 I want to try and do in probably 20 minutes or so is to talk about what I think is a neglected dimension of a neglected problem. It has been neglected up until in recent years, the issue of malnutrition or undue nutrition. What I am going to focus on is undue nutrition, recognising that clearly there is a major issue of urban nutrition and that they are linked, so we do, but many of these issues are common to those dimensions of the problem, but the political dimension has been neglected a lot and that is part of the reason why. Until recently there hasn't been enough traction and movement in terms of generating commitment and turning that commitment into impact. So this is what I am going to try and do in the next 20 minutes or so, talk about the nature, what exactly is the problem we are talking about, what causes some of these outcomes that we are aware of and the high levels and the fact that there has been quite a lot of inertia and not much has changed in recent years. Why is this issue fundamentally political? What is actually happening and what is not happening? I want to focus on two papers that I have been involved in. The first one is on the issue around what we call enabling environments. I will explain what that is. That was a paper that came out, it was a paper for, and this is a joint collaboration with IDS, a paper for the Lancet series of last year, which you may have come across and I do have one page on that. The paper for looked at the issue of politics of nutrition, that was the first time the Lancet ever dealt with that. At all they had an early series in 2008. The second paper there has just been submitted to the Lancet, and it is a review of scaling up nutrition, not the sum, this is lower case, scaling up nutrition, the issue of how to generate large scale impact on nutrition, what we know and what we learnt or what maybe should we learn from other disciplines outside of nutrition. The big question is where do we go from here? So what is the problem? This is a map of where the problem is. The two big high burden I will do quite quickly through this, that I assume a lot of this is known to you. Two big high burden regions being South Asia and in sub-Saharan Africa, there are 34 countries in which 90% of the problem of stunting, and we are looking at child stunting, that is under five kids who are just not reaching a genetic potential for height for their age, and there are less than two standard deviations of what you would expect. Those are stunted kids, around 165 million globally. 40% of them are in India in fact, or at least a third of all stunted children reside in India, and then there is a large, as you can see from these, the redders are anything over 40% at national level, although data are a bit patchy, and that is another part of the problem we have. That is the map of stunting. Now what do we know about where the damage is done, or where the window of risk or the window of opportunity lies? What this is, I don't have many graphs like this, I assure you. This is child age on the bottom here. There are 54 countries using demographic and health survey data, national level data, and so we have child age up to age five years of age here in months, and we have Z score. Now what the Z score is simply a measure of stunting or underweight or wasting, and if this child was not, if you had kids in these populations growing at normal rate, it would be all along this line. So the extent of drop off from the line shows the degree of damage or the degree of deficit and when it's occurring in the child's age. And you can see, and we're looking at stunting, we know for various reasons, stunting is particularly important. It has major functional consequences for the child. He or she will, if she or she survives becoming stunted in childhood, be physically compromised, be mentally challenged, cognitive links are very well understood now, chances of earning a living later in life are much less, chances of learning in school are much less, and there are multiple spin-off effects at a level of national, at a level of nation states. Now the drop off, where you find most of the stunting actually occurring is in the first 24 months of life, but we also know about the thousand days, and the thousand day period is a period of nine months of pregnancy plus those two years of life. That is when most of the damage is done among children growing or not growing and that represents the wind of opportunity because if we can act here and if we can turn this round or we can push this line further back up here, we have a major possibility to address this issue. So that is the focus in the life cycle. Not only that, but that primarily will be the focus of the thousand days. This is a framework from the Lancet. In one slide gives you the whole picture of what we know as the major drivers of under nutrition. Before I mention that, I am just going to mention the Lancet series itself and what has happened globally on nutrition. The first Lancet series on malnutrition was in 2008 and in that series there was a paper that looked at the international nutrition system. It really was almost parentheses around that word system and it was really scathing and basically said that there is no system. It is functional, it is fragmented, it is all over the place. There are lots of actors squabbling over whether nutrition is a food issue whether it is a health issue and it is in the mess basically. That was 2008. The last four, sorry, the last six years have seen a huge change in harmonisation and consensus that has been generated around what is driving under nutrition and the reality that all these things are important and we all have to work together. There are various things that have been driving. This mental one is the sun scaling up nutrition movement. I would say it is driving the change. It has also been driven by the change and that came up. The sun movement was launched in 2010. There is a thousand days movement. Actually another reason of the change I think was the food price spike in 2008 which really shone a spotlight on the issue of hunger and nutritionists seized that and started to talk about what was needed to turn that around. Donors now have nutrition strategies, major pledges and nutrition for growth event last year generated $23 billion worth of pledges, $4 billion of which were for nutrition specific or direct actions up here and $23 billion worth of what we call nutrition sensitive. So there is a lot changing and the big focus now I think is retaining and sustaining that momentum politically but also turning the focus on implementation when we come to. But just to let you know, just to point out what this really says. We have the ultimate goal being optimum fetal and child nutrition development. Spinning off from that there are a whole series of benefits that occur over different generations not only for the same generation and not only for the same child. Below that we have the immediate level drivers and that relates to issues of feeding, caregiving health seeking or preventative health. Those are the practices, nutrition supporting, practices which support nutrition, good nutrition within the household. At the community or household level there is food security, there is caring capacity and there is access to health services in the same environment. We know and the Lancet talks about 13 interventions which are direct or nutrition specific which impact or designed to impact this level of the problem, more immediate level if you like. There is another paper 3 of the Lancet of 2013 which really goes as far as possible to lay out the evidence for these wider sexual actions. They are not just nutrition programs, they are agriculture, social safety notes, water sanitation and early childhood development. They are potentially very nutrition relevant and there is a potential to influence these programs and determine positive programs for nutrition. What we do know and this is slightly disturbing is that even if you scale up this package of 13 interventions to 90% in most countries we are only going to get about a quarter of the way we need to get, 25% of the way we need to get by doing this which means there is an absolute imperative to deal with nutrition sensitivity and what we say in paper 4, so this is paper 3, this is paper 4, this is paper 2 and this is paper 1, what we say in paper 4 is we cannot do that without really understanding the political environment, what we call the enabling environment which can be defined as a wider set of policy and political processes that require to build the momentum politically but crucially to turn that into effective actions to address on nutrition. And in our paper we characterize that enabling environment based on work, we did a literature review of nutrition relevant policy processes and we show some of the key dimensions and issues that need to be addressed to maximise, to strengthen that enabling environment because these two levels cannot work unless we have that. That is absolutely foundational, fundamental. It's also dynamic, it's not just locked in, it's changeable, we can influence it we can do research on this in the past nutritionists have been quite naive in many ways I think they haven't addressed political issues as if that's something for someone else to do. So that black box of the political economy of under nutrition was just a black box, it was just left out there and as long as we fed evidence into it we would expect things would happen at the other side of it, that didn't happen. So now we see it as a research issue and that's part of one of the things that people always intend to do. To cut a very long story short and to boil it down ridiculously simplistically into three core elements which comes from this review of the policy literature and the policy process literature not only in nutrition but in other spheres that relate to nutrition, agriculture, social protection etc. There are three core domains that we need to take into account and the first is evidence, knowledge but also crucially how that knowledge is framed and the narratives that go along with that or the stories that go along with that. The second is what we just title as politics and governance that's how that includes issues of horizontal coherence across sectors, how sectors talk to each other and collaborate, how the national level, policy level interacts with the grassroots and vice versa, that's vertical coherence. This will also involve how the public and private come together for nutrition issues of accountability which also links with data which will be here and then obviously there's a core issue around capacity to do anything really, capacity to design programmes, to implement programmes, to do proper monitoring and evaluation and so on and underpinning all this financial resources the funding to make this all happen in a sustainable way with flexibility for adaptations along the way. Putting all this together we can see from knowledge so that you can get into different case studies that we've run generate significant impact but what is really important also to know is that this is important, these three factors are important for generating political momentum but they're also important for generating for supporting implementation and we'll come to that, there's two sequential stages although they should act in parallel but they're important for different reasons which again we'll come to. Now if we just look at the evidence issue the first of those bubbles there are a whole set of stories around nutrition and sort of a nutrition champion or somebody who's advocating the cause of nutrition needs to understand which story or narrative may turn the key for nutrition in different contexts there are many and they're all mutually supported they're all available as a resource to use. Now one would be that nutrition is important for national growth, economic growth another is the idea of the supercharging of demographic dividend the increasing ratio of productive to nonproductive members of society and in populations given what we know about how important nutrition is for their productivity for their educability and their income in the future by investing in children you're supercharging this debt dividend which has major potential for economic growth and we just look at that. Nourishing minds, we know about micronutrient deficiencies iron iodine the damage that does to children and obviously continuing throughout life. Lower IQs, child survival 45% of all under child 45% of all under 5 child mortality is directly or indirectly related to some nutrition. Hidden hunger again is around the micronutrient dimension although I think a lot of hunger and under nutrition is hidden or invisible in many ways which is part of the problem. Stunted kids and we were talking about this just over lunch. Because there are so many in a village or in a setting they become normal that's the new norm visible visible. We're learning a lot more about preventing stunting as one way of preventing this wave of non-communicable disease, obesity, diabetes, cancer, hypertension, heart disease later in life. So these are different narratives. Another I haven't even put here is a human rights narrative there's a zero hunger there are multiple and they can be used and they can need to be backed up with evidence using current data. The second bubble I showed there was about earlier on was about the political and governance aspects. This is I think the only second and last graph I've been showing but this is just a tabulation horizontal coordination against virtue and what I mean by this this is sectors, agriculture, social protection, health for example. Are coordinated are they? Are they actually talking together about nutrition? Are they planning or are they taking joint integration action or not? If that's happening it's high level horizontal coordination. Vertical and this is often neglected. We're doing more of a multi-sectoral high level talk here but this is where it really matters. Vertical is from the national level down to the grassroots. Are those policies, plans, strategies actually being implemented? Are they understood throughout all levels right away from national down district to grassroots level? So that's virtual coordination. Now different countries have chosen different routes. The ultimate is to get both. You need good cross-sector coordination and I just realise I'm blocking you from that. And you need good cooperation between centre and local. That's where we want to aim. That's where countries really should aspire to or anyone trying to deal with under nutrition. Now you get countries going this route. They get the horizontal right first then they go into the vertical. Peru is one example of that in Peru. There was a child nutrition initiative led by a coalition of NGOs which extracted pledges from all presidential candidates in what was called a 5x5x5. That's in five year period under five. Stunting and under fires will be reduced by 5%. Those presidential candidates signed up to this and Alan Garcia who won that election was held to account for that pledge. A lot of high-level discussion was around nutrition in Peru at that time. Once I was off grounded there was much more of a move to get roll-out multi-sectoral programmes within affected areas especially. That was a vertical. Malawi also, a similar thing. Now both Peru and Malawi have high level nutrition units linked to the offices of the Prime Minister which makes a big difference. That's what we've seen as well and that's been shown in work of the sun movement. That's Peru and Malawi go that way if you like. Another way is to go that way. In Maharashtra in India the Chief Minister of India could not believe, apparently just had a total shock one morning realising that 40% of all kids in this amazing economic success story were stunted and he didn't believe it and eventually he did believe it and said we've got to do something. We've got to do a big nutrition mission and just said what's the big nutrition programme in India? ICDS is the big programme. What's it doing? He basically shone a spotlight from the highest level on what ICDS was doing or not doing and there was a lot that it wasn't doing because they were just not even the right front-line workers weren't even in place. They didn't have the appropriate skills they weren't getting the right amount of training they weren't getting the right amount of support numerous things. Most disadvantaged tribal districts in Maharashtra putting all the energy into those districts and just getting people in their jobs supported, empowered to do what was always there on paper that they should do. That made a big difference and then again that was rolled out beyond those 15 districts but nothing is as simple as that. There are many ways to get to that final top-right sell and the important thing is to get there. Leadership Now we're going again part of capacity and part of the politics is about leadership. Leadership is absolutely pivotal in everything to do with nutrition and we sort of hoped and assumed that leaders would emerge and I think we need to do a lot more about building creating and centivising and supporting leaders or champions in the way we do in Transform we run a scheme called nutrition champions whereby nominations come in and through various places we shortlist key stories of how individuals have operated in nutrition they may be health workers at the community level they may be national politicians and it's designed to inspire others in terms of understanding how individuals can operate in this space. One aspect of leadership though it's not all top-down it's a lot of lateral leadership that's needed across sectors and that involves that requires in understanding how to communicate how to understand incentives how to look for the win-win solutions that exist out there. Leadership is absolutely key and we've done a study of leadership just papers coming out in food policy in the next week I think that 89 leaders were interviewed about what was driving there trying to understand why or how they became leaders and that's quite instructive it really looks at that background the knowledge that they've gained the types of knowledge and the skills that they've developed in terms of political and communication skills as well as the toolbox of nutrition but if anything it's more about those softer skills capacity again obviously fundamental almost by nature this has been used in the health world it's relevant to nutrition we have three levels of capacity tools and skills relate to an individual whether he or she has the right tools to do the job whether he has the right skills this is more middle-level organisational staff and infrastructure and then again at what we call a systemic level here it relates to let's say a national level how it relates very much to governance and governance structures how different ministries have forums to communicate to make decisions I mean the classic case in the sun movement the multi-stakeholder platforms is part of systemic capacity which is absolutely fundamental for generating the buy-in and the connections that are required now funding, actually in many cases funding is an issue it's not necessarily the biggest issue this is a way of thinking about funds, resources financial resources for nutrition and you can cross tabulate sorry I said this is no more table this is another table cross tabulate public, private only and then public private in the middle and looking at what donors might do and what high burden countries themselves might do and it's just a way of sort of being a bit more sort of fine grained about this discussion about resource mobilisation for nutrition there are obviously increased commitment from donors creating new centres that leverage high burden countries to invest in nutrition you look here at public private partnerships you see things like fortification, logistics, local innovation and so on I don't have time to go into too much detail with that but that's a way of looking at the needs to look everywhere be guided by a plan but with checks and balances and that's being key this is the final table of this paper which simply shows that all these issues here which are related to generating momentum can be boiled down into these three types of domains here and there are similarly the same framework is relevant for implementation but for different reasons or for different issues apply in those cells at that level I can hand these out to the end this table is on the other reverse of our policy brief which we found useful and we've applied this subsequently in countries in Eastern Africa and South Asia that's been quite useful that's the first part of what I want to say I'm going a bit slow the second quicker on this is a new paper that we have just submitted to the Lancet that the issue of scaling up a lot of people use these words scaling up, scaling up, scaling up what do they mean? Do they all mean the same thing? what do we actually know about scaling up nutrition impact is it is it about making something bigger is it about generating wider impact and sustaining that impact I mean it really is about this but it may require this making a program or project bigger but it's also about change things may change and need to change and need to be adapted as they go from small scale to large scale there's no reason why something that's successful at small scale is going to be automatically successful in large scale it's also about evolution things just, again it links to the change they will evolve and the actual nature of the program will need to change in those situations now we've come up with in this review nine elements which again, and this overlaps a little bit with what I was talking about earlier that are fundamentally important but one of them the first question is to ask we define scaling up as generating large scale impact it is not about making a program bigger it's not only about making a program bigger it could be many programs it's about sustaining those programs so the first thing to think about is what is the goal are all these stakeholders talking about the same thing is the vision the shared vision and then how do you measure that so what are the metrics measuring our vision without that we don't have accountability we don't know if we're getting there we don't know so that is key and there's a very good publication coming out the health systems group and WHO called beginning with the end in mind so the first question is not looking at the programs but figuring out what the vision is and then coming to the question of what is to be scaled to reach that end point or that vision and yes you may have a large scale nutrition program in your country and that may only be covering a certain proportion of the population but there are other things that will need to be done to maximise what I showed you in that first slide only 20% is going to be reached of that vision and we're going to get 20% of the weight of that vision with pure nutrition specific direct interventions so there has to be other things going on for that to happen the enabling environment or the context is absolutely key so the context can be the social economic, political, environmental but also the implementation context you can think of a very simple program like vitamin A capsules those capsules have been handed out through one sector health system that simple context, simple program relatively speaking although anyone doing that wouldn't say that but relatively that is relatively simple a more complex intervention is latching on a behaviour change component to an agricultural extension program you've got two sectors involved you've got two different types of programs two different types of capacity needed to and you've got to try and link them together to a complex program in a more complex environment so again that needs to be taken on board in thinking through as part of this the ingredients of this strategy for scaling up drivers and barriers these could be drivers or catalysts or triggers to scaling up nutrition champions can be such drivers there can also be changes for example the food price spike was actually a driver of the focus on nutrition barriers may be finances being reallocated out from a sector it may be a cultural tradition which is very negative for nutrition for example and often those do occur with infant feeding but other things as well fifth will be this what's the strategy what actually are we talking about and if we look at process and pathways there are I would argue also based on literature review work that's been done outside of nutrition you can think of four types of pathways for scaling up one is quantitative and that's pushing and making a program have wider coverage more population covered by that program that's number one, number two is functional and that means again the adaptation this program may start to change may start to link in with the agriculture sector so not only health but agriculture may start to link in with education school feeding perhaps there's a link between agriculture so the functional change is happening third will be political moving away from more of a hand out mode to more of an empowerment mode and generating the bottom of demand from communities and then the fourth process organisational when you see changes in organisations capacities that are required to reach that higher level of scale capacity I've talked a bit about that I won't repeat that but what we talked about earlier is key for scaling up and it's completely ridiculous to talk about scaling up without talking about capacity we have to talk about the two together this is often the elephant in the room assumed will be there or will be somehow appear and that's not happening capacity needs to be strengthened directly we need a concerted effort in the nutrition community I think to generate what I would call an investment roadmap for capacity and this will be 10 years not 3 to 5 years of donor cycle to a 10 years of investment in nutrition relevant capacity governance again we talked a bit about that earlier but here there's an interesting way of thinking about scaling up there's lots of trade-offs and tough decisions to be made do you go with the easy part of the population how do you get to those last 10% of a very remote it's going to cost a lot more to reach them so there's the issue of ease of scale up versus the need that's a challenge another one is quality against quantity in India they went in the ICDS in the early 90s when I was there there was a big push for universalising the ICDS programme it's just literally tick box how many districts have this programme quality went out of the window there was no incentives in the system to actually make sure that the animal body workers were actually in place they were working they had all the things that I mentioned in Maharashtra finally did was not there and surprise surprise there was no change in nutrition for the next 5 years more or less on national level I suggest although it was there it wasn't actually operational in a real sense speed you can go fast get scale fast but is it sustainable so again that's a balance and a dilemma financing the three core issues are adequacy flexibility and stability of financing for scale up and then monitoring evaluation learning and accountability all those things all about making sure that whatever is happening is documented that there are indicators they are being tracked they are being assimilated and put into usable formats and the accountability is clear to everybody so it's not just always up so information doesn't necessarily always go up but it can also and should also go down to community based organisations so they know what's going on I mean there's a lot of work on community score cards in health so it's going to be effective in improving service provision there's a lot that's needed around there the final final slide really is just to highlight what I think some of the key gaps and issues and challenges that we have still in nutrition and again using this three level or three cell categorisation of evidence so the one evidence governance and capacity and finance what types of framing narratives and evidence yield attention we haven't had time to talk about real time monitoring and the issue of responsiveness a lot of the problems we have in nutrition relate to data and the data are old they may be at a level where it's not actionable they may be national level we need more district level data that is more frequent and more meaningful and more functional so maybe something like using cell phones real time monitoring could improve growth and responsiveness and accountability multi-sexual co-ordination strategic coherence again we need to keep learning and understanding what's actually happening all of this has a length of implementation now accountability is absolutely key the global nutrition report is interesting it's been published in two months in Rome the global nutrition report is following up on pledges made a nutrition for growth event in London in 2012 at the Olympics and it positions itself as an intervention as an intervention for accountability literally keeping holding donors pledges to account for what they said they were going to provide and what actually it's being spent on so that's high level global but it helps it needed that all levels of accountability is absolutely key and civil society is key private sector is a big continuing issue around private sector engagement and again we were talking at lunch about this it's been a battleground for a long time in nutrition because of the issues of infant feeding that are continuing violations of the code of conduct we need to figure out where the space is for private and public to come together most effectively and meaningfully there was spectrum for nutrition relevant actions very broad not everything has to be focused on infant feeding issue but it is a major issue we have tried to address this within transform nutrition by carrying out a rigorous review of the evidence of the benefits of private sector involvement as far as possible and actually the evidence is very patchy we've also come up with certain types of models of public private partnerships and how they may operate and we want to hold a meeting next year to take with a mixed group to take that forward I know the sun also working on this area actively capacity and finance what types of investment what type of capacity how do we strengthen capacity do we select people and train them as leaders or champions do again probably we need to do at all levels work at all levels and do it maybe in a bit more connected cohesive way than we are at the moment and then resource mobilisation models I showed you early on some ways of looking at that one overriding all this the last thing I just want to say is we have in the last few years learnt a lot in a certain way from science we've learnt from for example a Lancet we're beginning to learn about real world situations we've known we've learnt how to generate momentum politically about high level prime minister's presence talking about nutrition what I think we need to do as a counterbuns of that is generate learnings from experience and that could be learning by doing at certain levels but it could be learning by others doing but to document stories of change in countries again it could be national it could be district level whatever level but actually document these stories the narratives of how all the obstacles and difficulties are navigated in different contexts and to actually start developing learning platform or establishing learning hubs or platforms whereby countries can share these experiences so it's experiential learning and not just scientific learning and I think we're aiming to move ahead on a project that focuses on stories of change next year I'll look at that. Thank you very much