Welcome everyone. On behalf of the Global Health Bureau and the Bureau for Food Security, we look forward to your input and the discussion that will follow this presentation.The subject for today’s discussion is nutrition. As nutrition is such a multisectoral issue, some of you who were present at the Child and Maternal Health reviews will remember that we discussed nutrition briefly then. Today, we’re planning to discuss the integration of nutrition in both our health and food security programming.
There is one nutrition goal for both the Global Health Initiative and Feed the Future, which is to reduce child undernutrition by 30% as measured by any one of the core indicators listed here.
The agenda today is divided as follows:First, we’ll briefly review the current global nutrition situation.Second, we’ll highlight some substantial changes that have occurred in the global nutrition field over the past several years. These changes provide the basis for how USAID’s new nutrition strategy is implemented.Lastly, we want to highlight some key questions for discussion. We’re looking forward to your feedback on the following:-Achieving our goal in the face of constrained funding-Approaches for delivery of a comprehensive set of interventions-Engaging the private sector
Globally, progress has been made on reducing chronic undernutrition. Two decades ago, 40% of children in developing countries were stunted. Today, the prevalence is 30%.Most of the progress has been made in South Asia. Sub-Saharan Africa is actually backsliding: while the prevalence of stunting has declined by a modest 4%, the sheer number of stunted children has actually increased by 10 million.Stunting is one of three core anthropometric indicators that we use. The other two are wasting, which reflects acute undernutrition, and underweight, which is the MDG 1 C target and reflects both chronic and acute undernutrition. Here at USAID, we are focused on stunting as the key indicator. The measurement of stunting reflects a impairment of physical growth—but we know that the impairments from stunting are also cognitive, which impedes a child’s ability to learn, do well and stay in school, and eventually to make as much money as her non-stunted peers.
In addition to stunting, wasting, and underweight, anemia in women and children is of critical importance to health and productivity. Nearly one third of women of reproductive age and one half of children under five suffer from anemia. But this global prevalence masks some significantly higher rates—countries Mali, Uganda, and Tanzania, where three in four children are anemic, or Haiti, Ghana, and Malawi, where half of women are anemic.Anemia can be caused by a variety of factors—iron deficiency, hookworm, and malaria are the big three. Like stunting, ANY anemia (not just severe, but even mild and moderate anemia) has consequences for the productive capacity of individuals and for the economic growth of nations. Anemia saps individuals of energy and of capacity to learn and work. And when we talk about our Feed the Future initiative, which seeks to—among many other things—improve productivity of smallholders, the majority of whom are women…reducing anemia becomes critically important. Estimates suggest that it costs Sierra Leone $100 million in agriculture productivity every five years due to losses in women’s work capacity. So we’re focusing on anemia, in addition to chronic undernutrition, as a high level goal of both Feed the Future and the Global Health Initiative.
Just as the causes of undernutrition are multisectoral, so too are the consequences. Chronic undernutrition undermines many of our development investments in:Health, contributing to increased mortality and increased susceptibility to diseasesEducation, as stunting in early childhood has permanent effects on a child’s cognitive development, which lowers their school performance……costs countries in terms of economic growth…and costs families in terms of lifelong earningsLastly, undernutrition and infectious diseases tend to become a vicious cycle, and undernutrition hastens HIV progression and reduces adherence to treatment.
That’s a brief snapshot of the global context. Now we’ll discuss some of the recent global developments in nutrition that have led USAID to where it is today.
Over the past five years, there have been 5 major developments on programmatic evidence and global consensus:First, the Copenhagen Consensus identified nutrition interventions as some of the most cost-effective development investments. Five of the top ten were nutrition-related. Second, the Lancet series on undernutrition was published in 2008. This series, among many other things, identified a core package of nutrition interventions and analyzed the potential impact of these interventions in terms of health and development.Third, the year following the Lancet, the World Bank costed that package of interventions.Throughout this time, more and more evidence was emerging that we need to target the window of opportunity from pregnancy to two years.And lastly, given this “burden of knowledge” as some call it, our partners are increasingly aligning ourselves around the scaling up nutrition movement, or SUN to support countries as they continue to make strides. More on this later.
So, what is the sea change? We have tried to simplify into six key changes, which USAID is embracing to achieve our ambitious target. We’ll go through each of these with specific examples of our investments. First, USAID has long invested in micronutrient supplementation. While we also invested in food-based programs, and have serious investments in improving infant and young child feeding practices, in the past—we’re transitioning to more smart integration.Second, we’re strategically focusing on that critical pregnancy to two years of age period in order to have the most impact.Third, we’ve supported and are now tracking new indicators that help us move from what some call “nutritionism”—which includes measuring nutrient-specific deficiencies—to look at a minimum acceptable diet for young children, which includes infant and young child feeding practices like exclusive breastfeeding—something USAID programs have done historically.Fourth, we’re balancing prevention and treatment. We know we need to do both, and while USAID has always invested in both, some would argue that the global community—USAID included—has emphasized treatment far too much in the past. So we’re shifting that balance more toward prevention.Fifth, we’re maximizing synergies with other sectors like agriculture and social protection.And sixth, the emphasis is on moving to geographic scale rather than pilot programs.
The first change is that we’re going from vertical micronutrient programs to food-based, integrated approaches. A great example is Tanzania. We’ve supported the government of Tanzania over the past decade to scale up its national vitamin A supplementation program, which has achieved high levels of coverage for the past decade. As we work to strengthen district level planning and budgeting for vitamin A, we are now transitioning our support to focus on an integrated health and agriculture program that is aligned with both FTF and GHI.
The second change reflects a shift in our targeting. We used to believe in “catch up growth” which means that we delivered interventions to all children under five, thinking that if they suffered from undernutrition it could be fixed. We now know that it can’t—and that we must target pregnant women and children under two to have any impact. Our programs are all embracing 1,000 days as both the development window of opportunity, and as a political window of opportunity that was launched last September in support of the scaling up nutrition movement. More on that in a minute.
The third change is around indicators. The field has evolved from measuring nutrient-specific deficiencies to measuring diet quality and diversity. USAID has worked closely with our global partners to develop new improved measurement tools, validating new indicators, building consensus, and calculating baselines using the Demographic and Health Surveys. Three such indicators are: women’s dietary diversity, the household hunger scale, and minimum acceptable diet. I’d like to highlight the last one, because it’s an excellent measure of both practices in the household, diet quality, and diet diversity. And it focuses on children 6-23 months, which as we highlighted before is the period of time we want to focus on. This is a key indicator in the 1,000 day window that complements exclusive breastfeeding from 0 to 5 months by measuring appropriate feeding practices—including the quality and frequency of feeding from 6 to 23 months, while factoring in continued breastfeeding. This chart is an example of the minimum acceptable diet for young children in Ethiopia: a whopping 3% consume a diet that is minimally acceptable. The average across our Feed the Future countries is only 17%. So clearly, there’s a big gap there and this indicator is now incorporated into the FTF results framework as a core indicator to drive progress toward.
The fourth change is not quite from one thing to another, but rather an emphasis on balancing prevention with treatment. The example used here is a result of some research in Haiti, where a food-assisted program was studied using two different methods. One was the traditional recuperative model, where children were given food if they were suffering from undernutrition. The other was a preventive model, where all children under two—regardless of nutritional status—and pregnant women were given food. The latter proved to be more effective in reducing stunting.Based on these results, our Food for Peace office has identified this approach—known as Preventing Malnutrition in under twos approach (or PM2A)—as the preferred approach in multi-year program guidance. Food for Peace PM2A programs are now underway in Burundi, Guatemala, Bangladesh…and because this is relatively new for Food for Peace, we are doing a lot of operations research related to cost-effectiveness, the product used, effective program/targeting approaches etc.
We are emphasizing multisectoral synergies in agriculture and health. Rather than just viewing nutrition as something best associated with a health delivery system, we recognize that by combining health and agriculture, we can achieve substantial reductions in stunting, wasting and underweight.So we have developed integrated bilateral programs in the vast majority of our focus countries. These programs have health components, agriculture components, and in some cases, social protection components. In many countries, we also have investments through PEPFAR or the President’s Malaria Initiative that are linked with our undernutrition programs. One of the key questions that we can return to later, raised by someone here in the audience already, is around supporting national capacity to develop these nutrition-sensitive policies across these sectors. USAID and many of our partners in the room are investing in strengthening this national capacity to inform policies and measure future impact.In addition, we have a new nutrition collaborative research support program that will be working in two countries—uganda and nepal—to conduct research on agriculture-nutrition linkages.
Lastly, the sixth sea change is moving from pilots and bringing nutrition to scale. Senegal is a great example. For about a decade, undernutrition stagnated—actually, increased in the early 1990s—until the government launched the National Nutrition Enhancement Program. USAID supported program models that demonstrated success and so were incorporated into this national program. Senegal was able to reverse the previous upward trend in undernutrition and is now seeing steady decreases in underweight prevalence, in line with its MDG 1 goal.
Now, we are going to highlight USAID’s programs to demonstrate how we’ve embraced this sea change.
Our programs are aligned with and support countries as part of the Scaling Up Nutrition movement. This is a movement that has a tremendous amount of momentum at the country level, and it has garnered a great deal of support from many of our development partners. This slide presents a list of why we’re involved, but I want to highlight that the core tenant of SUN is about countries being in the drivers’ seat. In fact, over 10 countries—we’ll show you this slide in a few—are now “early risers” in SUN. That means that the countries themselves have said they are committed to scaling up nutrition, that they are calling for increased alignment and partnership, and that they have or are planning to take some positive steps on policy and accountability.
Guided by both GHI and FTF principles, USAID is working with missions to develop strategic plans for USAID nutrition specific investments at the country level. These frameworks consist of an analysis of the multisectoral factors that lend to undernutrition as well as identify specific programs, partnerships and activities to move these strategies forward in line with national priorities and policies.
As you can see here, since 2009 (the red dots), the number of completed nutrition strategic plans has gone from 0 to 15 in just 2 years. In addition, these strategic plans have helped to inform a number of new nutrition procurements (in the middle) which are either nutrition sensitive or strengthened in an existing health or agriculture led program or nutrition focused which is a new program with specific goals to improve nutrition. To support these programs, USAID has increased its staffing to develop and manage these programs and 17 of the 19 countries now have a dedicated staff member or point of contact for nutrition. We’re also working on capacity strengthening of our staff by identifying technical training opportunities for nutrition and providing programmatic guidance for this relatively new way of doing USAID programs and funding for nutrition.
To choose countries, USAID started by looking at the 36 countries that account for 90% of the global burden (in numbers) of stunting. From there, we also looked at additional criteria including: FTF/GHI priority countries, country commitment and opportunities for synergy with other USG or partner programs.
Based on these criteria, USAID has identified 17 core countries where 80% of the Global Health and Child Survival nutrition resources will be invested. While Food for Peace and PEPFAR also have investments in some of the core countries, FFP has nutrition investments in an additional 6 countries and PEPFAR an additional 4 countries. Finally, a number of countries have also been identified as SUN early risers and are a focus of the Scaling Up Nutrition partnership mentioned earlier.
Measuring progress is an important component of the nutrition strategy and specific core indicators have been identified and incorporated into GHI and FTF Monitoring and Evaluation systems. These indicators will be collected primarily through DHS surveys and all of the new globally recognized indicators such as minimal acceptable diet, are being collected.
How does the sea change of interventions come together at the country level? This example from Malawi shows the multisectoral nature of nutrition and how the different sectors will contribute to improving nutrition. Each of the different programs were separated often geographically (for example, social protection in south and agriculture in the central region) and in looking at how to harness or leverage each other’s activities, changes are being made to create better synergies. Here in Malawi, we’ve also done a lot of work on PEPFAR programs and nutrition. There are opportunities to maximize our impact through nutrition assessments, counseling, and support; or through OVC programs; or with behavior change programs for infant feeding and PMTCT. And actually, we’re following the government of Malawi’s lead here and working closely with the Office of the President’s Director of HIV/AIDS and Nutrition who is passionate about scaling up nutrition.
Nepal, a FTF and GHI country, is another example of how the different aspects of the sea change in the nutrition strategy come together. Nepal’s nutrition activities focus on the prevention of stunting, which currently affects nearly half of Nepal’s children under five. Because the major causes include low exclusive breastfeeding rates and low dietary diversity in all areas of the country, these activities will be integrated into both agriculture and health led programs. Access to food, another critical contributor to child undernutrition takes on various roles in an ecologically diverse country like Nepal; therefore, while value chain work may be more appropriate as a platform in the west, income generating activities are more suited to isolated areas in the mountains where agriculture is limited and thus will be integrated into health led activities.
USAID works with a large number of US government agencies on nutrition. These activities are merely illustrative and capture the technical elements of our collaboration at a global level. Of course in some countries, we may work more closely with our interagency colleagues on a variety of issues.
In addition to the interagency, we are working with any number of civil society, private sectors partners, and the UN. Currently in USAID/Washington we have 4 main implementing partners—though as two are soon coming to an end, we plan to award a new one in the next few months. The Scaling up Nutrition movement helps facilitate collaboration between all of these partners in support of countries.
Now, to some important review questions.
First—our goal was to reduce undernutrition by 30% in five years. We recognized that this was quite ambitious to begin with. In light of higher food prices and a different funding scenario than we planned on, can we reach this goal? It certainly depends how much is leveraged as a result of US engagement in overall national efforts and the multilateral support systems. We’ve listed some possible options here, and we’d really appreciate your feedback on these options. For a bit of perspective in this discussion, we have a few slides that give you a snapshot of the tough budget choices we’ve had to make.
In two years alone, we’ve made some very difficult choices. The funding for nutrition has nearly doubled in a tough budget environment—so that’s the good news. We’ve actually cut the number of countries receiving nutrition funds in half though, in order to increase the average funding levels and make sure our priority countries receive enough funding to have robust programming. So in two years, we’ve gone from 16 countries programming less than $750,000 to zero, and from one country with more than $3 million to 13. On the positive side, that means the countries that Jim highlighted are able to implement evidence-based nutrition programs. On the down side, it means that over a dozen countries—some with significant burden of undernutrition—no longer have nutrition resources, however small.
But we are making this tough choices because we believe that a deeper level of investment means bigger impact. We haveIncreased concentration on top priority countriesDecreased resources for non-priority countriesPhasing out of sprinkled resourcesWe plan to continue this trajectory in the future to sustain our commitment. We recognize there are tradeoffs—so again, appreciate your thoughts on how to approach overall targeting.
For the second review question, we’d appreciate your thoughts on approaches for delivering a comprehensive package of nutrition interventions. At the heart of this is that we know we can’t do everything—so what is our strategic choice? There are just a few options listed here, though we recognize there are many more. To me, and one of our colleagues on the phone has actually stressed this, it comes down to the results framework: How well established is it, what are the multisectoral coordination and implementation mechanisms in place to support that results framework, and do we have evidence for the causal linkages between what our investments are and the impact we’re trying to achieve? And most importantly, as USAID, is what we’re investing in through this results framework owned by the government and supported by our other partners?
And lastly, engaging the private sector. There has been a tremendous amount of interest and work over the past few years on this subject, and we still have a lot of work to do. The key question is how do we engage in win-win partnerships that will enable poor communities in developing countries to access the products and services they need. And another key question that was raised by someone in the audience is how we are defining the private sector—it is certainly not homogenous and thus, our approach will be different depending on whether we’re talking about a huge multinational for profit, or a small local non profit, or a regional private sector body…And with that, we’ll close the presentation. Thanks for the opportunity to discuss our nutrition portfolio with you, and we look forward to your feedback and comments as we think through our nutrition programs under GHI and FTF moving forward.