Profiles in Nutrition: UNICEF's Nemat Hajeebhoy

Nigeria's struggles with nutrition are well known.

An estimated 2.6 million to 3 million children in Nigeria suffer from severe acute malnutrition, and malnutrition is believed to contribute either directly or indirectly to up to 45% of all deaths of children under five. Moreover, Nigeria, the most populous country in Africa, has the world's second highest rate of under-five stunting prevalence at 32%.

The country currently faces multiple ongoing humanitarian crises that contribute to nutrition challenges, including a conflict sparked by the brutal Islamist militant group Boko Haram that has plagued the northeast for over a decade. The country further faces regular droughts and floods that contribute to chronic malnutrition and outbreaks of disease such as malaria, pneumonia, and diarrhea that contribute to high rates of maternal, neonatal, infant, and child mortality.

For the past several years, Nemat Hajeebhoy, Chief of Nutrition for UNICEF Nigeria, has been working closely with the government and other stakeholders to improve the nutrition situation in Nigeria, especially for children. As part of a series highlighting people working to improve nutrition around the world to mark the 2023 Micronutrient Forum Global Conference, Exemplars News spoke with Hajeebhoy about what UNICEF is doing to address these crises and the lessons she's learned.

First, could you tell us a bit about your own journey? How did you come to focus on nutrition and why are undernutrition and stunting so important to you?

Hajeebhoy: I was poised to study neuropsychology in the United States, but I needed a 16th year of education, because in India by the time you graduate you have only 15 years. I had to find something to do for one academic year, so I enrolled in a master's of social work in medical and psychiatric social work in India. As part of that program, you have a placement for two days a week and mine was in an urban slum in Mumbai.

While I am a Mumbai girl, it was really the first time I had entered the bowels of an urban slum. I was working with women's groups on psychosocial support, but as I dug into the issues it became apparent that a lot of the mental health issues (of people in the slum) were stemming from a lack of access to basic needs – shelter, water, adequate food, safety for women, and access to toilets. It really made me think, 'What am I going to do if I go and do neuropsychology in the U.S.? I want to come back and work in my own country and I need to get to the root of the issue.' It's public health 101 – you want to prevent rather than treat.

I actually completed my second year of that course and then joined a rural NGO in the state of Maharashtra. We were 60 kilometers from the closest city – it was pretty remote. I would go early in the morning before women went to their fields and late in the evening after they came back from a hard day's work, trying to do counseling and what was then called 'information, education, and communication' around water and sanitation and maternal and infant nutrition. I realized that food and how women get access to food and how we feed our children is fundamental to us as human beings and we forget that sometimes. That experience, for me, fundamentally changed my thinking and I became really interested in maternal child health and nutrition. I never looked back.

Nigeria is currently contending with multiple humanitarian crises, including widespread food insecurity and high rates of severe acute malnutrition. Could you tell us more about the work UNICEF is doing to address these crises?

Hajeebhoy: I think the numbers tell the story. Nigeria is ranked number one in Africa and second in the world in terms of malnourished children. We have good policies in place, so it's not due to a lack of policies. What we need is the implementation of those policies. What UNICEF is doing in Nigeria is working closely with the government to try and make sure those policies are really implemented.

We have a couple of mantras to guide our work. First, we want to prevent children from becoming malnourished. Where prevention fails, treatment is a must.

Our second mantra is integration and scale. It's not about doing a few things in a few states. That won't make a difference. We need effective coverage, which means if you're looking at, let's say, pregnant women, currently about 30% of pregnant women (in Nigeria) receive iron and folic acid supplementation during their pregnancy. We want to see that go up to 70%. That's effective coverage.

There are three things we need to do to help make this happen. The first is coordination. This is not unique to Nigeria, but I always tell people there is no ministry of nutrition. If you work in any country, you have ministries for health, agriculture, and water and sanitation. How do you put in place an effective coordination mechanism that can hold each of those ministries accountable? Again, in Nigeria, we have a good structure. The vice president is the chair of the National Council on Nutrition and is committed to making sure that coordination happens.

The second piece we really need is to strengthen the availability of information and data so we can hold ourselves accountable, whether it's UNICEF, the government, or another donor partner. How do we invest in and utilize data that will give us information to help us pivot and drive things?

The last thing we need to do is increase investments. When I say investments, I mean both financial and human resources.

In January, you warned that the number of people without adequate food in Nigeria could rise from 17 million to about 25 million and that wasting was on the rise. Could you describe the current situation and the nutritional outlook for the country?

Hajeebhoy: That was based on what is called the Cadre Harmonisé analysis for the West Africa region. We're waiting for the new analysis, but the estimate of 25 million seems to be roughly the same. The president has declared a state of emergency on food security and is trying to put in place a response to the fact that 25 million people will not know where their next meal is coming from. I believe that's a step in the right direction.

The government also has a food systems transformation plan they're trying to execute. The vice president made strong commitments in Rome at the Food Systems Summit. Our surveys show that the number of children with acute malnutrition is likely to go up – we estimate somewhere between 2.6 million to 3 million.

We all need to work together in concert to make sure that the children who are the most vulnerable don't fall into this never-ending cycle, because once a child gets acutely malnourished, you can treat and save that child's life, but a lot of irreversible damage has already happened.

One of the things we are trying to do is provide state governments and the federal government with an opportunity to draw from an innovative match fund, managed by UNICEF and supported by a variety of donors who pooled money. It enables the governments to draw down on a one-to-one basis – for every one naira they put in (for nutrition programs), we would match with another naira and help bring in commodities that are not available right now in Nigeria that can help to effectively prevent and treat malnutrition. We already have some state governments stepping forward to use that financing mechanism and unlock domestic resources.

Despite all the difficulties facing the country, what lessons learned from Nigeria could you share with other countries?

Hajeebhoy: For me, one lesson is the need for coordination. For nutrition, it's really coordinating across the different parts of governments that need to work together. That's really key, because if only the Ministry of Health is working on it, that doesn't mean people will have access to safe, diverse, affordable diets year-round. We need the Ministry of Agriculture just as much.

My second lesson is that radical change for nutrition will happen when ministries of agriculture own the agenda and are not just responsible for food security but food and nutrition security. If we can't make diverse foods like eggs or meat, etc., affordable and accessible to people, we are not going to see radical change.

My last lesson is to not overcomplicate nutrition. We tend to say, 'Oh, but we have to do this and that, and that and that.' Our recent Maternal and Newborn Child Health Week campaign was a success and showed if you focus and bring folks together and rally them around some key issues, you can deliver. There are some things that'll take much more time, but let's go after the things that can be done in relatively short periods of time because even small progress is big progress.