28 June 2017

Narrowing the Gaps Take 2: Great for public investment, but what about private?

Back in 2010 I wrote a blog about UNICEF's efforts, under the leadership of Tony Lake, to resurrect equity as a prime issue in the child wellbeing debate.

The blog was about UNICEF's Narrowing the Gaps work which showed that while it might be more costly to reach those most in deprivation with child interventions, the benefits of doing so ore than outweighed he incremental costs in terms of Benefit Cost Ratios and, in doing so, narrowed the gaps in outcomes between children in poor and non poor households.

Now, for 51 countries, we have an update on this work 7 years on.  I'm happy to say that the new report shows:

1. The gaps in the coverage of programs (6 intervention packages, including neonatal and infant feeding and care) between poor and non poor groups has declined: 36% vs 59% in 2003 compared to 50% versus 65% in 2016.  The bad news for nutrition is that early initiation of breastfeeding showed the slowest rate of increase in coverage--for both income groups.

2. The reduction in under 5 mortality was nearly 3 times as fast in poor groups as in non poor groups.

3.  For those only moved by cold hard economic facts, the important news is that the benefit cost ratios are 1.8 times higher for those in poor groups compared to the non poor.  For every $1m invested in increasing the coverage of these 6 interventions, 166 deaths are averted in the poor group versus 92 deaths averted int he non poor group.  This is not terribly surprising--the response should be greatest for those most in need--but the relatively high cost of reaching the poor often preempts these kinds of returns.

So we have the great position of reducing inequality--an important goal per se--and generating the highest returns in doing so.  Win-wins don't get much more satisfying than this.

For commercial interventions in the food marketplace, however, the arithmetic is not quite so comforting.

We at GAIN are working on demand side interventions for healthy foods that bring the best of public and private approaches to the table.  But businesses tell us they not able to make these approaches work for those in the very poorest households.  Those living on less than $3 a day don't--at the moment--seem to provide businesses with enough purchasing power to de-risk their investments. This is why interventions such as public cash transfer schemes are so valuable--they enable the consumption of healthier but more expensive foods (although they also enable the consumption of less healthy food).  For those living on more than $3 a day (and this threshold is a guess--we need some serious research on what it is for different contexts), commercial solutions to improve the consumption of nutritious foods are more possible.

Can demand creation targeted to those above $3 a day work?  And can it help those below $3 a day by creating an aspiration for healthier food?  These some of the  challenges we have set ourselves at GAIN because most people buy food via markets.  We need to be able to draw on some serious research about what is the limiting factor stopping different income groups in different contexts from purchasing nutritious food: income, physical availability, affordability, or desirability.

The UNICEF work provides a convincing rationale for public sector interventions to be more equity enhancing.  Can it provide some inspiration for businesses to develop nutritious but loss leading food brands to inspire customer loyalty in preparation for the time when their incomes grow?  Working with our partners, we will keep exploring this space at GAIN.  We want nutritious foods to be available, affordable and consumed by all income groups--especially by those who are most malnourished.

23 June 2017

Innovative funding models to support research innovation in nutrition: The BPNR example

This week I was at an event showcasing nutrition research, held in Ottawa at the Aga Khan Foundation’s Canada headquarters, in partnership with them and the Global Affairs Canada (GAC), the Canadian Government’s Foreign Assistance agency.
So far, so normal, you may think.  But this was no ordinary research programme. It was the GAIN-GAC Business Platform for Nutrition Research (BPNR). And the distinguishing feature of the Platform is that it supports “pre-competitive” research that is useful to business sectors that are hoping to have a positive impact on nutrition status.
Precompetitive research provides answers to questions that all businesses in an industry want an answer to: questions that can be best answered though collective effort rather than by any business trying to go it alone.  The results are available to all, even if they did not collaborate in the research.  Once businesses have the research outcomes they can use them to develop competitive products. This approach tends to support activities where it makes no sense to have multiple answers (e.g. measurement methods and standards development), or where undertaking research requires alliances of stakeholders because of complexity of the issue (e.g. understanding the impact of climate change on food safety).
The BPNR platform works on a matching basis between GAC and the businesses that contribute a documented and certified amount of resources to the project (but not to GAIN).
The current themes under BPNR are:
  • Development of diet quality indicators using the Gallup World Poll as a platform. This work builds on the success of the FAO-Gallup Voices of Hungry work (the indicator was adopted as an official SDG indicator).  The protocol is being developed but it will focus on about 20 different foods.
  • Finding complementary foods (e.g. Lipid-Based Nutrient Supplements) that do not rely on the addition of sugar to increase palatability. This work is designed to find out if we can promote palatability at low levels of sweetness. This will involve Nutriset.
  • Development of mobile phone based markers of Aflatoxin – a blood or urine sample analysed by a small piece of kit in 10 minutes and plugged into a mobile phone to give a detailed quantitative read out. About $1 a test. (Cornell University and Mars).
Watch this space for more news on BPNR research as it generates interesting and useful findings over the next 18 months.
And this is just the beginning, with opportunities for new partners to come together around a range of new research questions that help us all to understand the complexity we are trying to navigate in improving nutrition, and that can shape investments in the demand for and access to nutritious foods, and the legislation and policies that enable these.
There were lots of good questions from the audience, many asking a variant of “what is in it for partners to work with the BPNR?” Answer: for businesses new resources are worth giving up intellectual property rights; for researchers there is a de-risking of the work with companies, because the BPNR platform has collectively agreed on the research question and it guarantees a fair and transparent peer review process.
The Government of Canada deserves a lot of credit for taking a risk on BPNR—it is a new mechanism for nutrition although quite common elsewhere.  It has taken longer than we thought to build relationships between businesses and researchers, and then to identify specific research questions around which there is a consensus, but it feels like the effort will be worth it because the relationships will be enduring, are transparent and will result in open access results in peer reviewed publications.
Several of the researchers present said they would not have pursued their research in the absence of the BPNR. So, if you aim to generate  innovative solutions in the food and nutrition space, think about developing innovative funding sources too.
The innovation in the second might well stimulate innovation in the first.
For more information about BPNR, please contact Lynnette Neufeld at GAIN lneufeld@gainhealth.org

Learn more about GAIN’s work here

18 June 2017

Food Must Fix It: The 2017 EAT Forum

The convening power of Gunhild Stordalen is astonishing.  The Crown Princess of Sweden, the President of Mauritius, Sir Bob Geldof and a large group of other influential leaders, doers, and thinkers.

This was my first visit to the EAT Forum, although I had worked with Gunhild on a joint newspaper article for the Norway launch of the 2015 GNR and knew how committed she was to making a difference.  Her commitment is contagious.

At the Forum, I gave a talk on 3 inequalities at the heart of the food system that generate poor nutrition outcomes. First, our rather conventional public health attempts to stimulate behaviour change in food choice which focus on “wholesomeness” and “good for you” exhortations and worthy messaging—all in comparison to commercial advertising efforts which persuade us to buy certain foods based on their convenience, deliciousness, crave-ability and status. Second, I noted the stark inability of most of the world to afford healthy diets: 52% of household incomes in South Asia would be needed to buy 5 fruits and vegetables a day.  Third, I argued that the lack of information, evidence and data on the impacts of business-government partnerships beyond profits (i.e. on people and the planet) hampers collaboration.

These are three areas where GAIN is working with a wide range of public and private stakeholders to increase the demand for healthy food, to increase the capacity of small and medium and large enterprises to meet that demand and make nutritious food available at a lower price, and to create an environment that enables businesses to do good things for nutrition and discourages them from doing unhelpful things.

My takeaways from the 2 days (disclosure, GAIN is on the EAT Advisory Board):

*As a newcomer to EAT Forum, I found the fact that I only knew about 10% of the participants to be really refreshing.  New organisation, new perspectives, and a fair amount of new thinking. Great.

*Businesses were very present, although mainly European and American ones.  It was great that they were there because, as the African proverb goes, “to change someone’s head they have to be in the room”: no engagement means fewer opportunities to influence.

*But, in general, the event was high income country focused.  Sure, there were people like me focused on low and middle income issues, but still from a European and North American perspective.  If the audience were more geographically diverse it would really accelerate the convergence of the 2 sets of conversations happening in the Forum: the high income and middle/low income ones.  It is clear that the Forum is very much hastening this convergence, but a more rounded and grounded set of perspectives would help us co-create a more unified vision and set of approaches to solution generation.

*A number of the presentations dwelled on the achievements of the presenters and their organisations. This was fine given that were many such fine achievements and the presenters were amazing people and communicators.  But, I wanted a bit more on the challenges they faced and how they overcome them—also, what did not work and why?  For sure there was some of this (and more than you would find at an academic audience!) but more would have been welcome.

*The focus on the links between food, health and the planet were really strong and quite seamless. But I am a data hound and I would have liked a few shamelessly scientific sessions, although perhaps that would have reduced the uniqueness of the meeting.

*The EAT Forum has been disruptive--in a good way.  It has challenged conventional wisdom and now it is rewriting conventional wisdom. So what does it do for a second act?  Bob Geldof reminded us that social change occurs when there is an initial disruption, then an amplification of the message around a set of leaders, followed by consolidation and organisation of the movement, and, underpinning it all, a relentless devotion to a cause.  So what is the future disruption role of the EAT Forum?  Does it just keep going and wait for others to get on the bus, or does it park the bus outside the halls of power and lure them in?  I don’t know.  I suspect the former.   But the disruption question remains. In many ways the EAT Forum could be more unconventional.  It would, for example, be great to get more schoolkids involved to talk about what they think, expect and can do; more journalists talking about what their readers want to read and how that can be influenced; more political activists teaching us about their strategies; and more people from the arts helping us connect outside the policy and business wonkosphere.  Perhaps I am being too demanding, but if so that is because the EAT Forum has raised expectations in a world that is desperately lacking the hope and energy of the period just before the global financial crisis—a world where dreams have been harshly dampened by the austerity our politicians have responded with.

The rallying point for the Forum was “food can fix it” whether health, climate, sustainability or access to a nutritious, safe, affordable and desirable diet.  This simple phrase was deceptively helpful in providing a focal point and, as Johan Rockstrom, the scientific lead for EAT, said at the end, it really should be “food must fix it”.  Agreed.

All in all I found the EAT Forum to be a very refreshing change from the same old meetings where you know everyone and you know what they are going to say well before they say it. Long may it continue to reinvent itself, to keep challenging tired conventional wisdom while catalysing unlikely partnerships that generate ideas and approaches that are truly transformative. 

In short, if the EAT Forum did not exist we would need to invent it.

04 June 2017

No Excuses for Inaction on Adolescent Nutrition

This years World Health Assembly (WHA) meetings (all the Ministers of Health attend) had a big focus on one sixth of the world’s population: adolescents.  The WHA launched the Accelerated Action for the Health of Adolescents (AA-HA!) a major report from all the key UN agencies on why we need to act now to improve adolescent health and what to do. In this context, I participated in two panels on adolescent nutrition.

My key takeaways were:

Adolescents are invisible in nutrition data.  It is ironic because adolescents are typically hard to miss: frequently opinionated, critical and emotional and deafening in their exuberance and silences. Yet in nutrition data, they are absent. Essentially, we don’t collect nutrition data on adolescent boys of 10-19 years of age or on adolescent girls in the 10-14 year age group.  This is extraordinary.  Attitudes and preferences are highly fluid in this 10-14 age group—like liquid concrete waiting to be set for life.  Also, why no interest in boys?  Yes, adolescent girls have higher micronutrient needs due to menstruation, but boys are just as important in shaping attitudes, norms and boundaries in nutrition practices—now and in the future.  This relative invisibility of adolescents to the nutrition community is all the more puzzling because iron deficiency anaemia is the number one cause of adolescent DALYs for girls and boys (see below). 

There are few nutrition interventions that are designed FOR adolescents.  Yes, there are plenty of interventions aimed at the wider population that should benefit adolescents (see here), but none are designed for adolescents particular needs save for iron-folate supplementation (IFA).  IFA seems to work when administered through schools, but not through communities (see here).  This is a problem because only 30% of adolescents in South Asia and Sub-Saharan Africa complete secondary school (see here).  Why do adolescents merit specially designed interventions?  It is primarily because of the plasticity of their attitudes and the rapid velocity with which these attitudes become relatively fixed but also the widening opportunity to act as the gap between biological maturity and social transition to adulthood increases.   The graphic below from the AA-HA! Report summarises things well.

There are even fewer interventions that are designed WITH adolescents.  Adolescents have increasing autonomy and they know what they like and don’t like and I would guess most nutrition intervention and policy wonks don’t have a clue what these likes are and how they can be leveraged and shaped.  Adolescents will have a better idea of where, why and how they can be engaged around nutrition choices.  But adolescents are also more vulnerable to risky food and nutrition options.  Adolescents will help us to think laterally and holistically about their lives, to find opportunities to work with them to influence and shape food and nutrition preferences via sports, clubs, social media, schools, music, film and comics.  Engaging with them will take us outside of our comfort zone and that is where innovation and change happens.

We are paralysed by the lack of evidence.  We are in a “lack of evidence, lack of action, lack of evidence” low level equilibrium when it comes to actions on adolescent nutrition. The consequences of trying something and getting it wrong are not negligible, but these have to be weighted against the consequences of inaction.  The adolescent window is opening and closing without any fresh thinking or action making it through the gap all while nutrition status is eroded throughout the lifecycle. Funders and development agencies need to be braver. They should support (a) the development of new approaches and actions that are grounded in formative adolescent centred research, (b) their implementation, (c) their evaluation, (d) share their results and (e) scale the promising ones.  Adolescents deserve no less.

The private sector has a big role to play, because adolescents are more engaged with the private sector than many other demographic groups: they are tied to their social media platforms (see below from Indonesia—90% of rural adolescents in Indonesia use Facebook!), they buy junk food after school, they buy street food on breaks from their factory work, they listen to commercial radio and watch commercial TV.  For example, how can we combine earnest public sector behaviour change efforts with the more calculated but creative private sector demand shaping efforts.  How can we create hybrid approaches that are greater than the sum of their parts?

The new AA-HA! Initiative from the UN is a great step forward and countries should use it as a guide to raise funds for this agenda and a guide on how to allocate those funds.  GAIN is using the above principles, working in Bangladesh, Pakistan, Indonesia and Mozambique, forming alliances for and with adolescents to generate and implement solutions to accelerate adolescent nutrition.  

Watch this space.