFF, if nutrition sensitive, will be a great way of leveraging health financing for nutrition, but what about the other sectors? Does the Bank have FF plans for agriculture, social protection, WASH, education and who in the Bank is looking out for nutrition in these? Best, Lawrence

Monique Vledder said...

Hi again Lawrence,

GFF is financing country led investment cases focused on health and nutrition results, that can be achieved through health sector as well as multisectoral actions. The focus is on financing high impact evidence based interventions at scale as well as ensuring long term sustainability. We are excited the there is a strong support for this approach in the multi-agency business planning team!

Best,
Monique Vledder, Senior Health Specialist and GFF Coordinator
The World Bank

Meera Shekar said...

Hi Lawrence -- There are complementary financing facilities (FFs) in other sectors too. For example, we just approved a 27m$ multisectoral nutrition project in Uganda financed from the Global Agriculture and Food Security Program (GAFSP). And, even without dedicated FFs, we are leveraging IDA in other sectors, such as Social Protection (SP), to impact on nutrition. Mali is a good example of a small nutrition pilot embedded in the Social Safety Net project, with the aim of expanding it if works. IFPRI is evaluating it. Similarly the new Bangladesh SSN project is designed to be nutrition-sensitive, and similar discussions are ongoing in Nigeria.

So watch out for more words and action at our Spring Meetings mid-April! If you want to discuss this further just give me a call.

Best
Meera Shekar
Lead Health and Nutrition Specialist
The World Bank