Public health surveillance

Nutrition Landscape Information System (NLiS)

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A. Indications for nutritional therapy

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Children aged months receiving v itamin A supplements. These indicators are the proportion of children aged months who received one and two doses of vitamin A supplements, respectively. The indicators are defined as the proportion of children aged months who received one or two high doses of vitamin A supplements within 1 year. Current international recommendations call for high-dose vitamin A supplementation every months for all children between the ages of 6 and 59 months living in affected areas.

The recommended doses are IU for month-old children and IU for those aged months. Programmes to control vitamin A deficiency enhance children's chances of survival, reduce the severity of childhood illnesses, ease the strain on health systems and hospitals and contribute to the well-being of children, their families and communities.

The World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of efforts to improve child survival and therefore of the achievement of the fourth Millennium Development Goal, a two-thirds reduction in mortality of children under 5 by the year As there is strong evidence that supplementation with vitamin A reduces child mortality, measuring the proportion of children who have received vitamin A within the past 6 months can be used to monitor coverage with interventions for achieving the child survival-related Millennium Development Goals.

Supplementation with vitamin A is a safe, cost-effective, efficient means for eliminating its deficiency and improving child survival. Immunization, Vaccines and Biologicals. These indicators are the proportion of children aged months who received one or two doses of vitamin A supplements. The indicator reflects the proportion of babies born in facilities that have been designated as Baby-friendly.

Proportion of births in Baby-friendly facilities is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. This indicator is defined as the proportion of babies born in facilities designated as Baby-friendly in a calendar year.

To be counted as currently Baby-friendly, the facility must have been designated within the last five years or been reassessed within that timeframe. Facilities may be designed as Baby-friendly if they meet the minimum Global Criteria, which includes adherence to the Ten Steps for Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes. The Ten steps include having a breastfeeding policy that is routinely communicated to staff, having staff trained on policy implementation, informing pregnant women on the benefits and management of breastfeeding, promoting early initiation of breastfeeding, among others.

The International Code of Marketing of Breast-milk Substitutes restricts the distribution of free infant formula and promotional materials from infant formula companies. The more of the Steps that the mother experiences, the better her success with breastfeeding. Improved breastfeeding practices worldwide could save the lives of over children every year.

National implementation of the Baby-friendly Hospital Initiative. Implementation of the Baby-friendly Hospital Initiative. Mothers of children months receiving counselling, support or messages on optimal breastfeeding. Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers.

Optimal practices include early initiation of breastfeeding within 1 hour, exclusive breastfeeding for 6 months followed by appropriate complementary with continued breastfeeding for 2 years or beyond. Even though it is a natural act, breastfeeding is also a learned behaviour. Virtually all mothers can breastfeed provided they have accurate information, and support within their families and communities and from the health care system.

This indicator has been established to measure the proportion of mothers receiving breastfeeding counselling, support or messages. The proportion of mothers of children months who have received counselling, support or messages on optimal breastfeeding at least once in the previous 12 months is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. The indicator gives the percentage of mothers of children aged months who have received counselling, support or messages on optimal breastfeeding at least once in the last year.

Counseling and informational support on optimal breastfeeding practices for mothers has been demonstrated to improve initiation and duration of breastfeeding, which in has many health benefits for both the mother and infant. Breast milk contains all the nutrients an infant needs in the first six months of life. Breastfeeding protects against diarrhoea and common childhood illnesses such as pneumonia, and may also have longer-term health benefits for the mother and child, such as reducing the risk of overweight and obesity in childhood and adolescence.

Breastfeeding has also been associated with higher intelligence quotient IQ in children. Salt iodization has been adopted as the main strategy for eliminating iodine-deficiency disorders as a public health problem, and the aim is to achieve universal salt iodization. While other foodstuffs can be iodized, salt has the advantage of being widely consumed and inexpensive.

Salt has been iodized routinely in some industrialized countries since the s. This indicator is a measure of whether a fortification programme is reaching the target population adequately. The indicator is a measure of the percentage of households consuming iodized salt, defined as salt containing parts per million of iodine. Iodine deficiency is most commonly and visibly associated with thyroid problems e.

Consumption of iodized salt increased in the developing world during the past decade: This means that about 84 million newborns are now being protected from learning disabilities due to iodine-deficiency disorders. Monitoring the situation of women and children.

Sustainable elimination of iodine deficiency disorders by Micronutrient deficiencies, iodine deficiency disorders. Population with less than the minimum dietary energy consumption. This indicator is the percentage of the population whose food intake falls below the minimum level of dietary energy requirements, and who therefore are undernourished or food-deprived. The estimates of the Food and Agriculture Organization of the United Nations FAO of the prevalence of undernourishment are essentially measures of food deprivation based on calculations of three parameters for each country: The average amount of food available for human consumption is derived from national 'food balance sheets' compiled by FAO each year, which show how much of each food commodity a country produces, imports and withdraws from stocks for other, non-food purposes.

FAO then divides the energy equivalent of all the food available for human consumption by the total population, to derive average daily energy consumption. Data from household surveys are used to derive a coefficient of variation to account for the degree of inequality in access to food.

Similarly, because a large adult needs almost twice as much dietary energy as a 3-year-old child, the minimum energy requirement per person in each country is based on age, gender and body sizes in that country. The average energy requirement is the amount of food energy needed to balance energy expenditure in order to maintain body weight, body composition and levels of necessary and desirable physical activity consistent with long-term good health.

It includes the energy needed for the optimal growth and development of children, for the deposition of tissues during pregnancy and for the secretion of milk during lactation consistent with the good health of the mother and child. The recommended level of dietary energy intake for a population group is the mean energy requirement of the healthy, well-nourished individuals who constitute that group. FAO reports the proportion of the population whose daily food intake falls below that minimum energy requirement as 'undernourished'.

Trends in undernourishment are due mainly to: The indicator is a measure of an important aspect of food insecurity in a population. Sustainable development requires a concerted effort to reduce poverty, including solutions to hunger and malnutrition. Alleviating hunger is a prerequisite for sustainable poverty reduction, as undernourishment seriously affects labour productivity and earning capacity.

Malnutrition can be the outcome of a range of circumstances. In order for poverty reduction strategies to be effective, they must address food access, availability and safety. Rome, October The State of Food Insecurity in the World Economic growth is necessary but not sufficient to accelerate reduction of hunger and malnutrition. FAO methodology to estimate the prevalence of undernourishment. FAO, Rome, 9 October Infant and young child feeding.

The recommendations for feeding infants and young children 6—23 months include: The caring practice indicators for infant and young child feeding available on the NLIS country profiles include: Early initiation of breastfeeding. This indicator is the percentage of infants who are put to the breast within 1 hour of birth. Breastfeeding contributes to saving children's lives, and there is evidence that delayed initiation of breastfeeding increases their risk for mortality.

Infants under 6 months who are exclusively breastfed. This indicator is the percentage of infants aged 0—5 months who are exclusively breastfed. It is the proportion of infants aged 0—5 months who are fed exclusively on breast milk and no other food or drink, including water. The infant is however, allowed to receive ORS and drops and syrups containing vitamins, minerals and medicine.

Exclusive breastfeeding is an unequalled way of providing the ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process, with important implications for the health of mothers. An expert review of evidence showed that, on a population basis, exclusive breastfeeding for 6 months is the optimal way of feeding infants. Breast milk is the natural first food for infants.

It provides all the energy and nutrients that the infant needs for the first months of life. Breast milk promotes sensory and cognitive development and protects the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhoea and pneumonia, and leads to quicker recovery from illness.

Breastfeeding contributes to the health and well-being of mothers, by helping to space children, reducing their risks for ovarian and breast cancers and saving family and national resources. It is a secure way of feeding and is safe for the environment. Infants aged 6—8 months who receive solid, semisolid or soft foods. WHO recommends starting complementary feeding at 6 months of age. It is defined as the proportion of infants aged 6—8 months who receive solid, semisolid or soft foods.

When breast milk alone no longer meets the nutritional needs of the infant, complementary foods should be added. This is a very vulnerable period, and it is the time when malnutrition often starts, contributing significantly to the high prevalence of malnutrition among children under 5 worldwide.

Children aged 6—23 months who receive a minimum dietary diversity. This indicator is the percentage of children aged 6—23 months who receive a minimum dietary diversity. As per revised recommendation by TEAM in June , dietary diversity is present when the diet contained five or more of the following food groups: Children aged 6—23 months who receive a minimum acceptable diet. This indicator is the percentage of children aged 6—23 months who receive a minimum acceptable diet.

Proportion of children aged months who receive a minimum acceptable diet is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. The composite indicator of a minimum acceptable diet is calculated from: Dietary diversity is present when the diet contained four or more of the following food groups: The minimum daily meal frequency is defined as: A minimum acceptable diet is essential to ensure appropriate growth and development for feeding infants and children aged 6—23 months.

Without adequate diversity and meal frequency, infants and young children are vulnerable to malnutrition, especially stunting and micronutrient deficiencies, and to increased morbidity and mortality. Source of all infant and young child feeding indicators. Infant and Young Child Feeding database. Infant and young child feeding list of publications.

Global Nutrition Monitoring Framework. Children with diarrhoea receiving oral rehydration therapy and continued feeding. This indicator is the prevalence of children with diarrhoea who received oral rehydration therapy and continued feeding. It is the proportion of children aged months who had diarrhoea and were treated with oral rehydration salts or an appropriate household solution and continued feeding. As oral rehydration therapy is a critical component of effective management of diarrhoea, monitoring coverage with this highly cost-effective intervention indicates progress towards the child survival-related Millennium Development Goals.

Health expenditure includes that for the provision of health services, family planning activities, nutrition activities and emergency aid designated for health, but excludes the provision of water and sanitation.

Health financing is a critical component of health systems. National health accounts provide a large set of indicators based on information on expenditure collected within an internationally recognized framework. National health accounts consist of a synthesis of the financing and spending flows recorded in the operation of a health system, from funding sources and agents to the distribution of funds between providers and functions of health systems and benefits geographically, demographically, socioeconomically and epidemiologically.

General government expenditure on health as a percentage of total government expenditure is the proportion of total government expenditure on health. General government expenditure includes consolidated direct and indirect outlays, such as subsidies and transfers, including capital, of all levels of government social security institutions, autonomous bodies and other extrabudgetary funds.

It consists of recurrent and capital spending from government central and local budgets, external borrowings and grants including donations from international agencies and nongovernmental organizations and social or compulsory health insurance funds.

GDP is the value of all final goods and services produced within a nation in a given year. Public health expenditure consists of recurrent and capital spending from government central and local budgets, external borrowings and grants including donations from international agencies and nongovernmental organizations and social or compulsory health insurance funds.

Private health expenditure is the sum of outlays for health by private entities, such as commercial or mutual health insurance providers, non-profit institutions serving households, resident corporations and quasi-corporations not controlled by government involved in health services delivery or financing, and direct household out-of-pocket payments.

These indicators reflect total and public expenditure on health resources, access and services, including nutrition. Although increasing health expenditures are associated with better health outcomes, especially in low-income countries, there is no 'recommended' level of spending on health.

The larger the per capita income, the greater the expenditure on health. Some countries, however, spend appreciably more than would be expected from their income levels, and some appreciably less. When a government spends little of its GDP or attributes less of its total expenditure on health, this may indicate that health, including nutrition , are not regarded as priorities. National health accounts - World Health Statistics, http: Human development report http: Core health indicators http: Human development report indicator glossary for indicator 3.

Wealth, health and health expenditure. General government expenditure on health as a percentage of total government expenditure is defined as the level of general government expenditure on health GGHE expressed as a percentage of total government expenditure.

The indicator contributes to understanding the weight of public spending on health within the total value of public sector operations. It includes not just the resources channelled through government budgets but also the expenditure on health by parastatals, extrabudgetary entities and notably the compulsory health insurance. The indicator refers to resources collected and pooled by public agencies including all the revenue modalities.

The indicator provides information on the level of resources channelled to health relative to a country's wealth. These indicators reflect government and total expenditure on health resources, access and services, including nutrition, in relation to government expenditure, the wealth of the country, and per capita. When a government attributes less of its total expenditure on health, this may indicate that health, including nutrition , are not regarded as priorities. UNDAFs usually focus on three to five areas in which the country team can make the greatest difference, in addition to activities supported by other agencies in response to national demands but which fall outside the common UNDAF results matrix.

For each national priority selected for United Nations country team support, the UNDAF results matrix gives the outcome s , the outcomes and outputs of other agencies working alone or together, the role of partners, resource mobilization targets for each agency outcome and coordination mechanisms and programme modalities.

The nutrition component of the UNDAF reflects the priority attributed to nutrition by the United Nations agencies in a country and is an indication of how much the United Nations system is committed to helping governments improve their food and nutrition situation. The indicator is "strong", "medium" or "weak", depending on the degree to which nutrition is being addressed in the expected outcomes and outputs in the UNDAF. UNDAF documents follow a predefined format, with a core narrative and a results matrix.

The matrix lists the high-level expected results 'the UNDAF outcomes' , the outcomes to be reached by agencies working alone or together and agency outputs. The results matrix the UNDAF document was used to assess commitment to nutrition , because it represents a synthesis of the strategy proposed in the document and is available in the same format in most country documents. The outcomes and outputs specifically related to nutrition were identified and counted.

The outputs were compared with the evidence-based interventions to reduce maternal and child under nutrition recommended in the Lancet Nutrition Series Bhutta et al.

The method and scoring are described in detail by Engesveen et al. What are the implications? A weak nutrition component in the UNDAF document does not necessarily imply that no United Nations agency in the country is working to improve nutrition ; however, unless such efforts are mentioned in strategy documents like the UNDAF, they may receive inadequate attention from development partners to ensure the necessary sustainability or scale-up to adequately address nutrition problems in the country.

The multisectoral nature of nutrition means that it must be addressed by a wide range of actors. Basing such action in frameworks for overall development contributes to ensuring the accountability of United Nations partners. Interventions for maternal and child under nutrition and survival. The Lancet Engesveen K et al. SCN News , Nutrition component of poverty reduction strategy papers.

The poverty reduction strategy approach was introduced in to empower governments to set their own priorities and to encourage donors to provide predictable, harmonized assistance aligned with country priorities. The PRSP should state the development priorities and specify the policies, programmes and resources needed to meet the goals. It is prepared by governments in a participatory process involving civil society and development partners, including the World Bank and the International Monetary Fund, and should result in a comprehensive, country-based strategy for poverty reduction.

The indicator is "strong", "medium" or "weak", depending on the degree to which nutrition is addressed in the PRSP, in terms of recognition of under nutrition as a development problem, use of information on nutrition to analyse poverty and support for appropriate nutrition policies, strategies and programmes.

The papers were systematically searched for key words to identify the parts that concerned nutrition , food security , health outcomes and interventions that would be relevant for the World Bank method. In order to classify the commitments to nutrition in the PRSPs, a scoring system was developed, which is described in more detail by Engesveen et al.

The emphasis given to nutrition in PRSPs reflects the extent to which the government considers it essential to improve nutrition for poverty reduction and national development. In other words, it can be an indication of the government's priority for improving nutrition.

A strong nutrition component in a PRSP means that the government considers nutrition a priority for poverty reduction and national development. A weak nutrition component in the document does not necessarily imply that no government department is working to improve nutrition ; however, unless such efforts are mentioned in strategy documents like PRSPs, they may not be sufficiently sustainable or be scaled-up to adequately address nutrition problems in the country.

Basing such action in frameworks for overall development contributes to ensuring the accountability of relevant government departments. Sources and further reading. Poverty reduction strategy papers. Assessing countries' commitment to accelerate nutrition action demonstrated in poverty reduction strategy paper, UNDAF and through nutrition governance. SCN News , , Shekar M, Lee Y-K. Mainstreaming nutrition in poverty reduction strategy papers: What does it take? A review of the early experience.

Health, Nutrition and Population Discussion Paper, Landscape analysis on countries' readiness to accelerate action in nutrition , This indicator is a description of the strengths and weaknesses of various aspects of nutrition governance in countries.

The following 10 elements or characteristics are used to assess and describe the strength of nutrition governance: These elements were identified by countries as key elements for successful development and implementation of national nutrition policies and strategies during a review of the progress of countries in implementing the World Declaration and Plan of Action for Nutrition adopted by the International Conference on Nutrition, the first intergovernmental conference on nutrition Nishida et al.

The components of the composite indicator have been identified by countries as important for determining the completeness of national nutrition plans and policies Nishida, Mutru, Imperial Laue , For instance, a national nutrition plan and policy was considered to provide the political basis for initiating action.

In many countries, official government endorsement or adoption of a national nutrition plan or policy facilitated its implementation. The role of an intersectoral coordinating committee in implementing national nutrition plans and policies was also considered crucial, although the nature i. Another important element was considered to be regular surveys and other means of collecting data on nutrition.

A periodically updated national nutrition information system and routinely collected data on food and nutrition were considered important for evaluating the effectiveness of national nutrition plans and policies and identifying subsequent actions.

Strategies for effective and sustainable national nutrition plans and policies. Modern aspects of nutrition , present knowledge and future perspective. Basel , Karger Forum for Nutrition 56 , This indicates whether a government has adopted legislation to monitor and enforce the International Code of Marketing of Breast-milk Substitutes, which helps create an environment that enables mothers to make the best possible feeding choice, based on impartial information and free of commercial influences, and to be fully supported in doing so.

This indicator is defined on the basis of whether a government has adopted legislation for effective national implementation and monitoring of the International Code of Marketing of Breast-milk Substitutes.

The Code is a set of recommendations to regulate the marketing of breast-milk substitutes, feeding bottles and teats. The Code aims to contribute "to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution" Article 1. Improper marketing and promotion of food products that compete with breastfeeding often negatively affect the choice and ability of a mother to breastfeed her infant optimally.

The Code was formulated in response to the realization that such marketing resulted in poor infant feeding practices, which negatively affect the growth, health and development of children and are a major cause of mortality in infants and young children. Breastfeeding practices worldwide are not yet optimal, in both developing and developed countries, especially for exclusive breastfeeding under 6 months of age. In addition to the risks posed by the lack of the protective qualities of breast milk, breast-milk substitutes and feeding bottles are associated with a high risk for contamination that can lead to life-threatening infections in young infants.

Infant formula is not a sterile product, and it may carry germs that can cause fatal illnesses. Artificial feeding is expensive, requires clean water, the ability of the mother or caregiver to read and comply with mixing instructions and a minimum standard of overall household hygiene. These factors are not present in many households in the world. Frequently asked questions , These indicators provide information on national policies for legal entitlement to maternity protection, including leave from work during pregnancy and after birth, as well breastfeeding entitlements after return to work.

Since the International Labour Organization ILO was founded in , international labour standards have been established to provide maternity protection for women workers. Key elements of maternity protection include: The right to cash benefits during absence for maternity leave is intended to ensure that the woman can maintain herself and her child in proper conditions of health and with a suitable standard of living.

The source of benefits is important due to potential discrimination in the labour market if employers have to bear the full costs. The right to continue breastfeeding a child after returning to work is important since duration of leave entitlements generally is shorter than the WHO recommended duration of exclusive and continued breastfeeding. A composite indicator on maternity protection is included as a policy environment and capacity indicator in the core set of indicators for the Global Nutrition Monitoring Framework.

It currently uses the ILO classification of compliance with Convention on three key provisions leave duration, remuneration and source of cash benefits , but an alternative method taking into account higher standards as stated in Recommendation as well as breastfeeding entitlements is under development. The ILO periodically publishes information on the above key indicators, including the assessment of compliance with Convention No.

However, an alternative method is under development which may use a scale to indicate the degree of compliance is under development.

This method will also take into account higher standards for leave duration and remuneration in Recommendation , as well as breastfeeding entitlements within both the Convention and Recommendation. Pregnancy and maternity are potentially vulnerable time for working women and their families.

Expectant and nursing mothers require special protection to prevent any potential adverse effects for them and their infants. They need adequate time to give birth, to recover from delivery process, and to nurse their children. At the same time, they also require income security and protection to ensure that they will not suffer from income loss or lose their job because of pregnancy or maternity leave. Such protection not only ensures a woman's equal access and right to employment, it also ensures economic sustainability for the well-being of the family.

Returning to work after maternity leave has been identified as a significant cause for never starting breastfeeding, early cessation of breastfeeding and lack of exclusive breastfeeding. In most low- and middle-income countries, paid maternity leave is limited to formal sector employment or is not always provided in practice.

The ILO estimates that more than million women lack economic security around childbirth with adverse effects on the health, nutrition and well-being of mothers and their children. Maternity cash benefits for workers in the informal economy. Rollins et al Why invest, and what it will take to improve breastfeeding practices? Database of national labour, social security and related human rights legislation. The legislative data are collected by ILO through periodical reviews of national labour and social security legislation and secondary sources, such as the International Social Security Association and International Network on Leave Policies and Research; as well as consultations with ILO experts in regional and national ILO offices around the world.

The composite indicator on maternity protection included in the Global Nutrition Monitoring Framework is currently defined as whether the country has maternity protection laws or regulations in place compliant with the provisions for leave duration, remuneration and source of cash benefits in Convention Documentation for the maternity protection database http: Degree training in nutrition exists. What does the indicator tell us?

This indicator reflects the capacity of a country to train professionals in nutrition in terms of having national higher education institutions offering training in nutrition. This indicator is defined as the existence of higher education institutions offering training in nutrition in the country. Higher education training institutions include universities and other schools offering graduate and post-graduate degrees in nutrition or dietetics, including public health nutrition, community nutrition, food and nutrition policy, clinical nutrition, nutrition science and epidemiology.

Trained nutrition professionals work at facilities including health facilities as well as at population and community levels and may influence nutrition policies, and designing and implementation of nutrition intervention programmes at various levels.

They also play an important role in training of other health and non-health cadres to plan and deliver nutrition interventions in various settings. It is recognized that availability, within a country, of sufficient workforce with appropriate training in nutrition will lead to better outcomes for country-specific nutrition and health concerns. A competency framework for global public health nutrition workforce development: World Public Health Nutrition Association.

Registering as Registered Nutritionist. Building systemic capacity for nutrition: Nutrition is part of medical curricula. This indicator reflects the inclusion of maternal, infant and young child nutrition in pre-service training of health personnel. This indicator is defined as the existence of pre-service training in maternal, infant and young child nutrition for health personnel.

The survey investigates training in three key areas of maternal, infant and young child nutrition, namely growth monitoring and promotion, breastfeeding and complementary feeding, and management of severe or moderate acute malnutrition. The first two of these three training topics are relevant for all forms of malnutrition, whereas the third topic only pertains to undernutrition.

Training on other topics e. Adequate training of health professionals is essential to ensure that nutrition activities are included in their regular health care activities. Nutrition counseling training changes physician behavior and improves caregiver knowledge acquisition. Nutrition Journal ; Trained nutrition professionals density. The focus of the nutrition professional indicator is on individuals trained to pursue a nutrition professional career, described in most countries as dieticians or nutritionists including nutrition scientists, nutritional epidemiologists and public health nutritionists.

These individuals are trained sufficiently in nutrition practice to demonstrate defined competencies and to meet certification or registration requirements of national or global nutrition or dietetics professional organizations.

Dieticians and nutritionists may complete the same training and perform the same functions in some countries but not others. This indicator is defined as the number of trained nutrition professionals per , population in the country in a specified year.

Validation of the indicator has shown that it can predict several maternal, infant and young child nutrition outcomes. Global nutrition monitoring framework: Density of nurses and midwi ves. Nurse and midwife density indicates whether nurses and midwifery personnel are available to address the health care needs of a given population. It is the number of nursing and midwifery personnel and density per 10 population.

These personnel include professional nurses, professional midwives, auxiliary nurses, auxiliary midwives, enrolled nurses, enrolled midwives and other personnel, such as dental nurses and primary care nurses. Traditional attendants are not counted here but as community or traditional health workers. There is no gold standard for a sufficient health workforce to address the health care needs of a given population. It has been estimated, however, that countries with fewer than 25 health-care professionals counting only physicians, nurses and midwives per 10 population fail to achieve adequate coverage rates for selected primary health care interventions that are priorities in the Millennium Development Goals.

The World Health Report Working together for health. The World Health Report papers. G ross domestic product per capita and annual growth rate. GDP per capita purchasing power parity is the GDP divided by the midyear population, where GDP is the total value of goods and services for final use produced by resident producers in an economy, regardless of the allocation to domestic and foreign claims.

It does not include deductions for depreciation of physical capital or depletion and degradation of natural resources. Purchasing power parity indicates the rate of exchange that accounts for price differences across countries, allowing international comparisons of real output and incomes. Purchasing power parity rates allow standard comparisons of real prices among countries, just as conventional price indexes allow comparisons of real values over time; use of normal exchange rates could result in over - or undervaluation of purchasing power.

GDP per capita annual growth rate is defined as the least squares annual growth rate, calculated from constant price GDP per capita in local currency units. Higher income is usually associated with lower rates of mal nutrition. Improving income however, reduces mal nutrition to only a small degree World Bank On the basis of the correlation between growth and nutrition , it is estimated that a sustained per capita economic growth of 2.

These estimates suggest that countries cannot depend on economic growth alone to reduce mal nutrition within an acceptable time. Repositioning nutrition as central to development. A strategy for large-scale action , Human solidarity in a divided world , Official development assistance received net disbursements as a percentage of Gross Domestic Product GDP is a measure of the flow of aid, private capital and debt in comparison with the value of goods and services produced within the country.

This indicator is official development assistance received as a percentage of the GDP. Net official development assistance consists of grants or loans to countries or territories from the official sector, with the main objective of promoting economic development and welfare, at concessional financial terms. GDP is the total value of final goods and services produced within a country's borders in a year, regardless of ownership. When official development assistance makes up a large proportion of the GDP, a country is highly aid dependent, with the risk of unpredictable aid and donor-driven aid programmes.

This can affect the resources allocated to nutrition , which are often not a donor priority in the sector-wide aid strategies promoted by the Paris Declaration Paris Declaration on Aid Effectiveness: This indicator identifies countries with low income and food inadequacy.

A country is classified by the UN Food and Agriculture Organization FAO as 'low-income food-deficit' for analytical purposes on the basis of low income and food inadequacy, and the status is agreed by the country itself.

The classification applies to countries that have a per capita income below the ceiling used by the World Bank to determine eligibility for International Development Association assistance and for year terms determined by the International Bank for Reconstruction and Development, applied to countries included in World Bank categories I and II.

The second criterion is based on the net i. Trade volumes of a broad range of basic foodstuffs cereals, roots and tubers, pulses, oilseeds and oils other than tree crop oils, meat and dairy products are converted and aggregated by the calorie content of individual commodities. The third criterion, which is self-exclusion, is applied when countries that meet the above two criteria specifically request to be excluded from the low-income food-deficit category.

In order to avoid too frequent changes of low-income food-deficit status, usually reflecting short-term, exogenous shocks, an additional factor is taken into consideration.

This factor, called 'persistence of position', postpones the 'exit' of a country from the list even if it does not meet the low-income or the food-deficit criterion, until the change in its status is verified for 3 consecutive years. In other words, a country is taken off the list in the fourth year after confirming a sustained improvement in its position. During these 3 years, the country is considered to be in a transitional phase. The rationale behind the low-income food-deficit classification is that being both food deficit and having a low income at the same time means that the country lacks the resources not only to import food but also to produce sufficient amounts domestically.

It is the combination of these two factors that makes these countries both food insecure and susceptible to domestic and external shocks, which could affect the nutrition al status of vulnerable populations.

The low-income food-deficit list is intended to capture this aspect of the food problem. In comparison with countries in other classifications commonly used for analytical and operational purposes, e. Reproducibility guarantees that an indicator can be measured at repeated intervals in a comparable manner - a quality which is crucial when using the indicator to assess and monitor the situation. A complementary characteristic is specificity, which refers to the ability to identify those not affected by the risk or characteristic.

Sensitivity is measured in practice by the ratio of the number of individuals identified by the indicator as being at risk or as having the characteristic to the number of individuals who are actually at risk or have the characteristic.

Specificity is the ratio of the number of individuals not identified by the indicator to the number of individuals who are actually not at risk or do not possess the characteristic. Sensitivity thus gives an idea of the degree of correct or misclassification linked to the use of an indicator.

Not all indicators lend themselves to an assessment of sensitivity. Sensitivity applies essentially to indicators with cut-off values. Moreover, sensitivity is measured with respect to a given goal; sensitivity of an indicator such as weight-for-height at a given cut-off value will not be the same, depending on whether the goal is to identify children who are wasted or those who are at risk of dying in coming months.

Data for quick computation of these parameters sensitivity, specificity are not always available, so in practice, reference is made to existing data from the literature to find those closest to the chosen cut-off values and expected prevalences.

One particular aspect of sensitivity is the ability of an indicator to measure change, not in order to identify or target a particular category of individuals as previously but to detect the smallest possible change in the phenomenon described, in a significant way.

While sensitivity, in general, is important when establishing a baseline, and for defining the target groups to which the activities will be directed, this ability for measuring change is crucial for assessing or monitoring trends, in particular to detect changes in the situation during implementation of the programme. However, it is relatively inert when assessing small progressive changes in nutritional status over time, and the weight-for-height indicator will be preferred in this case, since it is more sensitive to change.

Also, urinary iodine will respond to introduction of salt iodization in a region quicker than prevalence of goitre, which will decline only slowly. In addition to these inherent characteristics of indicators, their operational value should be examined; it will be essential when the choice of indicators is made, especially in terms of speed and cost of collecting data for producing these indicators.

It represents the practical possibility of making available the indicator in question. It implies the feasibility of collecting the corresponding data by whatever means.

There are indicators described as "ideal" which nobody is in practice able to collect. As a result of major international conferences and of programmes that have followed them during the last two decades, many of the required indicators are already systematically and regularly collected within the framework of such programmes and are thus very easily available. It affects use of the indicator not only at the descriptive stage, but also when monitoring the situation.

An indication of the quality of the measurements, of sampling and of the confidence interval of the result is essential here to assess dependability. Occasionally, it has been observed that the number of malnourished children estimated by nutritional surveys carried out by various organizations on identical populations and during the same periods, differed substantially; using the results for targeting purposes or for monitoring the situation is ruled out in this case.

The reason was usually the lack of precision of the anthropometric measurements or of the definition of age, and occasionally a sampling problem. Data on food consumption obtained by weighing food are more precise than those obtained with the "recall" technique, although the former implies technical constraints and can therefore only apply to small samples, so that there is a broad confidence interval in the results.

Recall techniques, on the contrary, can easily be applied to a large sample, obviously with a smaller confidence interval. The various available data must therefore be carefully examined before using them for monitoring purposes, and a choice will sometimes be made between data collected with a higher level of accuracy but lower power at the level of the target population, or the opposite.

On this depends, in part, the speed and frequency with which the indicator can be regularly measured. When the data necessary for the construction of the indicator need to be collected specifically for evaluation or monitoring, cost should be considered; it depends on the difficulty and sophistication of the measurements, the accessibility of the objects or people to be measured, the frequency of collection and the complexity of the analysis subsequently. The cost of non-collection may be measured, in the case of a food subsidy programme, for example, by the difference between the cost of the programme if it is carried out without particular targeting, in the absence of any indicator allowing targeting, and the cost of the programme for the target population, plus the cost of targeting, if the programme is to be directed at a high risk group only.

Nevertheless, information on the cost of collecting an indicator for each situation is seldom available. It is difficult to measure, and estimates are generally based on the cost of different types of survey within the country, taking account of the fact that several indicators are collected at the same time.

Indicators can be categorized schematically in the following way according to the level at which they are produced or made available:. They include both indicators regarding the implementation of services as well as indicators regarding the situation or the impact of actions under way. It is generally easy to obtain them from the departments concerned, which usually have time series that are very useful in distinguishing medium- and long-term trends.

Even so, it is not always possible to cross-tabulate these indicators, since they do not necessarily come from the same databases and are accessible only in a relatively aggregated form. It is also difficult to verify the quality of the original data. Lastly, even if the data are collected on a frequent basis monthly reports, for example , recovery and analysis may take too long.

Such data tend not to be immediately accessible except in summary form, although it is easy to organize new analyses with the departments in charge of them. These data allow statistical cross-tabulation to be made between the many variables collected simultaneously on the sample. Although carried out at best at very long intervals, they can be updated with reasonable projections, especially if information on trends in the fields of interest, based on routinely collected data, are also available.

These data are often kept together in national statistical offices. They consist of a regular collection of information based on a small number of selected indicators.

The system varies by country, those that perform best are based on an explicit conceptual framework and are linked to a clear decision-making mechanism. They can represent a sound basis for central monitoring. A particular category is derived from surveys conducted by international bodies for various purposes: These cross-sectional surveys are conducted directly at household level on samples which are representative at national level but of variable size; they include a wide variety of indicators in number, goals and qualities and are now frequently repeated.

Although conducted peripherally, they are generally available and used centrally. These sources, which are in principle fairly reliable, benefit from an advanced level of analysis allowing causal inference to be derived of relationships among various household indicators, and with individual indicators, such as nutritional status.

They represent a precious source when establishing a baseline and when analysing causes prior to launching an intervention. These are constructed primarily on the basis of routinely collected data from local government offices, community-based authorities. They are usually passed on as indicators or raw data to the central level, and then sent back to the decentralized levels, with varying degree of regularity, after analysis. They are often disaggregated by district or locality, but are not always representative, since they often refer only to users of the services under consideration.

They are generally grouped together at the central administrations of regions or administrative centres. The indicators relate primarily to activities that lend themselves to regular observation, either because they record activities indicators of operation or delivery of services or because they are necessary for decision-making crop forecasts, unemployment rates or for monitoring purposes market prices of staples, number of cases of diseases, etc.

They do not necessarily include indicators of the causes of the phenomena recorded and are not in principle qualitative indicators. Indicators collected at decentralized levels should meet both the needs of users on these levels and also those of users on the central level for the implementation and monitoring of programmes. If these regularly compiled indicators do not have any real use at the local level and are intended only for the national central level, there is a danger that their quality will drop over time, for lack of sufficient motivation of those responsible for collection and transmission - and gaps are therefore often found in available data sets.

Nevertheless, they are invaluable in giving a clear picture of the situation on the regional or district level, together with medium-term trends.

Generally speaking, their limitation is the low level of integration of data from different sectors. A certain number of indicators, particularly those concerning the life of communities or households and not touching on the activities of the various government departments, are not routinely collected by such departments and are in any case not handed on to the regional or central offices.

They are sometimes collected at irregular intervals by local authorities, but most often by non-governmental organizations for specific purposes connected with their spheres of activity - health, hygiene, welfare, agricultural extension, etc. Analytical capabilities are often lacking at this level, and the available raw data may not have led to the production of useful indicators. Action therefore should be taken to enhance analytical capacities or else sample surveys will have to be carried out periodically on these data in order to produce indicators.

A sound knowledge of local records and their quality is needed to avoid wasting time. New collection procedures often have to be introduced for use by local units, while being careful not to overload them or divert them from their own work. Otherwise a specific collection has to be carried out by surveying village communities targeted for analysis or intervention. These surveys are vital for a knowledge of the situation and behaviours of individuals and households and an evaluation of their relationship with the policies introduced.

In general, they offer an integrated view of the issues concerned. They may have the aim of supplying elements concerning the local situation and local analysis, in order to confirm the consensus of the population and of those in charge as to the situation and interventions to be carried out, and also to allow an evaluation of the impact of such interventions.

The participatory aspect should be emphasized rather than the precision or sophistication of data. An FAO work on participatory projects illustrates issues of evaluation, and especially the choice of indicators in the context of such projects FAO If data already collected are used or if a new survey is carried out for use on a higher level, the size and representativeness of the sample must be checked, and it must be ensured that the data can be linked to a more general set on the basis of common indicators collected under the same conditions method, period, etc.

Verification of the quality of the data is crucial. Before undertaking a specific data collection, a list of indicators and of corresponding raw data should be developed which can be used by services at all levels; it is not unusual to find that surveys could have been avoided by a better knowledge of the data available from different sources. To track down these useful sources and judge the quality of the data available and their level of aggregation, a good understanding is needed of the goals and procedures of the underlying information system.

The country had set up a monthly national information system on production estimates for 35 crops, covering information on crop intentions, areas actually planted, crop yields and quantities harvested in each state. The information was obtained during monthly meetings of experts at various levels - local, regional and national. The information was then put together at the state level, and then at the national level, reviewed by a national committee of experts, and sent on to the central statistics office.

The different levels thus had some rich information at their disposal, coming from a range of local-level sources. Although it was certainly fairly reliable, being confirmed by a large number of stakeholders and experts, its precision could not be defined, in view of its diversity. The usefulness of such data varies depending on information needs and thus on the quality of the data required. Data concentrated at the central level are probably useful primarily for analysing trends.

On the other hand, apart from the figures, more general information on production systems exists at local level, and this can be useful for identifying relevant indicators of causes, or for simplifying monitoring of the situation. We have seen that there is a great number of indicators which differ widely in quality; the availability of corresponding data is variable, and any active collection will be subject to constraints. Therefore the choice of indicators must be restricted to the real needs of decision makers or programme planners.

This implies that a method is needed for guiding the choice. The main elements that will guide choice are: Any intervention is based on an analysis of the situation, an understanding of the factors that determine this situation, and the formulation of hypotheses regarding programmes able to improve the situation.

A general framework was presented earlier see Figure , representing a holistic model of causes of malnutrition and mortality, which was endorsed by most international organizations and nutrition planners. However, the convenient classification that it implies, for instance into levels of immediate, underlying or basic causes needs to be operationalized through further elaboration in context. The benefit of constructing such a framework, over and above the complete review of the chain of events which determine the nutritional situation, is to allow the expression, in measurable terms, of general concepts which, because of their complexity, are not always well defined.

For example, it is not enough to refer to "food security"; one should state which of the existing definitions is to be used, on which dimensions of food security the focus is placed and the corresponding indicators.

The use of conceptual frameworks when implementing programmes or planning food and nutrition is not new. Many examples have been developed, focusing on different aspects. The concept of food security is generally perceived as that of sufficient availability of food for all.

However, several dozen different definitions have been proposed over these last 15 years! This concept may, for example, comprise different aspects depending on the level being related to: In the first case, analysis will focus on agricultural production, and in the second the emphasis will be on improving the resources of those who lack access to a correct diet.

This preliminary brainstorming exercise will allow a better definition of the perceived chain of causes production shortfall, excessive market prices, defective marketing infrastructures, low minimum wage, low level of education, etc.

It will then be easier to consider potential indicators of the situation and its causes, or potential indicators of programme impact. Obviously it is not so much the final diagram which is of importance as the process through which it was developed. Insofar as the relations between all the links of the chain of events or flow data, depending on the type of representation have been discussed step by step and argued with supporting facts, the framework will be adapted to the local situation and will become operational.

Methodologies have been developed for making this process effective in the context of planning, for example with the method of "planning by objectives" see ZOPP , which comprises several phases: During this planning process, all programme activities, corresponding partners, necessary inputs and resulting outputs as well as indicators for both monitoring implementation and evaluating impact of the programme will be successively identified.

The method acts as a guide for team work, encouraging intersectoral analysis and offering a simplified picture of the situation, so that the results of discussions are clear to all in the team. Let us again take the example of a problem of food security. It can be broken down into three determining sectors: A series of structural elements can be defined for each sector: These elements affect both production levels and operation of markets.

A certain number of macro-economic or specific policies will affect one or all the elements in this block. Each block can be considered in a similar way, and this will provide the groundwork for a theoretical model of how the system works see C.

The final steps in order to operationalize the model are i that of defining indicators that will, in the specific context of the country, reflect the key elements of the system, and ii , once policies and programmes have been chosen, that of identifying which of these indicators are useful for monitoring trends and evaluating programme impact.

This will be the basis for an information system reflecting the overall framework of the programme and how it should work. Another method has been proposed by researchers from the Institute of Tropical Medicine in Antwerp based on their field experience in collaboration with different partners Lefèvre et al.

Basically, it stresses the participatory aspect, with the aim of obtaining a true consensus on the local situation, the rationality of interventions in view of the situation, and the choice of indicators. It includes first a phase in which a causal framework is developed with the aim of providing an understanding of the mechanisms leading to undernutrition in the context under consideration.

The framework is constructed in the form of a schematic, hierarchized diagram of causal hypotheses formulated after discussions among all stakeholders. The way it is built tends to favour a clear, "vertical" visualization of series of causal relationships, eliminating the lateral links or loops that are often the source of confusion in other representations. In a second phase, a framework is developed linking the human or material resources available at the onset inputs , the procedures envisaged activities , the corresponding results of implementation outputs , and the anticipated intermediate outcomes or final impact of each activity or of the programme.

This tool is very useful for defining all the necessary indicators. This represents the formalisation of a real conceptual scheme. While many representations of conceptual models comprise comparable elements, it is essential that a model should never be considered as directly transposable, since it must absolutely apply to the local context. A direct transposition would therefore be totally counter-productive.

While it is obvious that the conceptual analysis must ideally be carried out before the programmes are launched, it can be done or updated at any time, leading to greater coherence and a consensus on current and anticipated actions; this applies even more in a long-term perspective of sustainability.

In operational terms, establishment of a conceptual framework allows to define in a coherent way the various types of indicators to be used at each level.

After defining the activities to be undertaken, status indicators referring to the target group will be identified, as well as indicators of causes that will or will not be modified by these activities, and indicators that will reflect the level or quality of the activities performed.

Lastly, indicators will be chosen to reflect the changes obtained, whether or not these are a result of the programme. Identification of precise objectives makes it possible to monitor changes in impact indicators not only vis-à-vis the original situation but also in terms of fulfilment of the objectives adopted.

During this initial phase, existing indicators are assessed, as well as those that will be taken from records or collected through specific surveys. It should be specified who needs this information, as well as who collects the data. In fact, it is important that this choice should be demand-driven, in order to be sure that the information selected is then actually used.

One might be dealing with several groups of users who do not exactly have the same needs: In this way, foundations can be laid for an information system essential for monitoring and evaluation. A proximate, often indirect, indicator will have to be sought and limitations to its validity in the context considered will have to be verified carefully which will depend on the precise objective.

For example, can a measurement of food stocks at a given moment be validly replaced in the context under consideration with a measurement of food consumption in order to assess the food insecurity situation of a target group? Is a measurement of food diversity a good proximate indicator for micronutrient intake? Does it at least consistently classify consumers into strong and weak consumers? Does it allow defining an acceptable level of consumption vis-à-vis recommendations?

Will it allow children to be classified correctly vis-à-vis a goal of improved growth? Validity studies are sometimes available locally, otherwise specific studies can be carried out; hence the usefulness of collaborating with research groups - for example from universities - who will be able to carry out this type of validation study under good conditions.

The relationship between two variables, making them interchangeable for defining an indicator, may vary over time as a result of implementation of a programme, and this must be taken into account. For example, if there is a clear link between family size and food insecurity in a given context, the criterion of family size can simply be taken as a basis for identifying families at risk.

However, if a specific programme has been successfully carried out among these families, this indicator could lose its validity. The ideal would be to use the same indicators in all places and at all times in order to have the benefit of common experience regarding collection and analysis, so that direct comparisons can be made.

In practice, however, concepts on indicators evolve steadily with the progress of knowledge, leading to the dilemma of being unable to carry out comparisons either with older series of indicators or with what is being done elsewhere. Comparability within time is obviously a priority in the case of monitoring. Preference will thus be given to indicators that, although not necessarily identical, are comparable, in other words give a similar type of information.

The issue of the comparability of data from different sources has been the subject of studies especially in the field of health indicators. Whenever traditional indicators seem inadequate or insufficient in capturing the phenomenon or situation under consideration, the value of "innovative" and potentially promising indicators with excellent basic characteristics should not be neglected - although it is important to make sure that they have been validated for circumstances similar to those under study.

Since such innovative indicators usually have to be collected "actively", especially at the community level, the decision often depends on their technical feasibility as a guarantee of the sustainability of collection. In a context of dietary transition, an indicator expressing the structure of food consumption for example the percent of energy from fat is more subject to major changes than the average consumption level expressed in calories, while also providing important information on the future health of the population considered.

In contrast, data on food habits tend not to change rapidly, unless an education programme is specifically developed for this purpose; the repeated collection of the corresponding indicators is thus of little use for purposes of short- or medium-term monitoring of the situation.

Slowness in collection and in getting the data back to user level are key factors to be considered, for many information systems are paralyzed by this problem, while timely information is often needed for decision-making or for adjusting the programme or the intervention e. From this point of view, the nature of potential sources of data for these indicators or the direct availability of these indicators at the level where they are needed can be decisive for their selection.

In practice, data collected to produce indicators need to be compared to a reference or to a "cut-off value". These can based on an international consensus within the scientific community or the political world, thus avoiding disagreement on interpretation and allowing comparisons between countries and regional extrapolations.

Even so, the information is still sometimes insufficient; moreover, there are no international references for several categories of indicators. In such cases, the value of the same variable at a previous date will be taken as a point of reference.

Interpretation of changes in an indicator can be carried out only on the basis of our knowledge of the original situation; knowing a baseline therefore forms part of the information value of a number of indicators. For instance, was it better or worse before? The only information it supplies as such is the difference from a reference situation in a country without any major problem of undernutrition defined as a prevalence of 2.

The impact of a programme cannot be measured without knowledge of the situation at baseline. The existence of chronological series for an indicator will be considered when choosing among several indicators, because such series allow a rapid interpretation of impact in terms of trends.

When previous data are old, an effort is made to assess their present level by projection, as is usually done for major demographic or economic indicators. In a certain number of cases, a preliminary survey is needed in order to establish the present level of various indicators. Many countries undertook national surveys of their nutritional situation prior to establishing their policies and programmes, so that they could decide on the type or scope of the programme, and could subsequently evaluate the impact.

Such surveys are not cheap, but their cost must be examined in regard to that of the programme to be developed, and of the potential cost linked to the lack of evaluation of a programme that fails to yield the expected results. When passive collection of data from existing sources does not provide the necessary indicators in an appropriate form, active collection should be considered through surveys among the population with an appropriate level of disaggregation.

This may also be needed when the administrative coverage of the population, particularly of groups at risk, is insufficient. Firstly, it is important to consider that the preferred level of expression of the indicators varies by discipline individuals for the expression of epidemiological risks, households for the level of food security, administrative units for an economist, etc.

The statistical units of measurement vary accordingly. These three expressions of the same situation cannot be treated in the same way statistically.

Data that have been collected at different levels, must be analyzed accordingly. Depending on the type of indicator required, quantitative or qualitative survey techniques will be used, each based on specific methodologies.

A good understanding of the limitations of the data thus collected in terms of their interpretation, representativeness, accuracy and precision is crucial.

Well-known guides written by specialists in each sphere are generally available. For the collection of data on the nutritional status of a population, for example, the WHO and FAO have published guides describing the procedures to be followed for sampling, collecting and interpreting anthropometric measurements in the context of cross-sectional surveys WHO, ; FAO, There is also a guide for the main types of surveys on food consumption Cameron and van Staveren, and publications on household food security indicators and how to measure them Maxwell and Frankenberger, ; Delaine et al.

Appropriate methods have also been developed in the fields of demographics, health WHO, and economics, in order to establish rough indicators when most of the usual sources are lacking.

These qualitative methods, developed and commonly used in the social sciences, especially anthropology, are now widely used in economics and agronomy Chambers, in combination with more traditional quantitative surveys, but those working in the food and nutrition sector are not always familiar with them.

A description of these methodologies, adapted to different uses, can be found in various publications Maxwell and Frankenberger, ; Chambers, ; Den Hartog and van Staveren, ; Kidima, Scrimshaw and Hurtado,

B. Nutritional assessment