The fall of nutrition as a global priority – and how to prevent it.
2020 is a big year for nutrition. Yet strangely I have never been more concerned about its future as a global priority.
Posted on October 18, 2019
The five-year countdown to the World Health Assembly (WHA) Global Nutrition Targets 2025 will begin, we will be halfway through the United Nations (UN) Decade of Action on Nutrition, and Japan will host the Global Nutrition Summit. Impressive progress has been made in nutrition, yet strangely I have never been more concerned about its future as a global priority.
I’m worried because nutrition is more fragmented today than it has ever been. I’m worried that without a focused message and a clear set of priorities, we’ll lose traction, and donors and countries will lean in elsewhere where more tangible progress can be made. I’m worried that nutrition will fall as a global priority and it will be the very people we exist to serve who will to pay the highest price. On my way back from the UN General Assembly (UNGA) a few weeks ago, I found myself wondering to what extent we in the global nutrition community might be part of the problem.
Many people conduct ‘post-mortems’ when things go wrong – to find out what happened so they can prevent it next time. I think it’s time for an honest ‘pre-mortem’ in nutrition. Let’s see if we can unpack some of the risks that might lead to the fall of nutrition as a global priority – and figure out how to head them off at the pass. I’m sharing these thoughts in the hope you’ll contribute your own ideas on the nutrition ecosystem and what we should do more of or less of in order to build the strongest possible case for keeping nutrition high on the global agenda.
Have you ever shined a flashlight on the wall and watched a cat chase it around? It’s fun. Add a dozen more cats – more fun. They’re all chasing that flashlight. Now add a dozen flashlights. Chaos. The nutrition community right now seems to be chasing a broad array of BSOs (bright shiny objects) without the prioritization or unity of focus required to drive concrete, measurable action at scale.
Nutrition is complex. There are some things we know, other things we don’t know yet, and many connections with other issues that determine nutrition’s impact are being explored. We need to fill data and evidence gaps – that is clearly important. However, the nutrition ecosystem right now is a cacophony of voices talking over – or past – one another.
We hear that food systems and diet are the most important things and the private sector holds the key. Others say the private sector is the problem and we should focus on regulation. Some say agriculture and food security are the best paths forward or that biofortification is the ultimate solution. There are those who want more focus on obesity and noncommunicable diseases, or the double or triple burden of malnutrition, while others advocate for early childhood development (ECD) approaches or call for greater action in the first 1,000 days.
We often hear of the imperative of multi-sectoral approaches or the centrality of the human capital approach. Climate change and its catastrophic impact on people and planet has led to public tug-of-wars on the virtues of plant-based versus high-protein diets. And with regularity, there are a multitude of high-profile studies on whether coffee, wine, and chocolate (to name but a few) are killing us or extending our lives.
The UN’s Decade of Action on Nutrition 2016-2025 is at risk of becoming the Decade of Meetings on Nutrition.
Listening to the global nutrition community and its many messages, people could be forgiven for being confused about where to start, what to do and how to do it, at what cost – and for what impact. If we are prioritizing everything – regardless of the availability or strength of evidence – is anything actually prioritized at all? In a resource-limited environment, this is a fatal mistake. The UN’s Decade of Action on Nutrition 2016-2025 is at risk of becoming the Decade of Meetings on Nutrition.
For example, the diverse nutrition messages referenced above are often being advanced as ‘better than’ (rather than ‘complementary to’ or ‘part of’) the other messages by organizations that seek funding for those very issues. The global nutrition narrative is being influenced by actors that are conflicted by their need to advance their own organization’s interests and this competition for slices of a still all-too-small pie is futile. With a unified front we stand a much better chance of growing the resource pie.
During the last cycle of global goals, nutrition was known as ‘the forgotten Millennium Development Goal’. For decades it languished on the sidelines. The 2008 Lancet series on Maternal and Child Undernutrition called for greater action after concluding that the global nutrition ecosystem suffered from:
The Scaling Up Nutrition Movement (SUN) was created in 2010 as a rallying point, and the 2013 Lancet Series on Maternal and Child Nutrition showed an evidence-based path forward to saving and improving the lives of millions. The 2013 Nutrition for Growth (N4G) Summit as well as leadership from the United Kingdom (UK), the Bill and Melinda Gates Foundation (BMGF), and the Children’s Investment Fund Foundation helped raise over $4 billion for strong, people-centered goals through 2020. Goals like improving the nutrition of 500 million pregnant women and young children, reducing under 5 stunting by an additional 20 million, and saving the lives of at least 1.7 million children. From this came the UN Decade of Action on Nutrition and the WHA Global Nutrition Targets 2025.
Since N4G in 2013, efforts to replicate this global high water mark for nutrition have failed and, on the road to Japan 2020, there are new risks to navigate. The UK is in disarray politically and may not be able to lead as it did in 2013, although their leadership is urgently needed and critical for success. The BMGF has just initiated a ‘strategy refresh’ on nutrition, the result of which won’t be known for some time (I will remain optimistic on this front however.) There is increasing replenishment fatigue across the development system with many priorities clamouring for attention, funding, and champions. Despite valiant efforts by the Government of Japan, without clear priorities, strong champions, and a unified voice, nutrition risks becoming the forgotten Sustainable Development Goal (SDG), putting the success of all the others at risk.
Here are several reflections about how we might keep nutrition high on the global priority list and drive greater progress and momentum:
We can’t break the intergenerational cycle of malnutrition and poverty without focusing on women, adolescent girls and children – putting their needs at the centre of our planning and prioritization. Specifically, we need to focus on women and pregnant women, adolescent girls, newborns, and children – those who have particularly acute nutrition needs. We need to prioritize doing everything we can to get the most vulnerable among them – by country, region, and district – the right nutrition at the right time.
We can’t break the intergenerational cycle of malnutrition and poverty without focusing on women, adolescent girls and children – putting their needs at the centre of our planning and prioritization.
The nutrition ecosystem has a major asset in the fight against malnutrition – six time-bound global nutrition targets due in 2025 that all countries have signed up to. Almost half of child deaths (5.3 million children in 2018) have malnutrition as the underlying cause. Recently, in India, a study put that figure at 68%. If you scaled up the World Health Organization’s list of Essential Nutrition Actions we could save 3.7 million lives by 2025. If you scaled up breastfeeding alone – we could save 800,000 lives each year.
We need to be speaking with one voice about the importance of this unfinished agenda, about the resource gaps, and about the impact we can have if we get it right. Specifically, we have to move faster than we currently are on interventions that make a measurable difference: vitamin A supplementation, multiple micronutrient supplements for pregnant women, weekly iron and folic acid for adolescent girls, zinc/ORS to treat diarrhoea, the proper treatment for severe acute malnutrition, exclusive breastfeeding (the most important part of the food system), and fortification are just some examples. We must strengthen the systems at country level so they can deliver. At the same time, we need to fill data gaps and work to build the evidence base for newer interventions.
The WHA nutrition targets are the canary in the coal mine for the 2030 SDGs.
Don’t get me wrong, I think the breadth of issues being taken on by the nutrition community are all important, but to varying degrees based on evidence, impact, and time horizon. To me, the WHA nutrition targets are the canary in the coal mine for the 2030 SDGs because they are due five years earlier and fairly tangible. If we’re a mile off, with no measurable acceleration of progress because we couldn’t generate the focus and urgency needed, why should donors or governments prioritize funding nutrition going forward vs. other areas where more impact can be made?
There isn’t a global plan to end malnutrition like there is for polio or tuberculosis (TB). We have a movement but there is no well-financed partnership or Global Fund for Nutrition similar to the one that accelerated progress in the fight against AIDS, TB and malaria or in vaccines. These issues have global plans, well-resourced partnerships, focused messages, and dedicated funding.
Many countries have built or are building national nutrition plans. Many partners are providing support in one way or another. Specifically, I’d like to see organizations and structures come forward with global plans in nutrition that are costed, evidence-based, and clearly define how they’re going to accelerate – and measure – progress towards the WHA targets. That would be a good starting point for bringing our efforts together.
We know that reaching the global targets will require more than just scaling up evidence-based interventions – we’ll also need to unlock the full nutrition benefit potential from education, WASH, ECD, agriculture, and food systems to get there. Scaling up what works along with building the evidence base in these and other areas should be our focus.
We need to figure out how to use other platforms to deliver the right nutrition at the right time, faster and at lower cost. Consider the following: malnutrition compromises the development of the two most important assets a human being has – their immune system and their brain.
Compromised immune systems are why 30% of people with TB have malnutrition as the main underlying cause. It is why malnourished children are twice as likely to die when they contract malaria. It is why malnutrition is a critical factor in determining health outcomes for people living with HIV/AIDS. The same is true for vaccines, which are less effective in malnourished children because their body cannot produce the strong immune response required. Compromised brain development due to malnutrition has similar impacts on education outcomes. No matter how many teachers we train, or books we buy, or schools we build, we will never achieve our education goals if children are cognitively damaged by malnutrition before they ever set foot through the door.
Organizations like GAVI, the Global Fund for AIDS, TB and Malaria or the Global Partnership for Education are investing billions of dollars every year scaling up evidence-based, proven interventions. Their outcomes are heavily compromised by malnutrition so it is in all of our interest to do much more to scale up nutrition too. Specifically, we need to take a ‘no missed opportunities’ approach and determine how to work with, support and leverage other organizations to accelerate progress towards the WHA targets – which are direct drivers of the SDGs. We’re all trying to reach the same people, it’s the right thing to do.
We also need to avoid missed opportunities by reaching out to other sectors to deliver the full spectrum of evidence-based interventions and we have to do this by being innovative and opportunistic. For example, in-school adolescent girls where anaemia rates are high should be able to access weekly iron and folic acid via school platforms. The same platforms should be used to advance awareness about the importance of healthy diets and other issues such as sexual and reproductive health, which are often much more difficult to establish in isolation.
We need to take a ‘no missed opportunities’ approach and determine how to work with, support and leverage other organizations to drive progress.
We should use existing delivery highways to rapidly roll out new nutrition innovations. For example, salt iodization is one of the biggest global health success stories in nutrition and has reached billions of people – let’s do the same for double fortified salt to fight anaemia and iodine deficiency as Madhya Pradesh is currently doing. This innovation is ready to scale. The evidence in maternal nutrition shows that multiple micronutrient supplements have a greater impact on low birth weight and other issues – let’s roll them out in place of iron and folic acid supplements where it is warranted. We must target social protection programs so they provide vulnerable populations with fortified quality food instead of the cheapest, lowest-quality staples. We can accelerate our pace in nutrition if we adopt these ways of thinking more systematically. We know the benefit of many of these approaches already, we just need more focus and funding.
We have seen some promising advances in nutrition in recent years. For example, the creation of the Power of Nutrition, an innovative financing initiative focused on scaling up a package of evidence-based interventions. The World Bank’s Investment Framework for Nutrition which mapped out the costs of going to scale and impact potential of similar interventions. The priority given to nutrition by former World Bank president Jim Kim and the sharp increase in financing for nutrition that followed.
The leadership of President Adesina to focus the African Development Bank more deliberately on people and ‘gray matter infrastructure’ development, supported by the Banking on Nutrition partnership with Big Win Philanthropy and Dangote Foundation. More than 60 countries signing up as members of the SUN Movement as a sign of their intent. Most recently, the appointment of the 27 global leaders to the SUN Lead Group, under the capable stewardship of UNICEF’s Henrietta Fore, offers an opportunity to bring renewed focus and attention. These are but a few examples.
Given the importance of the moment, and the fragmented nature of the nutrition ecosystem, nutrition leaders must pull different voices, agendas, and organizations together behind a common objective. Specifically, we must not only celebrate success but also look self-critically in the mirror when things could be better. Vision, creativity, diplomacy, and a good understanding of political economy are needed now more than ever in order to navigate differences, create alignment, increase momentum, and generate impact. This is a daunting task that many have dedicated significant time and genuine effort to, but it is time for a renewed call to action. There is an urgent need for leaders in nutrition to speak up about the existence and importance of the WHA targets with much more volume, intention, and consistency – particularly on the road to the Nutrition Summit in Japan. The cost of failure is simply too high not to.
Making faster progress in nutrition is possible. To do this, we need to scale up what works, support countries to deliver in new and innovative ways, and build the evidence base in other promising areas. We need to do this to accelerate progress towards global targets, and demonstrate that nutrition is worth investing in because it gets results. We need to remember to focus on people, especially women, adolescent girls, and children – and put them at the centre of everything we do because they hold the key to ending malnutrition.
It’s time to ring the alarm bell on the global nutrition targets.
The next opportunity to do that is the Global Nutrition Summit which takes place in Japan late in 2020. The Summit will be the starting gun for the last five-year sprint to the WHA Global Nutrition Targets in 2025. Between now and then we should do everything we can to encourage countries, donors, and partners to bring clear commitments that demonstrate how they will accelerate progress against the targets. The Summit will wisely come with a detailed accountability framework – and there is no accountability if the commitments cannot be measured. If we focus on driving impact against the WHA and SDG targets, there is every reason to believe we can leverage the kind of resources we see for GAVI and the Global Fund.
Malnutrition is a social justice issue – and the poster-child of inequity on our planet. People living in poverty experience the worst effects, and are the least able to afford nutritious food or low-cost, high-impact interventions that could save their lives and change their developmental trajectory. They can’t afford to wait. It’s time to ring the alarm bell on the global nutrition targets and it’s time to bring a new level of focus and alignment to our efforts to achieve them.