The road map for National Nutrition
Surveillance System
Introduction
Afghanistan has one of the highest rates of chronic malnutrition among children and high rates of
micronutrients deficiency among children and women. Also the country is prone to high rate of
acute malnutrition due to climate, insecurity and disease outbreaks time to time in several parts of
it. As conducting household surveys is not feasible due to technical, financial and practical
challenges, therefore having a functional surveillance system to monitor the trend of nutritional
status of the population and outcomes of the nutrition programs is the key to have a close eye on
the situation and stimulate timely response to the population needs in terms of nutrition services.
Data and information obtained through the Nutrition Surveillance System will help to achieve the
following objectives:
a)
To improve, strengthen and sustain effective programs by providing on-going data and
information on the quality, coverage and impact of interventions
b)
To provide evidence to guide development of relevant nutrition policies or programs,
c)
To provide evidence to mobilize resources and start programs to respond emergency
need of the population in terms of nutrition services
This document is providing guidance on developing the surveillance system in the light of above
mentioned objectives while taking into account the other available data collection and surveillance
systems in the MoPH for proper integration into the “integrated disease surveillance and
response” mechanism, which will be established by the MoPH in the future.
This guideline is the result of efforts of a group of national and international experts from WHO,
UNICEF, GAIN, and MoPH (public nutrition department, surveillance department, HMIS
department) working extensively through the nutrition surveillance taskforce under the leadership
of the public nutrition department. The team reviewed nutrition surveillance systems in several
countries including Pakistan, Srilanka, Bangladesh and consulted with several international
experts and finally developed this guideline.
1
Steps toward Design and Implementation of the Nutrition
Monitoring and Surveillance System:
Step One. Defining data needs
A minimum set of core indicators to track intervention quality, coverage and impact on nutritional
status and guide us in timely response to be defined. Different administrative levels in the system
have different roles, can provide different but complementary data, and will require different
feedback based on the data analysis. Not all data needs should be generated through the routine
system of data collection. Data that are not frequently needed or are required only for certain
subsets of the population can be generated through special studies and sample surveys. Data
can also be triangulated from other data collection system and analyzed to find the trend of
nutrition and nutrition related information of the population. The major categories of data relate to
nutrition status, nutrition related health status and “programs impact” are defined as following.
The primary nutritional status indicators of interest are:
1.
Anthropometry: These data consist of body measurements among children 0-24
months1to assess nutritional status:
Wasting (weight for height, bipedal pitting edema and MUAC2) as a measure of
acute malnutrition
Underweight (weight for age ) among children
Stunting (height for age) as a measure of chronic malnutrition among children
Low birth weight as a measure of nutritional status of pregnant women
2.
Micronutrient deficiency:
Anemia among pregnant women during the first antenatal visit
Neural Tube defects (NTD) such as Spina bifida, encephalocel and anencephaly
from total births (live birth and still birth) as outcome of folic acid deficiency
3.
Child feeding practices: These data measure practices related to feeding and caring of
infants and young children.
Early initiation of breastfeeding
Exclusive breastfeeding ( during past 24 hours)
Timely and appropriate complementary feeding(semi solid or solid food)
o Time of starting of complementary feeding
o Frequency of CF during the last 24hours
o Type of food given in the last 24 hours
4. Associated health indicators: These indicators has link with the acute malnutrition
and can detect risk factors for acute malnutrition among children
Diarrhea among children <2 years
ARI among children <2 years
Measles among children <2 years
4.
1
This category of the population is very sensitive to the nutrition status changes and there are
internationally accepted methodologies to define their nutritional status easily and appropriately.
2
Mid Upper Arm Circumference is the easy method to determine acute malnutrition among children aged
6-24 months.
2
5.
Program coverage:
Coverage of Vitamin A supplementation among children <2years
Coverage of iodized salt among households through schools
Coverage of fortified oil and ghee (once large-scale marketing starts) among
households
Coverage of fortified flour (once large-scale marketing starts) among households
Step Two. Review existing data collection and reporting
systems
Review the existing nutrition information and sources (indicators collected frequency of collection,
target population) to prevent duplication and ensure appropriate linkage or integration with the
relevant existing information systems is key to a sustainable surveillance system. The key
principle here is to build on the strengths, learn from the weaknesses of what already exists and
support the existing system to ensure quality data and information is collected Our analysis in
terms of the data collection on the key indicators are summarized in the following table:
Reportin Indicators covered
g
system
HMIS Acute Malnutrition
Limitations
Strengths
Recommendation
HMIS only gives number of
children screened, number
of children with MAM and
SAM, but we need age, sex,
weight, height, MUAC and
edema check of each child.
Majority of HFs
are measuring
children
and
registering
them.
NNSS focal point in
the
sentinel
site
should collect quality
data on age, sex,
weight, height, MUAC
and edema check of
each child.
The
registration
forms
need
improvement
and
staff
needs
training.
Focus to improve data
quality, especially in
the sentinel sites and
collect the raw data
directly
from
the
health
facilities
(delivery registers)
HMIS
Low Birth Weight
Only gives number of LBW
on live births, while we need
the exact weight of each
child in gram.
Weight record of
live births is
exists in the
facilities register
books,
HMIS
Anemia in pregnant HMIS only reports the
women
(
first number of pregnant women
antenatal visit)
who are anemic, but we
need all the women with
their
Hemoglobin
measurement.
Data is exist in
the register of
health facilities
for majority of
pregnant
women
HMIS
NTD
HMIS doesn’t report on NTD
3
With focus on the
data quality, Hb level
of
each
pregnant
women (first antenatal
visit)
should
be
reported. Training of
staff and provision of
necessary equipment
should be considered.
Data exists in NMSS focal point in
the
register the sentinel site will
books of most of collect and report on
the hospitals.
NTD together with all
the births (live and
stillbirths)
Nutrition Coverage of iodized There is a data collection
salt among house system,
which
needs
holds
improvement
Production
of
iodized
salts
reporting
by
production
factory
and
availability
of
iodized salt at
the household
levels
are
collected,
but
not
systematically
Nutrition Coverage of fortified Data is not available in PND
oil among house holds
Nutrition Coverage of fortified Data is not available in PND
flour among house
holds
Nutrition Early
initiation
breastfeeding
Production
fortified
reporting
production
factory
Data will be collected
through schools on
annual basis in future
of Data will be collected
is through schools on
by annual bases in future
of Data is no exist with the
PND
Nutrition Duration of exclusive Data is not exist with the
breastfeeding
PND
Nutrition Timely
and Data is not available with the
appropriate
PND
complimentary feeding
(semi solid or solid
food)
EPI/NID Vit-A supplementation Data collection is done by
EPI/NID team
DEWS
Diarrhea
Data on Vit-A
supplementation
during the NIDs
available
with
EPI for 6-11
months, and 1259 months.
Data
on
Diarrhea
is
available
with
DEWS/HMIS for
< 5 children.
4
Data will be collected
through schools on
annual basis by (drop
test)
Data can be collected
through
health
facilities during growth
monitoring quarterly
and from community
annually
Data can be collected
through
health
facilities during growth
monitoring quarterly
and from community
annually
Data can be collected
through
health
facilities during growth
monitoring quarterly
and from community
annually
Data will be taken
from EPI
Support EPI team to
ensure
quality
of
program and data
after agreement on
age breakdown for 624 months with EPI
department.
Data will be taken
from
DEWS/HMIS
after agreement on <2
years age breakdown
with
both
departments.
DEWS
ARI
Data on ARI is
available
with
DEWS/HMIS for
<5 children.
DEWS
Measles
Data
on
Measles
is
available
with
DEWS/HMIS for
<5
years
children.
Data will be taken
from
DEWS/HMIS
after agreement on <2
years age breakdown
with
both
departments.
Data will be taken
from
DEWS/HMIS
after agreement on <2
years age breakdown
with
both
departments.
Step Three. Determine sample size and data collection
mechanisms
Calculating the minimum number of cases to be able to measure the trend of indicators over time
is a key step. Sample size for each indictor is calculated based on the ‘sample size calculator for
two surveys with multiple outcomes’, developed by CDC/WHO. In this calculator two surveys
were considered as two data collection period so that we can calculate the trend of outcome,
when it changes in certain levels. For some indicators, such as wasting, the data collection time is
quarterly meaning we can calculate at least 4% variation in a quarter, while in indicators which
are not changing fast, we calculated the sample size to show the variation within a longer period
of time – one year. As the samples in this data collection is from sentinel sites, non-probability
convenience sampling, therefore, the design effects is considered 1, and response rate has been
considered 90%. The following table shows the minimum sample size for each indicator, the
period of time in which trend will be measured and the percentage of change in trend that can be
measured. Due to changes in the prevalence rate for each indicator, the sample size is subject to
change each year.
Indicator
Target
group
Sampling
area
Iodized salt
coverage
Wasting
Households
Province
Sample Sensitivity Period to Remarks
size
to change analyze
of trend
trend
357
10%
Annually
Children <
2Yrs
Province
686
5%
Underweight
Children < 2 Province
Yrs.
558
8%
Stunting
Children <
2Yrs
2398
3%
Province
5
Quarterly The 686 children will be
divided into three to seven
HFs and the same number
could be collected from
community
Quarterly At least 558 children will be
divided into three to seven
HFs and the same number
could be collected from
community
Annually With measuring 686
children in a quarter we
can see the trend if it is
more than 10%
BF initiation
Children <
2Yrs
Exclusive BF
Children <
2Yrs
Complementary Children <
feeding
2Yrs
Anemia in
Pregnant
pregnant
women
women
Low Birth
All Live
Weight
births
NTD
All births
Province
1542
5%
Annually
Province
1542
5%
Annually
Province
1094
5%
Annually
Province
1565
5%
Annually
Province
8982
1%
Annually
Province
11725
0.2%
Annually
Data collection mechanisms:
Data will be collected from sentinel sites that comprise health facilities, communities and schools
on regular basis and also small scale household surveys will be conducted when needed to verify
the prevalence rates in certain geographic areas.
The following table shows the main mechanisms of data collection for each of the selected
indicator:
Indicator
Wasting
Target group
Sites
Data collection Mechanism
Children < 2 Health facility Weight, height, edema of all children < 2 yrs. olds will be
Yrs.
measured as part of growth monitoring program and
MUAC of children 6-24months also will be measured;
this includes sick children as well as healthy children
coming for vaccination and any other reasons. A form is
designed (see annex) to register the variables for each
child and the focal person will collect the forms and
enter all data into the database at the provincial level.
The analysis and determination of prevalence of acute
malnutrition will be done by the database. The diagnosis
at the health facility level will be used to refer children for
treatment and counseling.
community
The CHWs have to measure the MUAC for 6-24 months
and check edema for 0-24 months to diagnose and refer
them for treatment. A form is designed (see annex) to fill
the variables (age, sex, MUAC and presence or lack of
edema as well as IYCF indicators) among all children
under two years and submit the forms monthly to the
DEWS focal point or nutrition surveillance focal point of
their respective health facility3. The forms will be
collected by the provincial focal points and will be
entered in the database for further analysis. 686 children
should be registered in a quarter, and based on this the
number of communities will be determined according to
the population coverage and case load.
3
One of the CHWs (male or female) must be literate to be able to fill the form, otherwise assistance from
another local member of the community will be sought.
6
Underweight
Children <
2Yrs
Health facility The age, sex, weight and of children < 2 year will be
measured and registered through growth monitoring
program and the registration form will be used by
provincial focal point to collect and enter the data in the
data base.
Stunting
Children <
2Yrs
Health facility
BF initiation
Children <
2Yrs
Children <
2Yrs
Children <
2Yrs
The age, sex, and height of children < 2 year will be
measured and registered through growth monitoring
program and the registration form will be used by
provincial focal point to collect and enter the data in the
data base.
Health facility The form that is used in the growth monitoring program
and contains data for acute and chronic malnutrition,
Exclusive BF
Health facility also have a question to be asked from mothers of each
child under two years regarding initiation of
Complementary feeding
Health facility breastfeeding and exclusive breastfeeding. There are
also three questions about complementary feeding (time
of introduction, type of food given and frequency) for
each child under 2 year old.
Anemia in pregnant
Pregnant
Health facility The health facilities with delivery service will measure
women
women
hemoglobin for each women attending for first ANC
during pregnancy. A form is designed (see annex) to
register the value of Hb for each women and the
provincial focal person collect the forms monthly to enter
them in the database for further analysis.
Low Birth Weight
All Live births Health facility The health facilities with delivery services already have
a register book and register the weight of all newborns
NTD
All births
Health facility at birth and if there are anomalies. From this register the
focal person for surveillance will prepare the report (or
simply copy the register) and the provincial focal person
will enter the data into the database for further analysis.
Vitamin A
Children 6-59 EPI
The supplementation of vitamin A is done during NIDs
supplementation
months
by the EPI teams and data on coverage will be collected
by them. We will use this data for our analysis and
including in the surveillance system.
Iodized salt coverage
Households Schools
In each province several schools, based on the sample
size calculated above, will be selected, preferably girls
Coverage of fortified oil Households Schools
high school. The students will be asked to bring a
Coverage of fortified Households Schools
sample of salt, flour and oil from their homes and the
flour
samples will be checked for availability of iodine using
droplet test kits.
ARI, Diarrhea, Measles
Children
<2years old
Health
facilities
Tests for oil and flour will be done once we have
introduced a large scale fortification program.
These data are collected regularly by DEWS, to avoid
duplication we will use their data in the system.
7
Step four: Select Sentinel Sites based on defined criteria
For selecting sentinel sites the analysis for each of the indicators shows some key areas to be
considered. The following table shows our analysis of the situation and based on it, we came up
with some key principles for selecting sentinel sites.
Indicators
Wasting
edema)
Target
group
(MUAC, 6-24
months
Type of site
Community
Frequenc Intervention to be
y of data available
collection
Quarterly Outpatient
and
inpatient treatment
of malnutrition4
Wasting
(W/H, 0-24
Edema, MUAC)
months
Health facility Monthly
Stunting (H/A)
Health
Facility
Monthly
Health
Facility
Pregnant
Health
(first ANC Facility
visit))
Monthly
LBW among
births
Anemia
0-24
months
live Newborns
Monthly
NTD among all Newborns
births (live and still)
Health
Facility
Monthly
Early initiation of Lactating
BF
mothers
Health
Facility
Quarterly
Exclusive BF
Lactating
mothers
Health
Facility
Quarterly
Complementary
Feeding
Lactating
mothers
Health
Facility
Quarterly
Diarrhea
0-59
months*
0-59
months*
0-59
months*
0-59
months
Health
Facility
Health
Facility
Health
Facility
Community
Quarterly
ARI
Measles
Vit-A
supplementation
4
Quarterly
Quarterly
Semi
annual
Recommendation
Active literate CHW
or alternative should
be there to collect
data, community is
not the catchment
area of HF SS
Growth Monitoring The health facility
and Counseling on should
be
fully
IYCF
functional as per
BPHS guideline, fully
staff, have enough
Counseling
on caseload
IYCF and Growth
monitoring
delivery
Functional delivery
room/s
antenatal
capacity to check Hb
consultation,
of each pregnant
delivery
services woman, especially in
and
functional first ANC visit
laboratory
delivery
Capacity
of
diagnosis
and
enough caseload
Delivery or growth Availability of trained
monitoring service staff on IYCF and
GM
Growth monitoring Availability of trained
Counseling
on staff
IYCF
Growth monitoring Availability of trained
Counseling
on staff
IYCF
Health services
DEWS sentinel sites
should be there
Health services
DEWS sentinel sites
should be there
Health services
DEWS sentinel sites
should be there
National
Vit-A
Immunization
supplementation
Day(NID) campaign must be included in
the two round of
This is to avoid community fatigue due to frequent data collection, without any services.
8
Coverage
of
iodized salt among
households
Coverage
of
fortified oil among
households
Coverage
of
fortified
flour
among households
NIDs
school with enough Production of iodized
students
salt
school
students
Community
(School)
Annual
school
students
Community
(School)
Annual
school with enough Production of fortified
students
oil
school
students
Community
(School)
Annual
Production of fortified
flour
*If DEWS can give us data on 0-24 months it will be triangulated, otherwise we can use data for
under five children.
A.
o
o
o
Criteria for selecting a sentinel health facility as data collection point:
The health facility should be fully functional as per BPHS guideline.
The health facility located in a vulnerable, or non-vulnerable ,at higher risk, or low risk for
malnutrition.
The health facility is accessible for monitoring and proper flow of data in terms of security
and other factors i.e. geography.
The health facility has high coverage of intervention and serves a considerable number of
populations.
The health facility should be the same sentinel sites as for DEWS
B.
o
o
o
o
Criteria for selecting a community based sentinel site:
The community should not be the catchment area of selected Health Facilities
The community is accessible in terms of geography, security and other factors.
There is some nutrition service delivery mechanisms exist in the community.
The sites can be re-evaluated every year and could be changed if necessary.
o
o
The selection of sentinel sites on community bases should be done on random bases, after
meeting the above four criteria,
A meeting will be held with PNOs, implementer NGOs, DEWS and CBHC colleague to select
sentinel sites and data collection points within the sites base on the above mentioned criteria.
Given the above mentioned criteria, priority will be given to those sites where DEWS is already
functioning. In the meeting focal point for each data collection point will also be specified.
Step Five. Determine the most appropriate data flow and
information dissemination
Data will be generated and collected at the community or health facility level (for coverage of
fortified food a school in the community can serve as the sentinel site). The staff of health facility
or CHWs will collect the data during the routine service delivery and the DEWS focal point at the
health facility will be responsible to collect the data from all relevant departments and submit it to
the PNO or DEWS officer at the provincial level. Data entry into the database will take place at
the provincial level and cleaned data will be submitted to PND. The PND also collect data from
other sources (ARI, Diarrhea and Measles from DEWS, food security data from WFP…) and
enter them into the database. The analysis will be done in the PND and information generated will
be shared with all stakeholders to the provincial and sentinel sites level as well as national level
with the relevant development and implementing partners in quarterly and annual bulletin see
annex 1, the format of bulletin. The nutrition cluster, BPHS implementing partners, UN partners,
9
donor agencies, authorities of the MoPH and other relevant agencies will receive the report, once
the data is analyzed and information is generated. The following flow diagram shows the flow of
data at different levels:
10
Data processing
Data Presentation
Data Interpretation
Decision for Action
Obtain more/different resources
PND-MoPH
Monthly reports
Quarterly reports
Annual reports
Feedback on reports
Monitoring findings
Analysis/information
sharing
Data compilation and consolidation
PNO/DEWS
Feedback on reports
Monitoring findings
Analysis/information
sharing
Monthly reports
Quarterly reports
Annual reports
Other
triangulated data
(Vit-A
supplementation,
Food
Security
data, etc.)
Data from DEWS
MUAC
Edema
Early initiation of BF
Exclusive BF
Comp. Feeding
Data collection at HF level
Weight
Height
MUAC
Edema
LBW
NTD
Delivery
Anemia
Early initiation of BF
Exclusive BF
Comp. Feeding
NMSS FP
at HF
(DEWS FP)
Diarrhea
ARI
Measels
Data at community level
Coverage of iodized salt
Coverage of fortified oil
Coverage of fortified flour
11
Data collection at school level
Step Six. Design the data collection and reporting tools
The capability of the staff for filling in the forms must be considered when designing the data
collection tools. The most effective data collection and reporting tools are simple and short.
Given the above Step.1 and Step.4, data collection and reporting formats and the instruction
guideline has been developed, see annex 2 the data collection tools.
Step Seven. Capacity building
To build the capacity of health care providers, the MoPH, WHO and UNICEF jointly will consider
the following activities:
A.
Training: considering the stewardship role of the MoPH, the training part of the program
is going to be contracted out to an independent firm. The core team of trainers of the firm will be
trained by PND, WHO and UNICEF. The firm will cascade the training to data providers at
provincial level, according to the MoPH guidelines and training manual. See annex 3, training
plan.
B.
Providing facilities for data providers: In order to have all necessary facilities – skills,
equipment, and tools at the sentinel sites, provincial offices and the PND efforts are going to be
done to address the important needs. Data collection tools, measuring equipment, supportive
supervision and on the job coaching, as well as recognition of best performances will be
considered.
C.
International experts support: As establishing and running nutrition surveillance system
is highly technical activity, an academic or experienced international institution will be contracted
to support the in-country team by providing professional consultancy based on need.
Step Eight. Piloting, redesigning and scaling up the system
The system will be piloted in five provinces (Nangarhar, Kabul, Herat, Kandahar and Balkh) which
are specified for the 1stphase of implementation. Training will be conducted for the sentinel sites
focal points on the methodology of data collection and how to use the data collection formats. The
aim of piloting of the system is to find out the challenges in the methodology of data collection,
how user –friendly are data collection formats, challenges in the data flow, data processing and
dissemination. Recommendations will be provided base on the challenges and system will be
revised accordingly. The adjustments based on findings of the pilot test will be presented to the
project advisory group to be validated for scaling up the program. Six months later from piloting,
scaling up of the system will be done into other provinces.
Step Nine. Monitoring the implementation process
Monitoring of the implementation process should be done in four stages with different
methodologies. Monitoring will cover all stages of the program cycle – inputs, process and
12
outputs – and will be conducted at the data collection point, data management points at the
provinces as well as data management unit at the PND. Please see annex 4 the monitoring
checklists.
1.
Monitoring of piloting process: Monitoring of the system should be done through close
observation of the system at the piloting sites to find out the challenges and obstacles in the
system implementation and propose recommendations for the improvement of the system and
readjust it accordingly.
2.
Monitoring of the capacity building of the staff: After pilot the surveillance system and
before real scaling up of the system, staff should be capacitated to implement the scaled up
system. Staff capacity building will be monitored through duration of the trainings, participant’s
attendance, pre/post test results, etc.; it will be tracked through a checklist for each of the
trainings.
3.
Monitoring of the scaled up and expanded system: A comprehensive checklist is
developed to track with proper use of data collection tools, data collection methodology, accuracy
of data, capacity of data collectors, etc.; PND, PNOs and NOGs nutrition focal points will be
involved in the monitoring process.
4.
Monitoring the dissemination and use of information generated by the surveillance system
and the level of response in terms of emergency preparedness, programs review and readjustment and resource mobilization activities will be considered as an important part of the
program.
Step Ten: Integrating the system into the integrated diseases
surveillance and response system of the MoPH
The MoPH is working to establish the “integrated disease surveillance and response” system. A
taskforce at the MoPH works to review different surveillance systems exist in the MoPH toward
the integration of all these system into one surveillance system. Once the “Nutrition surveillance
system” is successfully implemented in all provinces of the country the system will be integrated
with the other surveillance systems at the MoPH. The mechanisms and details of this integration
are under discussion among the members of the taskforce committee under the leadership of the
general director of the policy and planning of the MoPH.
13