25 February 2016

The Global Governance of Nutrition: Why it Matters

Recently I was asked to prepare 10 minutes of thoughts on the global governance on nutrition (I did not have much more guidance than this). It was for an influential group and I wanted to push myself to think more about the topic, so I said yes.

The picture in the blog is my attempt to put something down on paper.
Source: me
I did not think of it as a formal governance system.

Rather I thought of functions that make for good governance: (1) normative views that lead us to doing the right things, (2) reality checks on what is feasible politically and what actually works based on capacity, and (3) accountability mechanisms to tell us how well we are doing on improving nutrition outcomes and on implementing actions that we have  committed to, in one way or another.

I then hazarded a guess on where the centre of gravity is for various organisations and entities in nutrition. The placement reflects my own knowledge rather than any political world view.

The questions from the group were interesting:

Q1. Do we need a consensus map of nutrition global governance?

A.  I think we do.  Much like we have a map of the causes and interventions of malnutrition.  It helps locate activities and gives people a common language.

Q2. How do we assess the adequacy of nutrition global governance?

A. I suppose you could say things are better than they were in 2008 when the Lancet series of papers said global governance of nutrition was, essentially, dysfunctional.  Funding is up from donors, we have ICN2, an SDG on nutrition, the CFS is more focused on nutrition, the N4G moments of 2013, 2016 and 2020, governments who have formed a movement (SUN) etc.

But I have two problems with this perspective.

First it seems like a pretty low bar. Surely we want to assess whether our current global governance is good enough to get us to where we want to be?  Is it fit for purpose? The WB/R4D analysis highlighted in Ch 5 of the 2015 GNR suggested a doubling of government funding to nutrition and a quadrupling of donor spending is needed to reach the stunting WHA goal in 2025.  Is our global governance good enough to get us to this place?

Second, what will stop things backsliding to 2008?  Accountability mechanisms are stronger, but donors and governments are distractible and UN agencies are too.  The governance system has to have a set of one way valves that prevent the nutrition "blood" flowing backwards.

Q3. What is the value-added of good global governance?

A. There are lots of opportunities for nutrition in the next 5 years.  Good governance will help us seize them.  First, there are the political and resource alliances that are possible by a framing of nutrition "in all its forms". Second, food systems are big drivers of all forms of malnutrition--we need to engage with people outside of nutrition if we are to influence them. Third, the SDGs represent another big opportunity: there are at least 50 indicators in the 17 SDGs that are highly relevant for nutrition--to influence them we have to form partnerships outside of the nutrition bubble.  Good enough governance can help us get there.

Finally, what is there to push us towards seizing these opportunities? It is not clear to me.  Leadership is diffuse on nutrition and that can be a strength when things are going well, but where is the forcing moment every one or 2 years where everyone gets together and prioritises action step?  We need some kind of apex moment to force this prioritisation.

The nutrition global governance landscape is changing.  We need to shape it as well as be shaped by it. Governance matters.

24 February 2016

Anaemia Amnesia? Why does no one seem to care about it?

OK the title of this blog is perhaps a bit hyperbolic (I know plenty of people who care about it) but I just don't get the lack of urgency on anaemia.

Data on global anaemia

* A quarter of the world's population suffers with anaemia (see table on right from WHO). 1.6 billion people!

* Levels are high all over the world:  For girls/women 15-49 it is 15% in the UK, 12% in the US,  19.6% in Brazil, 22.5% in Indonesia, 48.1% in India and 48.5% in Nigeria.

* For children the data are even scarier: 47.4% of all preschool children--293 million kids.

* The rate of progress in reducing anaemia is very slow.  As the GNR 2015 highlights only 5 countries out of 185 are on track to meet the WHA 2025 target of reducing the 2012 base rate by 50%.

This is by far the worst performance of any undernutriiton indicator in relation to the 2025 targets.  By way of contrast 39 countries are on track to meet the stunting target.

* The consequences are significant and lifelong: reduced work capacity, impaired cognitive development, premature birth and low birth weight, perinatal, child and maternal mortality

And yet, I don't see or hear the outrage.  Maybe I am looking in the wrong places.  If I am please tell me.

What might be the causes of this lack of outrage?  I am not an expert, but let's speculate.

* Maybe the fact that it affects women so disproportionately, and yet men tend to be in powerful decision making positions.

* It has multiple causes--not just low iron intake, but hookworm infection, malaria, schistosomiasis--so it is complex to address

* The corollary to the previous point means it requires multi-sector coordination to address this effectively: infection control, food and diet interventions, iron supplementation, prevention of other micronutrient deficiencies etc. Such coordinated action is a challenge, but we now accept the need for it as the norm.

* The manifestations are not as obvious as they are for stunting or wasting and are certainly not as easy to assess.  Invisibility and inertia rule.

There are probably lots of other reasons (please share).

This is the year of Women Deliver: 16-19 May 2016, the world's largest conference on the health, rights, and wellbeing of girls and women in the last decade.  

Surely the time is right for a major new push on this condition?  

With such high levels of anaemia  women's ability to deliver is diminished.  We all need to deliver on a commitment to accelerate declines in anaemia rates for women, children and men. 

11 February 2016

What will the UK’s commitment to nutrition be at Rio? (And I’m not talking about DFID.)

Last night I attended the Food Foundation event on the state of UK nutrition and how to improve it. The Food Foundation is a new non-profit working on UK food and nutrition issues, funded by a couple of non-industry foundations and run by the stellar Anna Taylor.

The event kicked off with Prof. Boyd Swinburn who gave us a really nice overview of how to improve the food environment (the bit in between people and their diets):  the economic costs of different foods, the rules set for businesses by governments (policies and legislation) and cultural norms. 

The 3 key things for shaping the food system? Strong government leadership, noisy but organized civil society and responsive businesses. 

I presented some data from the GNR on the UK.  Stats that surprised me? The UK is last in fresh food purchases (using Euromonitor data) but middling in terms of purchases of fruits and vegetables.

Fiona Watson presented some of the work the Food Foundation is doing on applying the INFORMAS Food EPI food system scorecard to the UK (should be interesting when done).

Inge Kauer presented the latest Access to Nutrition Index which holds companies to account for their commitment and actions. She noted how some companies respond well to the scores and some don’t (not always clear why) and that investors and investment advisors are beginning to pay attention to the score and factoring it into their investment decisions.

Jo Ralling from the Jamie Oliver Food Foundation mentioned some of their work including their in-restaurant sugar tax (first proceeds allocated to water projects in UK).

Andrew Opie from the British Retail Consortium told us that government needed to show strong leadership and apply any new rules to all businesses and all other stakeholders.

Guy Poppy from the UK Food Standards Agency reminded us how much evidence matters, and the government’s  reliance on systematic reviews.

Some takeaways

*The title of this blog is inspired by Glen Tarman’s  (Action Against Hunger) semi-epiphany --what is the UK going to commit to in the upcoming Rio Nutrition for Growth Summit—not for other countries but for its own population?  What is the UK government's nutrition accountability to its own people?

*Our colleague from the retail association noted that the price of healthy foods had actually declined in the last 10 years.  I noted that the ODI report from 2015 on food prices did not agree with that. Andrew replied that their data was better than the governments and I could buy it for £6000 :) 

*A representative from the National Obesity Observatory told the audience to tear up the UK Nutrition Country Profile (nice) because it was wrong: the UK did have data on under 5 overweight.  Afterwards I told this gentleman that I went to visit Public Health England last year and they told me categorically that they did not have any data on under 5 year olds.  It turns out this gentleman was referring to data for kids in reception (age 4-5).  So don’t rip up the UK Nutrition Country Profile just yet. 

*In response to a question from the floor about whether food is the new tobacco (and the retail consortium colleague flatly rejected this analogy), Boyd Swinburn made the great point that the fight to prevent obesity has parallels with many public health efforts to prevent automobile accidents, industrial pollution, and unsafe food. That is the first time I have heard that.  

*Finally, there was a lot of strategizing about Rio.  I reminded the audience that commitments for nutrition can be made by anyone, at any time.  It’s good to be organized, but let’s not be too paralysed by summit politics. 

The panel was well chaired by Corinna Hawkes who reminded us that the struggle to improve food systems is essentially about power and how civil society needed to power up to engage properly in the negotiation (as Brazil has done).