I just returned from a trip to Islamabad to meet the GAIN team and some of our partners. I’m no expert on Pakistan, but compared to 2013, the commitment to accelerate reductions in malnutrition seems to have increased significantly.
First, nutrition is reported to be much more prominent in the next 5 year draft National Development Plan which is waiting to be ratified by the new Government elected in late July.
Second, guided by the Ministries of Planning, Development and Reform and the National Health Services, and supported by the Scaling Up Nutrition Movement (SUN), the outgoing Federal Government has already committed 10 billion rupees (about $100m) to nutrition in this financial year, which represents a major boost.
Third, civil society is trying to replicate what was so successful in Peru—getting all the political parties to make SMART commitments to nutrition in their manifestos and then holding whichever one gets into power to those promises.
Fourth, the Provincial Food Authorities have become powerful forces for change in the Provinces. Starting out in the food safety space these Authorities are extending their interests into the nutrient dimensions of food.
Fifth, businesses really seem to be stepping up to the plate. The Sun Business Network (SBN) has revived with a new injection of resources and capacity and has 33 member businesses with plans to get to 100 in the next couple of years.
Sixth, the government officials I talked to in the Ministries of Planning, Development & and Reforms and in the National Health Services were all talking about food systems and how these systems frame the nutritious foods choices people have and how they make the choices.
Seventh, the adolescent and youth agenda is high on the development agenda with senior policy makers and development partners understanding that the current youth bulge can bring both a new set of opportunities (e.g. empowerment, entrepreneurship and a redefinition of what a healthy diet looks like) but also problems (unemployment and unrest) if the approach is not right.
Finally, the urban agenda is surfacing—with the World Bank a strong proponent of leveraging urbanization for nutrition.
Of course all of these opportunities present risks. There is “many a slip between cup and lip” when it comes to what is in development plans and what actually gets done (in all countries!). Committing to spend $100m on nutrition is good, but what will it be spent on and what is the capacity to spend it (wisely)? Party political manifestos are often not worth the paper they are written on. A food systems framing can lead to action in new areas, but also to paralysis, as policymakers are overwhelmed with data and things they could do within the system. Provincial Food Authorities can be powerful agents of change, but less so if they do not align standards to make the work of business as seamless as possible over different geographies. And we know businesses can be as much a part of the affordable nutritious food problem as it is a part of the solution. Finally, a focus on urbanisation that is detached from rural transformation will run the risk of deepening divides.
But from a non-expert perspective, I detected a steely glint in the eye of all the public and private officials I met (most of them not nutritionists, by the way) and a determination that they are not going to let this moment slip to press home the advantage for nutrition. As a recent editorial by a former Finance Minister in a leading national newspaper put it “Pakistan is one of the emerging economies of the world with a notable economic growth potential that is threatened by the burden of pervasive malnutrition. Unless immediate action is taken, the crisis of malnutrition will continue to negatively affect Pakistan’s economic performance. It also has the potential to condemn future generations to a catastrophic future of deprivation and poverty.”
I couldn’t agree more and GAIN will do whatever we can to work with all stakeholders to make sure these opportunities are seized to accelerate reductions in malnutrition — in all its forms.
We at GAIN wanted to learn from others as we build on our adolescent nutrition landscape reports and begin working with our partners in Bangladesh, Indonesia, Mozambique and Pakistan to design interventions that are likely to improve the nutrition status of adolescents.
There were 2 key features of the consultation that GAIN and WHO were determined to make happen: (1) we wanted to learn from those outside the nutrition ecosystem who had extensive experience of working with adolescents and (2) we wanted direct and meaningful engagement with adolescents themselves. It would have been much easier not to do this, but much less interesting and legitimate we thought.
But the x-factor in the consultation was the participation of 10 adolescents from Bangladesh, Indonesia, Pakistan and Zambia. More about them later.
I can’t possibly do justice to the richness of the meeting, but here goes.
Why focus on adolescents?
There are a lot of adolescents. Asia and Africa are experiencing a youth bulge as their countries go through a demographic transition. In the next 5-10 years we will be at “peak youth” as they hit the labour force and the voting rolls.
Despite being so prominent in the population numbers, adolescents are virtually invisible in nutrition data and in nutrition programming. We really only have data on 15-19 year old girls. Virtually nothing on girls 10-14 or boys 10-19.
The data we do have suggests that a very large proportion of adolescents experience at least one form of malnutrition.
Malnutrition in adolescence affects the development of key brain functions—there is plenty of development going on after the first 1000 days into the 4000 -7000 day period.
Because the transition from childhood to adolescence carries the promise of more power to make their own decisions, adolescents are catalysts for social change. Whether campaigning for stricter gun control in the USA, the prevention of child marriage or bans on single use plastics, adolescents have enormous potential agency. Adolescents can redefine norms around, say, healthy eating—if we support them in the right way.
What kinds of actions or programmes should be developed?
The specifics are less clear here. But there are some key principles:
First, as Dr. Chandra-Mouli from WHO said, we should stop doing “interventions” we know do not work in this space (e.g. high profile public meetings, and one off trainings).
Second, try to build nutrition into existing policies and programmes that seek to improve the wellbeing of adolescents.
Third, in building nutrition in, do not dilute the existing programs’ ability to talk about really difficult and awkward topics, e.g. on puberty and sexuality.
Fourth, the demand side is vital: find ways to engage with adolescents on their terms—what influences their choices (e.g. taste, convenience, privacy, looks, aspiration, sports, celebrity, superheroes)—but don’t talk explicitly about nutrition (its boring).
Fifth, what can we do to make sure healthy food is available in or near schools (our Zambian adolescents shared some heart-breaking reality about food at school) or in markets (e.g. in Java, where is the healthy fast food that tastes good and is the “cool” thing to buy and eat?)
Finally, strengthen accountability around what powerful stakeholders are or are not doing with or for adolescents, e.g. State of Youth reports, petitions, campaigns, declarations and policy scorecards.
How to design and implement programming?
First and foremost—work with adolescents in a meaningful way. As one participant said, “let them be your guide”. They best understand their reality, the opportunities and limits and how to seize and navigate them. They can help us figure out where they are and how to get there—they will not necessarily be where the programmers want the programming to be.
Second, build the capacity of the adolescents and the rest of us to engage with each other. As one participant said the “peacocks” (adolescents) and the “turtles” (the rest of us) need to work together for change and neither group probably has much experience of doing so. They both need to learn.
Third, like any agents of change, adolescents can achieve more working together (the “power with” multiplying the “power within”). We need to support their organisation, their ability to educate and their ability to agitate.
Finally, we need to let them lead. This is potentially the most challenging aspect because we are so used to being in control. But if adults only view adolescents as instrumental to the former’s goals, they are being exploitative.
So what does all this mean?
Interestingly it seems to me that the adolescent agenda is not plagued by the usual institutional territoriality in development. Not yet anyway. For example, there is no obvious UN agency charged with promoting the rights and wellbeing of this age group. This creates space for duplication, but also for collaboration. Fortunately, we are more in the collaboration space at the moment.
This lack of formalised institutional leadership also gets us into a different but familiar territory, namely that “adolescents are everyone’s business and no one’s responsibility”. And because there is a bit of a vacuum of leadership around adolescent nutrition, many agencies are stepping in, in a coordinated way, and that is encouraging. Now the challenge is for the stepping stones to actually create a path towards significant commitments of resources to adolescent nutrition programs and policy.
We need the UN to come together around the adolescent nutrition agenda and call a meeting in 2019 where member state governments can shape a series of “asks” and turn them into commitments for governments, and all other investors–such as NGOs, research organisations, businesses, development donors–to make.
The one group we don’t have to ask to make commitments is adolescents—they are living their commitment. And if the rest of us do not step up to make commitments to support them, then they may just do it without us. “Never about us without us” may become “if you don’t step up then step away”.
Fortunately, at the consultation, a large number of organisations made commitments that they will report back on publicly in June 2019 – to the adolescents attending the meeting and to everyone else. The commitments do not involve major funding, but they do involve change. And even though some of the commitments probably relate to actions that were going to be undertaken in any case, the most important thing is that the commitments were made public, allowing all of us to monitor them and to assess progress against them.
We are still working on finalising the wider set of specific commitments from the different organisations, but GAIN’s are as follows:
GAIN will not organize any meeting on adolescent nutrition without meaningful involvement from adolescents
GAIN will attempt to connect the Indonesian adolescent representatives with the Ministry of Health in Indonesia and set up a dialogue between the adolescents and the Ministry’s representatives
GAIN will set up or use existing national adolescent networks for meaningful engagement and capacity building in the design phase of adolescent nutrition programs in countries where GAIN is/will be working
Such public pledging is unusual, and I think it happened because the adolescent participants made us not only think about the issues, but to really experience feeling and emotions around the issues. And when thinking and feeling come together, action is inevitable and change is unstoppable. A fire is lit and it cannot be extinguished!