Why is UNICEF such a vital nutrition champion and could it do more?

Today, the UNICEF nutrition leads from their Eastern and Southern African Regional Offices (ESARO) invited me to make a video link presentation of the GNR at their regional meeting in Nairobi.

I was delighted to do so.  In the Q and A a number of questions came up about UNICEF's role.  What could it do more of?

Well, I've never been employed by UNICEF and I'm not an expert on it, but I am of course familiar with some of its work.

So my answers were:

1.  Continue to be strong champions.
At the global level we see this, for example, via UNICEF's strong advocacy and messaging, Tony Lake's leadership and activism, and UNICEF-Nutrition's ability to leverage resources (e.g. its critical role in the Power of Nutrition).

But there are three areas in which they do great work but I think can be even more ramped up:

2.  Be boundary champions.  UNICEF works in education, health, child protection, gender, water and sanitation etc. We need these sectors to become more animated about nutrition.  UNICEF with its fingers in many pies can help to link them up.

3. Be accountability champions.  UNICEF supports governments to collect a multitude of nutrition data via, for example, the Multiple Indicator Cluster surveys (MICs).  These are incredibly valuable.  How could they do more?  Innovate with community scorecards for improving nutrition service delivery.  Experiment with mobile operators to improve knowledge about nutrition practices.  Evaluate rigorously. Share learning.

4. Be story champions.  Stories about nutrition improvements are too often sliced and diced.  This intervention, that policy, this investor.  But in truth we need to see the wider angle view.  Which things come together to accelerate nutrition? Which things come together to generate the perfect storm to hold it back?  UNICEF is in a unique position to tell such stories--again, it must be rigorously done--because it works across sectors and from the community to policy and back. These stories help everyone better understand progress, learn from it and by inspired by it.

UNICEF, thank you for the great work, now can you take it to the next level?  I think you can--and I hope you will.

New: Healthy Food for a Healthy World (But how to make it happen?)

The influential Chicago Council on GlobalAffairs has produced a new report “Healthy Food for a Healthy World” with an analysis and recommendations for the US Government on how agriculture and food can better leverage improved nutrition.

The report does a good job of outlining a series of outcomes that we would like to see along the food system chain: from natural resources and inputs (e.g. secure land tenure for women) to health and nutrition (e.g. coordinate food system interventions with health and social protection programmes).

The report notes that (1) the improvements in agricultural productivity, if focused on smallholder farming families, can lead to income generation that is very pro-poor and if women in the food system can be empowered then this is doubly good for nutrition, (2) the food system is much too tolerant of lots of food waste—much of it affecting foods that are rich in micronutrients but which need cold storage such as animal products, fruits and vegetables, (3) only ¾ of harvests are not contaminated by the poisonous fungus mycotoxin, (4) the food system is tending towards producing more and more ultraprocessed foods which are, in large part, unhealthy and (5) climate change and urbanization are challenges for--but also opportunities to rethink--our food systems.

I also really liked the panels from Roger Thurow, breaking through the statistics to let us see the stories and hear the voices of those most affected by malnutrition.  The inspired use of photographs to bring home the paucity of diets in many parts of the world is also hard hitting.

So far, so good.  What are the recommendations for the US Government?

The first set of recommendations is very pragmatic—what should be done within existing instruments?  Have a whole of government approach to healthy food systems—not just USAID but USDA and other agencies.  Make food aid more efficient (untie from US shipping, allow more food to be purchased locally) and support efforts to make social protection more nutrition sensitive (as in Ethiopia with the Productive Safety Net Programme). Align all interventions around the 6 World Health Assembly targets.  Encourage more trans-disciplinary research, i.e. mash ups of existing approaches to address complex issues such as nutrition. This is all good sense—first change things that are more under US government control (although untying aid is far from “simple”).

The second set of recommendations is around research.  Incentivise international and national agricultural research to do more work on fruits and vegetables to increase profits and lower their cost in the marketplace.  Close data gaps between agriculture and nutrition surveys.  Invest more in biofortification.  Measure the nutrition impact of agricultural interventions, and so on.  This is important set of recommendations—how can we begin to get a sense of which agricultural investments, under which circumstances, are most nutrition enhancing?  Vital information.

The third set is perhaps the most exciting because while important it is usually ignored—develop leaders for whom making the link between food systems and nutrition is second nature.  Invest in research centres in the US and overseas that are committed to this.  Invest in leadership programmes that stress whole of society working.  Invest in innovation awards that set new norms about what agriculture is for.  Train Peace Corps volunteers in what nutrition sensitive development looks like. 

Finally, develop public-private partnerships that can incentivize businesses towards healthier food systems: support infrastructure to reduce food losses and promote food safety, support entities that monitor firm behaviour, support budding nutrition-oriented SMEs, increase technical assistance on monitoring food safety in Africa, and support stronger global advocacy of voluntary guidelines on nutrition sensitive marketing to children.

For me, the thing that is missing from the analysis is the political economy of it all.  

Why should members of the Congress and the Senate support these measures to promote voluntary guidelines on marketing unhealthy food to children if they risk upsetting businesses who have located in their state?  What is in it for agricultural and nutrition researchers to work together more closely?  How can infrastructure investments that will promote fresh fruit and vegetable access be made more attractive? If food aid has been tied for decades, why might it become untied now?  Having a whole of government approach to a healthy food system is great, but why has it not happened before? How can we encourage trans-disciplinary research when most journals prefer disciplinary research?

I’m not suggesting these questions are easy to answer.  Far from it. But I would have liked to have seen some recognition of this and some ideas for moving forward. 

Nevertheless, I very much enjoyed reading this report—it is a thoughtful analysis, well written, and contains many pragmatic good ideas. If its recommendations were acted on they would make a big difference to nutrition status the world over.  

I hope the Council will maintain a scorecard and tell us which of its recommendations have been taken up and which have not.  And explain why. 

What the Different UK Political Parties Really Think about DFID

14 days to go to the closest UK General Election in recent history and we have not heard much about DFID/UKAid/Overseas spending, except from UKIP which is not keen at all.

This lack of election fever debate is good in the short run and reflects a consensus that having a sizable international development budget is the right and smart thing to do.

But in the medium run it would be good to have a discussion of when and how the aid budget changes and evolves. An election is exactly the wrong time to do this because everything in the discourse becomes binary, simplistic and shrill.

However, we do need a debate on the long term future of UK Aid and I hope the new Government starts thinking and consulting about it.

In any case, a friend asked me if I was going to do a blog on the different parties' views on DFID--as I did back in 2010.  I told him I thought there was not enough grist for a decent blog.

But behind the harmony of the public positions, what are the UK political parties really thinking about DFID?

Here is my entirely non-serious attempt to read their minds (apologies to non UK readers for the in-jokes):

Conservatives: well, that was a real vote winner!

Greens: we'll double the 0.7% to 1.0%. Er, hold on..

Labour: blimey, I hope we're not supporting zero hours jobs overseas

Plaid Cymru (Welsh Nationalists): it already sounds like a Welsh town & Wales is international, right?

Scottish Nationalist Party: it supports strong national governments all over the world ;)

UK Independence Party: nuke it, nuke it, and then nuke it again

Liberal Democrats: what they said...

Needed: Nutrition Behaviour Change Communication for the Powerful

This week I was invited to give a keynote on the global nutrition situation in the context of a book launch on Development and Nutrition: The Role of Social Norms by the excellent Elaina La Ferrera and Annamaria Milazzo of Bocconi University with the support of the Fondazione Romeo and Enrica Invernizzi, one of the supporters of the Milan Expo 2015 which starts next month.

The book reviews norms around inheritance, intrahousehold resource allocation and beliefs around diet and nutrition. The authors report on some interesting issues such as what happens to diets when people move to different states or countries (sometimes good for nutrition, sometimes not) , the differences in nutrition status across religions controlling for all other factors (e.g. Hindus with stronger son preference compared to Muslims in India), the strengthening of inheritance rights for women (good for infant nutrition), the delineation of certain crops as being grown by women or men and the brake that puts on household food security. 

This is a fascinating review, but it tends to focus on norms that affect the household.  But these norms also affect powerful decision-makers in the public and private sectors. And these individuals are perhaps better positioned to change the norms. 

Consider the following social norms I commonly encounter in policy circles:

*Income growth will take care of nutrition status. It will take care about half of undernutrition—in the long term.  Kids don’t have the luxury of waiting.  Keynes said in the long run we are all dead, but for young children, they are more likely to die in the short run without adequate nutrition.

*Food security is the same as nutrition. Food security is one of the 3 legs of the nutrition table.  Care and health environments are the other 2.  Food security is necessary but not sufficient for good nutrition. 

*Children 0-2 grow differently in different countries.  The WHO growth standards study shows definitely that they do not.  After the age of 2 maybe, but until then, no.

*Women’s time is less valuable than men’s.  While women tend to have less access to resources, control and authority, asking them to do more things may be even more disempowering.  They need to have more control over the priceless commodity of time.  

All of these norms need to be challenged and updated.  As any good community behavior change communication initiatives will know, information and evidence are vital, but not nearly enough.

Engagement, mobilization, ownership and collective action are all vital for changing norms at the community and household levels. They are vital in policy circles too.   

Why Has Stunting Declined So Fast in Tanzania? Poverty Reduction & Nutrition Spending Increases Matter

I just returned from a week in Tanzania, exploring options for evaluating the impact of m-nutrition initiatives on nutrition behaviours and status.  More on that as it develops.

During the trip I found out about a recently released 2014 SMART national nutrition survey that shows under 5 stunting rates at 34.7% in 2014, down from 42% in 2010.  That is 7.3 percentage points in 4 years. Good news.  This is an annual average rate of reduction of nearly 5% -- well above the nearly 4% required to meet the World Health Assembly targets.  If this can be maintained then this is even better news.  But there seems to be no consensus as to what is driving the decline.

I don't know of a study that looks into this for Tanzania (my IFPRI colleague Derek Headey has done these kinds of studies in Ethiopia, Bangladesh and Nepal), so I went to the Global Nutrition Report's Tanzania Nutrition Country Profile.  The profile shows that the rates of food security, improved water and improved sanitation are all increasing, but very slowly.  Unimproved sanitation + open defecation rates remain very high (79% in 2012).  Economic growth is steady but not spectacular.  The big change seems to be $1.25 a day poverty rates which have almost halved in 12 years: 85% in 2000 to 43% in 2012. 

As you can see from the link to the 2014 survey results, infant and young child feeding has not improved and for exclusive breastfeeding rates have actually decreased.  Iron Folate supplementation rates have increased, Vitamin A supplementation rates for under 5's have increased and women's thinness has declined:  but none of these positive changes are huge.

The Government of Tanzania's health expenditure has increased substantially between 2008 ($383 million) and 2014 ($622 million).  The 2014 Nutrition Public Expenditure Review is even more revealing. As the picture below shows, the total budget for the nutrition sector has increased rapidly.  Equally important the share of the government in that expenditure, although quite low at about 30%, has held steady, so real GoT expenditure on nutrition is also increasing rapidly.

This is the really good news story--an increasing government commitment to nutrition, not only in words, but also in cold hard cash that has multiple alternative uses.  Of course, money is not the only important resource, and it has to be spent on things that can improve nutrition, but scale up of programmes is impossible without it.

So, while we need a proper study to confirm it, maybe, just maybe, it is the declining poverty rate combined with increased nutrition spending by government and external partners, that is responsible for the decline in stunting in Tanzania.  And more good news: there is plenty of room for improvement in water, sanitation and infant and young child feeding programme coverage rates. 

Can Tanzania meet its WHA targets? If these trends are maintained the situation seems very positive. 

Measuring Women's Empowerment: Is it worth it? Yes.

There are two things about empowerment.  First it is a process: a process of increasing power.  Second it is about "power".   As a process it is perhaps not that easy to quantify.  As for "power", well, the ways in which that is exercised are highly context specific and difficult to recognise.  Trying to quantify women's empowerment in a cross-region context is a task for brave souls.  

And yet this is exactly what my IFPRI colleagues Hazel Malapit and Agnes Quisumbing have attempted to do with the Women's Empowerment in Agriculture Index (WEAI), working with colleagues from OPHI and USAID's Feed the Future. Malapit and Quisumbing's latest paper --on Ghana--has just come out in the journal Food Policy.  

Why is it even worth attempting to measure women's empowerment?  Well we know that various measures of women's power to control resources, their own bodies and their own mobility are associated with a range of food security and nutrition status outcomes and we know that women are routinely denied access to the same kinds of agricultural inputs that men take for granted.  So if we can identify domains or geographical areas where their power relative to men is low, then we can better try to take the power imbalance into account --and even contribute to eifforts to change it--thereby improving a range of food security and nutrition status outcomes (as well as a range of other outcomes and of course women's status to control decisions is a vitally important outcome in and of itself). 

As the authors note, the WEAI is a survey based index that “directly assesses women’s empowerment across five domains in agriculture, namely, agricultural production, access to and control over productive resources, control over the use of income, leadership in the community, and time allocation. The women’s empowerment score reflects the extent to which women are empowered in these domains. Comparing women’s and men’s empowerment scores enables us to assess the inequality between the achievements of women relative to the men in their households.”  

There are 10 indicators across the 5 domains (see picture at top of post).  One domain has one indicator (e.g. sole or joint control over income and expenditures) and it is weighted as 1/5 of the index.  One domain (resources) has 3 indicators and each of them are weighted as 1/15 of the index.  The overall index is useful as a headline, but the real value is that the WEAI can be broken down into the 5 domains of empowerment: production resources, income, leadership and time.

This paper asks: in Northern Ghana, which domains of empowerment are associated with (a) infant and young child feeding practices AND (b) child and women nutrition status.  Ordinary least squares are used to assess associations between various domains of WEAI and these nutrition related outcomes, controlling for a wide range of individual and household characteristics.  The authors also test whether the associations between WEAI components and child nutrition status differ for boys and girls.  The IYCF outcomes are exclusive breastfeeding up until 6 months of age, minimum diet diversity and minimum adequate diet scores for children 6-24 months of age, stunting wasting and underweight and for women the indicators relate to diet diversity, underweight and BMI.

For the sample of women in northern Ghana all 10 indicators have significant deficits in terms of women’s empowerment, with access to and control over assets, credit and income being the most important.

The results show:

* On IYCF practices, WEAI index and component domain scores show a few statistically significant associations (p less than 0.05) but they are mixed (some positively associated with practices, some negatively)

* No significant associations (p less than 0.05) between WEAI or components and child nutrition status measures

* No significant associations (p less than 0.05) between WEAI or components and women’s BMI, but positive and significant association between women’s control of credit decisions and women’s diet diversity

These results are interesting, but raise more questions than they answer.  The authors are not surprised by the complexity of the findings and acknowledge that context is everything; that not all domains of empowerment will be associated with all manner of nutrition practices and outcomes;  and when they are associated, the direction of association may be counter intuitive. 

The WEAI is available for 18 countries.  It should be used by policymakers who care about nutrition—to identify bottlenecks to improved nutrition practices and outcomes (such as access to and control over credit decisions and the strong positive associations with women’s diet diversity in northern Ghana)—but also because gender parity is a right and women’s empowerment has many benefits to women, families and society that just cannot be measured in a quantitative way.