20 July 2016

So, Why Did I Join GAIN?

My warm thanks to the hundreds of you who have sent me messages of congratulations about my recent appointment to the Global Alliance for Improved Nutrition (GAIN).  So, why did I decide to apply for the GAIN Executive Director position and why did I accept the Board’s offer to join (I begin on October 1)? 

First, much of GAIN’s work revolves around improving access to food that is safe, nutritious and affordable.  Poor quality diets and diet related conditions represent the largest set of risk factors for the global burden of disease -- greater than unsafe sex, alcohol, drug and tobacco use combined.  These poor quality diets have massive economic consequences – equivalent to a having a global financial crisis every year, according to the 2016 Global Nutrition Report.  This state of affairs reflects enormous food system failures.  

The food environments that consumers make decisions in are not helping them make food choices that support high quality diets.  That is because these diet choices are unaffordable, not available, or are not framed by businesses and governments as desirable.  This makes improving the food environment, and the food system that underlies it, such an important challenge for the achievement of a wide range of Sustainable Development Goals. Food is not the only thing that is important for nutrition status—we all know that—but it is the thing that is least easy to change through public action alone (unlike say water and sanitation, health facilities and schools) and it is important for all forms of malnutrition. Public sector leadership on setting priorities and on establishing and enforcing regulatory frameworks is essential if businesses and NGOs are to play a positive role in nutrition, but the public sector cannot do it on its own.

That brings me to the second reason: food systems are not mainly populated by bureaucrats, but by consumers and businesses.  Some of the businesses—whether small, medium, large or very large--act positively for nutrition, some act negatively and some do both.  By working with businesses that have positive track records in nutrition –and evaluating those efforts independently--we can begin to change the food system to work harder to give consumers choices that support the pursuit of improved diets.  For businesses that do not have a good track record, we should be able to explain to them—with evidence--why what they do is negative for nutrition and what they can do to change that.  In this way GAIN and other organizations can make it easier for everyone to understand when, why and how it makes sense to engage businesses in efforts to accelerate malnutrition reduction.  Changing norms about businesses and nutrition away from “business=good” and “business=bad” towards something more nuanced and which helps identify and manage conflicts of interest, would be a major contribution. 

Third, it seems to me that there are not enough people and organisations working in this space, namely on how to make food systems more nutrition friendly.  There are lots of reports available now on what to do, but few have credibly evaluated attempts to actually innovate for change in the system.  GAIN and others have the opportunity to really populate this space with examples of things that were tried and worked (or did not).  The key is to learn and share the learning with others.  Hence the alliance- building role of GAIN is absolutely essential to moving forwards.  We all know that to end malnutrition we have to form alliances that are powerful enough to counteract the powerful forces that generate malnutrition.  In part this means people and organisations getting on with their jobs and doing them well, but in part it is about the strategic and tactical joining of forces to accomplish things that single organisations cannot do on their own.  GAIN, if it does this sensitively, carefully and wisely, can help build new positive alliances to end malnutrition, identifying ways of conducting due diligence on potential partners--whether from the public or private sector--and documenting behavior that is essential if nutrition status is to be improved and not diminished.   

Finally, I have been really impressed by the quality of the GAIN Board and staff that I have met.  They are clearly driven by a vision of ending malnutrition.  And they have brought GAIN a long way forward in a short space of time (GAIN is only 15 next year).  I really look forward to working with them to take GAIN to the next level.  What does success look like?  It is too early to tell, and this is just my opinion as of now, but in 10 years time I would like to see GAIN contribute to a handful of widely scaled innovations (systems, institutional, governance, technological) that have made it easier for those who are malnourished to claim sustainable access to food that is nutritious, safe and affordable. 

GAIN and the entire nutrition community have a fantastic chance to change the way we think and act about how food systems--and the actors within them--can work better for good nutrition.

Come and work with us to make it a reality.

16 July 2016

Three quick reflections from the 2016 IDS-IFPRI Nutrition Summer School

We just completed another IDS-IFPRI-Transform Nutrition Summer School.  I co-convene this with Nick Nisbett from IDS and Purnima Menon from IFPRI.

We had another great cohort of knowledgeable, committed and hardworking participants, drawn largely from the policy and programme world, who worked with the convenors of the 5 day course to go through the causes, consequences and solutions to ending malnutrition.

The Transforming Nutrition Class of 2016
As usual the course was a lot of fun and involved a lot of learning on all sides.  Here are a few quick reactions.

1. The participants were looking beyond the usual sectors for solutions that might be useful for nutrition

Where was the work on climate change (impacts of and strategies for mitigation)?  Where was the work on education (keeping girls in school, delaying age of first birth, teaching kids about high quality diets)?  We did expand the food systems section of the course, but the participants wanted more.  Maybe we will have to have parallel sessions next year. 

2.  There was a real thirst for how to put solutions together

So if you are in a region that experiences this kind of a malnutrition problem, and we can identify 30 things to do to improve the situation, how do you decide which are the priorities and how to sequence those?  We noted that there are precious few tools to help with this and one of our group suggested we use more systems thinking next time around to do this.  Good idea.  We also need to develop new tools. 

the participants working hard on their nutrition plans
3.  Finally, I was struck by how few of these courses there are throughout the world

I don't get it. Maybe it is as simple as not being able to demonstrate the benefit of the course in terms of cold hard cash to prospective investors.

But surely this problem bedevils most education initiatives.  And the participant evaluations of the course are great, and demand--the ultimate judge of value added-- is strong for the course (we can only accept 1 in 3 applicants).
our World Bank alumnus from 2014 

One qualitative indicator of benefit was the presentation of a class of 2014 participant who reached out to us to present at the course. He is a World Bank staffer working on nutrition in Lao.

He gave a great presentation that showed very clearly how the course has helped him and his team develop diagnostics with the Lao colleagues to really zero in on the key links in the Lao nutrition chain that need to be addressed.
Purnima (IFPRI) and Adam (TFNC, Tanzania) 

me, reaching for the data
When I move to GAIN on October 1,  I will certainly be working with GAIN colleagues to look at whether these immersions that bring together practitioners and evidence are a useful thing to do for our mission.

And get ready for the 2017 IDS-IFPRI course, held in July 2017.  Applications will be accepted early in 2017.  Check out this webpage early in 2017.

06 July 2016

Data: What India needs to end malnutrition by 2030

It may seem like a no-brainer to say that we need data to guide efforts to end malnutrition. 

Would you run an economy without a regular stream of credible data? You'd be flying blind if you did, and we know what happens if you try to do that. And yet this is precisely the situation that those trying to end malnutrition in India find themselves in.

Until the Rapid Survey on Children (RSOC) data from 2013-14, seven years had elapsed since the last nationally representative nutrition survey, the third National Family Health Survey (NFHS 3). We hear that NFHS 4, the next big government survey, is in the field and we very much hope it will be out by 2018. If it is, that will be a gap of five years since the RSOC.
Why is data important?

As the 2016 Global Nutrition Report reminds us, it is important because it tells us which types of malnutrition are being reduced and how fast that is happening. If we know this we can adjust efforts and reallocate resources before it is too late. It is also important for accountability: We need to know how resources have been allocated and the effect they are having if we are to assess the performance of key stakeholders, whether from the government, civil society, the development agencies or businesses.

What type of data is critical? There are at least five.

First, we need to know the extent of malnutrition: Where it is and how fast it is (hopefully) decreasing. In India, based on the RSOC data and the Global Nutrition Report, the speed of decline in stunting rates has improved as has the speed of improvement in exclusive breastfeeding rates and this is great news. But the rate of wasting of under-five's remains high at 15.1 per cent, adult diabetes rates are increasing and are currently 9.5 per cent and women's anaemia rates are essentially static at 48.1 per cent, one of the world's worst (170th out of 185; China and Brazil are under 20 per cent, Sri Lanka is 26 per cent and Nepal is 36 per cent). Data tells us where to apply the accelerator, where to try to apply the brakes and when to turn to different priorities.

Second, we need to know whether high-impact nutrition interventions are reaching the people they are supposed to reach. Interventions cannot work if they do not reach families at risk of malnutrition. India has a patchy record on coverage: Some interventions and practices such as exclusive breastfeeding have high rates of coverage but the coverage of infant and young child complementary feeding programmes is poor, with these infants and young children showing very poor diet adequacy and diversity. Coverage is where the rubber hits the road for nutrition action. We need to know whether the roads are seeing any rubber-and whether they are the right roads.

Third, we need to know more about how well certain sectors are doing in supporting nutrition improvement. Public distribution systems that use micronutrient-rich foods are more nutrition-sensitive than ones that do not. Water and sanitation programmes that have a child-centred focus are more nutrition-sensitive than those that do not. Cash-transfer programmes that incorporate some behaviour change communication work around nutrition will be more nutrition-sensitive than those that do not. The only way to assess the nutrition-sensitivity of these sectors is to go through the national and state and district budgets - as NITI Aayog member Bibek Debroy recently said - line by line, and designate certain line items, say, 0, 25, 50, 75 and 100 per cent allocations to nutrition. If they are fully nutrition-sensitive they will be given a 100 per cent weight. If they are not nutrition-sensitive at all they will score zero per cent. The challenge is to increase the overall percentage allocated to nutrition. To meet that challenge, we need data.

Fourth, we need the first three types of data at the state and sub-state levels. As the India Health Report clearly shows, different states and different districts have different nutrition problems, have different capacities to address them and show different levels of political commitment and leadership. Moreover, the distance between people and their leaders narrows as we move towards the district and community levels, and so, accountability is easier to build. To guide action and promote everyday accountability, we need more disaggregated data.

Fifth, we need to know what works. If we don't know whether a nutrition programme actually works, where it works, for whom it works, why it works and how it works, then we are, again, flying blind, wasting resources and acting irresponsibly. More research funding inside and outside India needs to be directed towards making Indian nutrition interventions more effective and more easily scaled up. Innovations need to be developed, piloted, tested and, if cost effective, scaled up. While the costs of evaluating interventions are not trivial, as the 2014 Global Nutrition Report showed, the benefit-cost ratios of identifying and scaling up the interventions that work to prevent malnutrition are huge: Over 34 to 1 for India. The implementation of a national, state or district economic strategy without reliable and regular data would not be attempted-investors simply would not take any such strategy seriously. And yet this is tolerated for a nutrition strategy.

The signing of the Sustainable Development Goals by the Indian government provides the perfect opportunity for India to develop its own dashboard of nutrition indicators-one that is linked to specific, measurable, achievable, relevant and time-bound (SMART) targets. The hardest thing for any government to do is to put in place measures for its people to hold it accountable. But all governments need to act confidently and match the bravery exhibited by the mothers, fathers and families that struggle to prevent and cope with the malnutrition that affects too many of the world's next generation. 

A government that stands up and allows itself to be counted on nutrition is a government whose bravery will be rewarded by an incredible legacy-the ending of malnutrition by 2030.