27 January 2017

Challenges for Indonesia in addressing malnutrition in all its forms

I just returned from a trip to Jakarta to meet with GAIN’s key partners.  Indonesia is one of our most interesting offices: a large decentralised country struggling with a double burden of malnutrition, with a thriving business community, a government that is clearly motivated to address malnutrition in all its forms and with development partners slowly but surely exiting the country as it enters middle income status.

Indonesia is on track for only one of 8 WHA nutrition targets (Exclusive BF)
I first gave a talk at the National Nutrition Day, highlighting some of the Global Nutrition Report (GNR) 2016 findings.  This was great because Nila Moeloek, the Minister of Health (and a supporter of the GNR) was right there in the audience while the GNR was painting a challenging picture of nutrition progress (one out of eight indicators is on track to meet WHA targets—exclusive breastfeeding rates--although it is close to meeting two others –women’s anemia and under 5 overweight).  

Some very new data were presented by the Government showing stunting rates of 27-29%--very good news indeed if they hold up to further stress tests, although the very rapid decline (7 percentage points in 2-3 years) is hard for some to fathom. 

Minister Moeloek, DG Anung, and Ravi Menon
Ravi Menon, the GAIN country director also presented Minister Moeloek with the “emo-demo” behaviour change module (involving games and interactions with mothers on changing complementary feeding practices) pioneered by GAIN and partners. 

In the afternoon I presented the Global Panel Foresightreport on food systems and diets at the Agricultural University at Bogor.  The nutrition and agriculture students asked me great questions (about compliance with laws and codes, food labelling, adolescent diet choices, GMOs, decentralisation). Tough.

Bogor Agricultural University Students and Faculty

The next day we hosted two roundtables with GAIN partners: NGOs/CSOs and Donors/Businesses.  The topic here was key challenges faced by the partners in addressing malnutrition in Indonesia and what role could/should GAIN play. 

My main takeaways from the visit:

1.     Since my last visit in Feb 2015 the issue of overweight and obesity has really emerged on the government radar.  The toll that these outcomes take on health, productivity and health care is becoming clearer to policymakers.  The challenge for them now is what to do about it when there is so little positive experience from elsewhere.  But because it is becoming more and more artificial to separate the different expressions of malnutrition from root causes, now is the time for the Government to try some things that are at least plausibly effective, particularly the double duty actions identified by the GNR (interventions such as breastfeeding promotion, school based healthy diet education and food system transformation).

2.     Decentralisation of responsibility and funding for preventing malnutrition to the more than 500 districts has made the need for capacity development at this level ever more evident. In a sense decentralisation has forced a frank assessment of capacity. From the Ministry of Health maps (did I mention the fabulous data resources the government has?) it is clear that some districts are doing well in meeting their outcome targets while others, seemingly similar, are not.  Just why some are and some are not would make for a great piece of analysis.  Capacity and governance, I suspect, will make a big difference.

3.     The withdrawal of development partners from the country when one third of under 5’s are stunted is a real challenge and opportunity for the government. Obviously the loss of funding will be felt. Although aid is not a significant source of overall funding for health, it is a catalyst for change and trying something new.  Indonesian foundations, businesses and the government will have the opportunity—and the responsibility--to step into this gap.

4.     Attitudes to the potential role of business in improving nutrition outcomes are opening up, but caution abounds. Given the existing context this is understandable.  Until we have clear processes for surfacing and managing conflicts of interest, for registering PPPs, for tracking the conduct of businesses, and credible impacts of the effects of business engagement in nutrition, this context will persist and will hold back the leveraging of resources and know how to improve nutrition.  GAIN, together with its partners, aims to contribute to strengthening the enabling environment for informed engagement with responsible businesses. 

5.     The biggest question of all, however, is how to drive changes in consumer demand and the food environment towards healthier diets.  How, for example can fish consumption be made more attractive?  With our partners, we are trying public service TV commercials (highlighted by the Minister of Health and the Health Director General in keynote speeches) and public health “emo-demo” approaches (designed with and for adolescents in urban environments). But my guess is that some of the advertising guile used in making us want junk food needs to be diverted to making us find healthy diets more attractive and aspirational.  Just how that can happen is the big, big question and one GAIN will be trying to address in the future.

The consultations on GAIN’s strategy identified some key comparative advantages: a focus on making safe and affordable foods more available, accessible and affordable, bringing public and private actors together, working throughout the food system, developing tools for scaling, and speaking truth to power--whether in the public or business spheres. 

Some GAIN partners--NGOs, CSOs and academics

Some GAIN partners--development partners and businesses

I really enjoyed meeting the relatively small GAIN team (only 7 people) and celebrating their successes (including helping to develop the first ever national food composition table), sharing their frustrations and helping them strengthen ties with government, CSOs, academia and businesses. 

Even though it has relatively few development partners, experiences in Indonesia will give us some foresight into how other countries—who are behind in the nutrition transition-- should or should not manage the double burden.  Development partners and other governments would do well to keep a close watch on what happens in this nation of thousands of islands. 

21 January 2017

Food Systems Take Over the Davos Fringe

Last week I was at the WEF meetings at Davos with colleagues from GAIN.  We were not at the WEF meetings proper (admission is very very expensive) but at the "fringe" meetings, mainly in the World Food Programme tent (thank you WFP!).  Like most festivals, the most informal, creative and interesting events were at the fringe, even if the biggest players were not around.  (At least this is what we tell ourselves!)

I was really stuck by three things:

1.  Food Systems are now a key framing for nutrition.  One of the participants said that "in the past at these meetings, agriculture was over there and nutrition was over there, but now they seem more connected". One example was the WFP hashtag: "healthy not hungry"which says we have to go way beyond ending hunger--we have to promote health.  This means focusing more on the quality of diet and that means focusing on food systems which drive healthy and unhealthy diets.  And of course engaging with food systems means engaging with businesses.

2.  The Davos crowd is not your typical food and nutrition crowd.  Lots of CEOs, tech people, social impact investors, financiers and socially motivated celebs.  I particularly enjoyed listening to the influential chefs like Sam Kass,  Manal Alalem and Jamie Oliver. These folks understand food cultures, how to connect to people's everyday feelings about food and how to make healthy diets desirable. They can help us combine left brain thinking (logic, data and rationality) with right brain thinking (emotion, aspiration, creativity). The challenge is to make it affordable and the impact investors have not yet figured out how to make an investment return on reaching D and E consumers (business speak for low income households).  Of course, this is one of GAIN's key missions--making safe and nutritious food affordable and attractive for vulnerable populations.

3. The strong focus on the creation of demand for healthy diets. For example, the term from "farm to fork" was flipped around by Fokko Wientjes of the World Business Council for Sustainable Development/DSM in his presentation of the FReSH initiative.  This is totally appropriate.  Without demand driving change, no healthy diets can be sustainable.

Businesses are brilliant shapers of demand, often for unhealthy foods, and we must find ways of engaging them in bending demand towards health.  It will be difficult though.  High income consumers in San Francisco might be increasing their demand for healthy food, but they can afford to.  How can we do this for consumers in low and middle income contexts?  Starting with the supply side is like pushing a wet noodle uphill: it ain't gonna happen.

My personal highlight of the 2 days was meeting Muhammad Yunus, the founder of the Grameen Bank (see pic).  What he did for the access of low income households to loans and savings services, is what GAIN wants to do for their access to safe and nutritious foods.

Not easy, but a vision worth striving for.