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Page 1 WHO Informal Consultation with Member States and UN Agencies on the Global Monitoring Framework on Maternal, Infant and Young Child Nutrition Geneva, 16-17 April 2015 Report INTRODUCTION In May 2012, the Sixty-fifth World Health Assembly approved a Comprehensive Implementation Plan on maternal, infant and young child nutrition. 1 The Plan established six global targets to be achieved by 2025. These six targets, many of which are inter-related, cover different aspects of nutrition, acknowledging the importance of both undernutrition and overweight. By including maternal nutrition, the Plan highlights the intergenerational aspects of malnutrition in all its forms. In May 2014 the World Health Assembly approved a first set of core outcome indicators to monitor the Comprehensive Implementation Plan and its global targets. 2 In January 2015 the 136 th Executive Board discussed a paper by the WHO Secretariat presenting 14 additional core indicators. 3 During the discussion at the Executive Board, Member States asked for clarification on a number of issues including the recommended frequency of data collection, the indicator standard definitions, the availability of data, operational aspects of data collection and the evidence for the validity of the selected indicators. Member States also recommended further discussion on the frequency of framework reviews, the potential flexibility of countries in selecting the core indicators, the coordination with partners on data collection and the analysis and support towards capacity building at country level. An additional background paper was requested along with the convening of an informal consultation with Member States and UN agencies. An informal consultation was, therefore, convened on 16 - 17 April 2015 to review the evidence and operational aspects of the proposed additional core indicators, taking into account the Executive Board discussions. The aim was to enable the WHO Secretariat to complete the work and submit a final set of additional core indicators for the Global Monitoring Framework on Maternal, Infant and Young Child Nutrition (GMF) to the Sixty- eighth World Health Assembly for consideration by Member States. The specific objectives of the consultation were to: review the operational definitions for the proposed additional 14 core indicators of the GMF; 1 http://www.who.int/nutrition/topics/WHA65.6_annex2_en.pdf 2 http://apps.who.int/gb/ebwha/pdf_files/WHA67-REC1/A67_2014_REC1-en.pdf#page=25 3 http://apps.who.int/gb/ebwha/pdf_files/EB136/B136_9-en.pdf

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Page 1: 2015 Informal Consultation Monitoringframework Miycn Indicators Report

Page 1

WHO Informal Consultation with Member States and UN Agencies on

the Global Monitoring Framework on Maternal, Infant and Young Child Nutrition

Geneva, 16-17 April 2015

Report

INTRODUCTION

In May 2012, the Sixty-fifth World Health Assembly approved a Comprehensive

Implementation Plan on maternal, infant and young child nutrition.1 The Plan established six

global targets to be achieved by 2025.

These six targets, many of which are inter-related, cover different aspects of nutrition,

acknowledging the importance of both undernutrition and overweight. By including maternal

nutrition, the Plan highlights the intergenerational aspects of malnutrition in all its forms.

In May 2014 the World Health Assembly approved a first set of core outcome indicators to

monitor the Comprehensive Implementation Plan and its global targets.2 In January 2015 the

136th

Executive Board discussed a paper by the WHO Secretariat presenting 14 additional

core indicators.3 During the discussion at the Executive Board, Member States asked for

clarification on a number of issues including the recommended frequency of data collection,

the indicator standard definitions, the availability of data, operational aspects of data

collection and the evidence for the validity of the selected indicators.

Member States also recommended further discussion on the frequency of framework reviews,

the potential flexibility of countries in selecting the core indicators, the coordination with

partners on data collection and the analysis and support towards capacity building at country

level.

An additional background paper was requested along with the convening of an informal

consultation with Member States and UN agencies.

An informal consultation was, therefore, convened on 16 - 17 April 2015 to review the

evidence and operational aspects of the proposed additional core indicators, taking into

account the Executive Board discussions. The aim was to enable the WHO Secretariat to

complete the work and submit a final set of additional core indicators for the Global

Monitoring Framework on Maternal, Infant and Young Child Nutrition (GMF) to the Sixty-

eighth World Health Assembly for consideration by Member States.

The specific objectives of the consultation were to:

review the operational definitions for the proposed additional 14 core indicators of

the GMF;

1 http://www.who.int/nutrition/topics/WHA65.6_annex2_en.pdf 2 http://apps.who.int/gb/ebwha/pdf_files/WHA67-REC1/A67_2014_REC1-en.pdf#page=25 3 http://apps.who.int/gb/ebwha/pdf_files/EB136/B136_9-en.pdf

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review rationale for collecting the data for these indicators in all countries and the

current data availability;

review tools to collect the data;

prepare recommendations to the Secretariat for finalizing the GMF;

suggest a process for the development of an extended list of nutrition indicators (i.e.

set of indicators which are useful in particular circumstances);

make recommendations to the Secretariat on the periodicity of the updates to the

GMF.

Representatives of 42 Member States, three specialized UN agencies, one UN Fund and

coordination mechanisms participated in the informal consultation.

Ms Abigail Perry from the United Kingdom and Mrs Rokiah Binti Don from Malaysia were

nominated and approved as co-Chairs of the meeting.

Dr Francesco Branca, Director of the WHO Department of Nutrition for Health and

Development, reminded participants that the aim of the GMF is to track progress towards the

six global nutrition targets with the least possible administrative burden and effort for

Member States. Ms Perry emphasized the importance of the consultation for participants to

express any concerns, doubts or questions on any of the indicators. It is very important for the

Secretariat to hear the views from those charged with operationalizing the indicators on the

ground. The indicators, and proposed definitions, are described in a background paper

prepared for the informal consultation.4 The following sections summarize, on an indicator-

by-indicator basis, the presentations by a member of the Secretariat or a partner agency and

the discussion that followed.

INTERMEDIATE OUTCOME INDICATORS

IO1 Prevalence of diarrhoea in children under 5 years of age

Dr Cynthia Boschi-Pinto, WHO Department of Maternal, Newborn, Child and Adolescent

Health, presented the proposed indicator on diarrhoea prevalence. As of February 2015, data

were available for 100 countries on this indicator (extracted from multiple indicator cluster

surveys (MICS) and demographic and health surveys (DHS) within the last 10 years). The

proposed indicator does not feature on the Global reference list of 100 core health indicators.

There are good, comparable data available (through MICS and DHS) for this indicator,

although it is not always frequently collected. One potential issue with the indicator is that the

two-week period covered in survey questions does not address seasonality, which is

important for diarrhoea. Other potential issues include problems of recall accuracy and that

data tend to only be available for low and middle income countries.

Discussion

A number of issues were raised in the discussion:

the global importance of this intermediate outcome indicator – which is highly

relevant to the stunting and wasting global targets and to child mortality – and its

strategic value in the GMF were recognized; there was considerable discussion about

4 See Annex 1. Indicators for the Global Monitoring Framework on Maternal, Infant and Young Child Nutrition (30 March

2015).

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the reporting requirements for countries where diarrhoea, and the related issues of

stunting and wasting are not public health problems; nonetheless, participants noted

that monitoring the prevalence of diarrhoea in children may allow early recognition of

factors that may eventually lead to malnutrition;

data collection – in some countries data are only collected for children up to the age of

two, so would not be available for the whole age range specified; the question of

whether hospital record data would be considered acceptable was raised;

reporting period – the appropriateness of the two-week reporting period was

questioned, and further explanation required.

Conclusion

It was agreed that this is a very important indicator and inclusion in the overall GMF is

strategically important.

It was also proposed that this indicator could be highlighted as an indicator for immediate

reporting but could be accompanied by a footnote to explain that alternative reporting – using

routine clinical data – would be admitted when prevalence of stunting and wasting is less

than 2.3% or when reporting on a restricted age group.

IO2 Underweight in women of reproductive age

Dr Gretchen Stevens, WHO Department of Health Statistics and Information Systems,

presented the proposed indicator on underweight in women aged between 15 and 49 years.

The preferred source for this data is population-based health examination surveys that include

measured height and weight, and there is fairly good data availability.

Potential challenges associated with the indicator include the frequent temptation to design

surveys that rely on self-reported height and weight data, when problems of bias with self-

reported data are well recognized. A further issue is that some nutrition surveys only monitor

mothers of children under five years of age.

Discussion

A number of issues emerged during the discussion:

definition of population group - the question of whether pregnant and breastfeeding

women are included was raised, since the inclusion of this group (with higher BMIs)

could give falsely reassuring results; the Secretariat clarified that women who are

pregnant are excluded;

data availability – some countries raised concern about the availability of the

necessary data covering the whole age range;

age range – participants challenged the appropriateness of the age range and

mentioned the need to harmonize the age range across the indicators where possible;

this age range (15-49 years) has been used for a long time in DHS studies;

calculations – for the 15-18 year olds, the BMI-for-age curves compared to the 2007

WHO growth reference5 should be used; there was discussion of whether specific cut-

offs might be required for different ethnic groups; an expert consultation on this issue

in relation to overweight and obesity in Asian populations had concluded that the

international BMI cut-off points should be applied, but trigger points for public health

action may be set at a lower level (i.e., BMI 23 kg/m2 and 27 kg/m

2) if it considered

by countries to do so.

5 See http://who.int/growthref/en/

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clarification was provided that this indicator is part of the additional indicators in the

Global reference list for health indicators; although this is the first time it has been

included in an official WHO framework, it already has a long-established history, and

UNICEF collects data on this indicator annually.

Conclusion

It was agreed to keep this indicator in the GMF. In later discussion it was proposed to

highlight this indicator for immediate reporting in the Report by the Secretariat to the Sixty-

eighth World Health Assembly.

It was proposed that the operational guidance for the indicator measurement should:

o explain the rationale for age range selected;

o provide more detail on the methodology for calculations depending on age-

specific indicator, cut-offs and reference;

o explain that women who are pregnant should not be considered for reporting

on this indicator.

IO3 Adolescent birth rate

Dr Michelle Hindin, WHO Department of Reproductive Health and Research, introduced the

proposed indicator on the adolescent birth rate (ABR), reflecting the number of live births to

15-19 year olds in a given year. Multiple data sources can be used, including birth

certificates/registries, retrospective surveys (including DHS and MICS) and census data, and

each of these sources have associated issues. The UN Population Division has data for 184

nations, and this indicator is part of the Global reference list of 100 core health indicators.

Discussion

A number of issues were raised in discussion:

upper age limit – the rationale for selecting 19 as the upper age limit, rather than 18,

which is the age of majority in many countries, is that 10-19 is the age range defined

by the UN for adolescence;6 there was a suggestion that the age span for this and

some other indicators should be harmonized; in fact, the 15-19 year age range was

selected to be harmonized with other indicators to ensure comparability;

lower age limit – there was recognition that important data would be missed about

pregnancy/births and associated health risks in younger girls; it was however felt that

this is an area where further effort is needed to extend data collection to girls under 15

years in the future and that retrospective estimates can be used to get these data with

existing data sources;

significance of the indicator - as it is now formulated the indicator captures data on

live births and not on pregnancy, while the risk is associated with pregnancy in many

settings – either birth at a young age or unsafe abortion; it was recognized that,

ideally, an indicator for pregnancy would be used, but currently available data do not

allow for such an indicator.

6 United Nation’s Children’s Fund. The State of the World’s Children 2011 – Adolescence, an age of opportunity. New

York: Unicef, 2011. (http://www.unicef.org/sowc2011/pdfs/SOWC-2011-Main-Report_EN_02092011.pdf, accessed 28

April 2015)

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Conclusion

It was agreed to keep this indicator in the GMF. In later discussion it was proposed that this

would be highlighted as an indicator for immediate reporting in the Report by the Secretariat

to the Sixty-eighth World Health Assembly.

The operational guidance for the indicator measurement should:

o include clearer rationale for age range, and highlight the possibility for future

development to address such concerns;

o clarify exactly where the age range stops;

o expand the explanation of the causal logic for the indicator and how it relates

to the global nutrition targets;

o include a stronger recommendation to disaggregate the data by age group (i.e.,

10-14; 15-19 years) wherever possible.

IO4 Overweight and obesity in women

Mrs Leanne Riley, WHO Department of Prevention of Noncommunicable Diseases,

presented the proposed indicator on overweight and obesity in women aged 18+ years.

The preferred data source is population-based health surveys, preferably nationally

representative, that include measured height and weight. There is good data availability for

this indicator, which features in the WHO NCD global monitoring framework and the Global

reference list of 100 core health indicators. The possible limitations are similar to those for

underweight in women (IO2) – the bias in self-reported height and weight data and nutrition

surveys that only monitor mothers of young children – and problems with availability of data

for older age groups (usually 70 or over).

Discussion

A few issues were raised in the discussion:

age range – there was discussion about the age range, including the inconsistency

across indicators and that the age range is not consistent with the emphasis elsewhere

on women of reproductive age (15-49 years); the Secretariat clarified that the

indicator as formulated is highly correlated with overweight and obesity in women of

reproductive age, and collecting data on this indicator – which is already in use –

avoids making extra demands of Member States;

additional comments – it was suggested7 that waist circumference may be a possible

useful complementary measure to BMI, as a simple measure of overweight/obesity

and a good indicator of abdominal obesity.

Conclusion

It was agreed to keep this indicator in the GMF. In later discussion it was proposed that this

would be highlighted as an indicator for immediate reporting in the Report by the Secretariat

to the Sixty-eighth World Health Assembly.

The operational guidance for the indicator measurement should:

o explain the rationale for the selected age range;

o expand the rationale for inclusion and how it relates to the targets.

7 In written comments from the Norwegian delegation.

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IO5 Overweight and obesity in school-age children and adolescents

Mrs Riley also presented the proposed indicator for overweight and obesity in school-age

children and adolescents (5-18 years). The preferred data source is school-based or

population-based health surveys, preferably nationally representative. The limitations are

similar to the other weight/height-based indicators and the data availability for this group is

somewhat poorer than for adults. This indicator is part of the WHO NCD Global Monitoring

Framework and of the Global reference list of 100 core health indicators.

Discussion

The discussion highlighted a number of issues:

data availability – a concern was raised about the lack of available data where, for

example, data on obesity alone are collected for school-age children; experience in

collecting data for the Childhood Obesity Surveillance Initiative (COSI) in Europe

had already proven challenging, and it was suggested that it might be preferable to

state clearly which age groups are highest priority to start with;

age range – there was discussion about the appropriate age range for this indicator; the

current age proposed (5 – 18 years) is not identical to the age-range used in the

existing indicator for the NCD monitoring framework (10-19 years), which tends to

be routinely captured in school-based surveys; there is, however, enormous interest in

including this younger age group and, increasingly, data are being collected for these

younger children; further support will be needed to help Member States expand the

current reporting to also cover younger school-aged children (down to age five);

overweight and obesity – it was suggested that overweight and obesity should be

clearly separated out (as two indicators or as a single indicator with an option to

report obesity separately), and that this should be accompanied by clear explanation

of the calculations and the cut-off points;

rationale for inclusion in GMF - in response to a question, clarification was provided

on the causal logic for including this indicator in relation to the global nutrition

targets; the rationale relates to the life-course approach and the fact that 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 – so it relates to the global target on overweight in children under five (and

also to indicator IO4 on overweight and obesity in women);

additional comments – it was suggested8 that waist circumference may be a useful

complementary indicator for children.

Conclusion

It was agreed to keep this indicator in the GMF. In later discussion it was proposed that this

would be highlighted as an indicator for immediate reporting in the Report by the Secretariat

to the Sixty-eighth World Health Assembly.

The title of the indicator should be changed from ‘Overweight in school-age children and

adolescents’ to ‘Overweight and obesity in school-age children and adolescents’.

The operational guidance for the indicator measurement should

o provide a clear explanation of the methodology, calculations and cut-off points

and reference data for both overweight and obesity;

8 In written comments from the Norwegian delegation.

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o expand on how the indicator relates to the global targets, (including clear

evidence on the importance of including data for five to nine year olds);

o clarify that the indicator includes both overweight and obesity and that, where

possible, disaggregated data for obesity should be given.

PROCESS INDICATORS

PR1 Minimum acceptable diet

Mrs Julia Krasevec, UNICEF Data and Analytic Section, presented9 the proposed indicator

on minimum acceptable diet for children aged 6 – 23 months. The proposed indicator is a

composite of feeding frequency and diet diversity, which relates to infant and young child

feeding, particularly complementary feeding.

The indicator requires data on the previous day’s intake to be included in nationally

representative household surveys. Data availability is currently low (about 40 countries), but

this is a newly defined indicator so a rapid increase in data availability is expected.

Discussion

A number of issues emerged in the discussion:

global applicability - considerable discussion about the appropriateness of one

globally applicable definition and the possibilities of adapting it to reflect compliance

with national dietary guidelines; the Secretariat clarified that Member States should

be able to collect data on a longer list of food groups – to reflect national guidelines –

and then to collapse the data down again to meet the needs of the indicator; in this

way, Member States can generate data to inform their own policies as well as

reporting on the indicator, which is important to enable comparisons across countries;

there was recognition that currently this is the only indicator in the set that addresses

the issue of dietary quality;

measurement of the indicator - serious concerns were expressed about many aspects

of this indicator, including data availability, the complexity of data collection

(challenges during pilot testing were reported) and calculations, whether inclusion of

milk in the list of food groups could create confusion and whether there should be

greater emphasis on animal protein;

it was suggested that future development of this indicator might want to address

concerns about consumption of ultra-processed foods by infants and young children.

Conclusion

It was agreed that this is an important indicator, for all countries and it should be kept in the

GMF. Considerable further work and guidance is needed, however, to enable Member States

to understand how existing data can be used and/or what new data collection is needed to be

able to generate this indicator.

In the operational guidance for the indicator measurement, the definition of daily meal

frequency should be changed to ‘three times for breastfed children aged 9 – 11 months’ and

‘four times for non-breastfed children aged 12-23 months’.

9 Speaking via remote link from New York.

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In later discussion, it was proposed that this indicator is reported starting in 2018 to allow

WHO, UNICEF and FAO to support Member States in data collection and, particularly,

analysis.

PR 2 Safely managed drinking water services

Dr Richard Johnston, WHO Department of Public Health, Environmental and Social

Determinants of Health and WHO/UNICEF Joint Monitoring Programme for Water Supply

and Sanitation (JMP), presented the proposed indicator on safely managed drinking water

services.

This indicator is a composite of quality and availability of water, and is aligned with the

current version of the indicator developed for the Sustainable Development Goals (SDG). It

is also part of the Global reference list of 100 core health indicators. It is based on self-

reported data, but research suggests this reflects observed data quite closely.

There is a broad database for the availability dimension of this indicator because many non-

health-related household surveys are relevant. On average, countries have nine data sets and

135 countries have at least five data sets. However, data on quality are scarce and collecting

such information will require new sources such as administrative data, potentially coming

from regulators of drinking-water services.

PR3 Safely managed sanitation services

Dr Johnston also presented the proposed indicator on safely managed sanitation services,

which requires information on the number of households with a basic sanitation facility that

is not shared with other households and where excreta are safely disposed in situ or

transported for safe disposal or treatment.

Data on household access to basic sanitation facilities, which is also currently a proposed

indicator for SDG 6, have been collected for 192 countries. Data on disposal, transport and

treatment of excreta will need to come from new sources including administrative sources

and targeted research studies. This indicator is also part of the Global reference list of 100

core health indicators.

The discussion and conclusions relating to PR2 on safely managed drinking water and PR3

are reported jointly, see below.

Discussion on PR2 and PR3

The issues raised in discussion included:

global applicability - there was considerable discussion of the universal applicability

of these indicators, and whether some alternative reporting requirements might be

appropriate for high income countries that do not consider access to water and

sanitation to be a great problem; there was recognition, however, that these indicators

currently feature in the SDG framework and, as such, all Member States will be

obliged to report on them; in addition, even if water and sanitation are not high

priority issues, it is still important for countries to be able to demonstrate coverage

levels; in fact, some high income countries do have issues with water and safely

managed sanitation, and access for disadvantaged groups can be less than ideal; in

country visits, the UN Special Rapporteur on the Human Right to Safe Drinking

Water and Sanitation usually identifies some groups that have little or no access; this

implies that data should be collected with a focus on inequalities, and disaggregation

of data will be important;

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data sources and availability - questions were raised about data sources and

availability, and about how to determine what has been ‘regulated by a competent

authority’, and whether this would require independent confirmation; clarification was

provided that, although the definition of ‘competent authority’ is yet to be finalized,

independence from the body responsible for ensuring supply will be critical;

furthermore, there was confirmation that these indicators now refer to ‘basic drinking

water sources’ and ‘basic sanitation facilities’, reflecting a shift from previous

language on ‘improved’ water and sanitation;

sub-indicator for informal settlements - there was discussion of whether there should

be a sub-indicator to monitor informal urban settlements or slums, which are often

excluded from household survey data collection; although, ideally, data on this setting

should be included, this currently presents a real challenge to data collection.

Conclusion on PR2 and PR3

It was agreed to keep both indicators in the GMF. In later discussion it was proposed that

these indicators would be highlighted as being for immediate reporting in the Report by the

Secretariat to the Sixty-eighth World Health Assembly.

The indicators need to remain aligned with the latest version of these indicators in the SDG

framework. Any changes to the indicators will be taken into account in the GMF.

PR 4 Iron and folic acid supplementation

Dr Juan Pablo Peña-Rosas, WHO Department of Nutrition for Health and Development,

presented the proposed indicator on iron and folic acid supplementation. WHO recommends

that all pregnant women consume daily tablets containing 30-60 mg of elemental iron and

400 µg folic acid, beginning as soon as possible during gestation and no later than the third

month.

The data source for the numerator is health facility data/antenatal clinic records and the

denominator should be sourced from population-based household surveys. DHS studies have

captured data on iron supplementation in 61 countries since 1999 – in some countries

questionnaires are modified to include iron and folic acid and in some others the responses

cover folic acid because countries give supplements that include iron and folic acid.

Potential issues with the indicator include the fact that it does not capture data on actual

consumption of the supplements, nor any indication of whether women receive appropriate

counselling alongside supplementation. In addition, the indicator only measures

supplementation during the last two trimesters of pregnancy. Further issues include problems

with accurate measurement of intake of supplements and with recall of purchases. In

addition, after the first trimester women may be receiving iron-alone supplements or other

multiple micronutrient supplements, and data is not captured on other supplementation.

Discussion

A number of different issues were discussed:

global applicability - there was considerable discussion about the applicability of this

indicator to all countries, since not all countries pursue an approach based on iron and

folic acid supplementation; a related issue was whether iron and folic acid should be

handled separately – with some arguing that the indicator should focus solely on iron,

while others advocating inclusion of folic acid; this indicator relates directly to a

WHO recommendation and its importance for two of the global nutrition targets

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(anaemia in women of reproductive age and low birth weight) was highlighted; other

strategies to tackle iron and folate status, such as fortification of staple foods, may be

dealt with through another, separate indicator;

indicator definition - the issue of how well receipt and/or purchase relate to

consumption was discussed, and whether the indicator should be adapted to try to

capture consumption; it was recognized that the current indicator is a proxy, which

gives a picture of supplementation coverage; in fact, DHS surveys collect data on

actual consumption, so this could be used to correct the data on receipt/purchase;

other concerns voiced include the potentially different time periods in the numerator

(during last pregnancy) and the denominator (last two years), and potential difficulties

with recall.

duration of supplementation period - the time frame specified for the consumption of

supplements – ‘at least six months’ – was queried; in countries where women present

late for antenatal care, this time period could exclude many women who do receive

supplements; furthermore, folic acid supplementation is particularly important pre-

pregnancy and in the first trimester; it was agreed that this should be

reviewed/revised.

Conclusion

Despite recognition of the importance on capturing data in relation to both iron and folic acid,

it was agreed that this indicator requires further guidance on how to collect and analyze the

information, including the indication of the time period for supplement consumption

(currently ‘for at least six months’). It was still recommended that the indicator should be

kept in the GMF.

In later discussion it was proposed that this indicator would be highlighted in the Report by

the Secretariat to the Sixty-eighth World Health Assembly as being for reported starting as of

2018, and that further work and technical support would be carried out by the Secretariat.

PR5 Births in Baby-Friendly hospitals

Dr Laurence Grummer-Strawn, WHO Department of Nutrition for Health and Development,

presented the proposed indicator on births in baby-friendly hospitals. The Global Strategy on

Infant and Young Child Feeding calls for maternity facilities to adhere to the Ten Steps to

Successful Breastfeeding set out by WHO and UNICEF. The Baby Friendly Hospital

Initiative (BFHI) is a designation process that requires adherence to the Ten Steps and

compliance with the International Code of Marketing of Breast-milk Substitutes. It has been

shown to be effective in increasing breastfeeding rates.

Data sources for this indicator include a list of designated facilities (and their number of

births) for the numerator and census data on the total number of births for the denominator. A

number of surveys have data on baby-friendly facilities across countries and a global survey

is planned to update this information. One of the potential issues with this indicator is that

some countries may report the number of facilities designated baby-friendly rather than the

number/proportion of births in baby-friendly facilities.

Discussion

In the discussion, a few issues emerged:

BFHI implementation - there was strong support for the BFHI process and recognition

that the process needs to be revitalized; concerns were raised that the BFHI has been

effectively abandoned in some countries and in some other countries an alternative

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approach to promoting breastfeeding in healthcare facilities has been adopted or the BFHI

process is not mandatory; large countries with many different healthcare providers face

particular challenges;

baby-friendly certification - there was discussion of the certification/designation process,

including the length of validity of baby-friendly certification and whether non-certified

facilities (or facilities that have not been re-certified recently) would be included; there

was clarification that the indicator refers to ‘currently designated’ but it is up to countries

to set out the process for designation and to decide how long designation is valid for

(globally, the recommendation is for three to five years); the process for re-designating

facilities is known to have been weak in many countries and WHO is working with

UNICEF to strengthen this aspect;

Relevance of the indicator - the implications of changes in maternity care since the BFHI

was introduced – new mothers leave hospital much sooner after giving birth or the move

towards supervised home deliveries – for this indicator were discussed; WHO and

UNICEF have produced a detailed guidance package on implementing the Initiative,

including on applying the principles to other types of health facilities and the

community.10

Conclusion

There was support for the potential of this indicator’s inclusion to revitalize the BFHI, but

further guidance and support needs to be provided on its measurement. It was therefore

agreed to keep the indicator in the GMF.

In later discussion, it was proposed that this indicator should be included in the Report by the

Secretariat to the Sixty-eighth World Health Assembly as one for immediate reporting,

sending a clear message that work on this issue will not be delayed. There was recognition,

however, that further support will be needed to make this fully operational, and the

Secretariat will be able to provide support to some Member States to enable them to revitalize

the process and collect data.

PR 6 Breastfeeding Counselling

Ms Julia Krasevec presented the proposed indicator on provision of breastfeeding

counselling. This indicator requires data on the date of birth of women’s children, whether

women received any counselling/support/messages on optimal breastfeeding in the last year

and, if so, who they received such messages from. Currently, the data on counselling are not

collected, but could be included in population-based household surveys. Standard modules

and adaptation instructions need to be developed to facilitate inclusion of this indicator.

One of the issues with this indicator is that the list of recognized trained providers of

counselling would need to be customized – and thus require pre-definition, testing and pilot

work – for each country. In addition, the list would need to be updated as situations evolve.

The limitations of the indicator are that it assumes that all the providers have been trained

according to the national standards. The indicator also measures whether women received a

message from a trained person, without determining the quality of such messages.

Discussion

A number of issues emerged through discussion:

10 See http://www.who.int/nutrition/topics/bfhi/en/

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standardization - the importance of the issue was recognized, but there were concerns

that the complexity of the indicator, the lack of standardized definitions of terms and

problems with data availability would affect comparability across countries; there

were particular concerns about the need to standardize who can provide counselling

(and who is responsible for defining who is an appropriate provider) and what

constitutes counselling/support or messages; related to the issue was the question of

how this indicator relates to settings where the majority of deliveries take place

outside health facilities; there was clarification that governments will be responsible

for defining who is an appropriate provider; it is clear that the indicator is trying to

capture provision of counselling by people trained to national standards (preferably to

follow WHO guidance), and in some countries this would include unpaid volunteers

as well as salaried health workers; this is a process that has already been used to

develop comparable indicators in other health sectors, such as the definition of

traditional birth attendants;

definition of the indicator - it was suggested to break the indicator down into different

types of counselling ((i) provision of counselling and support (ii) communication of

messages); the issue of the quality of advice provided was also raised and this is an

area where further development work will be needed; it was suggested that the

indicator should be changed to 0 – 5 months, or that the indicator should be stratified

into four intervals (post-partum counselling, 0-5 months, 6-11 months and 12-23

months); it was also suggested that the indicator should be harmonized with the WHO

Essential Interventions, Commodities and Guidelines for Reproductive, Maternal,

Newborn and Child Health;

scope of the indicator - there was discussion of whether the indicator should be

extended to cover other areas of infant feeding (e.g., ‘counselling on optimal breast

feeding and early child nutrition’ or ‘counselling on appropriate infant feeding’);

there was clarification that the indicator is intended to capture important messages

about continued breastfeeding as well as the initial messages on early initiation and

exclusive breastfeeding; there are concerns that expanding the indicator to cover all

aspects of infant/young child feeding would probably suggest complete or near

complete coverage, so the specific focus on breastfeeding is important;

it was suggested that this indicator would be more appropriate as a Policy and

Environment indicator.

Conclusion

The importance of this issue is recognized and it was agreed to keep the indicator in the

GMF. However, there were concerns about the complexity of this indicator and the

practicability of implementing it at this stage. In later discussion it was proposed that this

indicator be included in the Report by the Secretariat to the Sixty-eighth World Health

Assembly as one of the indicators for to be reporting from 2018, with further development

work to be undertaken.

POLICY, ENVIRONMENT AND CAPACITY INDICATORS

PE1: Trained nutrition professionals

Dr Chizuru Nishida, WHO Department of Nutrition for Health and Development, presented

the proposed indicator for trained nutrition professionals. This indicator is designed to

capture data on human resources for implementing nutrition actions in a country and is

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considered to be important to monitor in order to truly assess countries’ capacity to scale up

action in nutrition. There is increasing evidence of a strong correlation between the density of

human resources for health and health outcomes of the population and this indicator is

developed based on the same principle and concept to address human resources for

implementing nutrition actions in a country and nutrition outcomes of the population.

Some data for this indicator are available at the country level, as evidence by the in-depth

Landscape Analysis country assessment that has been conducted in 19 countries to date.

Alternative proxy indicators for countries’ capacity to deliver nutrition interventions could be

considered. One such proxy would be the density of nursing and midwifery personnel

(density per 1,000 population), available through the Global Health Observatory. Another

option would be to further refine the indicator, by identifying the number of health workers

trained in one, two or three of the most common areas of training provided to health workers

on maternal, infant and young child nutrition. These data are available from the Landscape

Analysis country assessment in 19 countries, Global Nutrition Policy Review in 123

countries and Accelerating Nutrition Improvements in Sub-Saharan Africa (ANI) project in

11 countries.

Discussion

Issues raised in discussion:

value of the indicator - there was support for the concept behind this indicator, but

concerns about the lack of any readily available standardized definition for nutrition

professionals; concerns were expressed that limiting this to health personnel only

would miss important data on professionals from other sectors (e.g., education,

agriculture) that are involved in important work towards the global nutrition targets;

there was a suggestion, however, that the definition should be tightened to include

only those professionals trained on maternal, infant and young child nutrition, to

ensure relevance to the targets; although the contribution of other sectors is clearly of

tremendous importance, the indicator had really been designed to try to capture health

system capacity to deal with nutrition; the risk associated with broadening the

definition is that the indicator becomes too broad to be really meaningful;

self-employed professionals - it was noted that in some countries many health workers

are self-employed, rather than employees of the health system, and the work of these

professionals needs to be included; in some countries community health workers

receive training on nutrition and these individuals also need to be taken into account.

Conclusion

There was agreement that it is important to monitor capacity to deliver required nutrition

action to achieve the global nutrition targets across all countries and to include the indicator

in the GMF, but further work is needed on this indicator.

In later discussion, it was proposed that this indicator be included in the Report by the

Secretariat to the Sixty-eighth World Health Assembly as one for reporting from 2018,

pending further development and guidance.

PE2 Regulation of marketing of breast-milk substitutes

Mr Marcus Stahlhofer, WHO Department of Maternal, Newborn, Child and Adolescent

Health, presented the proposed indicator on regulation of marketing of breast-milk

substitutes.

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The indicator is based on adoption of the International Code of Marketing of Breast-milk

Substitutes and subsequent relevant WHA resolutions, in order to protect exclusive and

continued breastfeeding from commercial influence and unethical marketing of breast-milk

substitutes. It does not measure implementation, monitoring and enforcement of legislation.

A great deal of data is available, through existing Code monitoring and reporting

arrangements. Access to legislative documents is required and these need to be verified and

analyzed.

In order to give a better picture of the strength of Member States legislation it would be

possible to refine the indicator to give a score. This would require development of a

standardized methodology and checklist for analysis of legislation.

Discussion

A number of issues were highlighted:

value of the indicator - the complexity of the task in implementing the Code was

acknowledged, and there is recognition that there are different approaches in place;

the indicator is designed, however, to encourage adoption of all the relevant

provisions of the Code;

format of the indicator - the indicator as currently proposed is in a binary format, with

a Yes or No assessment of whether the country has adopted comprehensive

legislation; there is good data available for the indicator in this format, although some

analysis will still be required;

future development of the indicator - it would be possible to develop the indicator to

be able to score countries for the strength of their implementation, again based on

currently available information; this is an issue which WHO is currently discussing

with other partners involved in Code monitoring; this is important because there is a

clear association between the strength of Code legislation and breastfeeding rates;

whilst there was interest in developing this scored indicator, it was agreed that it was

too soon to include it in the GMF; the recommendation was to retain the binary

version until WHO is able to demonstrate how this approach would work in practice

for possible inclusion in the next update of the framework.

Conclusion

It was agreed to keep the indicator as it is currently formulated in the GMF. In later

discussion it was proposed that this indicator would be included in the GMF as one for

immediate reporting.

PE3 Maternity protection

Ms Susan Maybud, ILO Gender, Equality and Diversity Branch, presented the proposed

indicator on maternity protection. The indicator – based on whether a country has maternity

protection laws or regulations in place in line with the ILO Maternity Protection Convention

183 and Recommendation 191 – is important to enable exclusive breastfeeding and to

facilitate continued breastfeeding.

No further data collection would be needed. The indicator would be based on data already

collected by ILO and analysis of the aspects on maternity leave and breastfeeding

entitlements (entitlement to breaks, remuneration and duration of entitlement).

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Discussion

The discussion focused on the proposal to develop – on the basis of the data that ILO already

collects – an indicator that scores the strength of Member States’ implementing legislation.

Although various criteria and thresholds have already been well defined, further work would

be needed on how these would be aggregated into a single score (and if/how to weight the

different elements).

Conclusion

There was no opposition to this indicator as currently proposed (with a Yes/No answer). If

the Secretariat decides to pursue development of an indicator which scores the strength of

country’s protection, Member States would need to review the detail of that before they could

agree to its inclusion.

In later discussion it was proposed that the indicator as it is currently formulated (with a

Yes/No answer) be included in the GMF as one for immediate reporting.

GENERAL DISCUSSION ON THE INDICATORS

During the discussion on indicators11

, a number of points were raised that were not specific to

any one indicator:

the precise implications for a nutrition indicator of not being included on the Global

reference list of 100 core health indicators was raised as a question; it was also

suggested that it would be valuable to have more information about the coordination

of these two processes;

it was suggested that priority should be given to the development of indicators that

can be reported or estimated through routine health information systems and not only

through survey data;

in relation to the periodicity of reporting, it was suggested that biennial reporting

would be most appropriate for the majority of indicators.

COUNTRY EXPERIENCES

Eight country representatives presented their national experiences on nutrition surveillance,

with a particular focus on their experiences in collecting some of the data required for the

indicators. The following section includes brief summaries of these presentations.

Burkina Faso

Ms Bertine Ouara, Director of Nutrition in the Ministry of Health, presented a summary of

the nutrition situation in Burkina Faso and the nutrition surveillance in place.

Nutritional surveillance in Burkina Faso is based on a combination of data collected routinely

in health services and, since 2009, annual SMART surveys. These annual surveys cover the

whole country, with data disaggregated in half of the country’s provinces and, since 2012, the

infant and young child feeding indicators have been incorporated. There are no formal costs

associated with the routine data collection, while the costs are high for the surveys (around

300 million CFA francs per year for disaggregated data).

11 And in written comments received from the Norwegian delegation.

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The difficulties associated with surveillance include inconsistent internet access, the heavy

workload and poor motivation of regional workers, and patchy, and sometimes delayed,

transmission of data. In order to tackle such difficulties the ability to enter data when not

online has been introduced, along with a system of direct access to the database for some

health facilities.

Further difficulties include the fact that not all nutrition indicators are taken into account in

the software, the very high costs of the national surveys, problems with funding of the

vitamin A supplementation campaigns (an important source of data) and infrequent reporting

of other national demographic and health indicators related to nutrition.

Strategies to deal with these challenges include adoption of a multisectoral approach,

development of multisectoral strategic plan for 2016 – 2020, implementation of a joint

multisectoral monitoring framework, effective arrangements to monitor direct nutrition

interventions and nutrition-sensitive interventions and integration of infant and young child

feeding indicators into routine monitoring. In addition, improved monitoring of overweight,

anaemia and other micronutrient deficiencies is needed. A variety of initiatives in place –

including workshops, field visits, specific surveys and creation of alliances – will also

improve nutrition surveillance and nutrition action.

Chile

Ms Anna Christina Pinheiro Fernandes, from the Ministry of Health, presented a summary of

the nutritional status and nutrition surveillance arrangements in Chile.

Nutrition surveillance is carried out through nutritional assessments at the primary healthcare

level and data are compiled and sent to the regional level, which then sends collated data to

the Ministry at national level for analysis. These health data on people covered by the public

health system cover around 80% of the population in Chile, and there are no specific costs

associated with data collection. These data are used to monitor the situation and also to

formulate policies and implement actions.

The difficulties associated with data collection include problems with the quality of data at

the primary healthcare level, the lack of data review or analysis at the regional level and the

failure to detect errors at the national level. In order to tackle these challenges a series of

initiatives have been implemented to improve data quality (e.g., anthropometry training for

health professionals) and the analysis of data at the regional and national levels.

In relation to the proposed indicators for the global monitoring framework, data is already

being collected for indicators IO2, IO4, IO5 and PE3. Data is available for some other

indicators, while for others there is currently no data available. For indicator PR1, for

example, there would be difficulties with data availability in the short term. Other sources of

data include the Ministry of Education – which measures and weighs children in public

education annually – along with the National Statistics Institute’s five-yearly national

household income survey and Ministry of Health national surveys (including one National

Survey of Food and Nutrients Intake to date).

In response to a question, Ms Pinheiro clarified that to facilitate the trickle down of data from

the national level, the database is sent to all health centres so that they can look at local level

data.

Ireland

Dr Nazih Eldin, National Obesity Advisor at the Department of Health, presented a summary

of data collection, analysis and nutrition surveillance in Ireland. This data collection is taking

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place against the backdrop of the tremendous social change that Ireland has experienced in

the last seven years due to the dramatic change in the economy.

A preliminary analysis of nutrition surveillance across all of Ireland identified 56 studies,

projects and reviews. Data is collected through the national healthcare system, the Economic

and Social Research Institute and various independent academic institutions. The data that are

collected reflect the country’s priority on obesity and overweight rather than on stunting or

wasting.

The data collection system is highly complex, very fractured and not standardized, but it is

influential. Data are fed into the healthcare system and policy development, as well as being

of great professional and public interest.

From July 2015, Ireland will be moving to a new system of surveillance through primary

care, requiring reporting to the Ministry of Health, and this will cover the primary outcome

indicators in the GMF.

In relation to PE1 on trained nutrition professionals, further clarification is needed on what

level of training is needed for professionals to be included. Ireland has 685 fully qualified

dieticians, but is also training all maternity and child health staff on Brief Intervention for

Healthy Weight Management Before, During and After Pregnancy.

The Irish experience, forced through the economic difficulties, suggests that fractured and

uncoordinated data collection systems can be improved to ensure better coordination and

greater cost-effectiveness.

Kuwait

Dr Mona AlSumaie, Head of Community Nutrition Supervisory in the Food and Nutrition

Administration, described the nutrition surveillance system in Kuwait.

The Kuwait Nutrition Surveillance System (KNSS) was established in 1995 and is designed

as a sentinel data collection operation with ‘convenience’ or ‘purposive’ sampling. The

system is run by 26 nutritionally trained staff, covers the six governorates and targets Kuwaiti

nationals (33% of the population).

The indicators used in the system include anthropometric indicators in all subjects,

micronutrient indicators in all except under six months, risk factors in adults, infant feeding

practices in infants and young children up to two years and young children’s dietary habits in

children between two and five years old.

Data obtained through the KNSS have led to the initiation of various interventions and

prevention programmes, including the National Program for Obesity Prevention, the

Breastfeeding Promotion and BFHI Implementation Program, and the Flour Fortification

Program.

The challenges for the KNSS include a lack of qualified human resources, the fact that the

adult sample is national only (and not disaggregated by residence), that only indicators

related to health are collected and a lack of effectiveness of the recommendations because

there is no clear national nutrition policy.

In conclusion, the KNSS is simple, sustainable and tailored to the needs of the country and it

provides useful information on trends, which can alert the health authorities and trigger

policy changes. Recruitment of staff from outside health centres to run the surveillance

programme is highlighted as one of the main factors to enable the sustainability of the

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system. A national nutrition policy is needed to steer interventions and input from external

advisors (WHO/EMRO and CDC) to strengthen the surveillance system should continue.

Malaysia

Mrs Rokiah Binti Don, from the Ministry of Health, described nutrition surveillance in

Malaysia. Malaysia has a structured healthcare delivery system, with 90 per cent of the

population based within five kilometres of a community health clinic, and with a flying

doctor/mobile clinic system for very remote areas.

The nutrition surveillance system in Malaysia is comprised of three components:

1. nutrition aggregated data collected at the government/public health clinics;

2. nutrition data integrated with the relevant government agencies such as Ministry of

Education and Department of Statistics;

3. repeated National Nutrition Surveys or National Health Surveys:

a. the Malaysia School-Based Nutrition Survey: 2012

b. Malaysian Adult Nutrition Survey (MANS): 2003, 2014

c. National Health and Morbidity Survey (NHMS): 1986, 1996, 2006, 2011,

2015; from this year, this will be an annual survey.

In addition, a Registry for rehabilitation programme for malnourished children has been

implemented, covering data on malnourished children aged between six months and six

years. An IT-based tele-primary care system has also been established, which includes a

nutrition component (anthropometry, food basket and growth chart). Nutrition is also part of

the electronic reporting system for health information.

One challenge associated with the surveillance system is that there are limited nationally

representative population-based data collected at regular intervals. Food consumption data,

for example, are only collected once every 10 years. In order to address this, collaboration

with other partners is being explored. One key operational highlighted is the variations on

definitions for the indicator on exclusive breastfeeding, and clarification is required.

The lessons learned through Malaysia’s experience in implementing nutrition surveillance

include the need to have focal points to take charge, the necessity of standardizing or

harmonizing methodology and indicator definitions, and the need for a more harmonized

website for reporting and monitoring that has been agreed by the relevant international key

partners and Member States.

Philippines

Dr Maria-Bernadita T Flores, Assistant Secretary of Health, presented how progress in

nutrition is monitored in the Philippines.

There are particular challenges associated with data collection in an archipelago composed of

7,100 islands. The Philippines Food and Nutrition Surveillance System combines data

collected by privately-held databases, national and sub-national information systems and UN

agency information systems. Data collection is through population-based surveys and

administrative reports from local government units and researchers.

In relation to the global nutrition indicators, data collection is aligned for all of the six

primary outcome indicators, five intermediate outcome indicators and three policy,

environment and capacity indicators. The sources are generally the national nutrition survey

and DHS studies. Three of the six process indicators and nine of the 16 indicators in the

extended set are aligned. The indicator on safe water is not fully aligned, because bottled

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water is included as safe water source, but this can be re-computed to exclude bottled water.

The indicators for births in baby-friendly facilities and breastfeeding counselling are not fully

aligned with the proposed indicators.

One of the challenges associated with data collection is the high cost due to the difficult

topography. This has been addressed by drawing up statistical master sample frames, so that

statisticians do not need to be hired to do sampling for each survey. Other challenges include

limited data access due to the data sharing embargo and problems with the timeliness of data.

Fast-tracked data processing through better use of information technology and development

of human resources are among the strategies selected to address these challenges.

In conclusion, there is a need for a few critical tracer indicators to improve the cost-efficiency

and manageability of the system. Otherwise, despite remaining challenges, Philippines is

generally on track to generate nutrition data to monitor progress.

Senegal

Dr Maty Diagne, Director of the Food and Nutrition Division, Ministry of Health and Social

Action, presented a summary on the nutrition surveillance system in Senegal.

A process of revitalizing the nutrition surveillance system is underway, combining use of

routine indicators and increasing use of SMART surveys and DHS surveys.

Currently, despite the existence of a nutrition policy it has been difficult to have any picture

of the nutritional situation in the country, aside from the occasional national surveys. The

need for more regular data on the changing nutrition situation pointed to a need to revitalize

routine surveillance and to set up sentinel surveillance in the most vulnerable areas. Thus, in

May 2013, an action plan for nutritional surveillance was developed, starting with a

situational analysis of nutritional surveillance that found irregular data collection, snapshots

from surveys, difficulties linked to movement of health workers, and the operation of the

multisectoral platform. The process of implementing the sentinel surveillance sites is ongoing

and, to date, personnel have been trained and indicators have been defined.

The difficulties associated with data collection include inadequate human resources,

timeliness and completeness of data, a lack of coordination between stakeholders and

inadequate funding. Approaches to meet these challenges include, but are not limited to,

seeking funds, partnership and collaboration for implementation, monthly supervision of

surveillance at the sentinel sites, quarterly reviews of regional nutrition data and putting

nutrition on the agenda of health district coordination meetings.

The lessons learned through the experience in Senegal point to the importance of

commitment from the Ministry of Health, technical and financial support, leadership from the

Food and Nutrition Division, partnership with academic institutions, planning, the

involvement and ownership of regions and districts, participation of other sectors and NGOs,

and the development of technical documents.

Zimbabwe

Dr T K Nyadzayo presented an overview of nutrition surveillance in Zimbabwe.

The different methods of monitoring nutrition status used in Zimbabwe include national

nutrition surveys, demographic health surveys, community-based growth monitoring and

periodic surveys in sentinel sites. Community-based growth monitoring takes place in more

than 90% of the country’s health facilities on a monthly basis, but there are problems with

capacity and sentinel site surveillance was discontinued because of sustainability reasons (a

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rupture in funding). There are also some other surveys in existence. Traditionally, data on

child weight-for-age have been routinely collected through health facilities, but height-for-

age has now been introduced to monitor stunting.

Data is collected on a paper-based system at community-based level, before being entered

into a computerized system at district level. All those who are involved in the collection of

data, at all levels, are also encouraged to use the data.

The challenges associated with surveillance include the limited capacity of health workers to

measure height/length and to provide counselling on infant and young child feeding during

growth monitoring sessions. Other problems include the high dropout from monitoring after

immunization at 24 months, the low coverage of growth monitoring and the low capacity of

village health workers to measure heights and lengths. Other problems include the lack of

registers, the shortage of staff to work on the data, the fact that private practitioners and

facilities do not report to the national system, inadequate data analysis, poor information and

communication technology infrastructure and the separate reporting requirements and

systems of some donor-driven vertical programmes.

A number of approaches are planned to help overcome the challenges. These include the

introduction of training and mentoring on growth monitoring and customized nutrition

surveillance training, along with the development of a harmonized growth monitoring

register, school-based nutrition screening, data quality audits to improve data quality, use of

support staff (such as nurse aides) for growth monitoring, regular review workshops and

expanding the capacity of village health workers to collect data on severe acute malnutrition

using mid-upper arm circumference (MUAC) and oedema screening. In addition, building on

the Frontline SMS system to increase the flow of data is planned, along with more systematic

and regular data quality assurance meetings at district level and inclusion of data from private

health care providers.

Discussion on the country presentations

During discussion and questions on the presentations it was noted that there had been a great

deal of emphasis on data collection. The importance of analysis, interpretation and taking

timely action were also highlighted.

There was discussion of the challenges associated with balancing the investment in routine

data collection with that for specialist surveys. It is clear that building better bridges between

government and academic institutions could be one way to generate more resources for

surveillance. One approach – now being adopted in Ireland, for example – is to focus on

planned surveillance, meaning that a government does not have to implement everything

itself, but ensures that all the surveillance activities are complementary. Another approach to

bear in mind is the possibility to bring in resources from outside nutrition (e.g., from food

safety). Ireland’s experience since the economic crisis has demonstrated that, through

cooperation and coordination, it is possible to be more effective with less money. There was,

however, a word of warning on working with development partners and in partnership with

others – it is important to bear in mind from the outset that the funding or support from

development partners may not be sustainable. For continuous surveys, in particular,

commitment from government is needed. When such commitment is institutionalized, with a

dedicated budget, the quality of data improves.

There was a discussion on the introduction of routine monitoring for stunting, and whether

this is proving valuable for practitioners. In Zimbabwe, where routine height /length

measurements were introduced around a year ago, there have been some challenges with

implementation, given the existing heavy workload on health workers. It is hoped that this

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will be strengthened in the future and will prove useful. In the Philippines monitoring of

stunting has been introduced at community level to better engage local governments.

Workers have been trained to measure height and measurement tool and charts have been

developed, along with education materials for workers and mothers. In fact, measuring height

and length is increasingly become part of routine assessments, given that stunting is such an

important indicator. Work is ongoing to identify how this can be made meaningful and done

in ways that do not add to the monitoring burden.

Dr Branca thanked all of the presenters for sharing their experiences. WHO has been working

with 11 countries in the African region, with Canadian support, on surveillance issues and

this valuable work has prompted a proposal to establish a permanent network – also through

the SUN movement – to maintain a platform for useful exchanges on methodology. The

national experiences also point to the importance of developing this Global Monitoring

Framework that provides guidance for all those charged with surveillance. The Secretariat

aims to provide more tools for monitoring and surveillance, thus enabling a true data

revolution, whereby good quality data helps policymakers to understand where to target

resources and helps them to monitor changes that take place.

Ms Perry thanked the presenters and concluded the session. It is clear that countries have

done a great deal of work to incorporate global guidance into their national surveillance

systems. A number of common issues emerged, including a lack of capacity, problems with

the timeliness of data and how to transmit data. Surveillance is a substantial task, that

requires time, people and money, but it is also clear that Member States will continue to

further develop their surveillance systems and to use the data that they generate.

CONCLUSIONS

Since the discussions had revealed a number of outstanding questions on some indicators,

there was considerable discussion about how the framework could be taken forward while

addressing those areas that require further work. A number of different options were

discussed.

While acknowledging the operational challenges that remain in collecting and reporting some

indicators, Member States recognized the importance of moving forward with a single global

monitoring framework. It is vital to signal that this work is critical and that progress towards

the global nutrition targets cannot be delayed.

Taking into account Member States’ feedback, Dr Branca presented a concrete proposal for

next steps. It was proposed to submit the entire core set of proposed indicators for approval

by the Health Assembly. Of these, 10 indicators would be for immediate reporting and four

indicators would be highlighted as being for reporting in 2018 (see Table, below). Further

work to operationalize the indicators for delayed reporting would be carried out in 2016 by

the Secretariat with the support of a Technical Expert Advisory Group on Nutrition

Monitoring (TEAM).

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Proposed additional indicators for the core set of the global monitoring framework on

maternal, infant and young child nutrition

Indicators

Intermediate outcome indicators, monitoring conditions on the causal pathways to the targets

IO1 Prevalence of diarrhoea in children under 5 years of age12

IO2 Proportion of women aged 15-49 years with low body mass index13

IO3

Number of births during a given reference period to women aged 15-19 years/1000 females aged 15-

19 years

IO4 Proportion of overweight and obese women aged 18+ years of age14

IO5 Proportion of overweight and obesity15

in school-age children and adolescents (5-18 years)

Process indicators, monitoring programmes and situation-specific progress

PR1 Proportion of children aged 6 to 23 months who receive a minimum acceptable diet*

PR2 Proportion of population using a safely managed drinking water service

PR3 Proportion of population using a safely managed sanitation service

PR4 Proportion of pregnant women receiving iron and folic acid supplements*

PR5 Percentage of births in baby friendly facilities

PR6

Proportion of mothers of children 0-23 months who have received counselling, support or messages on

optimal breastfeeding at least once in the last year *

Policy environment and capacity indicators, measuring political commitment

PE1 Number of trained nutrition professionals per 100 000 population *

PE2

Country has legislation /regulations fully implementing the International Code of Marketing of Breast-

milk Substitutes (resolution WHA34.22) and subsequent relevant resolutions adopted by the

Health Assembly

PE3

Country has maternity protection laws or regulations in place in line with the ILO Maternity Protection

Convention, 2000 (No.183) and Recommendation No. 191

* Reporting is delayed until 2018.

A paper proposing this core framework will be submitted for discussion at the Sixty-eighth

World Health Assembly. If the Health Assembly adopts the framework, implementation

would begin with collection of country reports for reporting together with the global nutrition

targets in 2016. Further work to operationalize the indicators for delayed reporting (PR1,

PR4, PR6, PE1) would be ongoing throughout 2016. The extended indicators framework

12 Countries in which the prevalence of stunting and wasting is lower than 2.3 % may consider to report against this indicator

using routine clinical data. 13 Less than -2 standard deviations (SD) from the body mass index for age median (WHO 2007 growth reference,

http://www.who.int/growthref/en/ ) in women aged 15-18 years and less than 18.5 kg/m2 in women aged 19 years and above. 14 Body mass index above 25 kg/m2. 15 More than one standard deviation above the median body mass index for age and sex (WHO 2007 growth reference,

http://www.who.int/growthref/en/ ).

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would be under further development between 2016 and 2017. The Global Monitoring

Framework would be reviewed and updated in 2020.

As mentioned above, to help with the further development of the Framework, a joint

WHO/UNICEF Technical Expert Advisory Group on Nutrition Monitoring (TEAM) is being

established. The group, which would advise WHO and UNICEF, will include experts in

nutrition epidemiology, nutrition surveillance, nutrition policy indicators, statistics, system

science, medicine and biology, public health, food security, implementation science,

economics and nutrition biomarker specialists. The Group will discuss issues related to data

quality control and several methodological aspects. In addition, the TEAM will develop

frameworks, describing linkages, analyze constraints and explore strategies to mitigate these

challenges.

The TEAM will also look at the process for selecting optional indicators from the extended

list. The suggested process would include the development of a background paper on the

extended list of indicators, including setting out criteria for their applicability, by March

2016. This would then be the subject of consultation with Member States. The indicator list

would then be finalized and, as a technical document that would not require approval,

reported to the World Health Assembly as part of the periodic review of the Global

Monitoring Framework. A further important step would be the development of an electronic

platform to enable countries to sign in, select indicators and to report on progress.

A number of Member State representatives expressed their support for the proposal. Further

questions were asked about the process for developing the four indicators for delayed

reporting and when these would become fully operational. Under the process proposed, there

would be no further formal approval for these indicators at this stage, but all of the indicators

would be reviewed and reconsidered in 2020.

There was some further discussion of whether there would be an alternative reporting option

for the water (PR2) and sanitation (PR3) indicators. In fact, the inclusion of these indicators

in the SDG framework means that all Member States will be asked to report on them.

The criteria for selecting some indicators for immediate reporting and others for delayed

reporting was discussed. There may be indicators on the ‘immediate’ list for which some

concerns remain about the definition and/or implementation (e.g., PR5 births in baby-friendly

facilities). The Secretariat is aware that some guidance is still needed for some of the

indicators for immediate reporting, but this is not to the same extent as the four indicators for

delayed reporting. The Secretariat will work with Member States to ensure the adoption and

reporting of the GMF will not be disruptive to their national systems.

The consultation recommended that a revised paper is submitted to the Health Assembly,

incorporating the proposal for adoption of the entire core set of indicators, the proposed next

steps and a summary reflecting the discussion during the informal consultation. In addition,

the report of the informal consultation would be available on the WHO website.

The Co-Chair closed the meeting by thanking all the participants for their valuable

contributions and for the richness of the discussion. She also thanked the Secretariat for the

work in preparing the informal consultation.