Last week I spent some time in Lagos and Abuja with the GAIN Nigeria Office. We met with government officials, entrepreneurs, civil society, reporters and development partners. It was a stimulating visit set against the devastating backdrop of a mounting malnutrition crisis, especially in the North East of the country where a famine has been declared. In fact one of the officials I spoke to told me it had gone beyond a crisis to being a clear and present danger to national security.
Nigeria certainly has too much malnutrition. Stunting rates are 33 percent and declining too slowly, wasting rates were 7 percent in 2015 and are now surely significantly higher given the situation in the North East. In addition, anaemia rates and overweight rates for adult woman are, respectively, 49 percent and 55 percent. Unfortunately, the double burden is booming in Nigeria.
It should not be like this. Nigeria has an abundance of natural resources, a vibrant entrepreneurial spirit, and was an early member of the Scaling Up Nutrition (SUN) Movement (2011). It is true that the economy has been stagnant for the past few years and levels of poverty remain around 50 percent, but you get the feeling that the country has the potential to actually live up to the “economic powerhouse of Africa” tag it once had. The challenge is to enable the dynamism of the South of the country and elsewhere to drive nutrition improvement, livelihood generation, resilience and growth, especially in the more remote and conflict affected North East.
So where are the weak links in the nutrition improvement chain? As the excellent SUN Country Dashboard for Nigeria notes (above), the country does well on enabling environment and on legislation, relative to the other 60 SUN members. But it does less well on scaling of interventions and quality of food supply and on the SDG drivers of nutrition (such as WASH, women’s empowerment and age of marriage).
When we delve further into the aggregate scores and look at all 75 indicators, we can see that some areas of relatively good performance don’t actually look so good. For instance, the relatively good score on finance is due to development partners providing 99 percent of the total nutrition-specific funding. As for government spending, the SUN dashboard says that the Government of Nigeria spends only 0.8 percent of its 2014 budget on nutrition specific interventions. The Global Nutrition Report of 2017presents even more bleak statistics: it says the Government spends only 0.2 percent of its budget on nutrition sensitive AND nutrition specific interventions. Clearly the government needs to step up and invest its own resources in nutrition. Another example of hidden weak performance is the relatively good score for infant and young child feeding, but in absolute terms only 10 percent of infants meet the minimum diet adequacy score; this is shockingly low but only slightly below the SUN member median of 11 percent.
But for me, the most striking gap highlighted by the SUN dashboard is the Government’s apparent lack of appreciation that nutrition is a driver ofdevelopment. For example, Nigeria’s national development plans barely mention malnutrition (in any of its forms); the orientation of agriculture to nutrition is low, as measured by the SUN dashboard (although there is the promise of some change here); and, of course, there is the low spending on nutrition programs from the Governments own budgets, which is always the firmest test of commitment.
During my trip, I was struck (as in other GAIN country office trips) by how dynamic the small and medium enterprise CEOs are. Take the two partners in the Postharvest Loss Alliance for Nutrition (PLAN). This programme, conceived of and managed by GAIN and partners supports small and medium businesses that are trying to improve packaging and crating for transport and display, as well as their cold chains in fresh (and nutritious) produce so they can reduce their postharvest waste and grow their businesses. The two CEOs from Best Foods Nigeria Ltd. and Alyx Ltd. were restless, energetic, driven, focused and in constant problem solving mode. Ironically, they could see the bigger picture better than many policy analysts – because they are a part of that picture.
Alyx Ltd. Mobile cold chain. Abuja, Nigeria
For example, the CEOs noted several ways in which the government could help them better provide low cost fruits and vegetables to low income populations. Specifically, they pointed out that: (a) import tariffs on insulation materials for the portable cold chain collection points (that can be taken out into the fields) are around 30 percent, (b) as are the tariffs for solar panels and batteries that will allow the portable and fixed cold chain points to be off the grid and (c) reused materials (the companies repurpose existing metals and other materials) do not count as collateral when applying for formal finance loans.
So the policies and rules that could make a food system more nutrition sensitive are not always obvious to those working outside the system, that’s why GAIN strives for the duality of being both a participant within, and an analyst of, food systems: it gives us a wealth of insights as to how to work with partners to help fix the systems. The SUN Business Network which GAIN convenes in Nigeria (and which the World Food Programme convenes in other countries in the region) is also a fantastic platform for the nutrition community to forge new alliances and partnerships with businesses who are acting responsibly to improve nutrition.
In conclusion, there were several things that made me hopeful that more rapid progress on reducing malnutrition in Nigeria can be made: the profile the media is giving nutrition at the moment—this is an opportunity to get the message out that nutrition is an investment in resilience and development; the Dangote Foundation’s new US$100 million commitment to nutrition which should leverage even more external funding for development; the Federal Ministry of Agriculture and Rural Development’s ambition to scale up the availability of biofortified crops; the dynamism and thoughtfulness of the Chair and Vice Chair of the Healthcare Services Committee in the House of Representatives (just like the US system) and their commitment to malnutrition reduction; the development partners we met who were more passionate, informed and action oriented on nutrition than in many other places I have visited; and the enthusiasm of small and medium enterprises to develop their businesses in ways that make nutritious foods more available and affordable.
And the best way to sustain optimism and deliver on it is by strengthening nutrition accountability mechanisms to hold our feet to the fire. For example, I would like to see an annual Nigerian Nutrition Report, similar to the Global Nutrition Report (GNR) or the India Health Report, where outcomes, legislation, policy and investment could be tracked for all 36 states, highlighting successes, bottlenecks and solutions.
GAIN Nigeria will certainly play its part in supporting the government’s efforts to meet the Sustainable Development Goals. During my stay in Abuja, we hosted an event to mark our 15th anniversary (one of 15 events around the world). Fifty or so partners from a range of organisations were present. Together, we explored the malnutrition challenges in the country and the opportunities to make good nutrition a reality for all Nigerians. As Michael Ojo, our strong new Country Director put it: let’s remember who the real “boss” is here: those whose lives, livelihoods and lifecourses are at risk because of malnutrition. Remembering this will make us less likely to be complacent. He also said that working together we are more than the sum of our parts and that together we can accelerate reductions in malnutrition in Nigeria. Exactly.
This was the first GG since 2015 and the first held in a SUN member country. Its objectives include to energise and inspire, to reconnect and network, and to learn and reflect. The GG did brilliantly on the first two, but we could, in my opinion, improve on the “learn and reflect”.
On the energise and inspire front, the GG was remarkable. For instance, we had the Vice President of Cote D’Ivoire, the former President of Tanzania, many ministers from Africa and many other senior government officials from Africa, Asia and Latin America. Tony Lake was also present for the full three days, testimony to his dedication. These senior politicians and officials (such as Akin Adesina, the President of the African Development Bank) talked with great passion, authenticity and fluency. They knew the core facts: malnutrition affects one in three people, is responsible for nearly half of all under five deaths, leads to losses in GDP of at least 11 percent and investing in preventing it yields benefit cost ratios of 16:1. They weren’t speaking from scripts they were speaking from the heart and from a place of pragmatism (malnutrition is holding our economies back). This was mightily impressive and it is too bad that the top officials from donor agencies were not present to witness it.
But inspiration was not just restricted to these folks: for example, we had a junior Parliamentarian, 15 year old, Spectacular Gumbira from Zimbabwe (a well named, amazing and powerful speaker, completely unfazed by an audience of 900 people), Myriam Sidibe a powerhouse behaviour change advocate from Unilever and Catarina de Albuquerque, Executive Chair of Sanitation and Water For Allmaking connections into the WASH sector. In addition, a range of inspirational nutrition leaders were honoured by Sight and Life and by SUN, including Ellen Piwoz from the Gates Foundation who won two prizes, both richly deserved.
On the reconnect and network front, the GG did a great job. There were the marketplaces that were set up by all 60-country members, the long breaks in-between sessions, the network meetings and the well-chosen venue with plenty of meeting spaces. Having the meeting in a SUN member country also gave the proceedings a feeling of balance. People like me from European and North American organisations were not able to dominate the proceedings—this was a country first meeting, where egos and logos were checked at the door. The feeling was one of solidarity not hierarchy; one of ideas, not protocol. There was, as David Nabarro (Special Adviser to the UN Secretary General on Agenda 2030 and former SUN coordinator) put it, a lot of love. And I would add solidarity, too.
On the learning and reflection front there was a good session on nutrition in fragile contexts and how SUN could be more relevant, there was some progress on getting civil society and business networks talking to resolve issues around due diligence and accountability of businesses, and there was a short plenary on the new Monitoring, Evaluation, Accountability and Learning (MEAL) resources for guiding us along the SUN theory of change. Despite this, and this is solely my own view, we could have done better on the learning and reflecting front. This really matters greatly, as we know more about the damage malnutrition does, than what works to combat it.
For example, there are some big questions looming which we did not really take on:
SUN is scaling well and thinking more about impact, but what about its sustainability beyond 2020, which marks the end of the current funding cycle? Can we really call ourselves a movement if we are so reliant on donor funding? Shouldn’t some of the direct funding for SUN infrastructure come from members (to be fair, I know much of the indirect funding does already come from members)?
The double burden of malnutrition is rapidly increasing—the latest Global Nutrition Report (2017) counts 60 percent of countries facing significant burdens of undernutrition (under five growth faltering or adult micronutrient deficiency) as well as overweight/obesity. That percent is likely to grow before it diminishes, so what is the SUN movement’s response? What will we do differently? Can we shy away from the difficult but inevitable discussions which surround curbing some of the unhealthy dietary trends driving this?
Urbanisation is growing rapidly in Africa as elsewhere—this presents both an opportunity and a challenge to nutrition—what does the SUN movement need to do adapt? For example, SUN already has Indian States as members, should it also invite cities to be members?
All in all the GG was a great success. The SUN Coordinator, Gerda Verburg, deserves a great deal of credit for her energy and her “telling it like it is” style. Her team did a superb job of making all the thousands of moving parts mesh together well.
I leave you with one positive and I believe insightful reflection someone shared with me at the end. It was that at the first GG, country members looked a bit bewildered—what is this SUN Movement and what does it mean for me? Country representatives knew what they needed, but were less sure of how to articulate it and to negotiate for it. In Abidjan, they said, it felt as if the country members were in control of the movement: there was a clarity from them about what was needed from others, a confidence on the articulation of those needs and an abundance of know-how on what to do to secure the needed support.
And this country driven approach is essential to Scaling Up Nutrition. SUN’s ultimate success will be measured in terms of whether it contributed – at the country level – to mobilising additional domestic and external resources to nutrition advancement, whether it contributed to existing resources being spent more effectively and whether it contributed to nutrition being increasingly seen as a core driver of the SDGs. We must never forget that SUN is a global movement. That means movement the world over as well as movement in more “global” circles. The movement marches on!
I love the title and the narrative behind this year’s report, which can be summarised as:
1. “Let’s make good nutrition the global social norm”;
2. Disparate communities working on different nutrition outcomes need to come together to have a stronger voice. Implementers, investors and policymakers can do this by looking for double/triple duty actions that address more than one type of malnutrition;
3. Nutrition needs to be made compatible with other sectors – not just what they can do for nutrition, but what nutrition can do for them. Also we need coherence across sectors – even if we can’t convince sector x to do more for nutrition, let’s at least make sure it does not undermine nutrition; and
4. People should be put at the centre of our efforts—no person should be left behind and every voice should count.
I particularly like the sentence near the beginning of the report and repeated towards the end: “The bottom line is that nutrition needs some staying power. While global goal setting and dedicated decades for nutrition are important to spur action, let’s work to mainstream nutrition, so much so that it is considered commonplace to have optimal nutrition.”
Staying power, think about that. “Staying” implies that the good profile nutrition has right now is at risk – it might not stay. “Power” implies that nutrition is the vital “cog” in the SDG machinery. If it is not working, then things will grind to a halt. We have to find ways to make it stay around; we need to emphasise and enhance its cog-like functions in the SDG juggernaut.
But let’s get to the numbers between the beginning and the end of the report. There are plenty. Here are some facts that made me sit up and take notice:
On the magnitude, location, targets and pace of change of malnutrition outcomes:
All 140 countries with data on under five growth, women’s anemia and adult overweight suffer from one of these burdens. All of them. In previous reports at least we had one or two exceptions.
85 out of 140 countries have serious levels of overweight and one form of undernutrition. That is 61 percent, up from 44 percent in previous reports. The double burden of malnutrition really is the “new normal”. The challenge now is to make good nutrition the new norm.
Women’s anemia rates have increased overall, but more countries seem to be making progress—these are new World Health Organization (WHO) estimates that contain good and bad news.
Adolescents: “The nutritional status, behaviours and outcomes of adolescents form a very small part of global monitoring frameworks for nutrition. The only targets that address adolescent nutrition directly are the Maternal, Infant, Young Child Nutrition (MIYCN) target for anemia of 15-49 year olds, but these are not broken out by adolescents.” While the obesity target includes an indicator for adolescent obesity, the anaemia target does not look at anaemia in adolescents separately. Beyond these, indicators are largely missing.”
Why does the absence of data on adolescent nutrition matter? “Where estimates are available, from the WHO, these suggest that iron deficiency anaemia is the leading cause of disease burden and disability among adolescents in 2015”. Read that again: anemia is the leading cause of disease burden in adolescents, yet we have very poor data on it.
Country budget allocations to nutrition as a percentage of overall national budgets: once again the country estimates of nutrition spend (specific +sensitive) show wild variations. We need some analysis on why some countries are so low (e.g. Nigeria on 0.2 percent and why some are so high e.g. Nepal at 13.1 percent).
Of the nutrition sensitive ODA spending, only 11 percent is found in the education sector – are we doing enough here? Is this where we should be focusing much more on double duty actions?
ODA spending on obesity and diet related Noncommunicable Diseases (NCDs) constitutes only $25m – about 0.01% of global ODA. Feeble – we know it is difficult, but donors must do better, for example through double duty counting.
There are essential calls to improve the way nutrition actions are reported in the ODA Creditor Reporting System (CRS): to better align the nutrition specific codes with actual interventions and to also introduce a nutrition policy code in CRS for nutrition sensitive and policy actions. Donors can change this. But I suspect the nutrition champions within them need some evidence on the consequences of our current miscounting of nutrition spending.
The (self) reporting on the 2013 Nutrition for Growth (N4G) commitments continues in this GNR. This year the no response rate from the 200 or so commitments made in 2013 was 49 percent– worse that the 45 percent in 2016.
Businesses were the worst offenders: with a 66-70 percent no response rate. My colleagueJonathan Tench has some great and sophisticated ideas for improving response rates in a panel in the report. My suggestion is less sophisticated. Name the companies. This will get their attention and the attention of their investors.
On donor financial commitments I like Fig 5.3, which compares commitments made over the 2013-2020 period versus disbursements made over the 2013-15 period. Most donors seem to be on track.
Away from the numbers
But numbers are not everything. Imagery is important and the report also does well here.
For instance, the language around universality of the SDGs is motivating: we need greater disaggregation of data to ensure no one is left behind and less disaggregation in country groupings—north/south dichotomies are increasingly meaningless in a multiple burden world.
I like the idea of data value chains to help us identify the weak links in the generation, understanding and use of data, but how to get governments and donors more excited to invest in this? We really need a study showing the value added of good data. How do we make the benefits visible to stack up against the very visible costs?
The five areas for action that are illustrated beautifully on the cover are a nice way to reach across the 17 SDGs (roughly, food systems, infrastructure, health systems, equity & women’s empowerment, and peace).
There is the nice quote about “Improved nutrition cannot be a singular set of targets in a silo – rather it is an indispensable cog, without which the SDG machine cannot function smoothly.“
The examples of “double duty” actions introduced in the 2016 GNR are nicely expanded. Examples include paying more attention to NCDs within undernutrition interventions delivered by the health system, and focusing on access to improved water, not only for infection prevention, but also to act as a counterweight to high soda consumption.
The “gatefold sleeve” graphic (I’m really showing my age here) on pages 10-11 is great – stick it on your wall – as a visual story of the report. Indeed the graphics in the report keep getting clearer and simpler every year.
In general the “call to action” language was downplayed in this GNR but the four sets of actions remain powerful:
Build for nutrition while harnessing nutrition’s power across the SDGs.
Stand shoulder to should on obesity and diet related NCDs when addressing undernutrition.
Be bold in your commitments to nutrition improvement—we will not get the window of another Decade for Action—this is likely to be it, folks.
Invest in understanding and strengthening resource data value chains.
So a massive congratulations to the GNR secretariat, the Stakeholder Group, the Independent Expert Group, the funders, the authors, the other partners, the reviewers and, especially, the GNR co-chairs: Corinna Hawkes, Jessica Fanzo and Emorn Udomksemalee. I am proud that GAIN is a member of the report’s stakeholder group.
By nourishing the GNR, they are all nourishing the SDGs.