The Eleanor Crook Foundation’s written evidence to the International Development Committee on the UK Government’s work on achieving SDG2: Zero Hunger

The Eleanor Crook Foundation (ECF) was founded in 1997 with a single goal: to eradicate global malnutrition. We work to scale improved solutions to child undernutrition by deploying the power of research, policy analysis, and advocacy, with the ultimate goal of saving children’s lives and enabling them to excel in school, work, and beyond. We invest in research that proves what methods work, policy analysis to drive systems reform, and advocacy that makes the case for urgent action to address this global crisis. Our ‘Big Wins’ are momentous, positive reform goals for malnutrition - on a global, national, or major sub-national scale. These objectives guide the day-to-day efforts and are across the following focus areas:

1. Improvements in wasting treatment coverage in priority countries.
2. Management of at-risk mothers and infants (MAMI) taken to scale in priority countries.
3. Multiple micronutrient supplementation (MMS) taken to scale in priority countries.
4. Increased support for global malnutrition as a policy and funding priority by international donors with a specific focus on the U.S. and the UK.
5. Advancing multi-stakeholder partnerships for global malnutrition.

ECF brings together diverse philanthropic, corporate and government donors to make catalytic new investments to improve global nutrition outcomes. This allows for greater impact through matched investments and commitments in key high-impact and life-saving interventions such as Multiple Micronutrient Supplementation (MMS) and Ready-to-Use Therapeutic Foods (RUTF), amongst others.

In 2022, ECF helped secure an historic commitment of more than half a billion dollars from private philanthropies and bilateral donors for RUTF, providing millions of children with life-saving treatment. We remain focused on working across partners to catalyse more funding for nutrition and supporting policy reform so that more people can benefit from the most cost-effective solutions to malnutrition. Together with partner philanthropies we stand ready to partner with and match UK leadership on this agenda.

Context – why is tackling malnutrition foundational to achieving SDG 2?

The targets of SDG 2 include ensuring access to safe, sufficient and nutritious food for all (target 2.1), strengthening food systems and capacity for climate adaptation (target 2.4) and combating malnutrition through reduction in levels of wasting and stunting in children under 5 (target 2.2). Progress has been made but much, much more is needed.

Good nutrition is foundational to development, contributing to health, education, gender equity and economic growth. Malnutrition is one of the most urgent challenges responsible for 45% of child deaths.[1] Appropriate and adequate nutrition is key in achieving not only Sustainable Development Goal 2 (SDG2) but all the SDGs. It makes vaccines more effective and a well-nourished child is 11 times less likely to die from common infectious diseases such as pneumonia than a severely undernourished one.[2]

Good nutrition also improves birth outcomes, reduces maternal mortality, reduces the risk of obesity, cancer, and other noncommunicable diseases such as diabetes and cardiovascular disease (SDG3).[3][4] It is also crucial for mental and physical development, subsequently affecting learning capacity and in turn earning potential (SDG1, 4 and 8). Reducing malnutrition can raise per capita gross domestic product (GDP) by up to 11% and break the cycle of poverty, inequality, and food insecurity (SDG1, 2, 3, 4, 5, 8, 10) and help foster peace (SDG 16).[5][6] This list is not exhaustive. Good nutrition is interlinked with most, if not all, SDGs.

Despite global efforts, ongoing challenges such as conflict, accelerating climate change and lasting impact of the Covid-19 pandemic amongst others, the number of people facing hunger and food security has been on the rise since 2015. In 2022, about 9.2% of the world’s population (735 million people) were facing chronic hunger.[7] According to the World Food Programme, more than a third of these people faced food insecurity at crises or worse levels, an increase of over 33% from 2019. Current projections note that almost 600 million people will still face hunger in 2030.[8]

Approximately 148 million children also suffered from stunting (over 22% of children under 5) and while this was a modest improvement from over 26% in 2012, it is far above the target of 15% by 2030. 45 million children also suffer from wasting at any one time (7% of children under 5 globally) with the SDG2 target being less than 3%, this is also known as the prevalence of wasting.[9] Notably, the number of incident cases of wasting in a year is likely 2-3 times this number which means significantly more children need to be reached with lifesaving interventions throughout the year. The global community recommends urgent coordinated action and appropriate policy solutions to achieve progress, including ensuring adequate maternal nutrition, promoting optimal breastfeeding practices, providing appropriate nutrition in early childhood, and creating improved access to essential services. The UK plays a critical role in ensuring this happens.

For many years Britain has been a world-leader on efforts to combat global malnutrition and hunger. Importantly, this has been a collective, non-partisan effort. Whether that was achieving a significant increase in ODA under the Labour Government from 0.26% of GNI in the late 1990s to one not too dissimilar to today (over 0.5% with the goal of achieving 0.7%), or the UK hosting a Global Hunger Summit during the Olympic Games in London under the subsequent coalition government. The UK also hosted the world’s first Nutrition for Growth (N4G) Summit in 2013 at which donors collectively committed $23 billion for nutrition between 2013-20. This Summit effectively catalysed global efforts on this agenda.

Aid cuts in recent years have disproportionately impacted nutrition spending. According to the review commissioned by the UK Government, nutrition spending was cut by more than 60% in 2021.[10] Nonetheless it remains an area that is recognised by the government as a priority. The Integrated Review in 2021, and 2023 refresh[11], highlighted the importance of improving global food security and nutrition, including through increasing the availability of malnutrition treatment and prevention services.

The recent UK-hosted Global Food Security Summit (GFSS) further highlighted the UK’s bipartisan support for this issue as well as its importance within the new White Paper on International Development.[12] The White Paper’s goal of ending extreme poverty acknowledges the clear role malnutrition and hunger play in achieving SDG 2. However, it is critical that these commitments and assurances are supported by increased funding and efficient and effective programming.

Recommendations:

To improve effective progress towards SDG2, the UK should:

●       Ensure increased funding for targeted nutrition-specific programmes that upscale evidence-based interventions such as the Power 4 (emergency therapeutic foods, Vitamin A supplementation, breastfeeding support, and prenatal multiple micronutrient supplementation). This should be matched with a commitment to spending at least 20% of nutrition funding on nutrition-specific programming (in line with previous commitments and noted best-practice).

●       Support the uptake and implementation of the new WHO guidelines on prevention and management of wasting through dedicated diplomacy in-country and “mutually respectful” partnerships as outlined in the International Development White Paper;

●       Work with others, to accelerate progress on SDG 2 and food security through greater integration of efforts - including with Gavi - the Vaccine Alliance. The UK is one of the largest donor to Gavi and in the run up to the next replenishment has an opportunity to support their principle of taking a more integrated approach[13] by ensuring that its programmes actively incorporate nutrition more effectively and include greater collaboration with nutrition programmes.

●       Evaluate the evidence-base of the impact of nutrition-sensitive programming on nutrition status outcomes and ensure recommendations in this are supported by robust evidence. Currently almost all of the UK’s nutrition funding is disproportinately considered nutrition-sensitive despite limited evidence for impact whereas support for nutrition-specific interventions, which have strong evidence base to be cost-effective and highly impactful, continue to be deprioritised.

●       Indicators within programmes should ensure the right metrics are tracked to maximise impact. Including indicators of key high-impact interventions as well as corresponding commitments for coverage levels have had prior success in improving effectiveness of programmes and should be re-considered.

How could FCDO’s approach be improved?

●       FCDO should rebalance its portfolio to prioritise cost-effective, proven interventions to target those suffering most:

Evaluating the effectiveness of FCDO and UK’s approach involves a multi-faced consideration looking at various aspects of the initiatives. Firstly, the programme design and its relevance in terms of reaching those most in need. Progress towards reducing malnutrition and hunger requires a wide approach to address the determinants of malnutrition as noted by the Lancet framework for action to achieve optimum foetal and child nutrition and development.[14] This includes nutrition-specific and nutrition-sensitive programmes working in synergy. However, as the Independent Aid Commission for Aid Impact (ICAI) noted in its most recent review of DFID’s nutrition programming, the “evidence of the impact of nutrition-sensitive interventions on nutritional status is limited”.[15] While this does not negate the effectiveness of this approach in the long-term, the impact of disproportionate cuts to nutrition-specific programmes has led to FCDO's portfolio becoming overwhelmingly made up of nutrition-sensitive programmes. This shift away from funding nutrition specific programmes means the UK is not playing its part in tackling the scourge of malnutrition most efficiently. As such it is important that nutrition-sensitive interventions do not continue to be prioritised over nutrition-specific ones. Therefore, we recommend that the UK re-adopts a commitment to spend at least 20% of its nutrition spending on nutrition-specific interventions in line with its previous commitment made at N4G[16] as well as with the International Coalition for Advocacy on Nutrition (ICAN) UK’s best practice.[17]

In a prior submission by FCDO to the IDC for the sub-inquiry into the philosophy of aid, the department acknowledged the need to improve spending through focusing on ‘Best Buys’ in international development and collaboration with partners to improve effectiveness of the collective ODA.[18] This was reiterated in the Ending Preventable Deaths (EPD) strategy which committed to increased effectiveness and “focus on evidence based, cost effective ‘Best Buy’ activities with maternal, newborn and child health outcomes”.[19]

Eleven highly impactful interventions were identified in the latest Lancet series[20] and the Investment Framework for Nutrition[21] highlighted a priority package of interventions that are effective and scalable which include the “Power 4” - emergency therapeutic foods, Vitamin A supplementation, breastfeeding support, and prenatal multiple micronutrient supplementation.[22] In October 2023, The Hunger to Health initiative was launched presenting a valuable framework that can serve as a foundation for this approach.[23] While there is no one-size-fits-all solution to malnutrition, the Power 4 stands out for its evidence base, cost-effectiveness, scalability, and life-saving potential. Hunger to Health illustrated the impact of upscaling these interventions using modelling by Johns Hopkins University to show that the potential impact of an investment of £200m annually by the UK would allow the UK to deliver over 200 million prenatal nutrition and breastfeeding interventions to mothers worldwide, and take nearly 100 million preventative measures to protect vulnerable children.[24] Prenatal multiple micronutrient supplementation was also recently highlighted as a key priority for the SDGs by the Copenhagen Consensus, with a cost-benefit ratio of 37.5.[25] Additionally, other high-impact interventions such as Small-Quantity Lipid-Based Nutrient Supplements (SQ-LNS) should also be considered due to emerging evidence on its effective role as a preventive measure.[26]

Despite the strong evidence base for these ‘Best Buy’ interventions, their reach is nowhere near what it needs to be in order to achieve SDG2. More than one in three children miss out on vitamin A supplements[27] and fewer than half of children under 6 months are exclusively breastfed.[28] With up to 85% people facing acute food insecurity living in fragile and conflict settings in 2022,[29] it is crucial that efforts to achieve SDG2 include reaching these communities. The needs in these settings vary depending on the context and include upscaling cost-effective, easy to deliver interventions that can be disbursed even in the absence of a robust and functioning health system. This includes emergency therapeutic foods such as Ready-to-Use Therapeutic Foods (RUTF). RUTF, amongst other key cost-effective interventions, fall under the category of nutrition-specific interventions. However, only 20% of children who suffer from wasting get the lifesaving treatment they need.[30]

The upscaling of these interventions requires adequate funding and support. Instead, FCDO's spending on nutrition-specific interventions has decreased, from almost £150 million in 2017 to £41 million in 2021.[31] The UK dropped from being the top contributor to high impact nutrition programs in 2015 to fifth in 2021, making it the only top eight donor that is contributing less to high impact programs than in 2015.[32] Importantly, the number of nutrition programmes supported by FCDO also decreased significantly, for a third year in a row, to 86 programmes in 2021 from 100 in 2020 with only five of these being classed as nutrition-specific and another 24 having nutrition specific and sensitive components.

●       FCDO should work with partner governments to implement new WHO guidelines to add RUTF to national Essential Medicines Lists

Nine out of ten children under five who receive treatment for severe wasting are in emergency settings, primarily due to having a higher risk of death.[33] However, over three-quarters of children suffering from severe wasting actually live in non-emergency contexts with no or limited access to RUTF. This is due to it being absent from countries’ essential medicines and commodities list, and these countries having low levels of procurement.[34] At last month’s GFSS, the World Health Organization (WHO) launched new global guidelines for improved approaches to wasting treatment and prevention.[35] These guidelines have added RUTF to WHO’s Essential Medicines List (EML) for the first time.[36] The EML is a directory of ‘minimum medicine needs for every health-care system,’ meaning medicines deemed most essential for a population’s health. RUTF’s inclusion on this list not only signals its essential and crucial role in a functional health system but also allows for in-country nutrition champions to advocate for RUTF to be added to national EMLs.[37] The uptake and implementation of these guidelines will require dedicated diplomacy in-country, which the UK is well-placed to support.

●       FCDO should work with other donors, and multilateral agencies, to accelerate progress on SDG 2 and food security - including with Gavi - the Vaccine Alliance.

Increasing efficiencies and “promoting an integrated approach” through “prioritising interventions that lead to multiple outcomes”[38] is a key element of the UK’s approach to Ending Preventable Deaths and achieving SDG 2.

At the GFSS the Eleanor Crook Foundation, in partnership with Gavi, launched findings from a joint review on Immunisation-Nutrition Integration (INI) programming.[39] The review recommends co-delivering highly compatible nutrition and immunisation interventions for efficient co-delivery, supporting joint demand generation efforts at the community level and using all settings to actively generate further evidence on the impact and cost-effectiveness of integrated programmes.[40]

The UK is one of the largest donor to Gavi and in the run up to the next replenishment, within Gavi’s 6.0 strategy development, has an opportunity to support their principle of taking a more integrated approach[41] by ensuring that its programmes actively incorporate nutrition more effectively and includes greater collaboration with nutrition programmes overall for demand generation and its learning agenda.

●       FCDO should improve the way it assesses its work in tackling hunger and malnutrition effectively.

To improve monitoring of FCDO’s work in tackling hunger and malnutrition, the UK should:

●       Include a reach commitment to the current and any future financial pledges acknowledging previous success in this area; and,

●       Include specific coverage targets and indicators on high-impact interventions in future strategies and in any updates on existing relevant strategies in line with SDG2

The monitoring framework in EPD strategy is well aligned with key SDG 2 indicators including reduction in levels of stunting and wasting. However, it is important to note that while these are effective longer-term indicators, in the short term, they are less effective. This is because stunting rates change over a longer period of time and are more difficult to attribute to short-term interventions.[42] Examples of effective additional indicators to track progress in the short to medium term are tracking coverage of high-impact interventions in order to monitor progress and track investments: how many people are reached with these interventions?

As noted above, examples of high-impact interventions are emergency therapeutic foods, Vitamin A supplementation, breastfeeding support, and prenatal multiple micronutrient supplementation amongst others such as Small-Quantity Lipid-Based Nutrient Supplements (SQ-LNS). Coverage of key evidence-based high-impact interventions such as these, that are crucial in achieving SDG 2, should be included as part of wider monitoring frameworks such as the EPD strategy and commitments as well as individual project-based monitoring.[43]

With nutrition being a key element of the EPD strategy, and the overall skewed proportion of spending on nutrition-sensitive programmes by FCDO, including humanitarian assistance such as emergency food assistance, it is unclear where and how the targets on hunger are being monitored beyond overall mortality rates (under SDG 3). Much of the impact of nutrition programming by FCDO is challenging to track (beyond year-on-year spending comparisons) without clear indicators and goals on hunger and food insecurity levels. Clear establishment of these indicators and targets as well as evidence-based links with overall nutritional outcomes are crucial to truly determine the effectiveness of FCDO and UK programming.

In the past, the UK's commitment towards a target of reaching over 50 million people with nutrition programmes correlated to an increase in relevant ODA expenditure and the subsequent achievement of that target before its deadline.[44] In that time, the UK increased its nutrition-specific spending from approximately £45 million in 2012 to almost £150 million in 2017. However, a similar reach target was notably missing from its 2022 pledge, of £1.5 billion over eight years, following the Nutrition for Growth Summit.[45] It is important to note that a commitment of reach (coverage) has previously proved effective and has allowed for more targeted and focused programming which is currently at risk.