Nutrition surveillance – still needed..

By Veronica Tuffrey

A review of nutrition surveillance in low-income countries has just been released by the Transform Nutrition research consortium. It describes the use and value of nutrition surveillance for a number of purposes including early warning of malnutrition, to develop and evaluate policies and programmes, and to assess progress towards international development goals for better nutrition.

Nutrition surveillance – the regular and systematic collection of data on nutritional indicators – is a subject most nutritionists perceive to be important but would rather leave others to deal with it. Why?

First, it depends on quantitative data and statistical analysis, which puts many people off immediately. Second, it’s impossible to show that surveillance is effective in helping to prevent poor nutrition. The idea of doing something that has measurable value is more attractive (and easier to fund) than doing something that only has a plausible impact. Third, surveillance is complicated. Decisions are needed about the sampling method to use, how many people should be measured and how often, what other indicators to measure, or whether it’s sufficient to use data already being collected through health information systems. No wonder peoples’ eyes start to glaze over, as they wish good luck to the data analysts and turn away to address other concerns. So this leads to the fourth issue: surveillance is “boring but important”.  Although we recognise that it’s essential to have good quality information to inform decisions about how to improve human nutrition, it’s much less exciting to think about how best to ensure that this information is available compared with thinking about which actions or mix of actions to use to address poor nutrition, and how best to implement programmes.

To help understand the complex issues involved in nutrition surveillance, Save the Children commissioned a review of this hitherto somewhat neglected subject. This is good news for practitioners because the most recent information on methods relevant to nutrition surveillance in low income countries is now gathered together and simplified.

The review also presents a perspective on why surveillance systems are so hard to keep going and the key factors in systems that have been sustained, gained from the literature on the subject and from discussions with practitioners and experts. The findings were not surprising, yet still noteworthy. Sustainability was found to hinge on cost; individual and institutional capacity; ownership of the system including location of the institutional base; a demand for the outputs of the analysis, and participation and engagement in the process.

Four new topics have recently appeared in the literature on nutrition surveillance: how to provide information that can be used for advocacy; how to promote accountability for actions or lack of actions, including delivering nutrition services; how to harness recent developments in electronic technology, and how to have effective surveillance of overnutrition.

There is no point in repeating here why regularly collecting, analysing, interpreting and communicating data on nutrition are needed and why “data gaps” must be filled, when this is well described elsewhere for example in the first Global Nutrition Report. Instead I’ll touch on two themes of relevance to future nutrition surveillance activities that emerged from the review.

The first theme relates to the interface between the national and international nutrition systems. From the perspective of national nutrition leaders, it can often appear that the international nutrition system is indifferent to the political realities and timetables of nations and lacks clear priorities. Similarly, guidance provided by the international nutrition system can seem intermittent and inconsistent, both between organisations and over time. International initiatives exist to strengthen nutrition surveillance activities such as the WHO’s “Accelerating Nutrition Improvements in Sub-Saharan Africa”; to address critical data gaps such as DFID’s Strengthening Data for Nutrition programme; and to bring together data from multiple sectors to promote analysis that is relevant to policy, such as the EC initiative National Information Platforms for Nutrition. It will be challenging for the international community both to keep these initiatives and their successors as high priorities, and to assure countries that nutrition surveillance will remain a top priority. Also, to maximise sustainability, past experience shows that national decision-makers must be at the centre of deliberations about strengthening or creating surveillance activities, not the people who are providing technical advice and external resources.

The second theme is the repetition of history with respect to the multisectoral approach in nutrition. As Urban Jonsson observed, multisectoral nutrition planning was the dominant mind-set or ‘paradigm’ in world food and nutrition policy between about 1974 and 1980 (Jonsson U. The rise and fall of paradigms in world food and nutrition policy. (Commentary). World Nutrition. 2010; 3:128–58 ). Within this paradigm, child malnutrition was recognised as a structural problem with causes based in poverty and underdevelopment; nutrition interventions were to be multi-sectoral and integrated into national development policies, and food and nutrition surveillance systems were expected to provide information that contributed to planning processes in all sectors. This approach has returned – multisectoral activities are now recognised as key to reducing rates both of stunting caused by chronic undernutrition and of chronic diseases caused by overnutrition.

In 2010, Urban Jonsson pinpointed three factors to account for the previous decline in the multisectoral paradigm. First that the approach required much more data than any low-income country could or wanted to provide, second that the systems analysis was too complicated, and third that the paradigm was based on the false assumption that nutrition would become a political priority. Arguably the last is the only one of the three hurdles that remains to be overcome. But the difference now, compared with forty years ago, is the existence in many countries of the SUN movement.

It remains to be seen whether the SUN movement will overcome the challenges of weak capacity and resistance to collaboration between sectors, so that nutrition becomes a political priority in each country. If it does, effective information and knowledge management, including high quality nutrition surveillance, will be in great demand.

Unfortunately the main demand for information derived from nutrition surveillance in low-income countries still comes from the international nutrition community. But the recently increased focus on improving the collection and use of nutrition-related data is justified since the need “.. to watch over nutrition, in order to make decisions which lead to improvements in nutrition in populations” is as critical now as it was when nutrition surveillance was first promoted by the WHO forty years ago.

This blog is based on a review of nutrition surveillance commissioned by Save the Children and funded by DFID through Transform Nutrition. The full review was recently released (http://www.transformnutrition.org/2016/04/nutrition-surveillance-systems/ ) and two papers based on the report were published in open-access journals, one about the methods (http://www.ete-online.com/content/13/1/4 ) and one about the development and sustainability of nutrition surveillance in low-income countries (http://www.biomedcentral.com/2055-0928/2/15 ).

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