Ashoka
We recently spoke with Ashoka Fellow Steve Collins. Steve is one of our Fellows from Ireland and also a 2010 Ashoka Globlizer Fellow. Steve has revolutionized community-based therapeutic care of Severe Acute Malnutrition through ready-to-use food and more effective distribution. His organizations Valid International and Valid Nutrition have spread the system internationally and reach 1 million children. Read our conversation below to learn more about Steve, his work, and the critical role Ashoka and the Ashoka Globalizer program are playing in helping Steve go to scale. Enjoy!
Tell me about your work.
The main work is focused on the treatment and prevention of starvation. The initial work was to dev a comm.-based model to deliver nutritional treatment to children on the edge of starvation. We did a lot of that and developed a huge database showing the impact.
UN has adopted the model and it has become national policy in about 25 countries and another 10 are trying it out.
What is that policy?
The policy of how to treat malnutrition. How you diagnose, how you treat it.
How does your approach differ from previous approaches?
Previously children were treated as in-patients, so they were admitted to hospitals or clinics and their parents would have to stay there. They would spent 2-3 weeks away from their families and would get intensive treatment.
We instead work with communities to understand what malnutrition is and to identify malnutrition early enough that they can be treated as out-patients. So they stay at home with their parents, you don’t separate families, and they visit a clinic once a week. It’s much more popular with families and communities and much cheaper to deliver.
In developing countries where malnutrition is most common they always have a shortage of trained stuff. The number of hospital beds simply aren’t available either. What that meant was that the coverage rate was extremely low – under 5% of those who needed treatment ever got it. Whereas now with these new programs coverage rates are up to 75%. Mortality rates in hospitals for the treatment of acute malnutrition have been at 20%-30% and have been unchanged since the 50s. NGOs have done better but it has been very very resource intensive. The mortality rate of those treated by our program is 4-5%. So you have a huge increase of those entering treatment and a huge decrease in morality of those in treatment. And that’s why this approach was adopted very quickly, we had all this data to prove it worked dramatically better than the previous approach.
Usually these things move very slowly but in this case we did our first pilot in 2000 and by 2007 the UN had adopted it as new policy. We collected data on 22,000 cases so we had a huge dataset to demonstrate the impact of the approach. The whole aim of Valid International, the first organization I set up, was to produce an evidence base for how humanitarian organizations could address malnutrition more effectively.
How did you get involved in malnutrition issues?
When I left school l worked on building sites for 6 months and then I traveled through developing countries. I realized there was incredible poverty and I hated being a tourist just looking at other peoples problems. So I decided to do medicine. Did a couple of years of medicine then did an extra degree in anthropology and philosophy. I took a year off college and travelled through Africa and ended up in the famine in Sudan in 1985. So I got a job distributing famine food. And it made me realize these people were so marginalized, the poorest of the poor, and that very simple measures could have a huge positive effect. So when I went back to med school I was interested in nutrition and relief at that stage.
Once I got my degree I went and worked in Jamaica for a couple of years and was exposed to a lot of the up-to-date thinking on nutrition. Straight after that, in 1992, I went back to Africa and realized that practice was lagging behind the research. There was a major famine in 1992 in Somalia and I went to set up an adult treatment center and the diets people were using there I realized weren’t the same as the new diets that I had seen being developed in Jamaica. So I changed the and I took down data as I did it. In the swollen adults there was an incredible reduction in mortality rates when we changed the diets. So that made me realize that the evidence base was vital and that nutrition could have huge impact if done right. That got me on the map as an expert in adult malnutrition. For the next 10 years I went around to the various famines and wars in Africa treating adult and child malnutrition. By then it was all the inpatient model so I slowly developed the outpatient model. But this didn’t get traction until the Ethiopian government banned the opening of clinics in 2000. They had seen that they hadn’t worked so they prevented agencies from setting up new feeding centers. So I had an opportunity to try this outpatient treatment approach I had been thinking of.
That was the delivery part of the equation. So basically this model has been adopted worldwide. That was the first organization, Valid International. It was obvious that the outpatient model was going to work, but we needed to improve the food products. When we started the food was this nutritional paste, made in France at the time. I realized there’s no way you could have a model that required the importation of foods from developed countries. So I set up a charity which operates as a food manufacturing company called Valid Nutrition. And that’s unusual in that it’s a charity that trades and makes a profit but it reinvests that profit. It is run by food company executives recruited to run it as a food business but the board is made up of humanitarians.
To actually make a difference you need both product and delivery, one without the other doesn’t work. If you’re delivering something that doesn’t work or if you can’t deliver it effectively it can’t work. So you need both. So the delivery model is now operating in about 35 countries. We have factories producing the product in Malawi, Kenya, Ethiopia and we’ll be starting in West Africa by the end of the year.
A key thing is that there’s competition – now people can make money out of these areas there are people trying to manufacture these foods in developed countries like America. I think a key message to get across is that creating dependence on subsidized imports from developed countries is not going to change things. Even if these companies are charities if they’re swamping developing countries with subsidized foods that could be produced locally using local products then it’s undermining development.
The whole goal was to create an economically viable model. To do that you need to link agriculture and the production of crops to adding value in local factories to delivering to people that need it. So it was the natural next step - once you have a product that works and a delivery model that can get it to people then you’ve got to link the production of that product to local development. You can use the production of the product as a means to prevent malnutrition. So you can treat with the product and prevent with its production, in an economically viable way.
I think a key thing here is that a third of the developing world population have had their brains damaged by malnutrition. Irreversibly damaged. If you look at the World Bank data it shows that malnutrition is therefore the greatest cause of poverty in the world today. All other development intervention are predicated on behavior changes (education, or producing better crops, etc), but if you have a third of the world’s population with damaged brains because of malnutrition you have undermining all other development interventions. So preventing malnutrition in the first two years of life is the foundation of all development interventions.
So now what we’re doing is expanding the range of products to prevent malnutrition. We’re testing a range of new products.
What are your scaling ambitions are do you have a timeline for your scaling process? If so, what is it?
We need to establish manufacturing in East, South, and West Africa. Then we need to increase the proportion of children in the countries where the programs are operating who have access to the programs. And we need to introduce the techniques of the community based model into India and Asia. Because India and Asia haven’t taken them up yet. We’re talking within the next year we’ll have our manufacturing collaborating all up and running within Africa. Then we need to find local partners to manufacture in Asia.
How do you hope Globalizer will contribute to this?
There’s certain problems in scaling. Certainly in scaling the delivery model. The service we provide is based around having very very high quality staff and knowledge and in scaling that globally we are searching for ways to scale up the training of staff – how do we scale up the availability of skilled staff and make that available globally? Then we need business knowledge on how to scale manufacturing and reduce costs.
Given that it’s such a huge problem, a third of the developing world population, it can’t be left to the public sector. So a key things for us in Globalizer is to get more ideas on how to harness private business, the big food companies, how can we work with them more effectively to use their capacity to deliver this food to people in the most cost-effective way and at the most affordable prices?
How has partnering with corporate sector helped spread your innovation thus far?
Our sub-contracts are private sector. They have allowed us to scale up quicker and with less demands on our working capital. They also know the environment where they’re manufacturing so they’re more effective than us learning the environment in each location we move to. Basically they also have scale. If you go to villages in Africa you’ll find small soap packets available in the most inaccessible places. We want to see ours or other peoples nutritional products with a similar reach. We want to encourage other people to enter this market to create healthy competition. We really believe in competition and want to see that elsewhere.
What is your criteria for selecting corporate partners to work with?
We are very wary – we want to ensure that partners have a strategy to have manufacturing in developing countries rather than importations from developed countries. And obviously there’s certain key ethical criteria such as they need to be complying with the code on the marketing of breast milk substitutes and things like that. We’re interested in their ethical practices and their ethical audits. But beyond that we want them to be effective commercial partners who have the capacity to manufacture and deliver these products at an affordable price.
What are you most looking forward to at the Globalizer Summit?
Being challenged by people who are really profound thinkers.
Who are you most looking forward to meeting?
There are a few. I was actually very eager to meet Bill Drayton. I really admire his thought and what he’s trying to do so I’m looking forward to having an hour with him. I think Dermit Desmond is a mighty Irish business leader who I’m looking forward to meeting.
Do you hope to partner with any of the other Globalizer Fellows?
To be honest, yes, I met an Ashoka Globalizer Fellow today who had already independently started to work with one of our sub-contractors. It’s sector and its’ geographical and its capacity based so I’m looking forward to exploring that.
How do you choose which countries to enter next? Barriers to entry or where the need is greatest?
Based on need and opportunity. Basically there’s data on the prevalence of malnutrition, so that’s easy, we know where the greatest burden is. Then it’s going there and looking at the opportunities, the availability of partners, the manufacturing sector, etc. This is an area the Globalizer Fellows can help us with as they’re well–connected globally, they will know who we need to talk to.
What needs to happen for the world to abolish malnutrition?
I think that large commercial orgs need to realize, which they’re starting to, that investment in good early childhood malnutrition is a good economic investment which has huge returns in the long term. There’s data that the right nutrition intervention in the first two years of life results in a 40% increase in adult earning capacity. So they need to understand that and then they need to develop business models that allow them to engage with the problem, that allows them to accept lower margins and lower returns in the short-term, realizing that this will build up their customer base in the future. We just need to find the right model that will allow them to engage. Once they see malnourished people as legitimate customers they can bring huge economic scale to the equation.
Economic models that increase customer base in the long term. Once they do that this problem is treatable. 200-300 million kids who need $30-40 worth of small doses of essential nutrients during the first two years of life. When you get big business involved this is easily do-able. Once you find a business model that allows them to engage then the problem is definitely solvable.