23 October 2017

Buoyant in Buenos Aires: the IUNS Conference

Last week, several of the GAIN team were participating in the 2017 International Union of Nutrition Sciences (IUNS) meeting in Buenos Aires. There were thousands of participants from all over the world and hundreds (perhaps thousands) of presentations. Quite a lot of bench science, but also a lot of field and program research, and even some policy research.
All in all the GAIN team made 14 presentations and showcased 12 posters. I was really proud of all of them, but a special mention is reserved for Lynnette Neufeld, GAIN’s Director of Knowledge Leadership. Wonderfully, Lynnette was voted by the Council and country representatives as the new President Elect of the IUNS. This means she has four years to prepare for her tenure, which begins at the 2021 IUNS in Japan. This is an incredible honour, one that is bestowed on her by her peers and the full membership. I know she will do a great job and we will support her all the way.
So what did I make of the Conference?
Obviously I could not go to that many sessions (I gave a talk on nearly every day; there were lots of small group meetings I needed to attend, and many of the formal sessions I wanted to go to ran simultaneously) so, as usual, my views are impressionistic and partial. (And yes I would have made these observations and recommendations even if Lynnette were not the President Elect!)
1. The sessions could have been better aligned so that they aggregated up to answer big questions. There was, of course, some of this (and it must be like n-dimensional chess to get the alignment right), but I felt the presentations somehow did not build on each other enough. Half the world is malnourished, we need science to help find practical solutions, fast.
2. There weren’t enough young people presenting. There were lots of people in their 40s and 50s making great presentations, but I would have liked to have seen more mentoring of younger people. The presentations by our own Djeinam Toure and Corey Luthringer were two of the most interesting I heard. Look at dynamic sectors such as business and IT: they are brimming with young people and benefit accordingly.
3. There was not as much disciplinary diversity as I would have liked to see. I suppose this is the international union of “nutrition sciences” but the “how” is just as important as the what and why, and we need to reach out to other disciplines who are working on nutrition issues to understand these “how” issues better (e.g. the political scientists, the financial analysts, the institutional economists, the behavioural psychologists, the business administrators, the lawyers and the climate scientists). For example, there was not one presentation over the six days including the word “governance” or the phrase “public-private partnership”. Real world solutions desperately need to better link new evidence to stakeholders outside academe.
4. Everyone had to state whether they had a conflict of interest before their presentation, but in none of the sessions I attended did anyone have a conflict to declare. That struck me as odd. In the last of my five talks, I declared an interest. The talk was arguing for more independent evaluations of public-private partnerships in nutrition. This is clearly in GAIN’s interests because we want more independent evaluations to draw on. This will allow us to do better work and attract more resources, so we can have bigger impact. OK, it is not exactly Big Tobacco, but this class of conflict is worth declaring, it seems to me. This is not just about duties, it makes interventions more interesting and real.
But without a doubt the most fun event was the GAIN 15th birthday party organised by Bonnie McClafferty, our Director of Food Value Chains. Bonnie had organised a really interesting session earlier in the day on “Shaping Food Systems”, but the birthday party had better music and dancing.
We had the party because we wanted to thank the folks we asked to give us input into our new strategy, as well as our staff, partners and investors: past, present and future.  We had over a 100 people there and the positivity was fantastic. It was wonderful to be able to celebrate our contributions, standing shoulder to shoulder with our partners, over these past 15 years, and to mark the great year we have just had.
But the birthday party is merely the appetiser for the main course. To mark our 15th birthday a bit more seriously, in the next two months each of our 15 country offices will host a policy roundtable discussion on the future of food systems: in Abuja, Addis Ababa, Copenhagen, Dar es Salaam, Delhi, Dhaka, Geneva, Islamabad, Jakarta, Kabul, London, Maputo, Nairobi, Ottawa, Utrecht and Washington DC.
Watch out for them!

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19 October 2017

Micronutrient Powders: Getting a Grip on Effective Implementation

I had heard of micronutrient powders (MNPs) before I joined GAIN, and, I suspect like many non-experts, I assumed it was a pretty simple intervention.
How wrong I was.
For those of you who are less familiar with the nutrition world, MNPs are sachets of powdered vitamins and minerals that can be added to complementary foods and given to children on a daily basis. They were introduced by Dr. Stanley Zlotkin (who is also a member of GAIN’s Board) in the late 1990s. Easy to use, MNPs do not change children’s dietary habits but can be added to semi-solid foods that are already part of a child’s diet. More importantly, MNPs boost children’s micronutrient intake and reduce their risk of iron deficiency and anaemia.
A just published Supplement of Maternal and Child Nutrition contains a series of papers emerging from a Consultation that summarise the lessons learned from operationalizing MNPs. A subsequent paper which took advantage of the Consultation’s extensive systematic literature search published in Current Developments in Nutrition summarises what is known about factors affecting adherence to MNP recommendations.
The Consultation drew on the reflections of 49 MNP implementers and experts and a review of published and grey literature.
Here are the key points from the overview article by Dhillon et al. and adherence paper by Tumilowicz et al.
1. Iron deficiency anemia (IDA) is the leading cause of years lived with disability among children (I did not know that!)
2. Peak prevalence of IDA occurs at 18 months after which iron requirements decline and iron intake increases through complementary foods (I did not know that either)
3. MNPs have generally replaced iron drops/syrups because they show similar efficacy in reducing IDA (by 51 percent) and anemia (by 31 percent) in children under two years of age, but with higher acceptability and fewer side effects
4. Global scale up has been helped by the fact that MNPs are easy to use and do not require dietary change and, on average, cost USD 0.02 per sachet to produce.
5. Scale up of MNPs has been rapid: from 36 interventions in 22 countries in 2011 to 59 interventions in 50 countries in 2014.
6. Of the 50 countries, nine were implementing national programmes and 20 subnational programmes (I guess the remaining 21 were doing pilots).
7. Despite rapid adoption the extent to which the quality and scalability of MNPs can be maintained is yet to be established. Hence this Consultation.
8. The Consultation looks at 3 dimensions of MNP implementation (1) planning and supply, (2) delivery, social and behaviour change communication, and (3) continuous program improvement
9. Planning and Supply
  • High quality research and data analysis to justify MNP intervention is not always conducted fully
  • Leadership is an important driver of intervention uptake, but so too is the need to find more effective approaches to address childhood anemia
  • Sustainable funding remains a challenge despite evidence of high cost effectiveness – it is good to discuss long term funding early on in implementation. Adding to existing national programmes improves sustainability (e.g. social protection in Mexico and Dominican Republic)
  • Securing reliable and regular supply of MNPs is a challenge for many countries. This means that countries often rely on global suppliers, but this uses valuable foreign exchange, and can lead to long procurement lead in times and problems around local languages and packaging
10. Delivery, Social and Behaviour Change Communication and Training
  • Here the models vary by design feature: (price: free, subsidized or full cost) x (point of distribution: facility health workers, community members, pharmacists) x (sector: health, social protection, agriculture
  • Free distribution through the non-health sector – for example, social protection and early childhood development programs – has shown higher coverage rates than free distribution via health systems
  • Subsidized distribution has achieved a wide variety of coverage rate
  • Whatever the delivery strategy, more and more MNP programmes have been linked to broader infant and young child nutrition objectives
  • Programs are increasingly measuring appropriate use and intake adherence in addition to just coverage
  • Social and behaviour change (SBCC) need to be applied throughout program cycle
  • Regular refresher training of MNP distributors is essential to ensure high quality counselling and messaging
  • Two thirds of all MNP interventions are funded entirely by development partners and this is not really sustainable
11. Continuous Program Improvement
  • Lack of documented MNP experiences, especially those implemented at scale. There are 15 peer reviewed papers and most come from pilots and were externally funded with few examples of them being used to improve implementation
  • Most programmes do not apply a mapping of programme theory to track progress or make course corrections efficiently
12. Factors Affecting Adherence
  • From the perspective of caregivers, positive changes in their children (for example, improved health, increased appetite, increased energy) and acceptance of food mixed with MNP are the main reasons for continuing to use it
  • Caregivers are less likely to stop feeding MNP if they are informed of potential negative side effects (such as changes in stool)
  • In addition to SBCC strategies, administration regimen (fixed or flexible dosage schedule), which may be related to caregivers’ capacity to remember to give MNPs, is frequently cited as a program design feature affecting adherence.
As the papers note, “..implementing MNP programmes effectively remains a complex challenge” and “preparing food with MNP correctly and succeeding in getting a child to eat it depends on a complementary feeding process that requires a complex set of caregiver behaviors and caregiver-child interactions”.
As someone who has spent time outside as well as inside the nutrition world, I’m wondering how complex MNP programs are to implement effectively compared to the program it replaced, namely iron drops/syrups. I’m also wondering how MNPs stack up against other nutrition interventions (e.g. promotion of exclusive breastfeeding, Vitamin A supplementation, biofortification) and against other development interventions (e.g. social protection, WASH, public works programs).  My experience suggests they all require careful planning, linking of supply and demand elements, and learning feedback loops.  They all require sustainable funding.  The impacts of none are resilient to poor design and implementation.
The state of MNP implementation reminds me of the state of conditional cash transfers in the 90’s.  Everyone was jumping on the bandwagon, and many of the transfer programs did not have an impact on nutrition status because of poor design, poor implementation, poor evaluation, or some combination of the three.  But as the good evaluations rolled in, meta-analyses were able to identify the rules of thumb that made positive impact more likely and sustainable at scale, and this was the trigger for governments, such as Ethiopia, to invest their own resources in them.
In sum, there are two things I have learned from the past year at GAIN that speak to these issues: (1) it is harder to design and implement effective programmes than it is to design and implement effective evaluations of them and (2) if you don’t evaluate programmes it is even harder to design and implement them effectively!
The papers in this supplement are a valuable reflection on the MNP experience to date, and I am happy that GAIN was a contributing partner in the endeavour.

11 October 2017

The New Expert Panel Report on Nutrition and Food Systems: What is Different?

The UN Committee on Food Security’s (CFS) High Level Panel of Experts (HLPE) report on “Nutrition and Food Systems” was released at the 44th CFS this week.  The team was led brilliantly by Prof. Jess Fanzo. I was one of the team members.
There have been a number of reports on food systems in the past year – including the Global Panel Report and the IPES report – and next year we have the EATLancet Commission report on sustainable and healthy food systems. This report is specially important as the CFS is the apex body in the international UN system looking at nutrition and food policy.
So what is different about the HLPE report? Here is my take:
First, its main audience is CFS members: governments, UN agencies and other development partners, civil society groups and companies.  This means it has to be couched in the more measured, careful language of diplomacy rather than advocacy.
Second, the report was produced through a very inclusive process. The report team was balanced by geography, disciplinary background and organisation type.  This meant forging compromises that all team members could live with, with the expectation that this will increase the chances of a wider buy in from stakeholders.
Third, it is, subversively, a bit radical. Statements such as “The risks of making well intentioned but inappropriate policy choices are much smaller than the risks of using a lack of evidence as an argument for inaction” are fairly heretical for many nutrition investors guided by Lancet 2008 and 2013. For the more market based interventions within the food system the hard evidence is usually not present and one has to trust educated best guesses and calculated risks as a guide to action. This is an implicit challenge to a trend towards ever more specific searches for evidence to prove interventions are justified.
Fourth, the report gives equal focus to three features of food systems: food supply, food environments and consumer orientation.  Some of the other reports mentioned have not been as balanced and especially do not spend enough time on the creation of the demand for healthy food.
Fifth, the report is very action orientated. For example, there are 26 pages of text on priorities for action in food supply chains, food environments, and in orienting consumer behaviour.  The “investment priority wheels” for the three types of food systems are also useful guides to sequencing action.
Sixth, the report bravely takes on the barriers and enablers for action: bravely because these are all quite context specific and deal with power asymmetries. This kind of political economy analysis needs to be developed further in future HLPE (and other) reports.
Seventh, climate issues are woven throughout the report, not confined to one section or chapter. Other environmental footprint issues could be strengthened in future reports, but to be fair the evidence on the wider environmental footprint of different foods in different countries is sorely lacking.
Finally, the private sector is taken seriously. It is not merely characterised as a malevolent actor.  One of the HLPE team members was even from the private sector –a first, I believe for the HLPE, but brave and necessary.  Given, as the report notes, the public sector is the duty bearer for ensuring food systems enhance food security and nutrition for all, and the private sector is main investor in food systems, it makes sense for the two sides to understand each other better.
I did, however, have quibbles with some of the private sector language (come on, did you expect me to have no quibbles with anything?).  For example, the report states “The private sector is primarily seen as part of the problem, but it can and should also be part of the solution.” Some stakeholders do in fact see the private sector this way, as primarily part of the problem, but many do not.  And the private sector is already part of the solution – it is just that it is also part of the problem (as, incidentally are governments – some of whom have good, some less good policies). Also, the report does little to dispel the notion that the private sector is a multinational monolith.  For example, Small and Medium Income Enterprises (SME) are only mentioned once.
Jessica Fanzo, the Report Team Leader, and Eileen Kennedy, the HLPE member who was our spiritual guide and inspiration, deserve a great deal of credit as do the HLPE secretariat.  They got us through the hard times when it all seemed too overwhelming and when we could not sometimes reach consensus.
All in all, it is a report I’m proud to be associated with. The content, presentation and generation process were all thoughtful, deliberative and inclusive.
So, read it, critique it, share it, but most of all, use it and act on it!

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09 October 2017

Overcoming the Data Roadblocks to Public Private Engagement to Improve Nutrition

I am sorry if this sound like a rather techy title, but I believe it touches on some of the most sensitive issues holding back progress on the Sustainable Development Goals (SDGs). Why?
At a recent meeting of public and private sector organisations I was asked to share some thoughts on the data gaps that inhibit productive engagement between the public and the private spheres to advance nutrition. The meeting was addressing how to push food systems to both feed AND nourish the world, and for this market actors (private sector) and policy setters (governments, development actors) simply have to work together for meaningful change. We are far from this.
My sense is that the data gaps that are inhibiting us all fall into at least five categories: 
1.Having a joint goal. If you don’t know what you want to achieve, no partnership will succeed, no matter the partners.  What is the common objective?
2. Lack of a sense of opportunities. In the public private space in nutrition we tend to get blinded by the hotspots of breastmilk substitute marketing and products high in added sugar. These are of course vital issues to address, but there are many other issues too.
3. Demonstrated benefits from engagement. The perceived costs of engagement – exclusion, criticism, reputation – are very visible and quickly felt, but the potential benefits are less clear because they are rarely validated by independent and careful evaluations. PR is no substitute for evidence.
4. Lack of a data mechanism for building trust and ensuring transparency. This type of mechanism is important in any relationship. The Access to Nutrition Index (ATNI) does this well for major food and beverage companies every two years, but we need additional mechanisms which are lighter, can cover the major part of the food system, namely the farmers, entrepreneurs and local companies, and can be collected in real time.
5. Lack of a mechanism for sharing data and evidence. This is important because it provides examples to spur action. This could be a register of public private partnerships or a web portal that screens, curates and mobilises evidence in the public private domain on what works.

The table below provides more examples and detail.  These are issues we are working on at GAIN as one contribution to making it easier to engage across the public private divide to improve nutrition for all, especially the most vulnerable. Stay tuned, or better, share your ideas!
Roadblock to public private engagement to improve nutrition
How can data help overcome roadblock
1. Lack of a joint goal
- Identify key groups and dimensions of malnutrition where little progress is being made
- Accelerating reductions in Anemia in women and children

- Improving adolescent nutrition
2. Lack of a sense of the breadth of opportunities
- Collect data on firms by sector and product—who is doing what?

- Collect data on sales of different foods and food products—how is demand changing?
- Screening and segmenting SMEs that have nutritious foods at the heart of their business model

- Collecting data on the sales of packaged foods in low income countries
3. Lack of sense of benefits to a particular type of engagement
- Independent evaluations of process and impact of public private engagements: by product type, market segment, engagement type
- More independent evaluations commissioned and published

- Public research programmes on PPPs in nutrition
4. Lack of mechanism for assessing conduct and building trust
- Evaluations of company performance

- Indicators of government efforts to create nutrition friendly enabling environment for food and which tracks businesses who want to do the right thing for nutrition.
- Initiatives like ATNI, SDG2 Scorecard

- Indicators to characterize the strength of the ecosystem support for businesses who are working in areas that could advance nutrition outcomes
5. Lack of a mechanism for sharing data, knowledge and evidence
- Knowledge mobilization around what works to advance nutrition in the government-business sphere (and the types of benefits) and what does not work (and the risks and how avoided)
- Establish a Knowledge Hub on Markets for Nutrition

This blog is also available on the GAIN website
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Published 9 October 2017

04 October 2017

Discussing how to make food systems deliver more nutrition with the European Commission

Last week I presented on the role of business in food systems to improve the consumption of nutritious safe foods.
I focused on the need to develop innovative ways to create the demand for healthy food, ways of supporting businesses and governments to meet and shape that demand, and what governments can do to make it easier for businesses to do the right thing for nutrition and harder to do the wrong thing. I highlighted each of the three points with impact examples from GAIN’s own work. The slides are here.
It was an audience of European Commission (EC) officials and the Brussels NGO community and I got some good questions:
  • What data are missing in the public-private space?
A: One example is that businesses in low-income-countries have very little public (or for purchase) market information data to draw on.
  • What is the impact on farmers of more affordable foods?
A: Farmers are also businesses, so they have to get fair prices, and they set their prices to maximise sales revenue. But lower prices further along the value chain need to generate good demand linkages for their products.
  • How can we guarantee the foods that are supposed to be fortified, actually are at the point of consumption?
A: GAIN regularly undertakes Fortification Assessment Coverage Toolkit (FACT) surveys which measure the coverage (was fortified food actually consumed?), coverage of adequately fortified foods (was the food properly fortified?) and effective overage (is enough fortified food consumed to close a nutrient gap?). Through our ENABLE Platform and country teams we work with businesses and governments to help them, comply with and monitor, respectively, the national laws and standards.
  • What about the environmental impacts of different “healthy” foods?
A: The evidence base on the trade-offs with water, soil and energy of producing more nutritious foods is not there right now so we have to be very careful to do no environmental harm.
A: Where animal source food consumption is low, the requirements per kg are high and there are few alternatives for getting the nutrients in the right concentration then animal source food consumption is justified on nutritional grounds. If you eat high levels, you should consider reducing your consumption—this is essentially the advice from WHO and national food based dietary guidelines.
  • What are the implications for research?
A: More research needs to be done to increase the productivity of, for example, fruits, vegetables, pulses, eggs and dairy. In addition we need a dedicated research programme on the nutrition impacts of public-private collaboration—there is too little evidence on whether the private sector collaborations actually add nutrition value.
  • Do you consider ultra-processed fortified foods to be nutritious foods?
A: No. The science around these foods is not settled but we are taking a precautionary approach and not including these as part of our definition of nutritious foods.
  • Food is important, but what about the other determinants of malnutrition?
A: Absolutely, the aim is to work where poor diet is one of the key limiting factors.  That is why we do contextual and formative research ahead of programme development.
The External Investment Plan
As Commissioner Mimica stated at the Scaling Up Nutrition (SUN) Lead Group meeting in New York last week, the European Union (EU) wants to do more to engage the private-sector intelligently to bring in new capacities, resources and opportunities to advance nutrition while not doing anything to endanger the advances of the past 10 years.
Although it is a general development facility (EUR€ 3.5billion) to engage the private-sector, the new External Investment Plan represents a good opportunity for nutrition given its triple objectives of (1) mobilising resources, (2) providing technical assistance to businesses, governments and civil society and (3) a focus on the enabling environment for businesses that want to do good things for nutrition.
We should all stand ready to help nutrition champions within the EU to leverage this facility to transform markets to make them more pro-nutrition.

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