Transcript Overcoming hidden hunger in children’s first 1000 days

Overcoming Hidden Hunger
in Children’s first 1000 Days:
Political Economy and Research Directions
Joachim von Braun
Center for Development Research (ZEF)
Professor for Economic and Technological Change
University of Bonn
Opening key note to
2nd International Congress on Hidden Hunger
March 4, 2015 / Hohenheim, Germany
Agenda
1. The Range of Problems
2. Political Economy of (In-)action
3. Research Directions
J. von Braun 2015
State of the problem
Globally 805 million (1 in 9) people
undernourished
Yet 2 billion people suffer from hidden
hunger
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Hidden Hunger
• Hidden hunger: “…a chronic lack of vitamins
and minerals that often has no visible warning
signs, so that people who suffer from it may
not even be aware of it.
• Hidden hunger can lead to mental
impairment, poor health and productivity, or
even death.”
• Majority of burden among women and
children in low- and middle-income countries
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Source: Micronutrient Initiative
A global problem:
micronutrient deficiency by regions
Percentage of population with selected micronutrient deficiencies
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Source: GHI report 2014, data from Lancet 2013
Anemia prevalence in pregnant women
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The aggregate picture: Micronutrient
deficiencies (in terms of DALYs) are widespread
and affect large shares of populations
Population-adjusted hidden hunger
associated Disability Adjusted Life Years
(DALY) (HHI-DBa) in 136 countries.
Source: The Global Hidden Hunger Indices and Maps: An Advocacy Tool for Action
Sumithra Muthayya, Jee Hyun Rah,Jonathan D. Sugimoto, Franz F. Roos, Klaus Kraemer and Robert E. Black. PLoS One. 2013; 8(6): e67860.
Critical data gap: no sound time
dependent MN deficiency information
> poor metric for
national and global
monitoring of
progress
> when tracking
progress is
constrained this leads
to low commitment
to invest
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Must get to time series of these data!
• Iodine (~1.8 billion)
– Reduced mental capacity, goiter
• Iron (~1.6 billion)
– Impaired motor & cognitive
development, increased maternal
morbidity and mortality
• Vitamin A (190 million preschool
children; 19 million pregnant women)
– Night blindness, higher risk of
illness and death in children
• Zinc (1.2 billion)
– Weakened immune system,
stunting
Source: Global Hunger Index Report 2014, p.26
Data weaknesses matter for
political positioning of MN-problems
Capacity gaps and political concerns can pose barriers
– Out of date or scarce data on nutrition trends and program
effectiveness
• Quality of surveys may be questioned
• Slow analysis and dissemination
Lack of “data” champions
– Need evidence based consistent messages from organizations
involved in nutrition (SUN, 1000 days, etc.) on programming
(more see Global Nutrition Report, IFPRI 2014)
These data limitations weaken the position of
nutrition in the SDGs
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The importance of the First 1,000 Days
The first 1,000 days are the most critical period for
adequate growth and development
Poor maternal and child nutrition during this critical
time seems often irreversible
Improving the nutrition and health of women and
children can have lasting effects for future
generations
United Nations : http://www.un.org/en/issues/food/taskforce/pdf/UN_SUN_FactSheet.pdf
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Agenda
1. The Range of Problems
2. Political Economy of (In-)action
3. Research Directions
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The framework
on “basic” and
“immediate”
causes by The
Lancet (2008)
is good, but
attention by
research and
policy action
focusses too
little on “basic”
causes
Policy and Market failure
Issues to be addressed
What are the basic causes for the
large MN problems?
•
•
•
•
•
Poor people are too poor to act
The affected people do not know
Goverments do not know how to
Goverments do not have enough resources
The MN problems are too complex to fix
These are certainly part of the reasons,
but not the fundamental reasons!
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The fundamental causes of persistent MN
deficiencies
• Policy / Government failures
and
• Market failures
Unfortunately: both failures exist for
reasons not easy to overcome
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Market failure and
Policy/Government failure
• Market failure is a problem which prevents
the market from operating efficiently
• Government failure is a systemic problem
which prevents an efficient government
solution to a problem
• Government and market failures can be on
both the demand side and the supply side.
Ronald Coase (1935), Roland McKean (1965)
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The role of governance matters for MN
Governance?
… the traditions and institutions by
which
authority in a country is exercised.
…The capacity of the government to
effectively formulate and implement
sound policies; and
…The respect of citizens and the state
for the institutions that govern
economic and social interactions
among them.
Governance Components:
Voice and Accountability, Political Stability and Absence of Violence, Government
Effectiveness, Regulatory Quality, Rule of Law, Control of Corruption
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Policy / Governance Failures seem
to matter for MN Deficiencies
Micronutrient deficiencies
Voice and accountability deficiencies
Children <1000 days have no political voice, except through their
care givers, who often also have no voice
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Part of basic causes : Marginality (incl.
discrimination and exclusion) relates to MN deficiencies
Source: von Braun, Gatzweiler (ed) 2014, Graw & Husmann, Ch5, free online book
http://www.springer.com/environment/book/978-94-007-7060-7
Taboos and dogmas may neutralize
will for policy action
Who, what, and how?
– Length of breastfeeding in different contexts
– Complementary early childhood feeding
– Fortification of which type (supplem., industrial
fortif., bio-fortif., healthy diet grown at home,
GMOs for fortification, etc.)
– Public sector only / private sector only
Contentious debates keep public policy at low levels of
engagement
All these themes need more evidence based research
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Multiple policy failures lead to low supply
and demand for public MN-services
Public policy failure on supply (S) and demand (D) side
SMNpolicy
=
DMNpolicy
• lack of public policy incentives for MN Supply
• Lack of incentive for quality and efficiency of
public services for MN Supply
• lack of MN deficiency affected political voice
for MN services Demand
Result: both S and D remain at low levels
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1000
900
800
wheat $/tonne
700
500
150
400
300
100
200
50
100
0
0
Source:FAO, FAO Giews.
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Index
1/2000
5/2000
9/2000
1/2001
5/2001
9/2001
1/2002
5/2002
9/2002
1/2003
5/2003
9/2003
1/2004
5/2004
9/2004
1/2005
5/2005
9/2005
1/2006
5/2006
9/2006
1/2007
5/2007
9/2007
1/2008
5/2008
9/2008
1/2009
5/2009
9/2009
1/2010
5/2010
9/2010
1/2011
5/2011
9/2011
1/2012
5/2012
Price ($/mt)
Extreme Food Price Volatility as a
Symptom of Market Failure
300
rice $/tonne
250
cereal price index
200
600
Volatility: a risk for Children‘s nutritional status
Underweight
Stunting
-4.408*
(2.605)
-6.292*
(3.238)
-0.327***
(0.109)
-0.375***
(0.114)
9.904***
(1.490)
3.894**
(1.619)
Female/male school
enrolement
-0.156***
(0.0710)
-0.213*
(0.108)
N
R-squared
Number of countries
300
0.430
93
291
0.392
92
A panel regression.
Data: Low and middle
income countries
Sources:
Log GDP (PPP/cap)
Worldbank development
indicators: GDP
Improved Sanitation
WHO: Sanitation,
Stunting, Underweight.
ILO: Food price indices
1990 - 2012
significant at
*** 1%, ** 5%, * 10%
level;
country fixed effects
included
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Food Price Volatility (CV
of FPI)
Source: Kalkuhl et al. 2013 (ZEF)
Multiple market failures lead to low supply and
demand for private sector MN goods and
services
The market for MNs: failure on supply (S)
and demand (D) side because of hidden
benefits
Smarket
=
Dmarket
Price
• lack of private sector incentives in S
• lack of users‘ D due to lack of awareness
• no efficient price formation for MN goods and
services
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Yet: there is a market for supplementary
nutrients, mostly trageting the rich
A growing market for Vitamin C, D, Omega 3,
multi-vitamin supplements, fortified products etc.
• What regulations could make these markets
effective to reach deficient population groups?
• How can these markets be expanded to work
pro poor?
• What role for public information and labelling
to enhance healthy user behavior?
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So what to do in view of this set of
fundamental causes of systems failures?
•
•
•
•
•
•
Public Private Partnerships?
Corporate Social Responsibility?
Information campaigns?
Multi-stakeholder initiatives?
Policy dialogues for commitments (UN, G8/20)?
Donor funding?
…have not made the big impact so far
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Political economy of stakeholders, ideas,
and interests
• Creation and sustaining of momentum
– Incentivizing and delivering of horizontal coherence
(multi-sectoral coordination)
– Development of accountability to citizens
– Enabling and incentivizing of positive contributions from
the private sector
• Conversion of momentum into results
– Delivery of vertical coherence
– The role of civil society and the private sector in delivery
Gillespie, S. , Haddad, L. , Mannar, V. , Menon, P. , & Nisbett, N. (2013). The politics of reducing malnutrition: Building commitment and
accelerating progress. LANCET, 382(9891), 552-569.
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Pitfalls of Multi-stakeholder efforts
• Hidden prioritization of own interests
• Power play constraining inter-sectoral cooperation
(e.g. public health / agriculture / water)
• Lack of accountablity
• Long ways to trust
• Timid re scaling up
• Low risk taking / high preference for conventional
approaches
• Free riding on positive results
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Scaling up Nutrition (SUN)
• In recognition that direct interventions are not enough to
prevent stunting, nutrition sensitive approaches incorporated
into global advocacy
• SUN framework action is driven by multi-sectoral platforms at
high-level supporting both nutrition specific and nutrition
sensitive
The start of SUN was a positive change in national and
international nutrition policy, but the end game of SUN needs to
be different:
Growing from SUN accountable nutrition agencies
facilitating nutrition action at national and
international levels
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SUN Results orientation
• Collective action bringing together
governments, civil society, the United Nations,
donors, businesses and scientists
• After 4th year, 54 countries scaling up nutrition
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Public Private Partnerships (PPP) –
show some progress
• SUN reports interest from countries in
gaining a greater understanding of
private sector role and market-based
approaches (SUN-BA)
• 29 countries have requested support
from SUN-BA
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Source: Global Nutrition Report 2014
Research points at positive examples of
countries or Public Private Partnerships
• China: Marketing and selling of multinutrient
powders (Ying Yang Bao) to caregivers of children
aged 6–24 months reduced the risk of anemia by
87% (Sun J, Yaohua D, Shuaiming Z, et al. Implementation of a program to market a
complementary food supplement (Ying Yang Bao) and impacts on anemia and feeding
practices in Shanxi, China. Mat Child Nutr 2011; 7: 96–111)
• Western Kenya: Sale of MNP via community vendors
reduced iron and vitamin A deficiency in children
aged 6–35 months. (Suchdev PS, Ruth LJ, Woodruff BA, et al. Selling Sprinkles
micronutrient powder reduces anemia, iron deficiency, and vitamin A deficiency in young
children in Western Kenya: a cluster-randomized controlled trial. Am J Clin Nutr 2012; 95:
1223–30.)
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Addressing the fundamental causes
of in-action
1. Market failures?
Create markets by prioritizing the demand side to pull
supply side (information, nudging, campaigning)
2. Policy / Government failures?
Create demand for action by strengthening voices of
MN deficient people
3. To address both failures: toward dedicated nutrition
organizations at national and international levels
(rather than spending high transactions costs on multistakeholder initiatives)
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Agenda
1. The Range of Problems
2. Political Economy of (In-)action
3. Research Directions
J. von Braun 2015
Must invest in the continuum of data
and analytical needs
These data weaknesses must be overcome
• Biomarkers:
– For many of the micronutrients, no reliable biomarkers exist
• Zinc ex. serum or plasma zinc concentrations are informative, but still gaps in our
understanding of the relationship between them and zinc intakes and needs
• Iron, vitamin A need improved biomarkers
•
Individual level health/nutrition:
– Relationship between intake and utilization is not well understood for many micronutrients
– Host-level factors
•
Population level:
– Micronutrient surveys are complex and expensive
• Scarce resources channeled to other priorities
• Lack of political will and commitment
•
Cross-sector analysis:
– Evidence linking nutrition sensitive (and other sectors) to nutritional impact lacking
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Research has shown the ways towards effective
micronutrient interventions (some examples)
• Multiple micronutrient supplements, including
powders (MNP)
– Systematic review: micronutrient powders significantly improved
hemoglobin concentration and reduced IDA by 57%; retinol deficiency
by 21%
• Preventive zinc supplementation
– In at-risk of zinc deficiency populations, reduces the risk of morbidity
from childhood diarrhea and acute lower respiratory infections; may
improve linear growth & weight gain in IYC
• Vitamin A Supplementation
– Cochrane review of 43 randomized trials, in children 6–59 months, VAS
reduced all-cause mortality by 24% and diarrhea-related mortality by
28%
• Iron supplementation
– Cochrane review of 33 studies-intermittent iron supplementation to
children <2 decreased anemia risk by 49% and iron deficiency by 76%
Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, Webb P, Lartey A, Black RE; Lancet Nutrition Interventions Review Group; Maternal and Child Nutrition Study Group. Evidence-based interventions for improvement of maternal and child nutrition:
what can be done and at what cost? Lancet. 2013 Aug 3;382(9890):452-77. doi: 10.1016/S0140-6736(13)60996-4; Imdad A, Herzer K, Mayo-Wilson E, Yakoob MY, Bhutta ZA. Vitamin A supplementation for preventing morbidity and mortality in children from 6
months to 5 years of age. Cochrane Database Syst Rev 2010; 12: CD008524; De-Regil LM, Jefferds MED, Sylvetsky AC, Dowswell T. Intermittent iron supplementation for improving nutrition and development in children under 12 years of age. Cochrane
Database Syst Rev 2011; 12: CD009085.; Salam RA, MacPhail C, Das JK, Bhutta ZA. Effectiveness of micronutrient powders (MNP) in women and children. BMC Public Health 2013;13 Suppl 3:S22. doi: 10.1186/1471-2458-13-S3-S22.; Imdad A, Bhutta ZA.
Effect of preventive zinc supplementation on linear growth in children under 5 years of age in developing countries: a meta-analysis of studies for input to the lives saved tool. BMC Public Health. 2011; 11 (suppl 3): S22.
J. von Braun 2015
MN Research must come out of its niche and
link with related big issues
Big example: linking MN research with the sanitation and drinking
water research and action agenda for synergy captures
Proportion of population using improved sanitation in 2012
Source: WHO, UNICEF (2014)
Linking MN deficiencies to frameworks beyond
food - nutrition – health (especially water, sanitation, agriculture)
 What are the WaterSanitation - Food
System – MN - Health
linkages?
 Their trade-offs and
synergies?
 Impacts of joint
interventions?
 Economic efficiency
payoffs?
Water
Quality
&
Quantity
Health
&
Nutrition
Food,
Agriculture
&
Irrigation
Sanitation
&
Hygiene
Research: Coming to larger islands of consensus
• Operational research on delivery, and
implementation
• On scale-up of interventions, and contextual analyses
to achieve success at scale in various contexts
• Beyond “enabling environments” (Lancet 2013)
toward institutional and organizational innovations
and political economy
• Testing collaborative platforms to spearhead R&D to
benefit both, public health and private business
interests
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Research on First 1000 Days
• Evidence base of what are best nutrition
investments for First 1000 Days needs
strengthening, incl. focus on mothers
• Synergies between investments in health and
sanitation environments versus direct micronutrient actions needs research attention
• Nutrition governance needs hard research, not
just following believes that some form of
alliances is most effective and efficient for
nutrition progress
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Addressing the fundamental causes
Fundamental are policy failures and market
failures.
1. they need to be addressed frontally in
intergovernmental fora (UN, G7/20)
and by
2. strengthening of demand for public MN
goods and services, and driving that demand
needs science base and people movements
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