The private sector in nutrition - a player by default or choice?

I participated in a Round Table organised by South Asia Food and Nutrition Security Initiative SAFANSI In Colombo in June which was titled ”œPutting the Lens on the Consumer in Nutrition-Sensitive Agriculture and Food Systems in South Asia”.

Before I share highlights from the 2-day event, here is some background on SAFANSI -

SAFANSI, which is now in its second phase, is a multi-donor trust fund administered by the World Bank with the goal to foster cross-cutting actions that will lead to measurable improvements in Food and Nutrition Security. The fund finances activities in any of the countries of the South Asia Region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka) or regional activities, covering two or more South Asian countries. It was perhaps telling of the complexity of achieving good nutrition that the meeting was held in Sri Lanka which always finds mention as an outlier in South Asia – with single digit infant mortality rates and very high literacy rates comparable to developed countries but where nutrition indicators have remained stagnant.

The meeting in June brought together a mixed group of policymakers and programme planners, agriculture and nutrition experts working in public and private sectors, business, donor and civil society organisations. Private sector representation included 2 leading supermarket chains in Sri Lanka and one global company working in food, agriculture, financial and industrial products and services.

Headline nutrition data for South Asia, provided the backdrop to the discussion. South Asia:

1. Is home to 40% of the world’s stunted and 50% of the world’s wasted children and with only 1 in 5 children (under 5) in this region eating a minimally acceptable diet.
2. Has seen improved economic development and widespread presence of food and nutrition security programmes, but these have not always led to improved nutrition outcomes
3. Is experiencing rapid urbanization with very poor living conditions in poor urban settlements. Food consumption patterns in urban environments are now very different to those in rural areas
4. Has a growing private sector which is marketing aggressively to consumers (including infants and children), shaping demand for processed, packaged foods including unhealthy foods and beverages. This, coupled with erosion of traditional family structures and support systems, and loss of traditional food habits, can be seen to be one of the causes for very poor dietary diversity in children.
5. Is predicted to be impacted by climate change where studies show a likely decrease in food production and increase in food prices
6. Is showing a trend towards increasing consumption of non-cereal foods across wealth quintiles and simultaneously consumption of foods high in sugar, salt and fat (data from India and Bangladesh).

The June meeting looked at various aspects of the food system and interactions between the different actors with some examples of work from the participating countries. The discussions over 2 days aimed to answer a few key questions:

• Most countries have developed dietary recommendations keeping in mind locally available foods and eating habits in the country conforming to WHO Dietary Guidelines but a point of concern is whether the recommended diet is affordable. In the case of Sri Lanka, the recommended daily diet with all the food groups in proper quantity costs about 2 USD/person per day which can be afforded by only about 50% of the population.
• Many countries in the region have introduced legislation that ban fizzy sugary drinks in schools (e.g. Sri Lanka, Pakistan). This was presented as being an important step to keep unhealthy foods out of reach of children; but is not enough. The reach of the informal unregulated sector as a source of high sugar and salt content foods, is wide, and it was recognised that bringing these under legislation is a challenge.  
• Subsidies and Tax exemptions for locally produced products in Afghanistan are a means of encouraging a newly expanding market which is presently dominated by  imported goods including food items.  
• Fortification of staples like rice and wheat flour, oils, salt are at various stages of development across the region and this is being recognised to reach large populations especially when fortified staples are supplied through Public Distribution systems and social safety net programmes like "Midday meals" programmes in schools or targeted supplementary feeding programmes (for example in India). Read about a successful experience of combating anaemia in schools in Odisha an Indian state using iron fortified rice in midday meals. Pakistan has lifted all import duties on machinery used in fortification of wheat flour and reduced heavily taxes on micronutrient pre-mixes to facilitate fortification and encourage all producers to adopt the practice. Prevalence of Vitamin A deficiency has drastically reduced according to recent evidence from Sri Lanka attributable to universal fortification of oils and many packaged foods. This could result in cessation of  the Government led  bi-annual supplementation of Vitamin A for children.
• Food safety laws are being reviewed and strengthened in many countries to establish systems for regular food safety inspections in food processing units and slaughter houses. There has been a concerted effort in Bangladesh to modernise slaughter houses, establish cleaner wet markets and monitor hygiene conditions in urban street food markets which are very popular across the country. The country has also been vigilant on the use of unapproved and harmful chemicals in ripening and preserving fruits and vegetables through regular inspections and sustained campaigns on Food safety. In India the FSSAI has been set up as an autonomous body by an Act of Parliament as a single reference point for all matters relating to food safety and standards, by moving from multi- level, multi- departmental control to a single line of command.
• Bhutan is a country dependent on imports from its neighbours. Food safety was not part of the Food Act originally in Bhutan but steps are being taken to strengthen food inspections at the borders. The country is promoting cultivation of fruits and vegetables without the use of chemical fertilisers and pesticides and measures to curb entry of such products into the country are also being instituted at the borders.
• The region is a mix of countries that produce their own food and are nearly self-sufficient (for example India and Pakistan) and countries that are heavily reliant on imports mostly from neighbouring countries (like Maldives, Bhutan and Afghanistan). This situation calls for a regulatory framework for the region that covers various aspects related to food to ensure that foods, irrespective of their origin, adhere to safety standards. Using SAARC as a platform to advocate for a Regional regulatory framework on Food safety and standards was an important suggestion that came from one of the participating country delegations.

• It emerged clearly at the meeting that the private sector’s role will become increasingly important as populations access foods from new types of markets. The food value chain is becoming longer with the private sector playing a big role in linking the producer and the consumer - this also means that foods are becoming more expensive. To illustrate- in countries like Sri Lanka which grow fruits and vegetables throughout the year post harvest loss of upwards of 40% renders fruits and vegetables very expensive - the necessary infrastructure for food processing and preservation is not developed. This is a reality that the private sector must contend with and hence is unable to keep prices low. It is here that Government has a role working with the private sector to set up infrastructure to store fresh produce close to the farms and food preservation and processing units which will make green produce available through the year, minimise losses and in the long run stabilise prices.
• Private sector representatives in the room expressed the view that there must be greater efforts from Governments to regulate the informal markets which escape being subject to many regulations - for example, use of trans fats and high sugar levels in street markets that sell, locally produced snacks but have no appropriate labelling.  
•  Aggressive marketing tactics of the private sector was mentioned many times in discussions, and was said to confuse and mislead consumers. A common approach seen across Asian countries is using successful sportspersons and film personalities to market high energy and sugar malts or fizzy drinks - this advertising is typically targeted at the adolescent population. All agreed that regulations alone are not the answer and can never be all encompassing - self-regulation and ethical marketing were called for by all present. As has been discussed in other forums, a clear consensus on working within scientifically established guidelines is warranted. 
• The SUN Business Network (SBN) which has a global secretariat co-convened by GAIN and WFP aims to reduce malnutrition by mobilising business to invest and innovate in responsible and sustainable actions and operations. Currently there are 16 established country chapters of the SBN with 2 established networks in Asia in Indonesia and Pakistan. SBNs in Bangladesh and Myanmar are in the pipeline. Despite the burgeoning private sector in Asia the level of mistrust between the private and public sector is high. A few pointers shared by the Pakistan team on how the SBN in that country has begun work merit attention:

1. Bringing on board small and medium sized enterprises rather than limiting membership to large corporate houses.
2. Having a clear well-crafted strategy in place which allows all players to understand their roles and to manage expectations
3. Identifying focus themes - e.g. the Pakistan SBN priorities included - Food fortification, BCC strategy and, complementary feeding.

• The region can also provide examples of good practices involving Private-public partnership. For example:

1. The Corporate Social Responsibility Law in India which mandates all companies of a certain size to invest a share of their profits in developmental activities in the country. Learn more about this from this interview.
2. The SAFANSI Milk Fortification Project in India is a good example of Public Private partnership involving The World Bank, The National Dairy Development Board, FSSAI and Tata Trusts which is a philanthropic trust set up by one of India’s oldest industrial families aims to fortify 2 million metric tonnes of milk and reach 30 million consumers by the end of 2 years. The implementing Agencies are Dairy Federations, Producer Companies and Milk Unions and currently 13 projects are in place with 14 more approved proposals to be implemented very soon.

This will have to be influenced on the basis of local context and lived realities of families and households vulnerable to malnutrition. As more women work outside of the home, increasing spending power is gained at the household level but it does not necessarily translate into access to the correct information regarding safe and nutritious foods for children in the household.  The South Asia region has the lowest consumption of animal source foods by infants and young children, even in countries where meat is not taboo. Price plays a major role and so ways and means to make these first-class proteins available to growing children must be devised.

• The importance of increasing awareness on the link between NCDs and early diets both in terms of quantity and quality was also discussed as a critical part of the malnutrition picture in South Asia. This should take place alongside all other efforts to regulate the market and legislation.
• It was pointed out by delegates from Bhutan that poor dietary diversity is not limited to just children – with entire families eating very poor-quality food. It would require a social movement to bring about change in eating habits of the entire population. The importance of provision of correct information through various media throughout the year and not just sporadically was emphasised. Concerns were also raised about Government campaigns having to compete with the big budget advertising of the private sector.
• Many opined that people eat food not nutrition – cultural preferences and aspirations and age-old beliefs dominate why people eat what they eat. An interesting initiative which looks at restoring traditional foods to the daily plate is the Hela Bojun canteen which was started by the Ministry of Agriculture in Sri Lanka. In this programme, women are trained in food hygiene and basic entrepreneurship and are provided spaces to start a canteen. Traditional Sri Lankan fare is provided at low prices- this initially started in some districts has now been introduced in many hospitals and schools and is looked at as a real alternative to packaged snacks for children.

Special mention must be made of a session which presented the research on biofortification from Bangladesh and India and the challenges around it. Bangladesh has been one of the first countries in the region to have embraced this new technology and is currently in the middle of upscaling cultivation and commercial production of Zn fortified rice, Zinc and Iron Fortified Lentils, Vitamin A rich Sweet Potato and Zinc fortified wheat. Zinc Fortified Rice is now available widely across the country in 62 districts through a network involving Government distribution channels, NGOs and Private sector companies. Similar research in India on Iron fortification of Pearl millet. ENN published an article on Biofortification which might interest readers who would like more information. Bio fortified produce like post-harvest fortified staples needs to be mainstreamed through Public distribution systems.

Final thoughts

This meeting covered a lot of ground and did well to bring multiple stakeholders to the table.  

With hindsight there may have been one missed opportunity though. Let me explain-

All countries in the region are signed up to the International Code of Marketing of Breast milk substitutes and have their own legislations and guidelines to implement the code. This has been achieved through many years of hard work of professionals, social workers and activists. Breastfeeding is a practice which needs the unstinting and vociferous support of all powers and which has strong scientific evidence backing its importance. Despite this, there has been consistent (and sadly) successful undermining of breast feeding practices by Formula Milk manufacturers. This, more than anything else, has constrained collaboration with the private sector when it comes to Nutrition. But, as demonstrated above, there are many ways in which the private sector can collaborate successfully with the public health and nutrition agenda.  I would therefore have liked to see an unequivocal statement from all present at the meeting that there is consensus and commitment from private sector, Governments and other stakeholders to abide by the Code and in doing so committing to protecting infants and young children.

This seems now even more important keeping in mind the recent attempts by the USA to block a resolution on IYCF at the World Health Assembly held in Geneva.

This meeting gave me an opportunity to hear a wide range of perspective but 2 statements from prominent actors in nutrition still ring in my ear 'Profit is not bad- exploitation is' and 'Profit must be legitimate and equitable'. To enable this it is clear that partnerships must be forged across sectors and that all actors must be brought to the table for dialogue but with no compromise on rights of infants and young children.