A Paradox

The topic of nutrition presents a paradox. On the one hand, nothing should come as naturally as good nutrition.

Like breathing, drinking water, and sleeping; it is essential to survival, and should be programmed into everything we do. It should not require a second thought. Our biological and social systems should be designed to deliver this most essential function, effortlessly. Yet malnutrition in one form or another affects nearly half of the world’s population. And we know that hunger and malnutrition have been with us for least tens of thousands of years.

Far from being taken for granted, nutrition occupies the thoughts of hundreds of millions of people every day. It is a tragic daily obsession for those suffering acute hunger. Some 805 million people in the world do not have enough food to lead a healthy active life. That’s about one in nine of us.

Nutrition is also a daily obsession for millions concerned with obesity and weight loss.

In the US alone, the weight loss industry is estimated to be worth 60 billion dollars last year. It has fuelled a long string of packaged diets –Atkins, South Beach, Beverly Hills, Dukan, Paleo, Sniff Vanilla, Paint your Kitchen Blue. They all come with breathless and often miraculous claims of transformational change. They go in and out of fashion. Even though, as a nation, we become more and more obese.

My own daily obsessive thoughts began at the age of 14 when a bulging belly and adolescent angst prompted me to follow the Atkins Diet for six weeks. That started a lifetime of struggling to manage my own weight through a combination of diet and exercise – that has sometimes worked, but often failed. I still live in an obesogenic environment, and follow an obesogenic lifestyle.

As a young adult, I read Frances Moore Lappé’s remarkable book, Diet for a Small Planet.

It prompted me to be vegetarian for nine years in an effort to save the planet from the wasteful ravages of industrial meat production. Sadly, my single act of conscience has not stopped climate change. And I’m long back to eating meat. Individual choices matter.

But as we all know, real and sustainable change has to happen at the level of policy and systems.

The Knowledge
That has been a theme of the Forman lectures for more than 20 years: change policies; change systems. And Marty Forman . . . though I never had the honour of meeting him . . . advanced that key insight as one of the great champions for better nutrition policy. Looking around this room today, we have row upon row of champions on nutrition. Looking back at previous lectures, there’s an encyclopaedia of insight and knowledge on what works; particularly for tackling food insecurity, stunting, wasting, and anaemia.

If we focus on undernutrition, we have known for some years what needs to be done: Good health care is essential. And many factors are required to make sure mothers and children get the right nutrients at the right time. Exclusive breastfeeding, care practices, and dietary diversity count. Agriculture, WASH, and social protection all have a role to play.

This package was originally posited in the UNICEF conceptual framework in 1990 and reinforced ever since. For this to succeed we need to build capacity, evaluate what works, and collaborate across the political and business divide. Again this is familiar territory. They are themes from the back-catalogue of the Forman lectures.

What is really interesting is the way that these themes have come together in a new consensus in recent years. We have seen this in the Lancet series of 2008 and 2013, in the creation of the SUN Movement, and the 2013 Nutrition for Growth commitments. Nutrition seems to have all the ingredients for success: we know more, the topic has a higher profile, and we are doing more.

But the plain truth is this: . . . . our collective efforts are not adequate to meet the challenge. Improvement rates in stunting are still slow. Anaemia rates remain stubbornly high. Millions still suffer from micronutrient deficiencies. And acute malnutrition still affects 51 million children!

And yet more than 20 years of Forman lecturers have pointed toward what needs to be done. So why have we repeatedly failed to translate that knowledge into the required level of political commitment and practical programming that is needed to end malnutrition?

It’s complicated.

But one problem is that there are still too many one-off, piloted and partial programmes, addressing part of the challenge, often for a fixed period of time. To meet the challenge of undernutrition, we should stop ad hoc, isolated and short-term interventions. And replace them with a collective and holistic approach that binds us together with policy, systems and behaviour change.

Let’s call this a change in lifestyle.

To support this lifestyle change, the solution I offer today is that we should all adopt the Data Diet.

This means changing our eco-system so that we eat, breathe, and digest the right data at the right time to inform critical decisions. It means real and sustainable change to policies and systems, based on quality data. It means using our collective knowledge to build capacity, collaborate across sectors, and evaluate what works…… based on the numbers.

Data Diet
Admittedly, data is the new diet craze in international development. In May 2013, the UN High Level Panel on the Post-2105 Development Agenda called for a “new data revolution”. The Panel Report was, unfortunately, rather fuzzy about the exact nature of the revolution. But it served to agitate, with an outpouring of commentaries, seminars, working papers, and arguments about how to bring about a data revolution.

I have to hold up my hand in taking responsibility for some of the confusion, since I was the behind-the-scenes scribbler who coined the phrase data revolution . . . but also left the data prescriptions in the report fairly vague. I still believe in the new data revolution. And it’s happening before our eyes, as data increasingly informs everything we do in business and government and in our daily lives.

Only good data can tell us where the problems are and where the money is going. Only by investing in data and evidence can we measure the impact of what we do. . . . Without measurement we are guessing. . . . In the development sector we should be horrified by how little basic data we have about most topics, and how little we know about what is and what isn’t working beyond the pilot phase.

It’s easy to see how we would create a Data Diet for better nutrition outcomes. Many of the basic ingredients for the diet have been gathered by the WHO, the FAO, the World Bank, UNICEF, and others for many years. Organisations like IFPRI have added to that with research, but also contributed some serving suggestions on how to make the data more digestible – for example the excellent Global Hunger Index, which has done so much in recent years to highlight hidden hunger.

Last month a more ambitious data diet got a big boost with the publication of the first Global Nutrition Report. Launched at the International Conference on Nutrition in Rome.

Global Nutrition Report
I’m incredibly excited about the  Global Nutrition Report. But I was shocked by what it has to say about data. First of all, the Global Nutrition Report reminds us that in most places, good nutrition data just doesn’t exist. At the most basic level, we are not able to assess whether countries are making progress on the six targets adopted for nutrition by the World Health Assembly.

The Assembly did not help things by framing two of the six targets in a way that makes it impossible to assess progress. But of the remaining four, the Report says, 40 per cent of the 193 member countries of the United Nations cannot track more than two of the targets. And most countries have not set their own national WHA targets, so the link between national and global achievement is hard to trace.

We are working blind for lack of data on interventions we know are important to improve nutrition.

Take exclusive breastfeeding. Isn’t it shocking that we have no idea how many children in Nigeria, India, Ethiopia, or Bangladesh are being reached by programmes promoting early or exclusive breastfeeding? How can we know whether these programmes are working or even taking place if we don’t have the data? We need to measure breastfeeding; but we also need to measure the money. The Global Nutrition Report calls for “data identifying and tracking domestic financial resources to nutrition”. Because nutrition is a multi-sectoral concern, this is really challenging.

But the authors are not even able to begin reviewing how much money needs to be mobilised for nutrition because so little is known about what is being spent currently. Again, in most places, there’s no data.

Secondly, the Global Nutrition Report reminds us that where there is data, what we’re consuming is old, stale and let’s be frank, often pretty useless. For example, over a third of all countries studied had not had a survey containing anthropometric data since before 2010. Lawrence Haddad has asked: you wouldn’t use five-year-old data to run your economy would you? So why are we content to use old data to make life and death decisions about nutrition programming?

And as if stale data wasn’t bad enough, we also serve ourselves most data in portions that are large, raw, and difficult to digest.

For instance, just imagine you are in charge of a local woreda health office in Ethiopia and want to know something about the state of nutrition in your area. Perhaps you want to use your flexible funding wisely. But the only data available is for the whole Amhara region – that’s you and 107 other woredas, many of which are fundamentally different from your patch.

As a local official, it’s impossible to use this data to understand what is going on. How can you diagnose what needs to be done? And even if you work hard, it is hard to see if long hours and huge personal effort are making any difference. So why bother?

We need much more granular data to make decisions.

The Global Nutrition Report describes vividly just how much work had to be put into compiling district-level nutrition data for just 11 districts in India….that leaves 665 more districts in India for which this work is yet to be done.

Finally, the Global Nutrition Report reminds us what a bad situation we are in when it comes to linking data to accountability. For example, getting donors to report in a consistent way on what they had spent on nutrition took literally months of e-mail exchanges, pleas and entreaties. So . . . the Global Nutrition Report maps the data challenge for us. How should we approach that challenge?

Let the Numbers Talk
Let’s imagine for a moment that instead of nutrition champions, we’re running a large and successful company. The world’s most successful companies are absolutely obsessed with spreadsheets to inform decision-making. Why? Because profit-margins are largely dependent on the right data-driven decisions. The company’s share price; its market share; and possibly its very survival are at stake. Capitalism is fuelled by a diet of data.

So how and why would a data diet help in nutrition? Keep imagining that we’re running a company and discussing Key Performance Indicators or KPIs for the year ahead. As we all know, key performance indicators are a vital tool for businesses of every size. The critical thing about a Key Performance Indicator is that it links data to decisions. A KPI is a data point with a sharp edge; a number with attitude; it is all about delivery.

How would a business approach nutrition KPIs?

SALES: One set of KPIs relate to the top line – how much of a product or services it sells. Every company monitors sales closely – most on a monthly basis, but many have daily reports or even minute-by-minute data feeds. When sales rise, stagnate, or fall, management will naturally want to understand why – and adapt accordingly. Businesses also need to understand as much as possible about their competitors. And all big companies tirelessly track their market share.

Nutrition programmes are broadly about delivering goods, services, and behaviour change to family homes and communities; especially for those at risk, such as pregnant women and young children. Now, what if ALL national and provincial nutrition programmes were able to map out and segment their target market? What if they were able to track how their products and services were being received?

Take for example the simple intervention of large scale food fortification. GAIN, the Global Alliance for Improved Nutrition, has been building programmes to promote food fortification for a decade. It is fairly easy to know how much oil, flour, or salt is fortified. But until recently they’ve had no real data on how much fortified food is actually reaching those in need.

GAIN has now developed a tool to assess fortification coverage. With this it can see that in Senegal, for example, about two thirds of women of reproductive age get at least 10% of their reference nutrient intake of iron from fortified flour. Such a simple metric. So useful. And until recently, simply not available. Of course the next question to understand is how fortified flour fits into the broader diet, and whether it is making an actual difference to anaemia.

Nutrition programmes are in desperate need of simple metrics to track the growth of their consumer reach, and more importantly, their consumer impact.

GAIN is in the business of nutrition but what about looking at sales through another distribution channel? For example, of every ten women who attend an antenatal clinic, how many actually receive the nutrition interventions that they should do? This is what marketing specialists call “converting leads”. What if we tracked data as obsessively as marketing departments do? Coverage of effective nutrition interventions would be transformed.

Let’s look at another business KPI . . .

CUSTOMERS: The most successful businesses obsess about measuring customer satisfaction. For big retail firms, it is standard to understand their customers purchasing practices, preferences, and life choices.

Governments, on the other hand, are often happy to ignore the fact that their facilities are empty, or that key commodities are out of stock, or that as disgruntled customers look for better service elsewhere. Creating feedback loops with good data has enormous potential to improve programme quality. We’ve seen this with the ground-breaking trial of community based monitoring in Uganda, which led to a significant increase in the weight of children under 18 months of age.

Until recently, many nutrition programmes have focused too narrowly on supplying new solutions – complementary foods, micronutrient powders, and the like – without paying enough attention to customer demand. Or customer experience. In contrast, big retail firms understand their customers. They invest in creative thought and effort to build brands, shape demand, and connect with the emotions and aspirations of those they reach. The best nutrition programmes do include social marketing, but are we doing enough to extract data from these? Do we really use social marketing information to drive decisions on a regular basis?

Now remember that I’ve asked you to imagine that you are in a business, thinking about Key Performance Indicators . . . we’ve talked about Sales and Customers, now let’s get a bit more hard-edged . . .

COSTS and expenditure are also indicators we should track relentlessly. When I ran my own business, I tracked costs very closely. Well, to be honest, I had a Finance Director who tracked costs very closely and then harassed me until I would take some action. But that was her job. In contrast, most governments have little idea what they have spent on nutrition. And neither governments nor donors know much about what it has cost to provide essential nutrition services.

Good costing data is the natural pairing for robust evidence on impact. At the moment, my guess is that the world spends far too much resource on nutrition initiatives which don’t have the wildest chance of being cost-effective, often because their impact is so low. It needs to be easier to screen out no-hope investments, and prioritise the best buys.

Let me turn to the last of my list of Key Performance Indicators which businesses track for data-driven decisions:

PEOPLE: A business is only successful if it leverages the energies and skills of its staff and workforce. So KPIs must also focus on people and performance.

Nutrition programmes tend not to think systematically about the people who deliver services. How many staff vacancies is the programme carrying? How many hours does it take to train a new agent? What is their daily absenteeism rate? What is the annual agent turnover? How much impact does each agent generate? The truth is that, currently, worker performance is the Achilles’ heel of most nutrition interventions. We must get better about identifying who is supposed to deliver each intervention, and track last mile delivery down to the last inch. Do workers have the resources they need to deliver? Are they doing it? If they did it last month, are they doing it this month?

From KPIs to Accountability
I have tried to suggest that Key Performance Indicators are a powerful tool for harnessing decisions to data. And common indicators can work at many levels, from community to continent, informing decision-makers all along the chain. So it is not enough to generate better data, we need to make that data digestible and put it in a framework for scrutiny.

The  African Leaders Malaria Alliance has a good example of linking data to accountability with the ALMA Scorecard, which enables African leaders to come together and jointly review progress in the fight against malaria. My hope is that the Global Nutrition Report, published every year with increasing granularity and clarity, will play a similar role in nutrition.

It’s why despite a gap of 22 years between international conferences on nutrition, ICN2 endorsed broadly the same 60 or so recommendations as ICN1. With very little data to show what has and hadn’t worked. It’s why 40% of countries cannot track more than two World Health Assembly nutrition targets.

There are some striking examples of countries that are innovating with data. In Rwanda, Community Health Workers already report nutrition data using their mobile phones, and this has been linked to incentives paid by the national government to their associations—a great way to link data and accountability! Next year, agricultural extension workers in Rwanda will start using a similar system so that a truly joined up, multi-sectoral response can be set in motion.

A Decade of Action on Data
So why am I pushing the data diet? It’s obviously NOT a miracle cure for malnutrition. But I believe it could transform the way we approach the huge tasks ahead.

To make real progress, we should commit to a decade of action on nutrition data. The Global Hunger Index and the Global Nutrition Report point the way, but we also need data that is linked to decisions. With that aim in mind, I would like to propose four actions for the nutrition community:

By this time next year, let’s see at least three or four new pilots for business-like Key Performance Indicators for nutrition programmes;

Over the same time period, let’s agree a jointly funded programme of work to dramatically improve the availability of coverage data at the sub-national level in at least 20 countries;

Over the next three years, let’s help Rwanda and a handful of other equally enthusiastic countries to pilot a system of real-time nutrition data feeding directly into better decision making at local and national levels;

Over the next three years, let’s eliminate half of the data deficits highlighted in the Global Nutrition Report.

There’s a lot at stake. We all know that under-nutrition is the underlying cause of 45% of child deaths. 161 million chronically undernourished children are not getting the right nutrients and health care at the right time.

So there is real URGENCY.

At the moment there is momentum in the global community to address the burdens of malnutrition. The next three years will be a pivotal time. There’s increased funding. There are great examples of success. But the momentum could fade. It’s up to us to make sure this isn’t some passing phase, or a fad diet, or a passing fashion.

So let’s embed the Data Diet, with a lifestyle and systems change , for a decade of action on nutrition data.

We can transform the world of nutrition and deliver on our promises of the past twenty years or so.

We know that with the right nutrition at the right time, every child has a chance to survive and thrive. And they deserve that.