In my 40 years of working on malnutrition reduction around the world I have rarely seen more promising conditions for rapid malnutrition reduction than in Rwanda, right now.
Consider the following.
First, Rwanda's malnutrition levels, assessed using stunting rates of children under 5 is already declining at a very respectable rate of one percentage point per year. So, the infrastructure to reduce malnutrition is already in place.
Second, President Paul Kagame has shown great vision and commitment to end malnutrition in Rwanda. He knows that child growth and economic growth go hand in hand. Such commitment from the very top is priceless, but it needs to be operationalized.
Third, more than in nearly any other country I have worked in, the Rwandan government takes data and evidence seriously. In all the conversations I have had with government officials they continuously ask me about what the research says. It is refreshing but perhaps not too surprising given that so many of them are subject matter experts with relevant research qualifications. It matters because there are choices in malnutrition reduction and their effectiveness differs by context—the choices must be evidence driven.
Fourth, there is an entrepreneurial spirit of experimentation, course correction and considered risk taking that is vital to malnutrition reduction. This is reflected in Rwanda's high rank in the World Bank's Ease of Doing Business index – the best in Africa. It is important for nutrition as SMEs in the food system are vital for making nutritious and safe food more available, affordable, and desirable.
Fifth, Rwanda's gender equality scores are one of the best in Africa and beyond. This is so important for nutrition for a whole range of biological, social, and economic reasons.
Finally, in line with this spirit of entrepreneurship, enabled by a well-functioning government, economic growth is strong. Economic growth is not necessary or sufficient for reducing malnutrition but it is incredibly helpful, especially when relatively broad based as in Rwanda. It allows families better access to clean water and sanitation, health care and nutritious and safe food.
Given this fertile ground, what needs to be done to accelerate malnutrition reduction by a factor of 2-3? In other words, how do we get from stunting rates of 33% in 2022 to rates below 20% by 2027?
First, we should ask, is this actually possible? It does not happen very often, but the answer is yes, it is possible. For example, between 2006 and 2012 in the Indian state of Maharashtra, with a population over 100 million, the stunting rate among children under two years of age declined from 39% to 24%. Maharashtra did this by elevating nutrition in the consciousness of the population, policymakers, development partners and entrepreneurs and by coordinating and intensifying efforts to reduce malnutrition.
What are some of the elements needed for Rwanda to achieve a similar level of elevation, coordination, and intensity?
These are my observations.
Attack malnutrition with all the levers at your disposal. Malnutrition is created by powerful combinations of poor diets and infection. Powerful alliances are needed to overcome it. This means effective action in the health system (e.g. multiple micronutrient supplementation for adolescent girls and women, especially during pregnancy and breastfeeding), in the food system (e.g. strategies to support SMEs and market systems that supply nutritious foods to base of the pyramid consumers), in the school system (e.g. providing fortified wholegrains in school meals), and the social protection system (e.g. design income transfer programs so they do more to stimulate the production and consumption of safe nutritious foods).
So far so good, but for this multipronged attack on malnutrition to get traction the following fundamental changes in the enabling environment are needed. They underline the importance of building a powerful alliance and collaboration of different players:
Operationalising high level political commitment across government. The extraordinarily high level political leadership on nutrition action needs to be translated within the government so that the operational leadership (i) has a direct link to the highest levels of government, and (ii) is empowered to bring different key line Ministries together. A Nutrition Champion to lead a Nutrition "Mission" would be helpful.
An ambitious but realistic five year nutrition strategy. A strategy under the Mission is needed to more than double the rate of stunting reduction from the current 1 percentage point per year to 2-3 percentage points over the next 5 years. This would be a road map for bringing stunting rates from 33% to less than 20% by 2027. The strategy would involve all 4 pathways above (health, food, education, social protection) but will refine the pathways into priority population groups, actions, and regions. The strategy would clearly support the goals of the new National Strategy for Development (NST2) and indeed would be an essential driver of it. The strategy would also be supported by a more nutrition sensitive Strategic Plan for the Transformation of Agriculture (PSTA 5). The nutrition strategy may need some additional domestic spending, but Rwanda currently has quite high levels of spend relative to other middle-income countries and so a reallocation of existing domestic resources may be considered first.
A nationwide campaign under the Mission is needed to showcase the critical nature of nutrition for national development. Economic growth tomorrow is dependent on child growth today. There needs to be a whole of society awareness of the criticality of nutrition as human capital. The media will be a partner in this campaign. Rwanda has a benefit cost ratio of 13:1 when it comes to investing in nutrition action. The Grow in Rwanda approach should apply to Rwandan children too.
Mobilisation of the private sector for nutrition. Private sector resources in Rwanda are very significant -- innovation, entrepreneurship, financial resources—but too few are being directed towards the production and supply and consumption of safe nutritious foods for Rwandans.
Defragmentation of the donor nutrition landscape. Donor funding is very small compared to domestic funding, but it can play a key catalytic role. There is good donor commitment to nutrition action but it is fragmented and hence dissipated. A multidonor nutrition fund is one way of forcing more coherence.
Coordination of UN agencies. UN agencies have access to specialist resources and are technically strong. They could be more aligned and accountable on how they are going to support the strategy developed under the Nutrition Mission.
Defragmentation of food system data. A Rwandan national and subnational food systems dashboard for nutrition could be developed, bringing existing Rwandan data together to that focuses on nutrition and uses near real time data to monitor progress, publishing an annual Rwandan Nutrition Report.
Are these achievable? I think so. I am an outsider to Rwanda and to Rwandan nutrition, and so some of my observations may be not well founded, but I am inspired by the ambition of the Rwandan leadership on nutrition. Based on my experiences, I am convinced that with the right focus, intensification and determination, that ambition can be realised. Fast.
The author is the Executive Director, Global Alliance for Improved Nutrition.
