NLiS Country Profile: Afghanistan

Nutrition Landscape Information System (NLiS)

Dietetics and Nutrition
As the lead organization in global public health, the WHO occupies a delicate role in global politics. Improved water sources include household connections, public standpipes, boreholes, protected dug wells, protected springs and rainwater collection. Virtually all mothers can breastfeed provided they have accurate information, and support within their families and communities and from the health care system. The source of benefits is important due to potential discrimination in the labour market if employers have to bear the full costs. Methodology and Analytical Issues September Millennium Development Goals indicators database.

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NLiS Country Profile: India

World Health Organization, Interventions by global target. Overweight in school-age children and adolescents. This indicator reflects the percentage of school-age children and adolescents years who are classified as overweight based on age and sex specific values for body mass index BMI.

Overweight indicates excess body weight for a given height from fat, muscle, bone, water or a combination of these factors, whilst obesity is defined as having excess body fat. The immediate consequences of overweight and obesity in school-age children and adolescents include greater risk of asthma and cognitive impairment, in addition to the social and economic consequences for the child, its family and the society.

In the long term, overweight and obesity in children increase the risk of obesity, diabetes, heart disease, some cancers, respiratory disease, mental health, and reproductive disorders later in life. Furthermore, obesity and overweight track over the life course — an overweight adolescent girl is more likely to become an overweight woman and, thus, her baby is likely to have a heavier birth weight.

Worldwide trends in body-mass index, underweight, overweight, and obesity from to Growth reference years. Commission on Ending Childhood Obesity. Halt the rise in diabetes and obesity. Anaemia has a wide variety of causes. Other conditions malaria and other infections, genetic disorders, cancer also play a role. Anaemia is defined as a haemoglobin concentration below a specified cut-off point, which can change according to the age, gender, physiological status, smoking habits and altitude at which the population being assessed lives.

Tests to measure haemoglobin levels are easy to administer. The test could be easily integrated into regular health or prenatal visits or household surveys to capture women of reproductive age, though one needs to consider the cost of the equipment and regular calibration.

Anaemia is associated with increased risks for maternal and child mortality. Iron-deficiency anaemia reduces the work capacity of individuals and entire populations, with serious consequences for the economy and national development. In addition, the negative consequences of iron-deficiency anaemia on the cognitive and physical development of children and on physical performance - particularly the work productivity of adults - are major concerns.

Anaemia is a global problem affecting all countries. Resource-poor areas are often more heavily impacted due to the prevalence of infectious diseases. The main risk factors for iron-deficiency anaemia include a low dietary intake of iron or poor absorption of iron from diets rich in phytates or phenolic compounds.

Population groups with greater iron requirements, such as growing children and pregnant women, are particularly at risk.

Overall, the most vulnerable, poorest and least educated groups are disproportionately affected by iron-deficiency anaemia. Prevalence cut-off values for public health significance. No public health problem. Mild public health problem. Moderate public health problem. Severe public health problem. Stevens GA et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for Lancet Global Health ; ; 1: Data about haemoglobin and anaemia for women of childbearing age 15—49 years were estimated for each country and for each year between and using survey data obtained from population-representative data sources from countries worldwide.

A Bayesian hierarchical mixture model was used to estimate haemoglobin distributions and systematically addressed missing data, non-linear time trends, and representativeness of data sources. More information on the methodology can be found in: Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Cut-off values for public health significance.

Vitamin A deficiency results from inadequate dietary intake of vitamin A to satisfy physiological needs. It may be exacerbated by high rates of infection, especially diarrhoea and measles. It is common in developing countries but rarely seen in developed countries. Vitamin A deficiency is a public health problem in more than half of all countries, especially those in Africa and South-East Asia, most severely affecting young children and pregnant women in low-income countries.

Vitamin A deficiency can be defined clinically or subclinically. The stages of xerophthalmia [clinical spectrum of ocular manifestations of vitamin A deficiency, from the milder stages of night blindness and Bitot spots to the potentially blinding stages of corneal xerosis, ulceration and necrosis keratomalacia ] are regarded both as disorders and clinical indicators of vitamin A deficiency.

Night blindness in which it is difficult or impossible to see in relatively low light is one of the clinical signs of vitamin A deficiency and is common during pregnancy in developing countries.

Retinol is the main circulating form of vitamin A in blood and plasma. Serum retinol levels reflect liver vitamin A stores when they are severely depleted or extremely high, but between these extremes, plasma or serum retinol is homeostatically controlled and therefore does not always correlate well with vitamin A intake.

Therefore, serum retinol is best used for the assessment of subclinical vitamin A deficiency in a population not an individual. Blood concentrations of retinol the chemical name for vitamin A in plasma or serum are used to assess subclinical vitamin A deficiency. Night blindness is one of the first signs of vitamin A deficiency. In its more severe forms, vitamin A deficiency contributes to blindness by making the cornea very dry and damaging the retina and cornea.

An estimated — vitamin A-deficient children become blind every year, and half of them die within 12 months of losing their sight. Vitamin A deficiency also contributes to maternal mortality and other poor outcomes of pregnancy and lactation. Furthermore, it diminishes the ability to fight infections. Even mild, subclinical deficiency can be a problem, as it may increase children's risk for respiratory and diarrhoeal infections, decrease growth rates, slow bone development and decrease the likelihood of survival from serious illness.

Serum or plasma retinol. Night blindness XN in pregnant women. Micronutrients Database [online database]. The new database is not yet publically available and the NLIS country profiles have not yet been updated. Global prevalence of vitamin A deficiency in populations at risk — Serum retinol concentrations for determining the prevalence of vitamin A deficiency in populations.

Xerophthalmia and night blindness for the assessment of clinical vitamin A deficiency in individuals and populations. Vitamin A deficiency, list of publications. Trends and mortality effects of vitamin A deficiency in children in low-income and middle-income countries between and This indicator allows an assessment of iodine deficiency at the population level. Iodine is an essential trace element that is present on the thyroid hormones, thyroxine and triiodotyronine.

It occurs most frequently in areas where there is little iodine in the diet—typically remote inland areas where no marine foods are eaten. Although goitre assessment by palpation or ultrasound may be useful for assessing thyroid function, results are difficult to interpret once salt iodization programmes have started.

The median urinary iodine concentration is considered the main indicator of iodine status for all age groups, because its measurement is relatively non-invasive, cost-efficient and easy to perform. Since the majority of iodine absorbed by the body is excreted in the urine, it is considered a sensitive marker of current iodine intake and can reflect recent changes in iodine status. Median urinary iodine concentrations have been most commonly measured in school children aged 6—12 years due to their easy access.

During the neonatal period, childhood and adolescence, iodine deficiency disorders can lead to hypo- and hyperthyroidism. Serious iodine deficiency during pregnancy can result in stillbirth, spontaneous abortion and congenital abnormalities such as cretinism, a grave, irreversible form of mental retardation that affects people living in iodine-deficient areas of Africa and Asia.

Of even greater significance is the less visible, yet pervasive, mental impairment that reduces intellectual capacity at home, in school and at work. Cut-off values for public health significance in different target groups. Concentration cut-off values for public health significance. May pose a slight risk of more than adequate iodine intake in these populations.

Risk of adverse health consequences iodine-induced hyperthyroidism, autoimmune thyroid disease. Urinary iodine concentrations for determining iodine status deficiency in populations.

Goitre as a determinant of the prevalence and severity of iodine deficiency disorders in populations. Iodine deficiency, list of publications. Global iodine status in and trends over the past decade.

In NLIS, it is used as a proxy for access to health services and maternal care. The indicator gives the percentage of live births attended by skilled health personnel in a given period. A skilled birth attendant is an accredited health professional—such as a midwife, doctor or nurse—who has been educated and trained to proficiency in the skills needed to manage normal uncomplicated pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of women and newborns for complications.

In developed countries and in many urban areas in developing countries, skilled care at delivery is usually provided in health facilities. Births do, however, take place in various other appropriate places, from home to tertiary referral centres, depending on availability and need. WHO does not recommend a particular setting for giving birth.

Home delivery may be appropriate for normal births, provided that the person attending the delivery is suitably trained and equipped and that referral to a higher level of care is an option, however this may lead to an overestimation of births attended by skilled personal as infants delivered outside of a health facility may not have their birth method recorded. All women should have access to skilled care during pregnancy and at delivery to ensure the detection and management of complications.

One woman dies needlessly of pregnancy-related causes every minute, representing more than half a million mothers lost each year, a figure that has improved little over the past few decades. Another 8 million or more suffer life-long health consequences from the complications of pregnancy. The lack of progress in reducing maternal mortality in many countries often reflects the low value placed on the lives of women and their limited role in setting public priorities.

The lives of many women in developing countries could be saved by reproductive health interventions that people in rich countries take for granted, such as the presence of skilled health personnel at delivery. Improved sanitation facilit ies and drinking-water sources. What do these indicators tell us? These indicators are the percentage of population with access to an improved drinking-water source and improved sanitation facilities.

How are they defined? Improved drinking-water sources are defined in terms of the types of technology and levels of services that are likely to provide safe water. Improved water sources include household connections, public standpipes, boreholes, protected dug wells, protected springs and rainwater collection. Unimproved water sources are unprotected wells, unprotected springs, vendor-provided water, bottled water unless water for other uses is available from an improved source and tanker truck-provided water.

Improved sanitation facilities are defined in terms of the types of technology and levels of services that are likely to be sanitary. Improved sanitation includes connection to a public sewers, connection to septic systems, pour-flush latrines, simple pit latrines and ventilated improved pit latrines.

Service or bucket latrines from which excreta are removed manually , public latrines and open latrines are not considered to be improved sanitation. Access to safe drinking-water and improved sanitation are fundamental needs and human rights vital for the dignity and health of all people. The health and economic benefits of a safe water supply to households and individuals especially children are well documented.

Both indicators are used to monitor progress towards the Millennium Development Goals. Water, Sanitation and Hygiene. World Health Statistics, Children aged 1 y ear immunized against measles. Estimates of vaccination coverage of children aged 1 year are used to monitor vaccination services, to guide disease eradication and elimination programmes and as indicators of health system performance.

Measles vaccination coverage is defined as the percentage of 1-year-olds who have received at least one dose of measles-containing vaccine in a given year. In countries that recommend that the first dose be given to children over 12 months of age, the indicator is calculated as the proportion of children under 24 months of age receiving one dose of measles-containing vaccine.

Measles is a leading cause of vaccine-preventable childhood deaths, and unvaccinated populations are at risk for the disease. Measles is a significant infectious disease because it is so contagious that the number of people who would suffer complications after an outbreak among nonimmune people would quickly overwhelm available hospital resources.

When vaccination rates fall, the number of nonimmune persons in the community rises, and the risk for an outbreak of measles consequently rises. Millennium Development Goals indicators database. This indicator reflects the percentage of women who consumed any iron-containing supplements during the current or past pregnancy within the last 2 years. It provides information about the quality and coverage of perinatal medical services.

Daily iron and folic acid supplementation is currently recommended by WHO as part of antenatal care to reduce the risk of low birth weight, maternal anaemia and iron deficiency. However, despite its proven efficacy and wide inclusion in antenatal care programmes, its use has been limited in programme settings, possibly due to a lack of compliance, concerns about the safety of the intervention among women with an adequate iron intake, and variable availability of the supplements at community level.

This indicator is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. The indicator is defined as the proportion of women who consumed any iron-containing supplements during the current or past pregnancy within the last 2 years.

Data can be reported on any iron-containing supplement including iron and folic acid tablets IFA , multiple micronutrient tablets or powders, or iron-only tablets which will vary by country policy. Improving the intake of iron and folic acid by women of reproductive age could improve pregnancy outcomes and enhance maternal and infant health.

Iron and folic acid supplementation improve iron and folate status of women before and during pregnancy, in communities where food-based strategies are not yet fully implemented or effective.

Folic acid supplementation with or without iron provided before pregnancy and during the first trimester of pregnancy is also recommended for decreasing the risk of neural tube defects. Anaemia during pregnancy places women at risk for poor pregnancy outcomes, including maternal mortality and also increases the risks for perinatal mortality, premature birth and low birth weight.

Infants born to anaemic mothers have less than one half the normal iron reserves. Morbidity from infectious diseases is increased in iron-deficient populations, because of the adverse effect of iron deficiency on the immune system. Iron deficiency is also associated with reduced work capacity and with reduced neurocognitive development.

Demographic and Health Surveys. Global Nutrition Monitoring Framework: Operational guidance for tracking progress in meeting targets for Children with diarrhoea receiving oral rehydration therapy.

This indicator is the prevalence of children with diarrhoea who received oral rehydration therapy. It is the proportion of children aged 0—59 months who had diarrhoea and were treated with oral rehydration salts or an appropriate household solution. The terms used for diarrhoea should cover the expressions used for all forms of diarrhoea, including bloody stools consistent with dysentery and watery stools, and should encompasses mothers' definitions as well as local terms.

Diarrhoeal diseases remain one of the major causes of mortality among children under 5, accounting for 1. As oral rehydration therapy is a critical component of effective management of diarrhoea, monitoring coverage with this highly cost—effective intervention indicates progress on an intermediate outcome indicator of the Global Nutrition Targets, prevalence of diarrhoea in children under 5 years of age.

Children with diarrhoea receiving zinc. This indicator reflects the prevalence of children who were given zinc as part of treatment for acute diarrhoea. Unfortunately, there are no readily available data on this indicator, which is maintained in the NLIS to encourage countries to collect and compile data on these aspects in order to assess their national capacity. Measures to prevent childhood diarrhoeal episodes include promoting zinc intake.

Diarrhoeal diseases account for nearly 2 million deaths a year among children under 5, making them the second most-common cause of child death worldwide. The greater the prevalence of zinc supplementation during diarrhoea treatment, the better the outcome of treatment for diarrhoea. WHO and the United Nations Children's Fund UNICEF recommend exclusive breastfeeding, vitamin A supplementation, improved hygiene, better access to cleaner sources of drinking-water and sanitation facilities and vaccination against rotavirus in the clinical management of acute diarrhoea and also the use of zinc, which is safe and effective.

Specifically, zinc supplements given during an episode of acute diarrhoea reduce the duration and severity of the episode, and giving zinc supplements for days lowers the incidence of diarrhoea in the following months. Currently no data are available. The impact of zinc supplementation on childhood mortality and severe morbidity. Report of a workshop to review the results of three large studies. Geneva , World Health Organization, 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. 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, Examples of application and comments on limits of interpretation also appear in the work by IFPRI already cited Von Braun and Puetz, and in Scrimshaw and Gleason Finally, a recent study presents an analysis of a substantial number of experiences in various fields Cornwall and Pratt, These surveys are based on observations or interviews, either open or structured and of varying lengths, concerning beliefs, perceptions, knowledge, behaviours or practices of individuals or social groups, with varying degrees of precision, triangulation or participation, and with results expressed in various forms diagrams, maps, calendars, case studies.

The main difficulty is to synthesize the information in order to reach a conclusion, so that the information collected can be used, without converting it inappropriately into reductive numerical data. Not every survey can, however, deal satisfactorily with everything. It is therefore important in this case to check that periodicity, level of collection, representativeness and confidence intervals are relevant for each indicator, otherwise it is better to undertake a separate survey suited to the indicator considered.

Surveys on sub-samples often save time and resources. It must also be ensured that the results can later be aggregated at an adequate level and in a coherent manner.

Two classical approaches are inevitably opposed when survey procedures are defined: Should a food consumption survey be based on the "frequency method" allowing a large sample to be surveyed, or should the "weighing technique" be used, providing more precise estimates but on a smaller sample because the method is cumbersome?

These choices, which reflect initial objectives, must be made at the conception stage of the programme and not later, on the basis of resources available and skills of local field-workers.

Large surveys often have to be combined with lighter ones in order to document particular points and work at different levels of representativeness. It is therefore essential to define a survey strategy that will ensure that methods of investigation focusing on different statistical units national surveys of a representative sample of individuals from different age groups, light surveys in particular communities at household level based on a convenience sample, etc.

In the context of large-scale assessment or monitoring, that may become difficult to manage if one is not organized, as results will be arriving out of order, at the wrong moment or without the required level of breakdown or representativeness. Collection therefore needs to be structured in line with the information required and the corresponding levels of analysis, right from the initial design stage.

In the context of monitoring and evaluation of programmes or in situations where comparisons are made between regions and times, the first issue is that of the sample and whether it should be a representative random , or convenience sample with a risk of bias or based on sentinel sites. The latter choice certainly has a practical advantage, but requires some periodic assessment of what the sentinel sites represent with respect to the overall population. This choice remains generally valid if trends are of greater interest than a strictly representative value.

There is then the issue of longitudinal collection versus collection through repeated cross-sectional surveys. Statistically speaking, it is clearly best to keep the same sample from one collection to the next, for this helps to reduce sample variance and to estimate the share of variance due to the intervention or to outside phenomena. However, this aspect becomes irrelevant if the individuals cannot be traced from one survey round to the next. Repeated sample-based nutrition surveys conducted among young children require a new sample each time, since the children from the previous sample will have grown in the meantime and the age distribution will no longer be comparable; and since this distribution must remain constant, a longitudinal survey is unsuitable.

On the other hand, the problem does not arise in the case of adults, since their nutritional status varies little with age, even over fairly long periods; by using the same sample each time it is easier to observe a change linked to an intervention or to other circumstances. A longitudinal survey is useful - and sometimes necessary - in order to assess specific intervention programmes, but is less useful for overall monitoring of a situation or in the case of more general socio-economic development programmes; in this case interest is focused more on changes among the population as a whole than on the impact on individuals or other units.

This factor is all the greater if measurements are taken at longer intervals or when the duration of the programme is particularly long.

The frequency of collection is more difficult to determine; it depends on a combination of several parameters:. When the parameter studied can normally fluctuate around average values from one collection to the next, measurements will be taken more often in order to give a clearer picture of significant trends. However, it is important to beware of the deceptive nature of over-frequent measurements in the case of major cyclic for example seasonal variations.

Finally, a relative homogeneity of the key indicators should be maintained between the different points of collection and over time so that comparisons continue to be meaningful.

Before starting the analysis, data from all sources need to be confronted. A local analysis of data is always possible and desirable, and is often a guarantee of obtaining the necessary indicators in time for decision-making.

However, at a certain point the data deemed indispensable for evaluating activities or monitoring the situation more consistently and at a more centralized level need to be assembled. If the data are on different computer platforms or in different formats, the services of a systems data analyst can be useful in organizing this stage logically and ensuring its sustainability. Most countries have statistical bureaus capable of doing this type of work. Constant coordination and consultation at all stages of the collection and analysis chain will greatly facilitate the overall efficiency of operations.

An analytical strategy based on the initial conceptual framework will be preferred, rather than carrying out a large number of time-consuming analyses - which also entail the risk of finding random associations.

When vaccination rates fall, the number of nonimmune persons in the community rises, and the risk for an outbreak of measles consequently rises. Millennium Development Goals indicators database. This indicator reflects the percentage of women who consumed any iron-containing supplements during the current or past pregnancy within the last 2 years.

It provides information about the quality and coverage of perinatal medical services. Daily iron and folic acid supplementation is currently recommended by WHO as part of antenatal care to reduce the risk of low birth weight, maternal anaemia and iron deficiency.

However, despite its proven efficacy and wide inclusion in antenatal care programmes, its use has been limited in programme settings, possibly due to a lack of compliance, concerns about the safety of the intervention among women with an adequate iron intake, and variable availability of the supplements at community level. This indicator is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework.

The indicator is defined as the proportion of women who consumed any iron-containing supplements during the current or past pregnancy within the last 2 years. Data can be reported on any iron-containing supplement including iron and folic acid tablets IFA , multiple micronutrient tablets or powders, or iron-only tablets which will vary by country policy. Improving the intake of iron and folic acid by women of reproductive age could improve pregnancy outcomes and enhance maternal and infant health.

Iron and folic acid supplementation improve iron and folate status of women before and during pregnancy, in communities where food-based strategies are not yet fully implemented or effective. Folic acid supplementation with or without iron provided before pregnancy and during the first trimester of pregnancy is also recommended for decreasing the risk of neural tube defects.

Anaemia during pregnancy places women at risk for poor pregnancy outcomes, including maternal mortality and also increases the risks for perinatal mortality, premature birth and low birth weight. Infants born to anaemic mothers have less than one half the normal iron reserves. Morbidity from infectious diseases is increased in iron-deficient populations, because of the adverse effect of iron deficiency on the immune system.

Iron deficiency is also associated with reduced work capacity and with reduced neurocognitive development. Demographic and Health Surveys. Global Nutrition Monitoring Framework: Operational guidance for tracking progress in meeting targets for Children with diarrhoea receiving oral rehydration therapy.

This indicator is the prevalence of children with diarrhoea who received oral rehydration therapy. It is the proportion of children aged 0—59 months who had diarrhoea and were treated with oral rehydration salts or an appropriate household solution. The terms used for diarrhoea should cover the expressions used for all forms of diarrhoea, including bloody stools consistent with dysentery and watery stools, and should encompasses mothers' definitions as well as local terms.

Diarrhoeal diseases remain one of the major causes of mortality among children under 5, accounting for 1. As oral rehydration therapy is a critical component of effective management of diarrhoea, monitoring coverage with this highly cost—effective intervention indicates progress on an intermediate outcome indicator of the Global Nutrition Targets, prevalence of diarrhoea in children under 5 years of age. Children with diarrhoea receiving zinc. This indicator reflects the prevalence of children who were given zinc as part of treatment for acute diarrhoea.

Unfortunately, there are no readily available data on this indicator, which is maintained in the NLIS to encourage countries to collect and compile data on these aspects in order to assess their national capacity. Measures to prevent childhood diarrhoeal episodes include promoting zinc intake. Diarrhoeal diseases account for nearly 2 million deaths a year among children under 5, making them the second most-common cause of child death worldwide.

The greater the prevalence of zinc supplementation during diarrhoea treatment, the better the outcome of treatment for diarrhoea. WHO and the United Nations Children's Fund UNICEF recommend exclusive breastfeeding, vitamin A supplementation, improved hygiene, better access to cleaner sources of drinking-water and sanitation facilities and vaccination against rotavirus in the clinical management of acute diarrhoea and also the use of zinc, which is safe and effective.

Specifically, zinc supplements given during an episode of acute diarrhoea reduce the duration and severity of the episode, and giving zinc supplements for days lowers the incidence of diarrhoea in the following months. Currently no data are available. The impact of zinc supplementation on childhood mortality and severe morbidity.

Report of a workshop to review the results of three large studies. Geneva , World Health Organization, 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 This indicator gives the prevalence of people living in extreme poverty, as measured by their daily income, and allows comparisons and aggregation of data on the progress of countries in reducing extreme poverty and allows monitoring of global trends.

As this poverty line has fixed purchasing power across countries or areas, it is often called the 'absolute poverty line'. Measures of poverty in countries are generally based on national poverty lines. Comparisons of poverty measures within countries are also difficult, especially for urban-rural differences. As the cost of living is typically higher in urban than in rural areas, the urban monetary poverty line should be higher than that for rural areas.

The difference between the two in practice, however, may not properly reflect the difference in cost of living. Mal nutrition is the single one of the most important risk factor for disease. When poverty is added, it results in a downward spiral that may end in death. Turning the tide of mal nutrition. Responding to the challenge of the 21st century.

Washington DC, World Bank. Millennium Development Goals indicators series metadata. Indicators for monitoring the Millennium Development Goals. New York , United Nations, 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.

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