24 June 2015

You say you want a nutrition data revolution? Well, you know, we’d all love to see the plan

One of my favourite book reviews (as long as it never applies to me) is: “This book fills a much needed gap” (think about it).  Those who advocate for more nutrition data need to ask themselves the same thing: do these data simply fill a much needed gap?  In other words, do we really need to fill any given data gap?

Yesterday I participated in a brainstorming meeting at WHO on data gaps that matter for scaling up nutrition interventions.  Data are needed at the subnational, national and global levels to guide action, to assess progress, to help advocacy and to strengthen accountability. 

We spent the whole day (a) identifying gaps that need filling, (b) mapping ways forward on data gaps that can be filled relatively straightforwardly and (c) brainstorming on the more difficult or “gnarly” data gap issues.

Some reflections:

The participants work mostly at the “global” level—and it showed.  It was important to keep in mind the constraints faced by people working with data in the domestic nutrition system.  There was a tension between framing things as “what do we need to do to get more domestic data into the international system?” and “what do countries want/need to move their nutrition agendas forward?”  Another tension was around framing that said “what additional data would be useful to countries?” and “what do countries need to make existing data more useful?”  All of the framings are valid, it seems to me, it is about listening to countries while also meeting global accountability and advocacy needs.  But how to “listen to countries” without burdening countries, while doing it in a demand driven way that is not patronising?  And then how to aggregate up?  Perhaps via country typologies in terms of the nutrition problems they face and the capacity they have to collect and use data.  

The parlous state of food consumption data. This was mentioned by nearly everyone as a problem.  Food intake is vital to address undernutrition, but also other forms of malnutrition driven by unbalanced diets.  How can countries formulate a strategy to address undernutrition in a balanced way if they do not know what their population eats? There are a number of initiatives in process to strengthen food intake data, but there was a general sense that data collection in this area needs to step up a gear.

Coverage data.  As the GNR 2014 pointed out, of 10 Lancet nutrition specific interventions, only 4 have internationally comparable data on coverage for more than a handful of data (vitamin A supplementation of under 5’s, iodized salt intake, zinc treatment of under 5’s with diarrhea and iron folate capsule intake during pregnancy). 

But what to do about nutrition specific intervention coverage?  Why is it not more routinely embedded in on going data collection activities such as DHS/MICS/SMART surveys?  One reason is that we do not have a set of agreed on and easily implemented coverage indicators that can be embedded in surveys or, indeed, in facility-based data collection.  We need such a set. 

And what to do about nutrition sensitive programmes? How do we know if they are nutrition sensitive and how do we figure out who they reach?  No answers I’m afraid, just prioritizing unknowns.

Cost data for nutrition interventions.  If we want to know how much reducing malnutrition costs—and try to make action more cost effective--cost information is essential.  What can we do to make sure these are always collected?  And how can these data be curated and made available to a wider audience?

So more questions than answers, but a list of follow up actions was drawn up, and different people committed to deliver on these actions.  Many were process actions, but that is OK it seems to me.  The costs of data collection are high and the costs of collecting the wrong data are even higher.  Doing data things in a deliberate and coordinated way is important.  

Surprises?  There were 2-3 strong advocates for better micronutrient surveys but not as many arguing for it as I would have thought given the large numbers of people affectedly them, the lack of specificity about who they are and the lack of progress in addressing the burdens.  We did not talk much about indicators for capacity (beyond the number of front line health workers) although this is an important issue.  We talked about the need for better data on preventing severe acute malnutrition and on the coverage of treatment, but not as much as the issue perhaps deserves.  As usual, the issues raised depend on who is in the room, no matter how objective they are trying to be. 

In the context of the broader dialogue, the group is aiming to write a more considered piece for public consumption to contribute to the wider discussion about which data to invest in.  And why that investment would fill a gap that is not much needed.  

01 June 2015

UNICEF and Nutrition: What Do We Want From It?

I was invited to the annual meeting of UNICEF nutrition leaders from around the world.  It was a bit like an episode of Marvel's "Avengers Assembled"  -- I had met so many of these great professionals at various stages in my own working journey. It was great to see them assembled in one place.

I had been asked by Werner Schultink, UNICEF Nutrition Chief, to speak to the topic of "What does the global community expect of UNICEF? How should it respond?  My powerpoints are here.

What do I expect of UNICEF on nutrition?

1. Leadership.  Nutrition is flavor of the month right now, but leadership is speaking up for nutrition when no-one else is doing so and UNICEF has been very good at doing that pre-2008.  Keep doing it, even if everyone else is. More importantly, help us keep our feet on the ground.

2. Innovation.  As Michael Anderson said at the IFPRI Forman Lecture last year, one can get carried away with innovation.  Many times we just want people to do their job.  But UNICEF has been a pioneer in so many areas: from the conceptual framework, to rights based programming, to using mobile phones and to being involved with the Power of Nutrition and UNIT LIFE financing facilities for nutrition.  Keep asking yourselves and the rest of us: "what's next?" in nutrition.

3. Measurement.  While I don't believe what gets measured always matters, we need to measure what does matter, and UNICEF is a fantastic fundraiser for surveys: from the regular MICS to one-off surveys in Maharashtra and the Indian nationwide Rapid Survey on Children.  The GNR tells us that 40% of countries have anthropometry data that is at least 5 years old.  Imagine what that statistic would look like without UNICEF.

4. Documenting stories.  In an era when research fashions have sliced and diced the change landscape, we need organisations like UNICEF to commission comprehensive stories of change or stasis.  If Kenya has just generated impressive declines in stunting, what has generated them?  There will be a self serving element here--the commissioned work can tell UNICEF about their role (and if good, provide some promotional material) but the wider service to the field is to describe, analyse, inform and inspire everyone else.  More please.

5. Support to countries.  I have seen the invaluable long term support UNICEF has provided to Maharashtra, Uttar Pradesh and Ethiopia.  They do it in a way that respects country leadership.  Changing nutrition outcomes does not take as long as we sometimes think, but it does require 7-10 years of constant support--and this is an eternity for some governments and donors.  UNICEF is patient.

6.  OK before you wonder if I have been paid by UNICEF to write this blog (nope), what could they do better?

* work across sectors better.  UNICEF is in a privileged position--they are not constrained by sector . So can they make the most of this liberty?  Some of the UNICEF staff were very open--they could do better, but this would require support from UNICEF Res. Reps.  Hey, if UNICEF cannot do it within their organization, how can the rest of us do it across organizations?

* help us all chart a pathway through the double burden terrain.  More and more countries are struggling with the realities of the coexistence of under and overnutrition.  What should they do?  Be blind to it or blinded by it? Neither.  We need a clear eyed vision, and UNICEF with their focus on health systems and schools can help.

* help us navigate another rocky terrain--business involvement in nutrition.  When to stick or twist?  And how to minimize the risks with doing either?  Because much of the controversy surrounds the role of business in marketing products to infants and young children, UNICEF has to speak up and help develop some norms of behavior. Get more involved in the private sector debate. 

* help us lock in the current high commitment to nutrition.  This means making more noise about the lack of nutrition in the SDGs.  UNICEF is a stone's throw (literally) from those haggling over the SDGs.  Sharpen those elbows. 

* help us make SMARTER commitments on nutrition.  There is a big pledging moment coming up in Rio in August 2016.  With a few exceptions, the nutrition community is not brilliant at making pledges that we can be held accountable for, so UNICEF maker your own commitments water tight and then help the rest of us to.

In many ways UNICEF is our moral compass on nutrition.  Its influence and size are increasing: nearly $0.5 billion of spending on nutrition, 500 nutrition professionals world wide.  These are numbers that we could only have dreamed of 10 years ago.  But with power comes responsibility.  In 3-5 years UNICEF will need to show what is has accomplished with this strong wind at its back.  The time to start measuring is now.  I have no doubt that the organization will rise to the challenge.