DFID’s new position paper ‘Scaling Up Nutrition’ declares a crucial role for research. The paper declares: “We will be achieving our results in nutrition through scaling up programmes where there is evidence of fast and sustainable impact. And we will be working with others to make sure that we fill knowledge gaps and generate new research on what works and what does not in our drive for value for money.”
The scale of the problem of undernutrition in and amongst the poorest in some middle-income countries continues to be an uncomfortable fact in the global food security debate. It is a condition described by UNICEF Executive Director Anthony Lake as a preventable silent emergency. Levels of global hunger remain unacceptable; at least one billion people go hungry every year and a further one billion don’t get enough vitamins and minerals. Estimates suggest that 195 million children under 5 years of age are chronically malnourished and more than 1 in 10 children are acutely malnourished.
The ‘known knowns’ on nutrition and development
We know that high levels of coverage of nutrition-specific interventions can reduce stunting by a third - if delivered at scale - and address a quarter of child deaths.
Nutrition-specific interventions, which address the immediate causes of undernutrition, have been proven to deliver among the best value for money of all development interventions. Vitamin A and zinc supplementation, salt iodisation and crop bio-fortification have been ranked among the top 5 best development buys. And evidence from large scale studies involving 24,000 households has confirmed that women and children benefit enormously from eating orange-fleshed sweet potatoes they grow themselves, because of high vitamin A levels that they contain. On the basis of this evidence, DFID has pledged to provide high-zinc rice to 1 million households in Bangladesh by 2016 and is contributing to CGIAR efforts to get orange-fleshed sweet potato to 10 million people in 17 countries.
It has also pledged to place increasing priority on building the evidence base through research, and coordinating with others on their research investments, to ensure that there is a much larger body of high quality evidence available by 2015 to inform future programmes. It has committed to double its investments in nutrition research.
Advances in science and technology offer unprecedented opportunities to improve the nutrition and health of those most at risk of undernutrition. But the evidence on how to achieve high levels of coverage and what are the best approaches to tackling adolescent and maternal undernutrition, is still incomplete.
Why, after so many years of being a peripheral topic that was visible to many but acted upon by few, has nutrition ‘come into the light’ of public attention now?
The perfect storm
Nutritional security has become an issue for developing countries because of a coincidence of factors and changing contexts which are shaping debates on intervention. Rising and volatile food prices, increasing pressure on natural resources, climate and environmental variability all continue to place unprecedented burdens on agriculture in the developing world. In this context, there is renewed interest in the types of intervention that build resilience; why past interventions failed to have a sustainable impact; and how better nutrition outcomes can be achieved across different development sectors.
Research on nutrition and nutritional security are areas where new thinking needs to be defined enough to deliver coherent development interventions, yet open enough to realize the complexities of the problem and not constrain innovation. The Global Hunger Index (GHI) 2010 published by the International Food Policy Research Institute (IFPRI) considers the problem of undernutrition to be 1 of the leading causes of lifelong harm to health, productivity, and earning potential.
But as the ongoing humanitarian catastrophe in the Horn of Africa has highlighted, the nutrition problem is multi-faceted. Andrew Mitchell, Secretary of State for International Development, says in the new position paper on Nutrition published today, “Chronic undernutrition is born of many factors, including poor health, cultural issues, the status of women, low incomes, and ultimately, a dearth of concerted effort to address it. Any solution will need to take account of all these complexities”.
A journey travelled and some new perspectives
DFID has already made considerable investments in nutrition-related research to date. This diverse research portfolio includes core support for the work of the International Centre for Diarrhoeal Disease Research in Bangladesh on major aspects of public health such as nutritional interventions for prevention and cure of diseases such as kala-azar. This neglected disease is caused by the bite of an infected female sandfly, which thrives in the cracks and crevices of mud plastered houses, in heaps of cow dung, in rat burrows and in bushes and vegetation around the house. It is thought that around 50,000 people die from kala-azar every year, and in Bangladesh alone, 20 million people are thought to be at risk, the majority clustered in the north-eastern border area with India. In the most recent Annual Report from the Centre, Dr Dinesh Mondal explains that “Kala-azar mostly affects impoverished people, and so we offer nutritional interventions, as well as trying to eradicate the disease”.
A different entry point has been taken by another DFID-funded research programme which tackles women’s empowerment. The first Conditional Cash Transfer project to be carried out in the Arab world has made nutritional awareness sessions part of a package of conditions that came with monthly cash transfers for 160 families. The intervention, led by the Social Research Center of the American University in Cairo as part of the global Pathways to Women’s Empowerment research programme, has had positive results. These include increased demand for better healthcare in the district and higher demand for after-school clubs. Policymakers have taken note of this success, and the pilot has now been scaled up to reach 65 villages in rural Upper Egypt.
The DFID-funded Young Lives research programme, which follows the lives of 8,000 children in 4 developing countries, unpacks the global statistics. Their research shows average malnutrition rates ranging from 10% in Vietnam to 31% in Ethiopia. The situation is even worse for some sections of society: children living in rural Peru or in rural Ethiopia face average malnutrition rates of around 40%. The longitudinal study is important because it shows that nutritional deficits early on in a child’s life bring negative outcomes during later stages of childhood.
Future work focuses on expanding the range of systematic reviews to synthesise data on key areas of nutrition programming. In addition, large trials will be commissioned to rigorously test the impact of specific interventions such as transfers and nutritional counselling on low birth weight in Nepal; the impact of improved sanitation on nutritional status in Zimbabwe; and community-based treatment of severe acute malnutrition in Madhya Pradesh, India. DFID Research plans to support a randomised control trial to address a current evidence gap on what is the proportional impact of clean water and toilet provision on child health and nutrition in Orissa, India.
Two new major research programme consortia (RPC) have been commissioned during the year, each providing funding over six years. The first, Transform Nutrition (see section below) will address key research questions relating to the challenges of scaling up nutrition-specific interventions in different settings, the effectiveness of nutrition sensitive interventions, and the promotion of enabling environments.
A second RPC, which focuses on South Asia will be launched towards the end of 2011. It will ensure that high quality evidence is generated on the linkages between agricultural policies, investments and nutrition outcomes, and on effective actions for making agriculture more pro-nutrition. The programme will ensure that this evidence base is used by policy makers and practitioners in Afghanistan, Bangladesh, India and Pakistan to accelerate nutrition security.
A new Senior Research Fellow will be appointed provide expert guidance to the department, and a research mapping exercise in agriculture and nutrition is planned in concert with other donors to determine research gaps and potential additional areas of research investment.
Transform Nutrition seeks cross-sector interventions
A new 5-year DFID-funded research programme will be investigating the often overlooked problem of lifelong undernutrition. The Transform Nutrition Research Programme Consortium (RPC), which is led by IFPRI, seeks to transform thinking and action on ‘the neglected crisis’ of undernutrition in Sub-Saharan Africa and South Asia. The programme argues that research must first be appropriately prioritised, implemented, scaled up and sustained in different settings to have maximum impact on improving nutrition during early childhood.
“Why has nutrition been neglected for so long?” asks Dr Stuart Gillespie, CEO of Transform Nutrition, “Why has the massive size of the problem and the evidence of its multiple links and consequences for many different people, over different time spans, been relatively ignored until recently? Is it because it is so all-pervasive that it is seen as part of normal life? Undernutrition in many areas of Africa and South Asia is so widespread it is almost invisible - to mothers in villages, and to politicians in government”.
However he adds that nutrition overall is now better understood and concepts like the intergenerational transmission of undernutrition and the long-term damage of nutritional deficits in early life (first 1000 days) are key insights which are beginning to inform the design of cost-effective undernutrition prevention.
But how do we grapple with the multifaceted problem of undernutrition without being overwhelmed by it? The approach adopted by Transform Nutrition focuses on breaking down these problems and exploring practical solutions at three different levels. First, direct nutrition-specific interventions (the 12 essentials); second, indirect ‘nutrition-sensitive’ actions (in agriculture, social protection, water and sanitation, and women’s empowerment); and third, considering the significance of the ‘enabling environment’ (policies, politics, people) that has hardly been researched at all. In Dr Gillespie’s view the priority is to “build capacity and connections, but also to generate quick wins”.
Basing interventions on actionable evidence is essential for transforming thinking and action on undernutrition. We need, increasingly, to know ‘what works’ at scale and how to reduce lifelong undernutrition in challenging development contexts. To achieve this, DFID has pledged in its position paper to design effective nutrition-related programmes within its humanitarian, health, livelihoods and social development professional cadres. Specifically, it is supporting the London School of Hygiene and Tropical Medicine to develop a Distance Learning Course on multi-sectoral nutrition programming, which will be publicly available.
This new thinking on intervention and the significance of life-long nutrition reflects a growing policy consensus on how the nutrition challenge should be tackled. This is enshrined in a new global movement: Scaling-Up Nutrition (SUN), which was launched in September 2010 with the backing of global partners including DFID, who committed to give strong political backing to scaling-up nutrition interventions which focus on the first 1000 days of a child’s life. DFID has announced that it will do more to develop vitamin-enriched crops through the CGIAR Harvest plus Challenge Programme, getting vitamin A maize into the hands of an additional half a million farmers in SUN countries. Harvest Plus has delivered pioneering innovations aimed at improving the health of poor people by breeding staple food crops that are rich in micronutrients and have superior agronomic properties. It is rolling out 7 new key staple crops that will have the greatest impact in alleviating micronutrient malnutrition, or hidden hunger, in countries in Asia and Africa.
Global policies for scaling up nutrition (such as might be framed during the Agriculture Development and Food Security discussions at the 66th Regular Session of the UN General Assembly being held this week in New York) draw more now from research evidence than they did in the past. This is due partly to the increasing efforts of researchers to communicate their work more effectively to policymakers; and partly because the mantra of ‘evidence-based policymaking’ is - slowly - turning into increased demand for research evidence from the policymakers themselves.
However, whilst researchers may be able to help policymakers understand how programmes can be better implemented, the effective implementation of global policies on undernutrition remain hampered by a paradoxical relationship between food security on the one hand, and mechanisms of the market on the other.
Small details, big impact
The growing emphasis on lifelong nutrition has been pioneered by DFID and its global partners through support for innovative research in this important area. As a founding member and leading donor to the Consultative Group on International Agricultural Research (CGIAR) since 1971, DFID has been especially active and influential in backing research on food security, contributing to CGIAR’s impressive track record of delivering technology with a high impact on agricultural productivity. Core DFID funding has supported an array of initiatives including work of the International Maize and Wheat Improvement Centre (CIMMYT) into better seed and cropping practices and the development of plants that naturally resist diseases and pests, tolerate too much or too little water, overcome the limitations of poor soils, survive excessive cold or heat, offer more nutrition, are more marketable, and yield more grain for food or sale.
Potential Impact of the CGIAR’s Research: Some Examples
- research to increase rice yields will raise farm incomes, lower the price of rice, reduce hunger, and cut by 3 million hectares the land area required to grow this key food staple. The objective is to produce enough additional rice to free more than 100 million from hunger in Asia
- research to reduce disease risks and improve nutrition (e.g. through more nutritious crop varieties) will improve the health of poor and vulnerable people, especially women and children. Savings to the global economy could amount to US$30 billion
- research on climate change, agriculture and food security will reduce the vulnerability of crops to drought, flooding, salinity, pests and diseases. In so doing, it will help cut poverty by 10% and the number of undernourished rural poor by 25%. It will also cut greenhouse gas emissions
- research on water scarcity and land and ecosystem degradation will protect productive land and rehabilitate degraded land. Water and land management that sustains and improves ecosystem services will make poor farm households and communities more resilient and substantially increase crop yields
These are but a few examples of DFID support for research which places the emphasis squarely on science, evidence and sustainable impact. This new policy agenda which places nutritional security at the heart of long-term poverty alleviation is an important step forward, with nutrition no longer deemed a ‘footnote’ to agriculture and health spending.
Research also provides a way of keeping the nutritional debate sharp and refreshed. This is essential if policy discourses are to be informed by the best possible evidence. R4D is one example of the remarkable wealth of research materials now freely available online.
The role of research in the making of valid, sustainable interventions that deliver impact and value for money is now widely recognised. A broader focus on life-long nutrition appears to be gaining wider acceptance within the international development arena. The need for actionable evidence to support direct and indirect interventions has been recognised and supported by DFID and key partners in the international development community. Yet the current vocabulary of ‘scaling up’ is a constant reminder to us all of the need to do more to combat existing levels of lifelong undernutrition across the developing world, and ensure that global policies are implemented effectively.