Global Nutrition Report 2016: From Promise to Impact

From Promise to Impact: Ending Malnutrition by 2030 Global Nutrition Report 2016

From Promise to Impact

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The Global Nutrition ReportIndependentGlobalAll Forms of NutritionData DrivenEncourages Accountability

This is the third GNR

Produced by an independent expert group

It covers all countries

it covers all forms of nutrition

It is data driven

The GNR was called for at the N4G summit in London in 2013 to strengthen accountability of nutrition stakeholders to citizens. The first one was in 2014.

SUGGEST YOU DO NOT REMOVE THIS SLIDE

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Whats New in 2016?New Era: Global shift to SDGs New Opportunities: UN Decade of ActionNew Data: On Implementation, BudgetsNew Analyses: Funding GapsNew Success Stories: Ghana, Kenya, ChileNew Calls to Action

We just had a GNR 9 months ago--whats new in this one?We are in a new Era: SDGsNew opportunity: The Decade of Action was passed by the UN General Assembly in April 2016 new opportunity to mobilise action

Lots of new data some examples:on implementation of BMS codeon implementation of diet recommendationson which countries have targets for nutritionon nutrition spending for 24 countries

New analyses: e.g. World bank/R4D on funding gap to scale up nutritionNew stories of success: Brazil, GhanaNew set of calls to action


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OutlineKey FindingsCalls to ActionTakeawaysWhat you can do

This is the outline of the talk


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Key Findings


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1. Malnutrition creates ripples of individual and societal challenges & opportunities

Malnutrition leads to:

Human suffering, obviously

Health related consequences. e.g. the 45% of under 5 mortality linked to malnutrition

But also economic consequences


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Akin AdesinaPresident of the African Development BankWe need to invest in gray matter infrastructure.

Neuronal infrastructure is quite possibly going to be the most important infrastructure.Jim KimPresident, World BankWe couldnt have said it better ourselves..

Here are

Two quotes from leaders of development banksquite extraordinaryis this the beginning of a sea change in the way financial institutions think about nutrition?

YES


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2. The world is off track to reach global targetsbut there is hope.

globally we are off course to meet the targets set by the World health Assembly, but there is hope because many countries are actually on track...


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Meeting Targets: Where are we now?

Source: Authors, based on data from Stevens et al. (2013), UNICEF (2016b), UNICEF, WHO, and World Bank (2015), and WHO (2015a).

This is a dashboard that shows, for the 8 indicators we track, how well countries are doing in terms of on/off track

Dont pay attention to the detail in the chartthe key things are

there is quite a bit of green (on track)

But

there is way too much red (off track)

Much of the red is in anemia and overweight, obesity and diabetes rows


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3. Nutrition is central to the SDGs

We are now in the SDG era.

The SDGs are great for malnutrition reduction because they

challenge us to end malnutrition, by 2030

cover all forms of malnutrition

stress that we should leave no one behind

highlight the indivisibility of SDGs


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Nutrition feeds into 12 of the 17 SDGs and dozens of the indicators used to track the SDGsSource: Authors

This chart from the report

Reviews all 242 indicators that the UN have designated to track the 17 SGDs and concludes that 56 are highly relevant for nutrition (as determinants and outcomes)

Of course we could choose more if we relaxed the definition of highly relevant, but we wanted to be cautious. Even so, 56 indicators!

Key point: more indicators outside Goal 2 than inside it

Key point: at least 12 SDGs provide indicators that we need to track for nutrition


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4. There is a gap between current commitments and need

There are gaps between current commitments and need

These commitments are of a political, technical & financial nature


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There are few SMART targets in country plans

Source: Authors, based on data from Chizuru Nishida and Kaia Engesveen.

Setting SMART (specific, measurable, relevant, achievable and time-bound) targets is one indicator of commitment

This analysis is from the WHO team.

Unfortunately looking at 122 country nutrition plans, less than half have set SMART targets for the 6 WHA maternal and child nutrition indicators.

Stunting and EBF fare the best. Wasting, perhaps surprisingly, is given lower priority when it comes to setting SMART targets.


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Few Countries have Targets for Diet Related NCDsSource: Unpublished self-reported data from the NCD Country Capacity Survey, provided by the WHO Surveillance and Population-based Prevention Unit, Department for Prevention of NCDs. Printed with permission.%Percent of 174 countries with targets for

On the NCD side of things, less than a third of 174 countries surveys by WHO had targets (SMART or not) for obesity, diabetes and reduction of salt intake


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5. SMART Commitments and Targets Matter

Why are we worried about SMART targets?

Because

they lend themselves to stronger accountability

but also

they go hand in hand with performance (see next slide)


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Countries: Nutrition targets & rate of stunting reductionCompanies: Targets & performanceDonors: Public commitment & spending on nutrition

Commitment and Impact go hand in hand

In the report we give lots of qualitative examples of how commitment improved performance in reducing malnutrition

But we also provide some suggestive quantitative evidence

countries that set nutrition targets have higher rates of stunting reductioncompanies that set targets for key aspects of their performance, tend to perform better on those aspects (ATNI data)donors that make lots of public declarations about nutrition in their various documents tend to spend more on nutrition as a % of their overall spending

Causality is difficult to establish here. Determined stakeholders make commitments and back them up.

But the qualitative work in the report suggests that the making of commitments makes it harder to back out of action.


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SMART? Only 29%

Aligned to all forms of malnutrition? No. NCDs and obesity missing.

Response rate in 2016? 55% overall30% for businesses

Financial commitments?60% met good

Nutrition 4 Growth Commitments

One of the key things that the GNR does is to track Nutrition 4 Growth commitments made in 2013

We find

few of the original commitments in 2013 to be SMART (29%)original commitments not aligned to malnutrition in all its forms

High non response rate in 2016 despite us asking for self responses starting in January

On donor financial commitments the donors are doing really well (60% of 2014-2020 pledges met including US and WB (who made pledges for 2014-16) and 33% if they are excludedstill ahead of schedule)

We now look to the World Bank and the USG to make new commitments (their run out in 2016 while all the others run out in 2020) and we look to Canada, given its importance to international nutrition, to make an N4G commitment (they did not the first time around, in 2013).

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6. We must move beyond talk to action

We cant have results without good implementation.


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Coverage of nutrition-specific interventions remains highly variable across countries

This slide shows that when it comes to nutrition specific interventions there is a wide range of coverage achieved by different countries.

This is good and bad news.

Bad news because we want more countries with high coverage.

Good news in the sense that some countries have achieved high coverage but they are not obviously wealthier than the countries that have not.

We need to understand more about why some countries are near the top of the lines and some are near the bottom

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Implementation of the International Code on the Marketing of Breast Milk Substitutes is weak

Percent of countries with data (n=183) with no or few provisions of the Code in lawSource: WHO, UNICEF, IBFAN 2016. Marketing of Breast-milk Substitutes: National Implementation of the International Code, Status Report 2016. Geneva: WHO

Again, we know that implementing the Code is important, but implementation is not so strong.

Of 183 countries with info, 113 (or 62%) have few or none of the Code provisions in law.

Worst in the Americas and Europe!

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Data source: WHO, 2015,Progress on Implementing Diet Policies is Slow

Country self reported progress (to WHO) on implementing diet policies is also lagging.

Two thirds of all countries (n=193) report no progress.

Source: WHO 2015. Noncommunicable Diseases Progress Monitor 2015. Accessed March 2016. www.who.int/nmh/publications/ ncd-progress-monitor-2015/en/.

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7. Todays nutrition data are not sufficient to maximize investment

We need more data to guide action and promote accountability, especially at the subnational level.


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Stunting prevalence by region

Here are some DHS data and we show stunting rates for the administrative units with the highest and lowest stunting rates (ordered by gap).

There are wide disparities. At more disaggregated levels these may be equally large.

But we dont have very disaggregated pictures of nutrition outcomes (or coverage rates of programmes)

Any solutions? (next slide)

Source: Authors, based on data and analysis by Monica Kothari, Demographic and Health Surveys (DHSs), 20052014. Note: There may be discrepancies from data reported in the DHS reports because of subsequent transformations by the DHS team. All categories of prevalence have n > 50. DRC = Democratic Republic of the Congo.

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Map of stunting rates in Cambodia

One contribution could be from small area estimation maps. They combine survey and census data to give highly disaggregated nutrition maps.

They are common in poverty analyses and programming, less so in nutrition.

WFP is a leader in this area and we recommend more of these maps now be produced.

Source: Haslet et al (2013)

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Number of people displaced by war has risen45 million in 2012, 60 million in 2014Too little data on nutrition of refugee populations When they are measured (UNHCR), they are vulnerableIn the era of Leave No One Behind we needBetter monitoring of nutrition statusLeave no one behindrefugees included.

#leavenoonebehind

Unfortunately more people world wide are of no fixed location. They have been displaced by war.

45m in 2014, 60 m in 2015.

These people are very vulnerable & they are also vulnerable to malnutrition

We dont have much nutrition status data about them.

When they are measured (e.g. by UNHCR) they show high levels of malnutrition

The SDGs is the era of leave no one behindwe must not forget this highly vulnerable group, a large proportion of which are children.


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Calls to Action

We have outlined the 7 key findings

Now we do the same for the 5 calls to action.


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1. Make the political choice to end all forms of malnutrition

First of all, make nutrition more of a political issue. Technical issues are of course vital, but so too is political action.


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Reject current trendscontinuation of current trendsWHA goal15% by 202515% by 2084Anemia in Women

Dont accept current situation.

For example, look at this very simple extrapolation.

For womens anemia if we continue the current rate of progress as reported in Stevens 2013 Lancet paper, we will reach the Anemia target for women (prevalence of 15%) in 2084, not 2025.

Clearly this is unacceptable, but this is a potentially powerful political message that is not being made strongly enough.


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The ingredients for success are well known...and can lead to rapid improvements in nutrition.

Political leadership& SMART commitment

BrazilEthiopiaKenyaMaharashtra

Nutrition-oriented development

Bangladesh Colombia GhanaTanzaniaData Systems

GuatemalaIndonesiaPeruStrong implementation

ArgentinaBurkina FasoChile

And political leadership is vital for progress in nutrition

In the past 3 GNRs we have highlighted several countries experiences on moving nutrition indicators. They are listed.

Many factors are responsible and we have listed 4 sets.

Central to these is political commitment.

Remember: Ghana & Maharashtra halved their stunting rates 12 years. When forces are aligned properly rapid change can happen.


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2. Invest more and allocate better

Implementation takes financial resources.

Some of it needs to be new.

Some of it needs to be allocated differently.


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To meet WHA targets by 2025 funding will have to multiply:

Governments x 2

Donors x 3.5

Total x 3

World Bank/R4D Shekar et al. 2016Funding gaps: Substantial but bridgeable

Here are the estimates from the recent World Bank/R4D analysis.

They ask the question: how much extra money would it take to scale up nutrition specific interventions for all countries to meet WHA targets on stunting, EBF, womens anemia and to make significant progress on SAM (for various reasons they could not model the wasting WHA target).

They find that

Governments will need to at least double their spend 2016-2025

Donors will need to increase spend by a multiple of 3.5

Total spend will need to triple

Is this achievable?

Government funding to nutrition specific programmes would need to double. But it is very low currently (0.3% of current government expenditures for 24 countries) so this is surely achievable.

Donor funding would have to go up by a factor of 3.5. Encouragingly though, donor funding to nutrition specific interventions has double over the past 3-4 years.


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Mismatch of donor funding and disease burden for diet-related NCDs

10%0.04%0.04% of donor aid spending to diet related NCDs($50m)

Source: GNR 201610% % of disease burden in sub-Saharan Africa from diet related NCDs

Source: GBD Update 2015

For the first time we estimate the amount of ODA going to diet related NCDs

We find that only $50m is. This is 0.04% of overall aid spending.

Compare that to 10% of the disease burden in SSA coming from diet related NCDs

Clearly a mismatch

Donors need to do better


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3. Collect the right data to maximize the investments

What are the data needed to maximise the impacts of investments in nutrition?


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4. Invest in proven solutions & find new ones

To really make development work for nutrition, nutrition champions have to grow the circle of commitment for nutrition

This means getting out of our comfort zones and forging alliances with other sectors.


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Look outside nutrition to affect nutrition statusSource: Authors, based on data and analysis by Monica Kothari, Demographic and Health (DHS) surveys, 20052014.

Source: Authors, based on data and analysis by Monica Kothari, Demographic and Health (DHS) surveys, 20052014.

For example, the data we present shows a strong association between age of mother at birth and stunting rates of her children. (countries on left of graph)

How important for nutrition status might be a law that sets a floor for the minimum age of marriage that is consistent with health outcomes for the mother and child?

We dont know, but we should find out.

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agriculture and food systemssocial protectionwomens empowermentWASH

educationThere are many ways to support nutrition GNR analysis shows all 5 areas need strengthening

We need to find partners in these other sectors.

Some of the changes in them (to make them more nutrition oriented) might be very powerful for nutrition.

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5. Tackle malnutritionin all its forms

44% of all countries are facing multiple forms of under nutrition and NCD related nutrition outcomes

this % is likely to grow -- the latter are increasing faster than the former are declining


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Under 5 StuntingWomens AnemiaAdult OverweightEthiopia, Rwanda Ghana, Japan, Senegal, Sri Lanka, Thailand Argentina, Australia, Brazil, Chile, Colombia, Costa Rica, Germany, Mexico, Paraguay, Peru, FYR Macedonia, Tonga, USA, Uruguay Afghanistan, Angola, Bangladesh, Benin, Bhutan, Burkina Faso, Burundi, Cambodia, Cameroon, Central African Republic, Chad, Comoros, Congo, Cte dIvoire, Democratic Peoples Republic of Korea, Democratic Republic of the Congo, Djibouti, Eritrea, Gambia, Guinea, Guinea-Bissau, India, Indonesia, Kenya, Lao Peoples Democratic Republic, Liberia, Madagascar, Malawi, Maldives, Mali, Mauritania, Mozambique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Philippines, Sao Tome and Principe, Sierra Leone, Somalia, Sudan, Timor-Leste, Togo, Uganda, Tanzania, Zambia, Zimbabwe Honduras, Nicaragua Algeria, Azerbaijan, Barbados, Belarus, Belize, Bolivia, Bosnia and Herzegovina, Brunei Darussalam, Dominican republic, El Salvador, Gabon, Georgia, Guyana, Iran, Jamaica, Jordan, Kazakhstan, Kuwait, Kyrgyzstan, Malaysia, Mongolia, Montenegro, Morocco, Oman, Panama, Republic of Moldova, Saint Lucia, Saudi Arabia, Serbia, Seychelles, Suriname, Tunisia, Turkey, Uzbekistan, Venezuela Albania, Armenia, Botswana, Ecuador, Egypt, Equatorial Guinea, Guatemala, Haiti, Iraq, Lesotho, Libya, Namibia, Papua New Guinea, Solomon Islands, South Africa, Swaziland, Syria, Tajikistan, Vanuatu, Yemen

57 countriesSerious Problems

Here we can see that 57 countries for which data exist (44% of countries for which data exist) have serious public health problems with stunting/anemia AND overweight/obesity. (countries labeled in white).

India currently in the stunting and anemia category, but could easily slide across.


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Malnutrition is not destiny. Ending it is a political choicesupported by SMART commitments for accountability.Many countries are on course to meet targets.Many more are on the verge of doing so. Coexistence of multiple forms of malnutrition is the new normal. Nutrition stakeholders need to unite and then grow the nutrition constituency.Three takeaways

There is a lot of detail in the report and the slides.

But really there are 3 overarching messages that we would like you to leave with

politics matters. Malnutrition is not destiny. We can choose to end it. even though the world is off track to meet WHA targets, many countries are on course to meet these targets and many others are close to being so. There are many successes out there. Nutrition champions need to come together to raise nutrition on the political agenda


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Three things you can doChallenge decision makers with evidence on the slow pace of malnutrition reductionMake those essential but challenging alliances for nutrition with those outside your immediate circleMake SMART commitments for nutrition and ask others to do the same

But nutrition is not just about what governments and donors and businesses and CSOs can do, it is about what each of us in this room can do

Here are three things you can do


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Thank you

Thank you

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Global Nutrition Report 2016: From Promise to Impact

Education

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