Low birth weight

What does this indicator tell us?

At population level, the proportion of infants with a low birth weight is an indicator of a multifaceted public health problem that includes long-term maternal malnutrition, ill health and poor health care in pregnancy. Low birth weight is more common in developing than developed countries.

Low birth weight is included as a primary outcome indicator in the core set of indicators for the Global Nutrition Monitoring Framework.  It is also included in the WHO Global Reference List of 100 Core Health Indicators.

How is it defined?

Low birth weight has been defined by WHO as weight at birth of < 2500 grams (5.5 pounds).

What are the consequences and implications?

Low birth weight is caused by intrauterine growth restriction, prematurity or both. It contributes to a range of poor health outcomes: it is closely associated with fetal and neonatal mortality and morbidity, inhibited growth and cognitive development and noncommunicable diseases later in life. Low-birth-weight infants are approximately 20 times more likely to die than heavier infants.

Low birth weight is more common in developing than developed countries. However, data on low birth weight in developing countries is often limited because a significant portion of deliveries are done in homes or small health facilities where cases of infants with low birth weight often go unreported. These cases are not reflected in official figures and may lead to a significant underestimation of low birth weight prevalence. 

Source of data

UNICEF. Childinfo Database. http://data.unicef.org/topic/nutrition/low-birthweight

Further reading

WHO. Feto-maternal nutrition and low birth weight. http://www.who.int/nutrition/topics/feto_maternal/en/index.html.

WHO. Global Targets 2025 to improve maternal, infant and young child nutrition. http://who.int/nutrition/global-target-2025/en/  

WHO. Global Nutrition Targets 2025: Low birth weight policy brief.  Geneva, World Health Organization, 2014. http://who.int/nutrition/publications/globaltargets2025_policybrief_lbw/en/  

WHO. Global Reference List of 100 Core Health Indicators. Geneva: World Health Organization, 2015. http://www.who.int/healthinfo/indicators/2015/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target. http://www.who.int/elena/global-targets/en

Target 3: 30% reduction in low birth weight. http://www.who.int/elena/global-targets/en/#lowbirthweight

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Overweight in school-age children and adolescents

Overweight in school-age children and adolescents

What does this indicator tell us?

This indicator reflects the percentage of school-age children and adolescents 5-19 years who are classified as overweight based on age and sex specific values for body mass index (BMI). Overweight indicates excess body weight for a given height from fat, muscle, bone, water or a combination of these factors, whilst obesity is defined as having excess body fat.

Overweight in school-age children and adolescents 5-19 years is included as an intermediate  outcome indicator in the core set of indicators for the Global Nutrition Monitoring Framework. This indicator is also included in the NCD Global Monitoring Framework as well as in the WHO Global Reference List of 100 Core Health Indicators.

How is it defined?

Prevalence of overweight in school-age children and adolescents is defined as the percentage of children aged 5-19 years with sex-specific BMI-for-age above +1 SD from the WHO 2007 reference median. Prevalence of obesity in school-age children and adolescents is defined as the percentage of children aged 5-19 years with sex-specific BMI-for-age above +2 SD from the WHO 2007 reference median.

What are the consequences and implications?

The immediate consequences of overweight and obesity in school-age children and adolescents include greater risk of asthma and cognitive impairment, in addition to the social and economic consequences for the child, its family and the society. In the long term, overweight and obesity in children increase the risk of obesity, diabetes, heart disease, some cancers, respiratory disease, mental health, and reproductive disorders later in life. Furthermore, obesity and overweight track over the life course – an overweight adolescent girl is more likely to become an overweight woman and, thus, her baby is likely to have a heavier birth weight.

Source of data

WHO. Global Health Observatory.http://www.who.int/gho.

Input data and methods are described in NCD-RisC. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies with 128.9 million participants. Lancet 2017. DOI: http://dx.doi.org/10.1016/S0140-6736(17)32129-3.

Further reading

WHO. Growth reference 5-19 years. BMI-for-age (5-19 years). http://www.who.int/growthref/who2007_bmi_for_age/en/ 

WHO. Overweight and obesity. Fact sheet 311. http://www.who.int/mediacentre/factsheets/fs311/en/

WHO. Commission on Ending Childhood Obesity. http://www.who.int/end-childhood-obesity/en/

WHO. NCD Global Monitoring Framework. http://www.who.int/nmh/global_monitoring_framework/en/

WHO. Global Reference List of 100 Core Health Indicators. Geneva: World Health Organization, 2015. http://www.who.int/healthinfo/indicators/2015/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target. http://who.int/elena/global-targets/en/   

Target 7: Halt the rise in diabetes and obesity. http://www.who.int/elena/global-targets/en/#diabetesobesity

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Anaemia

What does this indicator tell us?

Anaemia has a wide variety of causes. Although iron deficiency is considered to be the most common  cause of anaemia, other causes include acute and chronic infections that result in inflammation and blod loss; deficiencies of other vitamins and minerals, especially folate, vitamin B₁₂ and vitamin A; and genetically inherited traits, such as thalassaemia. Other conditions (malaria and other infections, genetic disorders, cancer) also play a role. The terms ‘iron-deficiency anaemia’ and ‘anaemia’ are often used synonymously, and the prevalence of anaemia has often been used as a proxy for iron-deficiency anaemia, although the degree of overlap between the two varies considerably from one population to another according to gender and age.

Anaemia prevalence among pregnant and non-pregnant women are included as primary outcome indicators in the core set of indicators for the Global Nutrition Monitoring Framework to monitor progress towards reaching Global Nutrition Target 2,  a 50% reduction in anaemia among women of reproductive age by 2025. Anaemia in women of reproductive age and in children are also included in the WHO Global Reference List of 100 Core Health Indicators.

How is it defined?

Anaemia is defined as a haemoglobin concentration below a specified cut-off point, which can change according to the age, gender, physiological status, smoking habits and altitude at which the population being assessed lives. WHO defines anaemia in children under 5 years of age and pregnant women as a haemoglobin concentration <110 g/L at sea level and anaemia in non-pregnant women as a haemoglobin concentration <120 g/L.

Tests to measure haemoglobin levels are easy to administer. A few drops of blood obtained by a finger-stick  can be used to assess haemoglobin concentrations in the field using a portable haemoglobinometer.  The test could be easily integrated into regular health or prenatal visits or household surveys to capture women of reproductive age, though one needs to consider the cost of the equipment and regular calibration.

What are the consequences and implications?

Anaemia is associated with increased risks for maternal and child mortality. Iron-deficiency anaemia reduces the work capacity of individuals and entire populations, with serious consequences for the economy and national development. In addition, the negative consequences of iron-deficiency anaemia on the cognitive and physical development of children and on physical performance - particularly the work productivity of adults - are major concerns. Anaemia is a global problem affecting all countries. Resource-poor areas are often more heavily impacted due to the prevalence of infectious diseases. Malaria, HIV/AIDS, hookworm infestation, schistosomiasis and other infections such as tuberculosis contribute to the high prevalence of anaemia in some areas.

The main risk factors for iron-deficiency anaemia include a low dietary intake of iron or poor absorption of iron from diets rich in phytates or phenolic compounds. Population groups with greater iron requirements, such as growing children and pregnant women, are particularly at risk. Overall, the most vulnerable, poorest and least educated groups are disproportionately affected by iron-deficiency anaemia.

Cut-off values for public health significance

Reference: WHO, 2008.

Source of data

Stevens GA et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. Lancet Global Health; 2013; 1:e16-25.

Data about haemoglobin and anaemia for women of childbearing age (15–49 years) were estimated for each country and for each year between 1995 and 2016 using survey data obtained from 257 population-representative data sources from 107 countries worldwide. A Bayesian hierarchical mixture model was used to estimate haemoglobin distributions and systematically addressed missing data, non-linear time trends, and representativeness of data sources. More information on the methodology can be found in: Stevens GA et al. 2013.

Further reading

WHO. Global Nutrition Targets 2025: Anaemia policy brief. Geneva, World Health Organization, 2014. http://who.int/nutrition/publications/globaltargets2025_policybrief_anaemia/en/

WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2011 (WHO/NMH/NHD/MNM/11.1).  http://www.who.int/vmnis/indicators/haemoglobin.pdf.  

WHO. Vitamin and Mineral Nutrition Information System (VMNIS). Department of Nutrition for Health and Development (NHD), Geneva, Switzerland. http://www.who.int/vmnis/en/.

WHO. Anaemia/iron deficiency list of publications. http://www.who.int/nutrition/publications/micronutrients/anaemia_iron_deficiency/en/index.html.

WHO. Global Health Observatory. Indicator Metadata Registry. Prevalence of anaemia among women aged 15-49 years (%). http://apps.who.int/gho/data/node.wrapper.imr?x-id=4552

WHO. Global Reference List of 100 Core Health Indicators. Geneva: World Health Organization, 2015. http://www.who.int/healthinfo/indicators/2015/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA). http://www.who.int/elena/health_condition/en/#anaemia  

WHO. E-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target. http://www.who.int/elena/global-targets/en  

Target 2: 50% reduction of anaemia in women of reproductive age. http://www.who.int/elena/global-targets/en/#anaemia  

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Anaemia

What does this indicator tell us?

Anaemia has a wide variety of causes. Although iron deficiency is considered to be the most common  cause of anaemia, other causes include acute and chronic infections that result in inflammation and blod loss; deficiencies of other vitamins and minerals, especially folate, vitamin B₁₂ and vitamin A; and genetically inherited traits, such as thalassaemia. Other conditions (malaria and other infections, genetic disorders, cancer) also play a role. The terms ‘iron-deficiency anaemia’ and ‘anaemia’ are often used synonymously, and the prevalence of anaemia has often been used as a proxy for iron-deficiency anaemia, although the degree of overlap between the two varies considerably from one population to another according to gender and age.

Anaemia prevalence among pregnant and non-pregnant women are included as primary outcome indicators in the core set of indicators for the Global Nutrition Monitoring Framework to monitor progress towards reaching Global Nutrition Target 2,  a 50% reduction in anaemia among women of reproductive age by 2025. Anaemia in women of reproductive age and in children are also included in the WHO Global Reference List of 100 Core Health Indicators.

How is it defined?

Anaemia is defined as a haemoglobin concentration below a specified cut-off point, which can change according to the age, gender, physiological status, smoking habits and altitude at which the population being assessed lives. WHO defines anaemia in children under 5 years of age and pregnant women as a haemoglobin concentration <110 g/L at sea level and anaemia in non-pregnant women as a haemoglobin concentration <120 g/L.

Tests to measure haemoglobin levels are easy to administer. A few drops of blood obtained by a finger-stick  can be used to assess haemoglobin concentrations in the field using a portable haemoglobinometer.  The test could be easily integrated into regular health or prenatal visits or household surveys to capture women of reproductive age, though one needs to consider the cost of the equipment and regular calibration.

What are the consequences and implications?

Anaemia is associated with increased risks for maternal and child mortality. Iron-deficiency anaemia reduces the work capacity of individuals and entire populations, with serious consequences for the economy and national development. In addition, the negative consequences of iron-deficiency anaemia on the cognitive and physical development of children and on physical performance - particularly the work productivity of adults - are major concerns. Anaemia is a global problem affecting all countries. Resource-poor areas are often more heavily impacted due to the prevalence of infectious diseases. Malaria, HIV/AIDS, hookworm infestation, schistosomiasis and other infections such as tuberculosis contribute to the high prevalence of anaemia in some areas.

The main risk factors for iron-deficiency anaemia include a low dietary intake of iron or poor absorption of iron from diets rich in phytates or phenolic compounds. Population groups with greater iron requirements, such as growing children and pregnant women, are particularly at risk. Overall, the most vulnerable, poorest and least educated groups are disproportionately affected by iron-deficiency anaemia.

Cut-off values for public health significance

Reference: WHO, 2008.

Source of data

Stevens GA et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. Lancet Global Health; 2013; 1:e16-25.

Data about haemoglobin and anaemia for women of childbearing age (15–49 years) were estimated for each country and for each year between 1995 and 2016 using survey data obtained from 257 population-representative data sources from 107 countries worldwide. A Bayesian hierarchical mixture model was used to estimate haemoglobin distributions and systematically addressed missing data, non-linear time trends, and representativeness of data sources. More information on the methodology can be found in: Stevens GA et al. 2013.

Further reading

WHO. Global Nutrition Targets 2025: Anaemia policy brief. Geneva, World Health Organization, 2014. http://who.int/nutrition/publications/globaltargets2025_policybrief_anaemia/en/

WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2011 (WHO/NMH/NHD/MNM/11.1).  http://www.who.int/vmnis/indicators/haemoglobin.pdf.  

WHO. Vitamin and Mineral Nutrition Information System (VMNIS). Department of Nutrition for Health and Development (NHD), Geneva, Switzerland. http://www.who.int/vmnis/en/.

WHO. Anaemia/iron deficiency list of publications. http://www.who.int/nutrition/publications/micronutrients/anaemia_iron_deficiency/en/index.html.

WHO. Global Health Observatory. Indicator Metadata Registry. Prevalence of anaemia among women aged 15-49 years (%). http://apps.who.int/gho/data/node.wrapper.imr?x-id=4552

WHO. Global Reference List of 100 Core Health Indicators. Geneva: World Health Organization, 2015. http://www.who.int/healthinfo/indicators/2015/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA). http://www.who.int/elena/health_condition/en/#anaemia  

WHO. E-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target. http://www.who.int/elena/global-targets/en  

Target 2: 50% reduction of anaemia in women of reproductive age. http://www.who.int/elena/global-targets/en/#anaemia  

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Anaemia

What does this indicator tell us?

Anaemia has a wide variety of causes. Although iron deficiency is considered to be the most common  cause of anaemia, other causes include acute and chronic infections that result in inflammation and blod loss; deficiencies of other vitamins and minerals, especially folate, vitamin B₁₂ and vitamin A; and genetically inherited traits, such as thalassaemia. Other conditions (malaria and other infections, genetic disorders, cancer) also play a role. The terms ‘iron-deficiency anaemia’ and ‘anaemia’ are often used synonymously, and the prevalence of anaemia has often been used as a proxy for iron-deficiency anaemia, although the degree of overlap between the two varies considerably from one population to another according to gender and age.

Anaemia prevalence among pregnant and non-pregnant women are included as primary outcome indicators in the core set of indicators for the Global Nutrition Monitoring Framework to monitor progress towards reaching Global Nutrition Target 2,  a 50% reduction in anaemia among women of reproductive age by 2025. Anaemia in women of reproductive age and in children are also included in the WHO Global Reference List of 100 Core Health Indicators.

How is it defined?

Anaemia is defined as a haemoglobin concentration below a specified cut-off point, which can change according to the age, gender, physiological status, smoking habits and altitude at which the population being assessed lives. WHO defines anaemia in children under 5 years of age and pregnant women as a haemoglobin concentration <110 g/L at sea level and anaemia in non-pregnant women as a haemoglobin concentration <120 g/L.

Tests to measure haemoglobin levels are easy to administer. A few drops of blood obtained by a finger-stick  can be used to assess haemoglobin concentrations in the field using a portable haemoglobinometer.  The test could be easily integrated into regular health or prenatal visits or household surveys to capture women of reproductive age, though one needs to consider the cost of the equipment and regular calibration.

What are the consequences and implications?

Anaemia is associated with increased risks for maternal and child mortality. Iron-deficiency anaemia reduces the work capacity of individuals and entire populations, with serious consequences for the economy and national development. In addition, the negative consequences of iron-deficiency anaemia on the cognitive and physical development of children and on physical performance - particularly the work productivity of adults - are major concerns. Anaemia is a global problem affecting all countries. Resource-poor areas are often more heavily impacted due to the prevalence of infectious diseases. Malaria, HIV/AIDS, hookworm infestation, schistosomiasis and other infections such as tuberculosis contribute to the high prevalence of anaemia in some areas.

The main risk factors for iron-deficiency anaemia include a low dietary intake of iron or poor absorption of iron from diets rich in phytates or phenolic compounds. Population groups with greater iron requirements, such as growing children and pregnant women, are particularly at risk. Overall, the most vulnerable, poorest and least educated groups are disproportionately affected by iron-deficiency anaemia.

Cut-off values for public health significance

Reference: WHO, 2008.

Source of data

Stevens GA et al. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995-2011: a systematic analysis of population-representative data. Lancet Global Health; 2013; 1:e16-25.

Data about haemoglobin and anaemia for women of childbearing age (15–49 years) were estimated for each country and for each year between 1995 and 2016 using survey data obtained from 257 population-representative data sources from 107 countries worldwide. A Bayesian hierarchical mixture model was used to estimate haemoglobin distributions and systematically addressed missing data, non-linear time trends, and representativeness of data sources. More information on the methodology can be found in: Stevens GA et al. 2013.

Further reading

WHO. Global Nutrition Targets 2025: Anaemia policy brief. Geneva, World Health Organization, 2014. http://who.int/nutrition/publications/globaltargets2025_policybrief_anaemia/en/

WHO. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2011 (WHO/NMH/NHD/MNM/11.1).  http://www.who.int/vmnis/indicators/haemoglobin.pdf.  

WHO. Vitamin and Mineral Nutrition Information System (VMNIS). Department of Nutrition for Health and Development (NHD), Geneva, Switzerland. http://www.who.int/vmnis/en/.

WHO. Anaemia/iron deficiency list of publications. http://www.who.int/nutrition/publications/micronutrients/anaemia_iron_deficiency/en/index.html.

WHO. Global Health Observatory. Indicator Metadata Registry. Prevalence of anaemia among women aged 15-49 years (%). http://apps.who.int/gho/data/node.wrapper.imr?x-id=4552

WHO. Global Reference List of 100 Core Health Indicators. Geneva: World Health Organization, 2015. http://www.who.int/healthinfo/indicators/2015/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA). http://www.who.int/elena/health_condition/en/#anaemia  

WHO. E-Library of Evidence for Nutrition Actions (eLENA). Interventions by global target. http://www.who.int/elena/global-targets/en  

Target 2: 50% reduction of anaemia in women of reproductive age. http://www.who.int/elena/global-targets/en/#anaemia  

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Vitamin A deficiency

What does this indicator tell us?

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

How is it defined?

Vitamin A deficiency can be defined clinically or subclinically. The stages of xerophthalmia [clinical spectrum of ocular manifestations of vitamin A deficiency, from the milder stages of night blindness and Bitot spots to the potentially blinding stages of corneal xerosis, ulceration and necrosis (keratomalacia)] are regarded both as disorders and clinical indicators of vitamin A deficiency. Night blindness (in which it is difficult or impossible to see in relatively low light) is one of the clinical signs of vitamin A deficiency and is common during pregnancy in developing countries. Retinol is the main circulating form of vitamin A in blood and plasma. Serum retinol levels reflect liver vitamin A stores when they are severely depleted or extremely high, but between these extremes, plasma or serum retinol is homeostatically controlled and therefore does not always correlate well with vitamin A intake. Therefore, serum retinol is best used for the assessment of subclinical vitamin A deficiency in a population (not an individual).  Blood concentrations of retinol (the chemical name for vitamin A) in plasma or serum are used to assess subclinical vitamin A deficiency. A plasma or serum retinol concentration <  0.70 μmol/L indicates subclinical vitamin A deficiency in children and adults, and < 0.35 µmol/L indicates severe vitamin A deficiency.

What are the consequences and implications?

Night blindness is one of the first signs of vitamin A deficiency. In its more severe forms, vitamin A deficiency contributes to blindness by making the cornea very dry and damaging the retina and cornea. An estimated 250 000–500 000 vitamin A-deficient children become blind every year, and half of them die within 12 months of losing their sight. Deficiency of vitamin A is associated with significant morbidity and mortality from common childhood infections and is the world’s leading preventable cause of childhood blindness. Vitamin A deficiency also contributes to maternal mortality and other poor outcomes of pregnancy and lactation. Furthermore, it diminishes the ability to fight infections. Even mild, subclinical deficiency can be a problem, as it may increase children's risk for respiratory and diarrhoeal infections, decrease growth rates, slow bone development and decrease the likelihood of survival from serious illness.

Cut-off values for public health significance

Reference: WHO, 2009.

Source of data

Micronutrients Database [online database]. Vitamin and Mineral Nutrition Information System (VMNIS). Geneva: Department of Nutrition for Health and Development, World Health Organization; 2017 (http://www.who.int/vmnis/en/).

Note: The Micronutrients Database of the WHO Vitamin and Mineral Nutrition Information System (VMNIS)  has recently been upgraded and expanded.  The new database is not yet publically available and the NLIS country profiles have not yet been updated.  

Further reading

WHO. Global prevalence of vitamin A deficiency in populations at risk 1995–2005. WHO Global Database on Vitamin A Deficiency. Geneva, World Health Organization, 2009. http://whqlibdoc.who.int/publications/2009/9789241598019_eng.pdf

WHO. Serum retinol concentrations for determining the prevalence of vitamin A deficiency in populations. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2011(WHO/NMH/NHD/MNM/11.3). http://www.who.int/vmnis/indicators/retinol.pdf.

WHO. Xerophthalmia and night blindness for the assessment of clinical vitamin A deficiency in individuals and populations. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2014 (WHO/NMH/NHD/EPG/14.4). http://apps.who.int/iris/bitstream/10665/133705/1/WHO_NMH_NHD_EPG_14.4_eng.pdf.  

WHO. Vitamin A deficiency, list of publications. http://www.who.int/nutrition/publications/micronutrients/vitamin_a_deficieny/en/index.html.

Stevens GA, Bennett JE, Hennocq Q, Lu Y, De-Regil LM, Rogers L et al. Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled analysis of population-based surveys. Lancet Glob Health. 2015;3:e528-36. doi: 10.1016/S2214-109X(15)00039-X.

WHO. E-Library of Evidence for Nutrition Actions (eLENA). http://www.who.int/elena/nutrient/en/#vitamina

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Iodine deficiency

What does this indicator tell us?

This indicator allows an assessment of iodine deficiency at the population level. Iodine is an essential trace element that is present on the thyroid hormones, thyroxine and triiodotyronine. It occurs most frequently in areas where there is little iodine in the diet—typically remote inland areas where no marine foods are eaten.

How is it defined?

Although goitre assessment by palpation or ultrasound may be useful for assessing thyroid function, results are difficult to interpret once salt iodization programmes have started. The median urinary iodine concentration is considered the main indicator of iodine status for all age groups, because its measurement is relatively non-invasive, cost-efficient and easy to perform. Since the majority of iodine absorbed by the body is excreted in the urine, it is considered a sensitive marker of current iodine intake and can reflect recent changes in iodine status. Median urinary iodine concentrations have been most commonly measured in school children aged 6–12 years due to their easy access.

For school-age children (6 years of age and older) adequate iodine level is defined as a population median urinary iodine concentration between 100 µg/L and 199 μg/L whereas a population median  <100 μg/L indicates that the population’s iodine intake is insufficient. When the population median is < 20 μg/L, the population is described as having severe iodine deficiency; at 20–49 μg/L, they are described as having moderate iodine deficiency, and at 50–99 μg/L, they are described as having mild iodine deficiency. A population of school age children should have a median urinary iodine concentration of at least 100 μg/L, with less than 20% of values < 50 μg/L. For pregnant women, the median urinary iodine should be between 150 µg/L and 249 μg/L.

What are the consequences and implications?

Iodine-deficiency disorders, which can start before birth, jeopardize children’s mental health and often their very survival. During the neonatal period, childhood and adolescence, iodine deficiency disorders can lead to hypo- and hyperthyroidism. Serious iodine deficiency during pregnancy can result in stillbirth, spontaneous abortion and congenital abnormalities such as cretinism, a grave, irreversible form of mental retardation that affects people living in iodine-deficient areas of Africa and Asia. Of even greater significance is the less visible, yet pervasive, mental impairment that reduces intellectual capacity at home, in school and at work.

Cut-off values for public health significance in different target groups

Reference: WHO, 2013. Notes: *Applies to adults, but not to pregnant and lactating women. **The term “excessive” means in excess of the amount required to prevent and control iodine deficiency. ***Although lactating women have the same requirement as pregnant women, the median urinary iodine is lower because iodine is excreted in breast milk.

Source of data

Micronutrients Database [online database]. Vitamin and Mineral Nutrition Information System (VMNIS). Geneva: Department of Nutrition for Health and Development, World Health Organization; 2017 (http://www.who.int/vmnis/en/).

Note: The Micronutrients Database of the WHO Vitamin and Mineral Nutrition Information System (VMNIS)  has recently been upgraded and expanded.  The new database is not yet publically available and the NLIS country profiles have not yet been updated.  

Further reading

WHO. Urinary iodine concentrations for determining iodine status deficiency in populations. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2013. http://www.who.int/nutrition/vmnis/indicators/urinaryiodine.

WHO. Goitre as a determinant of the prevalence and severity of iodine deficiency disorders in populations. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2014 (WHO/NMH/NHD/MNM/14.5). http://apps.who.int/iris/bitstream/10665/133706/1/WHO_NMH_NHD_EPG_14.5_eng.pdf.

WHO. Iodine deficiency, list of publications. http://www.who.int/nutrition/publications/micronutrients/iodine_deficiency/en/index.html.

Andersson M, Karumbunathan V, Zimmermann MB. Global iodine status in 2011 and trends over the past decade. J Nutr. 2012;142:744-750.

WHO. E-Library of Evidence for Nutrition Actions (eLENA). http://www.who.int/elena/nutrient/en/#iodine

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Vitamin A deficiency

What does this indicator tell us?

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

How is it defined?

Vitamin A deficiency can be defined clinically or subclinically. The stages of xerophthalmia [clinical spectrum of ocular manifestations of vitamin A deficiency, from the milder stages of night blindness and Bitot spots to the potentially blinding stages of corneal xerosis, ulceration and necrosis (keratomalacia)] are regarded both as disorders and clinical indicators of vitamin A deficiency. Night blindness (in which it is difficult or impossible to see in relatively low light) is one of the clinical signs of vitamin A deficiency and is common during pregnancy in developing countries. Retinol is the main circulating form of vitamin A in blood and plasma. Serum retinol levels reflect liver vitamin A stores when they are severely depleted or extremely high, but between these extremes, plasma or serum retinol is homeostatically controlled and therefore does not always correlate well with vitamin A intake. Therefore, serum retinol is best used for the assessment of subclinical vitamin A deficiency in a population (not an individual).  Blood concentrations of retinol (the chemical name for vitamin A) in plasma or serum are used to assess subclinical vitamin A deficiency. A plasma or serum retinol concentration <  0.70 μmol/L indicates subclinical vitamin A deficiency in children and adults, and < 0.35 µmol/L indicates severe vitamin A deficiency.

What are the consequences and implications?

Night blindness is one of the first signs of vitamin A deficiency. In its more severe forms, vitamin A deficiency contributes to blindness by making the cornea very dry and damaging the retina and cornea. An estimated 250 000–500 000 vitamin A-deficient children become blind every year, and half of them die within 12 months of losing their sight. Deficiency of vitamin A is associated with significant morbidity and mortality from common childhood infections and is the world’s leading preventable cause of childhood blindness. Vitamin A deficiency also contributes to maternal mortality and other poor outcomes of pregnancy and lactation. Furthermore, it diminishes the ability to fight infections. Even mild, subclinical deficiency can be a problem, as it may increase children's risk for respiratory and diarrhoeal infections, decrease growth rates, slow bone development and decrease the likelihood of survival from serious illness.

Cut-off values for public health significance

Reference: WHO, 2009.

Source of data

Micronutrients Database [online database]. Vitamin and Mineral Nutrition Information System (VMNIS). Geneva: Department of Nutrition for Health and Development, World Health Organization; 2017 (http://www.who.int/vmnis/en/).

Note: The Micronutrients Database of the WHO Vitamin and Mineral Nutrition Information System (VMNIS)  has recently been upgraded and expanded.  The new database is not yet publically available and the NLIS country profiles have not yet been updated.  

Further reading

WHO. Global prevalence of vitamin A deficiency in populations at risk 1995–2005. WHO Global Database on Vitamin A Deficiency. Geneva, World Health Organization, 2009. http://whqlibdoc.who.int/publications/2009/9789241598019_eng.pdf

WHO. Serum retinol concentrations for determining the prevalence of vitamin A deficiency in populations. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2011(WHO/NMH/NHD/MNM/11.3). http://www.who.int/vmnis/indicators/retinol.pdf.

WHO. Xerophthalmia and night blindness for the assessment of clinical vitamin A deficiency in individuals and populations. Vitamin and Mineral Nutrition Information System. Geneva, World Health Organization, 2014 (WHO/NMH/NHD/EPG/14.4). http://apps.who.int/iris/bitstream/10665/133705/1/WHO_NMH_NHD_EPG_14.4_eng.pdf.  

WHO. Vitamin A deficiency, list of publications. http://www.who.int/nutrition/publications/micronutrients/vitamin_a_deficieny/en/index.html.

Stevens GA, Bennett JE, Hennocq Q, Lu Y, De-Regil LM, Rogers L et al. Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled analysis of population-based surveys. Lancet Glob Health. 2015;3:e528-36. doi: 10.1016/S2214-109X(15)00039-X.

WHO. E-Library of Evidence for Nutrition Actions (eLENA). http://www.who.int/elena/nutrient/en/#vitamina

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Births attended by skilled health personnel

What does this indicator tell us?

This indicator measures health system’s ability to provide sufficient cared during birth, a period of high risk of morbid and mortality. In NLIS, it is used as a proxy for access to health services and maternal care. This indicator is also included in the WHO Global Reference List of 100 Core Health Indicators.

How is it defined?

The indicator gives the percentage of live births attended by skilled health personnel in a given period. A skilled birth attendant is an accredited health professional—such as a midwife, doctor or nurse—who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of women and newborns for complications. Traditional birth attendants, whether trained or not, are excluded from the category of ‘skilled attendant at delivery’.

In developed countries and in many urban areas in developing countries, skilled care at delivery is usually provided in health facilities. Births do, however, take place in various other appropriate places, from home to tertiary referral centres, depending on availability and need. WHO does not recommend a particular setting for giving birth. Home delivery may be appropriate for normal births, provided that the person attending the delivery is suitably trained and equipped and that referral to a higher level of care is an option, however this may lead to an overestimation of births attended by skilled personal as infants delivered outside of a health facility may not have their birth method recorded.

What are the consequences and implications?

All women should have access to skilled care during pregnancy and at delivery to ensure the detection and management of complications. One woman dies needlessly of pregnancy-related causes every minute, representing more than half a million mothers lost each year, a figure that has improved little over the past few decades. Another 8 million or more suffer life-long health consequences from the complications of pregnancy. Every woman, rich or poor, has a 15% risk for complications around the time of delivery, but almost no maternal deaths occur in developed regions. The lack of progress in reducing maternal mortality in many countries often reflects the low value placed on the lives of women and their limited role in setting public priorities. The lives of many women in developing countries could be saved by reproductive health interventions that people in rich countries take for granted, such as the presence of skilled health personnel at delivery.

Source of data

WHO. Global Health Observatory (GHO). http://apps.who.int/ghodata/.

Further reading

WHO. Making Pregnancy Safer. http://www.who.int/making_pregnancy_safer/en/.

WHO. Global Reference List of 100 Core Health Indicators. Geneva: World Health Organization, 2015. http://www.who.int/healthinfo/indicators/2015/en/

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% Population using improved drinking water sources

Improved sanitation facilities and drinking-water sources

What do these indicators tell us?

These indicators are the percentage of population with access to an improved drinking-water source and improved sanitation facilities.

How are they defined?

Improved drinking-water sources are defined in terms of the types of technology and levels of services that are likely to provide safe water. Improved water sources include household connections, public standpipes, boreholes, protected dug wells, protected springs and rainwater collection. Unimproved water sources are unprotected wells, unprotected springs, vendor-provided water, bottled water (unless water for other uses is available from an improved source) and tanker truck-provided water. 'Reasonable access' is broadly defined as the availability of at least 20 litres per person per day from a source within 1 kilometre of the user's dwelling.

Improved sanitation facilities are defined in terms of the types of technology and levels of services that are likely to be sanitary. Improved sanitation includes connection to a public sewers, connection to septic systems, pour-flush latrines, simple pit latrines and ventilated improved pit latrines. Service or bucket latrines (from which excreta are removed manually), public latrines and open latrines are not considered to be improved sanitation.

What are the consequences and implications?

Access to safe drinking-water and improved sanitation are fundamental needs and human rights vital for the dignity and health of all people. The health and economic benefits of a safe water supply to households and individuals (especially children) are well documented. Both indicators are used to monitor progress towards the Millennium Development Goals.

Source

WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation. http://www.wssinfo.org/.

Further reading

WHO. Water, Sanitation and Hygiene. http://www.who.int/water_sanitation_health/en/.

World Health Statistics, 2010. http://www.who.int/whosis/whostat/2010/en/index.html.

Global Health Observatory (GHO). http://www.who.int/gho/en/.

The WHO Indicator and Measurement Registry (IMR). http://apps.who.int/gho/indicatorregistry/App_Main/browse_indicators.aspx

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Population using an improved sanitation facility and improved drinking water sources

Improved sanitation facilities and drinking-water sources

What do these indicators tell us?

These indicators are the percentage of population with access to an improved drinking-water source and improved sanitation facilities.

How are they defined?

Improved drinking-water sources are defined in terms of the types of technology and levels of services that are likely to provide safe water. Improved water sources include household connections, public standpipes, boreholes, protected dug wells, protected springs and rainwater collection. Unimproved water sources are unprotected wells, unprotected springs, vendor-provided water, bottled water (unless water for other uses is available from an improved source) and tanker truck-provided water. 'Reasonable access' is broadly defined as the availability of at least 20 litres per person per day from a source within 1 kilometre of the user's dwelling.

Improved sanitation facilities are defined in terms of the types of technology and levels of services that are likely to be sanitary. Improved sanitation includes connection to a public sewers, connection to septic systems, pour-flush latrines, simple pit latrines and ventilated improved pit latrines. Service or bucket latrines (from which excreta are removed manually), public latrines and open latrines are not considered to be improved sanitation.

What are the consequences and implications?

Access to safe drinking-water and improved sanitation are fundamental needs and human rights vital for the dignity and health of all people. The health and economic benefits of a safe water supply to households and individuals (especially children) are well documented. Both indicators are used to monitor progress towards the Millennium Development Goals.

Source

WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation. http://www.wssinfo.org/.

Further reading

WHO. Water, Sanitation and Hygiene. http://www.who.int/water_sanitation_health/en/.

World Health Statistics, 2010. http://www.who.int/whosis/whostat/2010/en/index.html.

Global Health Observatory (GHO). http://www.who.int/gho/en/.

The WHO Indicator and Measurement Registry (IMR). http://apps.who.int/gho/indicatorregistry/App_Main/browse_indicators.aspx

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Children aged 1 year immunized against measles

Children aged 1 year immunized against measles

What does this indicator tell us?

Estimates of vaccination coverage of children aged 1 year are used to monitor vaccination services, to guide disease eradication and elimination programmes and as indicators of health system performance.

How is it defined?

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

What are the consequences and implications?

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

Source

Millennium Development Goals indicators database. http://mdgs.un.org/unsd/mdg/Default.aspx.

Further reading

WHO. Measles. http://www.who.int/topics/measles/en/.

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Antenatal iron supplementation

Antenatal iron supplementation

What does this indicator tell us?

This indicator reflects the percentage of women who consumed any iron-containing supplements during the current or past pregnancy within the last 2 years. It provides information about the quality and coverage of perinatal medical services.

Daily iron and folic acid supplementation is currently recommended by WHO as part of antenatal care to reduce the risk of low birth weight, maternal anaemia and iron deficiency.  It is suggested that the supplement contains 30-60 mg of iron, with the higher dose preferred in settings where anaemia in pregnant women is a severe public health problem (40% or higher), along with 400 µg of folic acid.  Daily supplementation throughout pregnancy, beginning as early  as possible after conception is recommended in all settings. However, despite its proven efficacy and wide inclusion in antenatal care programmes, its use has been limited in programme settings, possibly due to a lack of compliance, concerns about the safety of the intervention among women with an adequate iron intake, and variable availability of the supplements at community level. Intermittent use of iron and folic acid supplements by non-anaemic women is a recommended alternative to prevent anaemia and improve gestational outcomes in areas where the prevalence of anaemia among  pregnant women is lower than 20%. The suggested dose is 120 mg elemental iron and 2800 µg (2.8 mg) folic acid provided weekly throughout the pregnancy, beginning as early as possible after conception.

This indicator is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. 

How is it defined?

The indicator is defined as the proportion of women who consumed any iron-containing supplements during the current or past pregnancy within the last 2 years. Data can be reported on any iron-containing supplement including iron and folic acid tablets (IFA), multiple micronutrient tablets or powders, or iron-only tablets which will vary by country policy.

What are the consequences and implications?

Improving the intake of iron and folic acid by women of reproductive age could improve pregnancy outcomes and enhance maternal and infant health. Iron and folic acid supplementation improve iron and folate status of women before and during pregnancy, in communities where food-based strategies are not yet fully implemented or effective. Folic acid supplementation (with or without iron) provided before pregnancy and during the first trimester of pregnancy is also recommended for decreasing the risk of neural tube defects.

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

Source

Demographic and Health Surveys. STATcompiler. http://www.statcompiler.com/.

Further reading

WHO. Weekly iron-folic acid supplementation (WIFs) in women of reproductive age: its role in promoting optimal maternal and child health. Geneva, World Health Organization, 2009. http://www.who.int/nutrition/publications/micronutrients/weekly_iron_folicacid.pdf.

WHO. Global Targets 2025 to improve maternal, infant and young child nutrition. http://who.int/nutrition/global-target-2025/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA):

• Iron and folic acid: daily supplementation during pregnancy. http://www.who.int/entity/elena/titles/daily_iron_pregnancy/en.
• Iron and folic acid: intermittent supplementation in non-anaemic pregnant women. http://www.who.int/entity/elena/titles/intermittent_iron_pregnancy/en.

WHO and UNICEF. Global Nutrition Monitoring Framework: Operational guidance for tracking progress in meeting targets for 2025. 2017 (forthcoming).

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Children with diarrhoea receiving oral rehydration therapy (ORT)

Children with diarrhoea receiving oral rehydration therapy

What does this indicator tell us?

This indicator is the prevalence of children with diarrhoea who received oral rehydration therapy.

How is it defined?

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

What are the consequences and implications?

Diarrhoeal diseases remain one of the major causes of mortality among children under 5, accounting for 1.8 million deaths among children worldwide. As oral rehydration therapy is a critical component of effective management of diarrhoea, monitoring coverage with this highly cost–effective intervention indicates progress on an intermediate outcome indicator of the Global Nutrition Targets, prevalence of diarrhoea in children under 5 years of age.

Source

WHO. Global Health Observatory (GHO). http://www.who.int/gho.

Further reading

WHO Statistical Information System (WHOSIS). Children < 5 years with diarrhoea receiving oral rehydration therapy (percentage). http://www.who.int/whosis/indicators/2007DiarrhoeaChildORTFluids/en/.

WHO. Global Targets 2025 to improve maternal, infant and young child nutrition. http://who.int/nutrition/global-target-2025/en/

WHO and UNICEF. Global Nutrition Monitoring Framework: Operational guidance for tracking progress in meeting targets for 2025. 2017 (forthcoming).

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Children with diarrhoea who received zinc

Children with diarrhoea receiving zinc

What does this indicator tell us?

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

How is it defined?

Whereas there is no internationally accepted indicator for zinc treatment of children with diarrhoea, it could be defined as the percentage of children under 5 years with acute diarrhoea who were given supplements of 20 mg zinc daily for 10-14 days or 10 mg/day for infants under 6 months.

What are the consequences and implications?

Measures to prevent childhood diarrhoeal episodes include promoting zinc intake. Diarrhoeal diseases account for nearly 2 million deaths a year among children under 5, making them the second most-common cause of child death worldwide. The greater the prevalence of zinc supplementation during diarrhoea treatment, the better the outcome of treatment for diarrhoea.

WHO and the United Nations Children's Fund (UNICEF) recommend exclusive breastfeeding, vitamin A supplementation, improved hygiene, better access to cleaner sources of drinking-water and sanitation facilities and vaccination against rotavirus in the clinical management of acute diarrhoea and also the use of zinc, which is safe and effective. Specifically, zinc supplements given during an episode of acute diarrhoea reduce the duration and severity of the episode, and giving zinc supplements for 10-14 days lowers the incidence of diarrhoea in the following 2-3 months.

Source

Currently no data are available.

Further reading

Rehydration Project. Zinc supplementation. ORS and zinc: treatment of diarrhoea is now more effective. Hong Kong, Mother and Child, Health and Education Trust, 2009. http://rehydrate.org/zinc/.

WHO. The impact of zinc supplementation on childhood mortality and severe morbidity. Report of a workshop to review the results of three large studies. Geneva, World Health Organization, 2007. http://www.who.int/child_adolescent_health/documents/zinc_mortality/en/.

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Children 6-59 months receiving vitamin A supplements

Children aged 6-59 months receiving vitamin A supplements

What do these indicators tell us?

These indicators are the proportion of children aged 6-59 months who received one and two doses of vitamin A supplements, respectively.

How are they defined?

The indicators are defined as the proportion of children aged 6-59 months who received one or two high doses of vitamin A supplements within 1 year. Current international recommendations call for high-dose vitamin A supplementation every 4-6 months for all children between the ages of 6 and 59 months living in affected areas. The recommended doses are 100 000 IU for 6-12-month-old children and 200 000 IU for those aged 12-59 months.

What are the consequences and implications?

Programmes to control vitamin A deficiency enhance children's chances of survival, reduce the severity of childhood illnesses, ease the strain on health systems and hospitals and contribute to the well-being of children, their families and communities. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of efforts to improve child survival and therefore of the achievement of the fourth Millennium Development Goal, a two-thirds reduction in mortality of children under 5 by the year 2015.

As there is strong evidence that supplementation with vitamin A reduces child mortality, measuring the proportion of children who have received vitamin A within the past 6 months can be used to monitor coverage with interventions for achieving the child survival-related Millennium Development Goals. Supplementation with vitamin A is a safe, cost-effective, efficient means for eliminating its deficiency and improving child survival.

Source

UNICEF. Childinfo database. http://www.childinfo.org/vitamina_coverage.php.

Further reading

WHO. Vitamin A deficiency, list of publications. http://www.who.int/nutrition/publications/micronutrients/vitamin_a_deficieny/en/index.html.

WHO. Immunization, Vaccines and Biologicals. Vitamin A supplementation. http://www.who.int/vaccines/en/vitamina.shtml.

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Children 6-59 months receiving vitamin A supplements

Children aged 6-59 months receiving vitamin A supplements

What do these indicators tell us?

These indicators are the proportion of children aged 6-59 months who received one or two doses of vitamin A supplements.

How are they defined?

The indicators are defined as the proportion of children aged 6-59 months who received one or two high doses of vitamin A supplements within 1 year. Current international recommendations call for high-dose vitamin A supplementation every 4-6 months for all children between the ages of 6 and 59 months living in affected areas. The recommended doses are 100 000 IU for 6-12-month-old children and 200 000 IU for those aged 12-59 months.

What are the consequences and implications?

Programmes to control vitamin A deficiency enhance children's chances of survival, reduce the severity of childhood illnesses, ease the strain on health systems and hospitals and contribute to the well-being of children, their families and communities. The 1990 World Summit for Children set the goal of virtual elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000. The critical role of vitamin A for child health and immune function also makes control of deficiency a primary component of efforts to improve child survival and therefore of the achievement of the fourth Millennium Development Goal, a two-thirds reduction in mortality of children under 5 by the year 2015.

As there is strong evidence that supplementation with vitamin A reduces child mortality, measuring the proportion of children who have received vitamin A within the past 6 months can be used to monitor coverage with interventions for achieving the child survival-related Millennium Development Goals. Supplementation with vitamin A is a safe, cost-effective, efficient means for eliminating its deficiency and improving child survival.

Source

UNICEF. Childinfo database. http://www.childinfo.org/vitamina_coverage.php.

Further reading

WHO. Vitamin A deficiency, list of publications. http://www.who.int/nutrition/publications/micronutrients/vitamin_a_deficieny/en/index.html.

WHO. Immunization, Vaccines and Biologicals. Vitamin A supplementation. http://www.who.int/vaccines/en/vitamina.shtml.

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Births in baby-friendly facilities

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Mothers of children 0-23 months receiving counselling, support or messages on optimal breastfeeding

Mothers of children 0-23 months receiving counselling, support or messages on optimal breastfeeding

What does this indicator tell us?

Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers. Optimal practices include early initiation of breastfeeding within 1 hour, exclusive breastfeeding for 6 months followed by appropriate complementary with continued breastfeeding for 2 years or beyond.  Even though it is a natural act, breastfeeding is also a learned behaviour. Virtually all mothers can breastfeed provided they have accurate information, and support within their families and communities and from the health care system. They should also have access to skilled practical help from, for example, trained health workers, lay and peer counsellors, and certified lactation consultants, who can help to build mothers’ confidence, improve feeding technique, and prevent or resolve breastfeeding problems.

This indicator has been established to measure the proportion of mothers receiving breastfeeding counselling, support or messages. The proportion of mothers of children 0-23 months who have received counselling, support or messages on optimal breastfeeding at least once in the previous 12 months is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. 

How is it defined?

The indicator gives the percentage of mothers of children aged 0-23 months who have received counselling, support or messages on optimal breastfeeding at least once in the last year.

WHO and UNICEF are in the process of further developing and validating this indicator. Meanwhile, an interrim indicator has been established to measure the avaiallbility of national-level provision for breastfeeding counselling services in public health and/or nutrition programmes.

What are the consequences and implications?

Counseling and informational support on optimal breastfeeding practices for mothers has been demonstrated to improve initiation and duration of breastfeeding, which in has many health benefits for both the mother and infant. Breast milk contains all the nutrients an infant needs in the first six months of life. Breastfeeding protects against diarrhoea and common childhood illnesses such as pneumonia, and may also have longer-term health benefits for the mother and child, such as reducing the risk of overweight and obesity in childhood and adolescence. Breastfeeding has also been associated with higher intelligence quotient (IQ) in children. Improved breastfeeding practices worldwide could save the lives of over 800 000 children every year.

Source

Tbd.

Further reading

WHO, UNICEF. Global Strategy for Infant and Young Child Feeding, 2003. http://www.who.int/nutrition/publications/infantfeeding/9241562218/en/

WHO, UNICEF. Global Targets 2025: Breastfeeding policy brief.  http://who.int/nutrition/publications/globaltargets2025_policybrief_breastfeeding/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA).

·         Breastfeeding education for increased breastfeeding duration. http://www.who.int/elena/titles/breastfeeding_education/en/  

·         Implementation of the Baby-friendly Hospital Initiative. http://www.who.int/elena/titles/implementation_bfhi/en/ 

WHO and UNICEF. Global Nutrition Monitoring Framework: Operational guidance for tracking progress in meeting targets for 2025. 2017 (forthcoming).

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Iodized salt consumption (% households consuming adequately iodized salt - 15 parts per million or more)

Households consuming adequately iodized salt (= 15 parts per million)

What does this indicator tell us?

Salt iodization has been adopted as the main strategy for eliminating iodine-deficiency disorders as a public health problem, and the aim is to achieve universal salt iodization. While other foodstuffs can be iodized, salt has the advantage of being widely consumed and inexpensive. Salt has been iodized routinely in some industrialized countries since the 1920s. This indicator is a measure of whether a fortification programme is reaching the target population adequately.

How is it defined?

The indicator is a measure of the percentage of households consuming iodized salt, defined as salt containing 15-40 parts per million of iodine. Preferably, household access to iodized salt should be greater than 90%.

What are the consequences and implications?

Iodine deficiency is most commonly and visibly associated with thyroid problems (e.g. hyper- or hypothyroidism, goitre or an enlarged thyroid gland) but takes its greatest toll in impaired mental growth and development, which contribute to poor school performance, reduced intellectual ability and impaired work performance.

Consumption of iodized salt increased in the developing world during the past decade: in the early 1990s, only about 20% of households consumed adequately iodized salt, but today 68% of households do so. This means that about 84 million newborns are now being protected from learning disabilities due to iodine-deficiency disorders.

Source

UNICEF. ChildInfo. Iodized salt consumption. http://www.childinfo.org/idd_profiles.php.

Further reading

UNICEF. ChildInfo. Monitoring the situation of women and children. Statistics by area: nutrition. Sustainable elimination of iodine deficiency disorders by 2005.  

http://www.childinfo.org/idd.html.

WHO. Micronutrient deficiencies, iodine deficiency disorders. http://www.who.int/nutrition/topics/idd/en/index.html.

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Population below minimum level of dietary energy consumption

Population with less than the minimum dietary energy consumption

What does this indicator tell us?

This indicator is the percentage of the population whose food intake falls below the minimum level of dietary energy requirements, and who therefore are undernourished or food-deprived.

How is it defined?

The estimates of the Food and Agriculture Organization of the United Nations (FAO) of the prevalence of undernourishment are essentially measures of food deprivation based on calculations of three parameters for each country: the average amount of food available for human consumption per person, the level of inequality in access to that food and the minimum number of calories required for an average person.

In 2011-2012, FAO improved the methodology used to estimate the prevalence of undernourishment indicator,  specifically: a comprehensive revision of food availability data (including improved estimation of food losses), improved parameters for dietary energy requirements, updated parameters for food access and a new functional form for the distributions used to estimate the prevalence of  undernourishment. Some of the changes in the revised estimates of undernourishment  from 1990 to 2012 published in the State of Food Insecurity in the World 2012 pertain to regular data updates carried out almost every year (population estimates, revision of food availability data), while others are the outcome of intensive efforts, aimed at substantially improving the methodology currently used.

The average amount of food available for human consumption is derived from national 'food balance sheets' compiled by FAO each year, which show how much of each food commodity a country produces, imports and withdraws from stocks for other, non-food purposes. FAO then divides the energy equivalent of all the food available for human consumption by the total population, to derive average daily energy consumption.

Data from household surveys are used to derive a coefficient of variation to account for the degree of inequality in access to food. Similarly, because a large adult needs almost twice as much dietary energy as a 3-year-old child, the minimum energy requirement per person in each country is based on age, gender and body sizes in that country.

The minimum dietary energy requirement is derived from the results of a FAO/WHO/United Nations University expert consultation in 2001 (published in 2004), which established energy standards for different sex and age groups performing sedentary physical activity and with a minimum acceptable body weight for attained height.

The average energy requirement is the amount of food energy needed to balance energy expenditure in order to maintain body weight, body composition and levels of necessary and desirable physical activity consistent with long-term good health. It includes the energy needed for the optimal growth and development of children, for the deposition of tissues during pregnancy and for the secretion of milk during lactation consistent with the good health of the mother and child. The recommended level of dietary energy intake for a population group is the mean energy requirement of the healthy, well-nourished individuals who constitute that group.

FAO reports the proportion of the population whose daily food intake falls below that minimum energy requirement as 'undernourished'. Trends in undernourishment are due mainly to:

·   changes in food consumption as reported on country food balance sheets;

·   changes in the distribution of dietary energy consumption in a population due to changes in the distribution of both dietary energy consumption by income level and dietary energy requirements based on weight for attained height by gender and age; and

·   changes in the minimum dietary energy consumption due to changes in attained height and the gender-age population structure.

What are the consequences and implications?

The indicator is a measure of an important aspect of food insecurity in a population. Sustainable development requires a concerted effort to reduce poverty, including solutions to hunger and malnutrition. Alleviating hunger is a prerequisite for sustainable poverty reduction, as undernourishment seriously affects labour productivity and earning capacity. Malnutrition can be the outcome of a range of circumstances. In order for poverty reduction strategies to be effective, they must address food access, availability and safety.

Source

FAO. Food security indicators.  http://www.fao.org/publications/sofi/food-security-indicators/en/

Further reading

FAO. Human energy requirements. Report of a Joint FAO/WHO/UNU Expert Consultation. Rome, 17-24 October 2001. Rome, FAO, 2004. ftp://ftp.fao.org/docrep/fao/007/y5686e/y5686e00.pdf.

FAO. The State of Food Insecurity in the World 2012. Economic growth is necessary but not sufficient to accelerate reduction of hunger and malnutrition. Rome, FAO, 2012. http://www.fao.org/publications/sofi/en/

FAO. The State of Food Insecurity in the World 2012 Technical note. FAO methodology to estimate the prevalence of undernourishment. FAO, Rome, 9 October 2012. http://typo3.fao.org/fileadmin/templates/es/SOFI_2012/sofi_technical_note.pdf.

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Population below $1 per day

Population below $1 per day

What does this indicator tell us?

This indicator gives the prevalence of people living in extreme poverty, as measured by their daily income, and allows comparisons and aggregation of data on the progress of countries in reducing extreme poverty and allows monitoring of global trends.

How is it defined?

The proportion of the population living on less than US$ 1 per day is the percentage living on less than US$ 1.08 a day at 1993 international prices. The US$ 1 per day poverty line is compared with consumption or income per person, including consumption of their own production and income in kind. As this poverty line has fixed purchasing power across countries or areas, it is often called the 'absolute poverty line'.

Purchasing power parity is defined by comparing economies on the basis of standardized international US$ price weights, rather than official currency exchange rates.

What are the consequences and implications?

The US$ 1 per day poverty measure is used to assess and monitor poverty at global level, but, like other indicators, it is not equally relevant in all regions because countries have different definitions of poverty. Measures of poverty in countries are generally based on national poverty lines. Comparisons of poverty measures within countries are also difficult, especially for urban-rural differences. As the cost of living is typically higher in urban than in rural areas, the urban monetary poverty line should be higher than that for rural areas. The difference between the two in practice, however, may not properly reflect the difference in cost of living.

Malnutrition is the single one of the most important risk factor for disease. When poverty is added, it results in a downward spiral that may end in death.

 Poor people may consume too little nutritious food, making them more susceptible to disease.

 Inadequate or inappropriate food consumption leads to stunted development or premature death.

 Nutrient-deficient diets provoke health problems.

 Disease decreases people's ability to cultivate or purchase nutritious foods.

Source

Millennium Development Goals indicators database. http://mdgs.un.org/unsd/mdg/Default.aspx.

Further reading

WHO. Turning the tide of malnutrition. Responding to the challenge of the 21st century. Geneva, World Health Organization, 2000. http://www.who.int/mip2001/files/2232/NHDbrochure.pdf.

Millennium Development Goals. 1a. Proportion of population below $1 (PPP) per day. Washington DC, World Bank. http://ddpext.worldbank.org/ext/GMIS/gdmis.do?siteId=2&contentId=content_t1a&menuId=lnav01home1.

Millennium Development Goals indicators series metadata. http://mdgs.un.org/unsd/mdg/Metadata.aspx.

Indicators for monitoring the Millennium Development Goals. New York, United Nations, 2003. http://mdgs.un.org/unsd/mdg/Resources/Attach/Indicators/HandbookEnglish.pdf.

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Early initiation of breastfeeding

Infant and young child feeding

To enable mothers to establish and sustain exclusive breastfeeding for 6 months, WHO and UNICEF recommend:

·   initiation of breastfeeding within the first hour of life;

·   exclusive breastfeeding, i.e. only breast milk with no additional food or drink, not even water;

·   breastfeeding on demand, as often the child wants, day and night; and

·   no use of bottles, teats or pacifiers.

The recommendations for feeding infants and young children (6–23 months) include:

·   continuing breastfeeding;

·   introduction of solid, semisolid or soft foods at 6 months;

·   appropriate food diversity (at least four food groups per day);

·   appropriate frequency of meals: two to three times a day between 6 and 8 months, increasing to three to four times a day between 9 and 23 months with nutritious snacks offered once or twice a day, as desired;

·   safe preparation of foods; and

·   feeding infants in response to their cues.

The caring practice indicators for infant and young child feeding available on the NLIS country profiles include:

• proportion of children aged 0–23 months who were put to the breast within 1 h of birth
• proportion of infants under 6 months who are exclusively breastfed
• proportion of infants aged 6–8 months who receive solid, semisolid or soft foods
• proportion of children aged 6–23 months who receive a minimum dietary diversity; and
• proportion of children aged 6–23 months who receive a minimum acceptable diet.

Early initiation of breastfeeding

What does this indicator tell us?

This indicator is the percentage of infants who are put to the breast within 1 hour of birth.

How is it defined?

Early initiation of breastfeeding is defined as the proportion of children born in the past 24 months who were put to the breast within 1 hour of birth.

What are the consequences and implications?

Breastfeeding contributes to saving children's lives, and there is evidence that delayed initiation of breastfeeding increases their risk for mortality.

Infants under 6 months who are exclusively breastfed

What does this indicator tell us?

This indicator is the percentage of infants aged 0–5 months who are exclusively breastfed.

How is it defined?

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

What are the consequences and implications?

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

Breast milk is the natural first food for infants. It provides all the energy and nutrients that the infant needs for the first months of life. It continues to provide up to one half or more of a child’s nutritional needs during the second half of the first year and up to one third during the second year of life.

Breast milk promotes sensory and cognitive development and protects the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhoea and pneumonia, and leads to quicker recovery from illness.

Breastfeeding contributes to the health and well-being of mothers, by helping to space children, reducing their risks for ovarian and breast cancers and saving family and national resources. It is a secure way of feeding and is safe for the environment.

Infants aged 6–8 months who receive solid, semisolid or soft foods

What does this indicator tell us?

The indicator is the percentage of infants who start solid, semisolid or soft foods at between 6 and 8 months of age. WHO recommends starting complementary feeding at 6 months of age.

How is it defined?

It is defined as the proportion of infants aged 6–8 months who receive solid, semisolid or soft foods.

What are the consequences and implications?

When breast milk alone no longer meets the nutritional needs of the infant, complementary foods should be added. The transition from exclusive breastfeeding to family foods, referred to as ‘complementary feeding’, typically occurs between 6 and 18–24 months of age. This is a very vulnerable period, and it is the time when malnutrition often starts, contributing significantly to the high prevalence of malnutrition among children under 5 worldwide.

Children aged 6–23 months who receive a minimum dietary diversity

What does this indicator tell us?

This indicator is the percentage of children aged 6–23 months who receive a minimum dietary diversity.

Proportion of children aged 6-23 months who receive a minimum dietary diversity is included as an interim process indicator in the core set of indicators for the Global Nutrition Monitoring Framework, while the original indicator “Minimum Acceptable Diet” is being further developed and validated under the leadership of the WHO-UNICEF Technical Expert Advisory group on nutrition Monitoring (TEAM). In June 2017, TEAM also recommended to revise the MDD indicator as defined by WHO (2008) to make it feasible and meaningful for Member State reporting. The revision concerned adding “breast milk” as an 8th food group and shifting the criterion for MDD accordingly, from 4 of 7 groups to 5 of 8 groups.

How is it defined?

As per revised recommendation by TEAM in June 2017, dietary diversity is present when the diet contained five or more of the following food groups:

·         breast milk;

·         grains, roots and tubers;

·         legumes and nuts;

·         dairy products (milk, yogurt, cheese);

·         flesh foods (meat, fish, poultry, liver or other organs);

·         eggs;

·         vitamin A-rich fruits and vegetables; and

·         other fruits and vegetables.

Children aged 6–23 months who receive a minimum acceptable diet

What does this indicator tell us?

This indicator is the percentage of children aged 6–23 months who receive a minimum acceptable diet.

Proportion of children aged 6-23 months who receive a minimum acceptable diet is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. 

How is it defined?

The composite indicator of a minimum acceptable diet is calculated from:

·    the proportion of breastfed children aged 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day and

• the proportion of non-breastfed children aged 6–23 months who received at least two milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day.

Dietary diversity is present when the diet contained four or more of the following food groups:

·         grains, roots and tubers;

·         legumes and nuts;

·         dairy products (milk, yogurt, cheese);

·         flesh foods (meat, fish, poultry, liver or other organs);

·         eggs;

·         vitamin A-rich fruits and vegetables; and

·         other fruits and vegetables.

The minimum daily meal frequency is defined as:

• twice for breastfed infants aged 6–8 months,
• three times for breastfed children aged 9–23 months and
• four times for non-breastfed children aged 6–23 months.

What are the consequences and implications?

A minimum acceptable diet is essential to ensure appropriate growth and development for feeding infants and children aged 6–23 months. Without adequate diversity and meal frequency, infants and young children are vulnerable to malnutrition, especially stunting and micronutrient deficiencies, and to increased morbidity and mortality.

Source of all infant and young child feeding indicators

WHO. Global Health Observatory (GHO). http://apps.who.int/gho.

UNICEF. Infant and Young Child Feeding database. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/.

Further reading

WHO. Infant and young child feeding list of publications. http://www.who.int/nutrition/publications/infantfeeding/en/index.html.

WHO. Global Targets 2025 to improve maternal, infant and young child nutrition. http://who.int/nutrition/global-target-2025/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA):

·         Breastfeeding: early initiation. http://www.who.int/entity/elena/titles/early_breastfeeding/en/index.html.

·         Breastfeeding: exclusive breastfeeding. http://www.who.int/entity/elena/titles/exclusive_breastfeeding/en/index.html.

·         Breastfeeding: continued breastfeeding. http://www.who.int/entity/elena/titles/continued_breastfeeding/en/index.html.

·         Complementary feeding. http://www.who.int/entity/elena/titles/complementary_feeding/en/index.html.

WHO. WHO Global Data Bank on Infant and Young Child Feeding. Department of Nutrition for Health and Development (NHD), Geneva, Switzerland.http://www.who.int/nutrition/databases/infantfeeding/en/index.html.

WHO/UNICEF. Global Nutrition Monitoring Framework. Operational guidance for tracking progress in meeting targets for 2025. WHO, Geneva. (forthcoming)

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Infants 6-8 months of age who receive solid, semi-solid or soft foods

Infant and young child feeding

To enable mothers to establish and sustain exclusive breastfeeding for 6 months, WHO and UNICEF recommend:

·   initiation of breastfeeding within the first hour of life;

·   exclusive breastfeeding, i.e. only breast milk with no additional food or drink, not even water;

·   breastfeeding on demand, as often the child wants, day and night; and

·   no use of bottles, teats or pacifiers.

The recommendations for feeding infants and young children (6–23 months) include:

·   continuing breastfeeding;

·   introduction of solid, semisolid or soft foods at 6 months;

·   appropriate food diversity (at least four food groups per day);

·   appropriate frequency of meals: two to three times a day between 6 and 8 months, increasing to three to four times a day between 9 and 23 months with nutritious snacks offered once or twice a day, as desired;

·   safe preparation of foods; and

·   feeding infants in response to their cues.

The caring practice indicators for infant and young child feeding available on the NLIS country profiles include:

• proportion of children aged 0–23 months who were put to the breast within 1 h of birth
• proportion of infants under 6 months who are exclusively breastfed
• proportion of infants aged 6–8 months who receive solid, semisolid or soft foods
• proportion of children aged 6–23 months who receive a minimum dietary diversity; and
• proportion of children aged 6–23 months who receive a minimum acceptable diet.

Early initiation of breastfeeding

What does this indicator tell us?

This indicator is the percentage of infants who are put to the breast within 1 hour of birth.

How is it defined?

Early initiation of breastfeeding is defined as the proportion of children born in the past 24 months who were put to the breast within 1 hour of birth.

What are the consequences and implications?

Breastfeeding contributes to saving children's lives, and there is evidence that delayed initiation of breastfeeding increases their risk for mortality.

Infants under 6 months who are exclusively breastfed

What does this indicator tell us?

This indicator is the percentage of infants aged 0–5 months who are exclusively breastfed.

How is it defined?

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

What are the consequences and implications?

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

Breast milk is the natural first food for infants. It provides all the energy and nutrients that the infant needs for the first months of life. It continues to provide up to one half or more of a child’s nutritional needs during the second half of the first year and up to one third during the second year of life.

Breast milk promotes sensory and cognitive development and protects the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhoea and pneumonia, and leads to quicker recovery from illness.

Breastfeeding contributes to the health and well-being of mothers, by helping to space children, reducing their risks for ovarian and breast cancers and saving family and national resources. It is a secure way of feeding and is safe for the environment.

Infants aged 6–8 months who receive solid, semisolid or soft foods

What does this indicator tell us?

The indicator is the percentage of infants who start solid, semisolid or soft foods at between 6 and 8 months of age. WHO recommends starting complementary feeding at 6 months of age.

How is it defined?

It is defined as the proportion of infants aged 6–8 months who receive solid, semisolid or soft foods.

What are the consequences and implications?

When breast milk alone no longer meets the nutritional needs of the infant, complementary foods should be added. The transition from exclusive breastfeeding to family foods, referred to as ‘complementary feeding’, typically occurs between 6 and 18–24 months of age. This is a very vulnerable period, and it is the time when malnutrition often starts, contributing significantly to the high prevalence of malnutrition among children under 5 worldwide.

Children aged 6–23 months who receive a minimum dietary diversity

What does this indicator tell us?

This indicator is the percentage of children aged 6–23 months who receive a minimum dietary diversity.

Proportion of children aged 6-23 months who receive a minimum dietary diversity is included as an interim process indicator in the core set of indicators for the Global Nutrition Monitoring Framework, while the original indicator “Minimum Acceptable Diet” is being further developed and validated under the leadership of the WHO-UNICEF Technical Expert Advisory group on nutrition Monitoring (TEAM). In June 2017, TEAM also recommended to revise the MDD indicator as defined by WHO (2008) to make it feasible and meaningful for Member State reporting. The revision concerned adding “breast milk” as an 8th food group and shifting the criterion for MDD accordingly, from 4 of 7 groups to 5 of 8 groups.

How is it defined?

As per revised recommendation by TEAM in June 2017, dietary diversity is present when the diet contained five or more of the following food groups:

·         breast milk;

·         grains, roots and tubers;

·         legumes and nuts;

·         dairy products (milk, yogurt, cheese);

·         flesh foods (meat, fish, poultry, liver or other organs);

·         eggs;

·         vitamin A-rich fruits and vegetables; and

·         other fruits and vegetables.

Children aged 6–23 months who receive a minimum acceptable diet

What does this indicator tell us?

This indicator is the percentage of children aged 6–23 months who receive a minimum acceptable diet.

Proportion of children aged 6-23 months who receive a minimum acceptable diet is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. 

How is it defined?

The composite indicator of a minimum acceptable diet is calculated from:

·    the proportion of breastfed children aged 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day and

• the proportion of non-breastfed children aged 6–23 months who received at least two milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day.

Dietary diversity is present when the diet contained four or more of the following food groups:

·         grains, roots and tubers;

·         legumes and nuts;

·         dairy products (milk, yogurt, cheese);

·         flesh foods (meat, fish, poultry, liver or other organs);

·         eggs;

·         vitamin A-rich fruits and vegetables; and

·         other fruits and vegetables.

The minimum daily meal frequency is defined as:

• twice for breastfed infants aged 6–8 months,
• three times for breastfed children aged 9–23 months and
• four times for non-breastfed children aged 6–23 months.

What are the consequences and implications?

A minimum acceptable diet is essential to ensure appropriate growth and development for feeding infants and children aged 6–23 months. Without adequate diversity and meal frequency, infants and young children are vulnerable to malnutrition, especially stunting and micronutrient deficiencies, and to increased morbidity and mortality.

Source of all infant and young child feeding indicators

WHO. Global Health Observatory (GHO). http://apps.who.int/gho.

UNICEF. Infant and Young Child Feeding database. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/.

Further reading

WHO. Infant and young child feeding list of publications. http://www.who.int/nutrition/publications/infantfeeding/en/index.html.

WHO. Global Targets 2025 to improve maternal, infant and young child nutrition. http://who.int/nutrition/global-target-2025/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA):

·         Breastfeeding: early initiation. http://www.who.int/entity/elena/titles/early_breastfeeding/en/index.html.

·         Breastfeeding: exclusive breastfeeding. http://www.who.int/entity/elena/titles/exclusive_breastfeeding/en/index.html.

·         Breastfeeding: continued breastfeeding. http://www.who.int/entity/elena/titles/continued_breastfeeding/en/index.html.

·         Complementary feeding. http://www.who.int/entity/elena/titles/complementary_feeding/en/index.html.

WHO. WHO Global Data Bank on Infant and Young Child Feeding. Department of Nutrition for Health and Development (NHD), Geneva, Switzerland.http://www.who.int/nutrition/databases/infantfeeding/en/index.html.

WHO/UNICEF. Global Nutrition Monitoring Framework. Operational guidance for tracking progress in meeting targets for 2025. WHO, Geneva, 2017. http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/.

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Children 6-23 months of age who receive a minimum acceptable diet

Infant and young child feeding

To enable mothers to establish and sustain exclusive breastfeeding for 6 months, WHO and UNICEF recommend:

·   initiation of breastfeeding within the first hour of life;

·   exclusive breastfeeding, i.e. only breast milk with no additional food or drink, not even water;

·   breastfeeding on demand, as often the child wants, day and night; and

·   no use of bottles, teats or pacifiers.

The recommendations for feeding infants and young children (6–23 months) include:

·   continuing breastfeeding;

·   introduction of solid, semisolid or soft foods at 6 months;

·   appropriate food diversity (at least four food groups per day);

·   appropriate frequency of meals: two to three times a day between 6 and 8 months, increasing to three to four times a day between 9 and 23 months with nutritious snacks offered once or twice a day, as desired;

·   safe preparation of foods; and

·   feeding infants in response to their cues.

The caring practice indicators for infant and young child feeding available on the NLIS country profiles include:

• proportion of children aged 0–23 months who were put to the breast within 1 h of birth
• proportion of infants under 6 months who are exclusively breastfed
• proportion of infants aged 6–8 months who receive solid, semisolid or soft foods
• proportion of children aged 6–23 months who receive a minimum dietary diversity; and
• proportion of children aged 6–23 months who receive a minimum acceptable diet.

Early initiation of breastfeeding

What does this indicator tell us?

This indicator is the percentage of infants who are put to the breast within 1 hour of birth.

How is it defined?

Early initiation of breastfeeding is defined as the proportion of children born in the past 24 months who were put to the breast within 1 hour of birth.

What are the consequences and implications?

Breastfeeding contributes to saving children's lives, and there is evidence that delayed initiation of breastfeeding increases their risk for mortality.

Infants under 6 months who are exclusively breastfed

What does this indicator tell us?

This indicator is the percentage of infants aged 0–5 months who are exclusively breastfed.

How is it defined?

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

What are the consequences and implications?

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

Breast milk is the natural first food for infants. It provides all the energy and nutrients that the infant needs for the first months of life. It continues to provide up to one half or more of a child’s nutritional needs during the second half of the first year and up to one third during the second year of life.

Breast milk promotes sensory and cognitive development and protects the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhoea and pneumonia, and leads to quicker recovery from illness.

Breastfeeding contributes to the health and well-being of mothers, by helping to space children, reducing their risks for ovarian and breast cancers and saving family and national resources. It is a secure way of feeding and is safe for the environment.

Infants aged 6–8 months who receive solid, semisolid or soft foods

What does this indicator tell us?

The indicator is the percentage of infants who start solid, semisolid or soft foods at between 6 and 8 months of age. WHO recommends starting complementary feeding at 6 months of age.

How is it defined?

It is defined as the proportion of infants aged 6–8 months who receive solid, semisolid or soft foods.

What are the consequences and implications?

When breast milk alone no longer meets the nutritional needs of the infant, complementary foods should be added. The transition from exclusive breastfeeding to family foods, referred to as ‘complementary feeding’, typically occurs between 6 and 18–24 months of age. This is a very vulnerable period, and it is the time when malnutrition often starts, contributing significantly to the high prevalence of malnutrition among children under 5 worldwide.

Children aged 6–23 months who receive a minimum dietary diversity

What does this indicator tell us?

This indicator is the percentage of children aged 6–23 months who receive a minimum dietary diversity.

Proportion of children aged 6-23 months who receive a minimum dietary diversity is included as an interim process indicator in the core set of indicators for the Global Nutrition Monitoring Framework, while the original indicator “Minimum Acceptable Diet” is being further developed and validated under the leadership of the WHO-UNICEF Technical Expert Advisory group on nutrition Monitoring (TEAM). In June 2017, TEAM also recommended to revise the MDD indicator as defined by WHO (2008) to make it feasible and meaningful for Member State reporting. The revision concerned adding “breast milk” as an 8th food group and shifting the criterion for MDD accordingly, from 4 of 7 groups to 5 of 8 groups.

How is it defined?

As per revised recommendation by TEAM in June 2017, dietary diversity is present when the diet contained five or more of the following food groups:

·         breast milk;

·         grains, roots and tubers;

·         legumes and nuts;

·         dairy products (milk, yogurt, cheese);

·         flesh foods (meat, fish, poultry, liver or other organs);

·         eggs;

·         vitamin A-rich fruits and vegetables; and

·         other fruits and vegetables.

Children aged 6–23 months who receive a minimum acceptable diet

What does this indicator tell us?

This indicator is the percentage of children aged 6–23 months who receive a minimum acceptable diet.

Proportion of children aged 6-23 months who receive a minimum acceptable diet is included as a process indicator in the core set of indicators for the Global Nutrition Monitoring Framework. 

How is it defined?

The composite indicator of a minimum acceptable diet is calculated from:

·    the proportion of breastfed children aged 6–23 months who had at least the minimum dietary diversity and the minimum meal frequency during the previous day and

• the proportion of non-breastfed children aged 6–23 months who received at least two milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day.

Dietary diversity is present when the diet contained four or more of the following food groups:

·         grains, roots and tubers;

·         legumes and nuts;

·         dairy products (milk, yogurt, cheese);

·         flesh foods (meat, fish, poultry, liver or other organs);

·         eggs;

·         vitamin A-rich fruits and vegetables; and

·         other fruits and vegetables.

The minimum daily meal frequency is defined as:

• twice for breastfed infants aged 6–8 months,
• three times for breastfed children aged 9–23 months and
• four times for non-breastfed children aged 6–23 months.

What are the consequences and implications?

A minimum acceptable diet is essential to ensure appropriate growth and development for feeding infants and children aged 6–23 months. Without adequate diversity and meal frequency, infants and young children are vulnerable to malnutrition, especially stunting and micronutrient deficiencies, and to increased morbidity and mortality.

Source of all infant and young child feeding indicators

WHO. Global Health Observatory (GHO). http://apps.who.int/gho.

UNICEF. Infant and Young Child Feeding database. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/.

Further reading

WHO. Infant and young child feeding list of publications. http://www.who.int/nutrition/publications/infantfeeding/en/index.html.

WHO. Global Targets 2025 to improve maternal, infant and young child nutrition. http://who.int/nutrition/global-target-2025/en/

WHO. E-Library of Evidence for Nutrition Actions (eLENA):

·         Breastfeeding: early initiation. http://www.who.int/entity/elena/titles/early_breastfeeding/en/index.html.

·         Breastfeeding: exclusive breastfeeding. http://www.who.int/entity/elena/titles/exclusive_breastfeeding/en/index.html.

·         Breastfeeding: continued breastfeeding. http://www.who.int/entity/elena/titles/continued_breastfeeding/en/index.html.

·         Complementary feeding. http://www.who.int/entity/elena/titles/complementary_feeding/en/index.html.

WHO. WHO Global Data Bank on Infant and Young Child Feeding. Department of Nutrition for Health and Development (NHD), Geneva, Switzerland.http://www.who.int/nutrition/databases/infantfeeding/en/index.html.

WHO/UNICEF. Global Nutrition Monitoring Framework. Operational guidance for tracking progress in meeting targets for 2025. WHO, Geneva, 2017. http://www.who.int/nutrition/publications/operational-guidance-GNMF-indicators/en/.

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Children with diarrhoea receiving ORT and continued feeding

Children with diarrhoea receiving oral rehydration therapy and continued feeding

What does this indicator tell us?

This indicator is the prevalence of children with diarrhoea who received oral rehydration therapy and continued feeding.

How is it defined?

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

What are the consequences and implications?

Diarrhoeal diseases remain one of the major causes of mortality among children under 5, accounting for 1.8 million deaths among children worldwide. As oral rehydration therapy is a critical component of effective management of diarrhoea, monitoring coverage with this highly cost-effective intervention indicates progress towards the child survival-related Millennium Development Goals.

Source

UNICEF. ChildInfo. Monitoring the situation of women and children. http://www.childinfo.org/diarrhoea_countrydata.php.

Further reading

WHO Statistical Information System (WHOSIS). Children < 5 years with diarrhoea receiving oral rehydration therapy (percentage). http://www.who.int/whosis/indicators/2007DiarrhoeaChildORTFluids/en/.

UNICEF. ChildInfo. http://www.childinfo.org/diarrhoea.html.

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Health Expenditure

Health expenditure

What do these indicators tell us?

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

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

How are they defined?

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

Public expenditure on health is the total expenditure of all levels of government on health, presented as a proportion (%) of gross domestic product (GDP). It consists of recurrent and capital spending from government (central and local) budgets, external borrowings and grants (including donations from international agencies and nongovernmental organizations) and social (or compulsory) health insurance funds. GDP is the value of all final goods and services produced within a nation in a given year.

Per capita total expenditure on health is the sum of public and private health expenditure (in purchasing power parity, US$) divided by the population. Public health expenditure consists of recurrent and capital spending from government (central and local) budgets, external borrowings and grants (including donations from international agencies and nongovernmental organizations) and social (or compulsory) health insurance funds. Private health expenditure is the sum of outlays for health by private entities, such as commercial or mutual health insurance providers, non-profit institutions serving households, resident corporations and quasi-corporations not controlled by government involved in health services delivery or financing, and direct household out-of-pocket payments. Purchasing power parity is derived by comparing economies on the basis of standardized international US$ price weights, rather than official currency exchange rates.

What are the consequences and implications?

These indicators reflect total and public expenditure on health resources, access and services, including nutrition. Although increasing health expenditures are associated with better health outcomes, especially in low-income countries, there is no 'recommended' level of spending on health. The larger the per capita income, the greater the expenditure on health. Some countries, however, spend appreciably more than would be expected from their income levels, and some appreciably less. When a government spends little of its GDP or attributes less of its total expenditure on health, this may indicate that health, including nutrition, are not regarded as priorities.

Sources

WHO. National health accounts - World Health Statistics, 2010 (http://apps.who.int/ghodata/) for 'General government expenditure on health as % of total government expenditure'.

UNDP. Human development report (http://hdr.undp.org/en/reports/global/hdr2007-2008/) for 'Public expenditure on health (% of GDP)'.

WHO. Core health indicators (http://apps.who.int/ghodata/) for 'Per capita total expenditure on health (US$)'.

Further reading

UNDP. Human development report indicator glossary for indicator 3. http://hdr.undp.org/en/humandev/glossary/#p.

WHO. National health accounts. http://www.who.int/nha/en/.

WHO. Wealth, health and health expenditure. WHO/NHA Policy Highlight No. 4, 2008. http://www.who.int/nha/use/Highlight_4_Aug25,2008.pdf.

The WHO Indicator and Measurement Registry (IMR). http://apps.who.int/gho/indicatorregistry/App_Main/browse_indicators.aspx.

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Commitment

Health expenditure

What do these indicators tell us?

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

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

How are they defined?

General government expenditure on health as a percentage of total government expenditure is defined as the level of general government expenditure on health (GGHE) expressed as a percentage of total government expenditure. The indicator contributes to understanding the weight of public spending on health within the total value of public sector operations. It includes not just the resources channelled through government budgets but also the expenditure on health by parastatals, extrabudgetary entities and notably the compulsory health insurance. The indicator refers to resources collected and pooled by public agencies including all the revenue modalities.

Total expenditure on health as a percentage of gross domestic product (GDP) is defined as the level of total expenditure on health expressed as a percentage of gross domestic product (GDP), where  GDP is the value of all final goods and services produced within a nation in a given year. The indicator provides information on the level of resources channelled to health relative to a country's wealth.

Per capita total expenditure on health is defined as per capita total expenditure on health expressed at average exchange rate for that year in US$. The indicator contributes to understanding the total expenditure on health relative to the beneficiary population, expressed in US$ to facilitate international comparisons.

What are the consequences and implications?

These indicators reflect government and total expenditure on health resources, access and services, including nutrition, in relation to government expenditure, the wealth of the country, and per capita. Although increasing health expenditures are associated with better health outcomes, especially in low-income countries, there is no 'recommended' level of spending on health. The larger the per capita income, the greater the expenditure on health. Some countries, however, spend appreciably more than would be expected from their income levels, and some appreciably less. When a government attributes less of its total expenditure on health, this may indicate that health, including nutrition, are not regarded as priorities.

Source

WHO. Global Health Observatory (GHO). http://apps.who.int/ghodata/.

Further reading

WHO. National health accounts. http://www.who.int/nha/en/.

WHO. Wealth, health and health expenditure. WHO/NHA Policy Highlight No. 4, 2008. http://www.who.int/nha/use/Highlight_4_Aug25,2008.pdf.

The WHO Indicator and Measurement Registry (IMR). http://apps.who.int/gho/indicatorregistry/App_Main/browse_indicators.aspx.

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Per capita total expenditure on health (US$)

Health expenditure

What do these indicators tell us?

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

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

How are they defined?

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

Public expenditure on health is the total expenditure of all levels of government on health, presented as a proportion (%) of gross domestic product (GDP). It consists of recurrent and capital spending from government (central and local) budgets, external borrowings and grants (including donations from international agencies and nongovernmental organizations) and social (or compulsory) health insurance funds. GDP is the value of all final goods and services produced within a nation in a given year.

Per capita total expenditure on health is the sum of public and private health expenditure (in purchasing power parity, US$) divided by the population. Public health expenditure consists of recurrent and capital spending from government (central and local) budgets, external borrowings and grants (including donations from international agencies and nongovernmental organizations) and social (or compulsory) health insurance funds. Private health expenditure is the sum of outlays for health by private entities, such as commercial or mutual health insurance providers, non-profit institutions serving households, resident corporations and quasi-corporations not controlled by government involved in health services delivery or financing, and direct household out-of-pocket payments. Purchasing power parity is derived by comparing economies on the basis of standardized international US$ price weights, rather than official currency exchange rates.

What are the consequences and implications?

These indicators reflect total and public expenditure on health resources, access and services, including nutrition. Although increasing health expenditures are associated with better health outcomes, especially in low-income countries, there is no 'recommended' level of spending on health. The larger the per capita income, the greater the expenditure on health. Some countries, however, spend appreciably more than would be expected from their income levels, and some appreciably less. When a government spends little of its GDP or attributes less of its total expenditure on health, this may indicate that health, including nutrition, are not regarded as priorities.

Sources

WHO. National health accounts - World Health Statistics, 2010 (http://apps.who.int/ghodata/) for 'General government expenditure on health as % of total government expenditure'.

UNDP. Human development report (http://hdr.undp.org/en/reports/global/hdr2007-2008/) for 'Public expenditure on health (% of GDP)'.

WHO. Core health indicators (http://apps.who.int/ghodata/) for 'Per capita total expenditure on health (US$)'.

Further reading

UNDP. Human development report indicator glossary for indicator 3. http://hdr.undp.org/en/humandev/glossary/#p.

WHO. National health accounts. http://www.who.int/nha/en/.

WHO. Wealth, health and health expenditure. WHO/NHA Policy Highlight No. 4, 2008. http://www.who.int/nha/use/Highlight_4_Aug25,2008.pdf.

The WHO Indicator and Measurement Registry (IMR). http://apps.who.int/gho/indicatorregistry/App_Main/browse_indicators.aspx.

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Nutrition component of UNDAF

Nutrition component of the United Nations Development Assistance Framework

What does this indicator tell us?

This indicator describes the strength of nutrition in the United Nations Development Assistance Framework (UNDAF), the strategic programme framework for United Nations country teams. UNDAFs usually focus on three to five areas in which the country team can make the greatest difference, in addition to activities supported by other agencies in response to national demands but which fall outside the common UNDAF results matrix. For each national priority selected for United Nations country team support, the UNDAF results matrix gives the outcome(s), the outcomes and outputs of other agencies working alone or together, the role of partners, resource mobilization targets for each agency outcome and coordination mechanisms and programme modalities. The nutrition component of the UNDAF reflects the priority attributed to nutrition by the United Nations agencies in a country and is an indication of how much the United Nations system is committed to helping governments improve their food and nutrition situation.

How is it defined?

The indicator is "strong", "medium" or "weak", depending on the degree to which nutrition is being addressed in the expected outcomes and outputs in the UNDAF. It been defined and estimated within the 'WHO Landscape Analysis', which is based on how the outcomes and outputs of the UNDAF address nutrition and the evidence-based interventions identified in the Lancet Nutrition Series (published in January 2008).

UNDAF documents follow a predefined format, with a core narrative and a results matrix. The matrix lists the high-level expected results ('the UNDAF outcomes'), the outcomes to be reached by agencies working alone or together and agency outputs. The results matrix the UNDAF document was used to assess commitment to nutrition, because it represents a synthesis of the strategy proposed in the document and is available in the same format in most country documents. The most recent UNDAF documents on the United Nations Development Group (UNDG) website were used. The outcomes and outputs specifically related to nutrition were identified and counted. The outputs were compared with the evidence-based interventions to reduce maternal and child undernutrition recommended in the Lancet Nutrition Series (Bhutta et al., 2008, Table 1, p. 42). The method and scoring are described in detail by Engesveen et al. (2009).

What are the implications?

A strong nutrition component in the UNDAF document means that the United Nations agencies consider nutrition to be a joint priority. A weak nutrition component in the UNDAF document does not necessarily imply that no United Nations agency in the country is working to improve nutrition; however, unless such efforts are mentioned in strategy documents like the UNDAF, they may receive inadequate attention from development partners to ensure the necessary sustainability or scale-up to adequately address nutrition problems in the country. The multisectoral nature of nutrition means that it must be addressed by a wide range of actors. Basing such action in frameworks for overall development contributes to ensuring the accountability of United Nations partners.

Sources

Completed UNDAFs, available from the UNDG website.  http://www.undg.org/index.cfm?P=234.

UNDG and United Nations System Staff College provide an online results matrix database.

Further reading

Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HPS and Shekar M (2008) What works? Interventions for maternal and child undernutrition and survival. The Lancet 371(9610):417-40. (online)

Engesveen K et al. Assessing countries' commitment to accelerate nutrition action demonstrated in PRSP, UNDAF and through nutrition governance. SCN News 2009, 37. http://www.unscn.org/files/Publications/SCN_News/scnnews37.pdf.

Maternal and Child Undernutrition Study Group (2008) Maternal and child undernutrition. The Lancet 371(9608-12). http://www.thelancet.com/collections/series/undernutrition.

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Nutrition component of PRSP

Nutrition component of poverty reduction strategy papers

What does this indicator tell us?

This indicator describes the strength of nutrition in the Poverty Reduction Strategy Paper (PRSP). The poverty reduction strategy approach was introduced in 1999 to empower governments to set their own priorities and to encourage donors to provide predictable, harmonized assistance aligned with country priorities. The PRSP should state the development priorities and specify the policies, programmes and resources needed to meet the goals. It is prepared by governments in a participatory process involving civil society and development partners, including the World Bank and the International Monetary Fund, and should result in a comprehensive, country-based strategy for poverty reduction.

How is it defined?

The indicator is "strong", "medium" or "weak", depending on the degree to which nutrition is addressed in the PRSP, in terms of recognition of undernutrition as a development problem, use of information on nutrition to analyse poverty and support for appropriate nutrition policies, strategies and programmes. The indicator has been defined and estimated within the 'WHO Landscape Analysis' using a methodology proposed by the World Bank (Shekar and Lee, 2006). The most recent PRSPs available on the World Bank website were used. The papers were systematically searched for key words to identify the parts that concerned nutrition, food security, health outcomes and interventions that would be relevant for the World Bank method. In order to classify the commitments to nutrition in the PRSPs, a scoring system was developed, which is described in more detail by Engesveen et al. (2009).

What are the implications?

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

A strong nutrition component in a PRSP means that the government considers nutrition a priority for poverty reduction and national development. A weak nutrition component in the document does not necessarily imply that no government department is working to improve nutrition; however, unless such efforts are mentioned in strategy documents like PRSPs, they may not be sufficiently sustainable or be scaled-up to adequately address nutrition problems in the country. The multisectoral nature of nutrition means that it must be addressed by a wide range of actors. Basing such action in frameworks for overall development contributes to ensuring the accountability of relevant government departments.

Sources and further reading

World Bank. Poverty reduction strategy papers. http://go.worldbank.org/ZBYSV47F10.

Further reading

Engesveen K et al. Assessing countries' commitment to accelerate nutrition action demonstrated in poverty reduction strategy paper, UNDAF and through nutrition governance. SCN News, 2009, 37. http://www.unscn.org/files/publications/SCN_news/scnnews37.pdf.

IMF. Poverty reduction strategy papers. http://www.imf.org/external/np/exr/facts/prsp.htm.

Shekar M, Lee Y-K. Mainstreaming nutrition in poverty reduction strategy papers: What does it take? A review of the early experience. Health, Nutrition and Population Discussion Paper, 2006. http://siteresources.worldbank.org/healthnutritionandpopulation/resources/281627-1095698140167/nutritionInprspsfinal.pdf.

WHO. Landscape analysis on countries' readiness to accelerate action in nutrition, 2011. (forthcoming).

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Nutrition Governance

Nutrition governance

What does this indicator tell us?

This indicator is a description of the strengths and weaknesses of various aspects of nutrition governance in countries. 

How is it defined?

The nutrition governance score is  "strong", "medium" or "weak", depending on the presence of a set of elements identified by countries themselves as crucial for successful development and implementation of national nutrition policies and strategies. The following 10 elements or characteristics are used to assess and describe the strength of nutrition governance:

·   existence of an intersectoral mechanism to address nutrition;

·   existence of a national nutrition plan or strategy;

·   whether the national nutrition plan or strategy is adopted;    

·   whether the national nutrition plan or strategy is part of the national development plan;

·   existence of a national nutrition policy;       

·   whether the nutrition policy is adopted;      

·   existence of national dietary guidelines;     

·   allocation of budget for implementation of the national nutrition plan, strategy or policy;

·   regular nutrition monitoring and surveillance; and

·   existence of a line for nutrition in the health budget.

These elements were identified by countries as key elements for successful development and implementation of national nutrition policies and strategies during a review of the progress of countries in implementing the World Declaration and Plan of Action for Nutrition adopted by the 1992 International Conference on Nutrition, the first intergovernmental conference on nutrition (Nishida et al. 2003). The method and scoring are described in detail by Engesveen et al. (2009).

What are the consequences and implications?

The components of the composite indicator have been identified by countries as important for determining the completeness of national nutrition plans and policies (Nishida, Mutru, Imperial Laue, 2003). For instance, a national nutrition plan and policy was considered to provide the political basis for initiating action. In many countries, official government endorsement or adoption of a national nutrition plan or policy facilitated its implementation. The role of an intersectoral coordinating committee in implementing national nutrition plans and policies was also considered crucial, although the nature (i.e. whether executive or advisory), members, organizational structure and location of the committee determined its effectiveness. Another important element was considered to be regular surveys and other means of collecting data on nutrition. A periodically updated national nutrition information system and routinely collected data on food and nutrition were considered important for evaluating the effectiveness of national nutrition plans and policies and identifying subsequent actions.

Source

WHO. WHO Global Database on National Nutrition Policies and Programmes. Department of Nutrition for Health and Development (NHD), Geneva, Switzerland.

Further reading

Engesveen K et al. Assessing countries' commitment to accelerate nutrition action demonstrated in PRSP, UNDAF and through nutrition governance. SCN News 2009, 37. http://www.unscn.org/files/Publications/SCN_News/scnnews37.pdf.

Nishida C, Mutru T, Imperial Laue R. Strategies for effective and sustainable national nutrition plans and policies. In: Elmadfa I, Anklam E, Konig JS, eds. Modern aspects of nutrition, present knowledge and future perspective. Basel, Karger (Forum for Nutrition 56), 2003:264-266.

WHO. Landscape analysis on countries' readiness to accelerate action in nutrition, 2011. (forthcoming)

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Maternity Leave

Maternity protection indicators

What do these indicators tell us?

These indicators provide information on national policies for legal entitlement to maternity protection, including leave from work during pregnancy and after birth, as well breastfeeding entitlements after return to work.

Since the International Labour Organization (ILO) was founded in 1919, international labour standards have been established to provide maternity protection for women workers. The ILO Maternity Protection Convention, 2000 (No. 183) represents the minimum standards, whereas the accompanying ILO Maternity Protection Recommendation, 2000 (No. 191) encourages additional measures. Key elements of maternity protection include:

·         Maternity leave duration: The mother’s right to a period of rest in relation to childbirth is a crucial means of safeguarding health and nutrition of the mother and her child. Convention No. 183 states that maternity leave should not be less than 14 weeks, while Recommendation No. 191 suggests that maternity leave be at least 18 weeks.

·         Amount of maternity leave cash benefits: The right to cash benefits during absence for maternity leave is intended to ensure that the woman can maintain herself and her child in proper conditions of health and with a suitable standard of living. Maternity leave cash benefits aim to replace a portion of the income lost due to the interruption of the woman’s economic activities, giving practical effect to the provision for leave. Convention No. 183 states that cash benefits should not be less than two-thirds of the woman’s earnings prior to taking leave, while Recommendation No. 191 encourages raising the benefits to the full amount of previous earnings.

·         Source of maternity leave cash benefits: The source of benefits is important due to potential discrimination in the labour market if employers have to bear the full costs. Convention No. 183 stipulates that cash benefits shall be provided through compulsory social insurance or public funds, and that individual employers shall not be liable for maternity leave benefits without that employer’s specific agreement.

·         Breastfeeding breaks and breastfeeding facilities: The right to continue breastfeeding a child after returning to work is important since duration of leave entitlements generally is shorter than the WHO recommended duration of exclusive and continued breastfeeding. Convention No. 183 states that women shall have the right to one or more daily breaks or a daily reduction of hours of work for breastfeeding, which is to be counted as working time and remunerated accordingly. Recommendation No. 191 states that where practicable, provision should be made for the establishment of facilities for nursing under adequate hygienic conditions at or near the workplace.

A composite indicator on maternity protection is included as a policy environment and capacity indicator in the core set of indicators for the Global Nutrition Monitoring Framework. It currently uses the ILO classification of compliance with Convention 183 on three key provisions (leave duration, remuneration and source of cash benefits), but an alternative method taking into account higher standards as stated in Recommendation 191 as well as breastfeeding entitlements is under development. 

How are they defined?

The ILO periodically publishes information on the above key indicators, including the assessment of compliance with Convention No. 183, as part of the TRAVAIL Database of Conditions of Work and Employment Laws and the NATLEX Database of National Labour, Social Security and Related Human Rights Legislation. The legislative data are collected by ILO through periodical reviews of national labour and social security legislation and secondary sources, such as the International Social Security Association and International Network on Leave Policies and Research; as well as consultations with ILO experts in regional and national ILO offices around the world

The composite indicator on maternity protection included in the Global Nutrition Monitoring Framework is currently defined as whether the country has maternity protection laws or regulations in place compliant with the provisions for leave duration, remuneration and source of cash benefits in Convention 183. However, an alternative method is under development which may use a scale to indicate the degree of compliance is under development. This method will also take into account higher standards for leave duration and remuneration in Recommendation 191, as well as breastfeeding entitlements within both the Convention and Recommendation. 

 What are the consequences and implications?

Pregnancy and maternity are potentially vulnerable time for working women and their families. Expectant and nursing mothers require special protection to prevent any potential adverse effects for them and their infants. They need adequate time to give birth, to recover from delivery process, and to nurse their children. At the same time, they also require income security and protection to ensure that they will not suffer from income loss or lose their job because of pregnancy or maternity leave. Such protection not only ensures a woman's equal access and right to employment, it also ensures economic sustainability for the well-being of the family. Returning to work after maternity leave has been identified as a significant cause for never starting breastfeeding, early cessation of breastfeeding and lack of exclusive breastfeeding. In most low- and middle-income countries, paid maternity leave is limited to formal sector employment or is not always provided in practice. The ILO estimates that more than 800 million women lack economic security around childbirth with adverse effects on the health, nutrition and well-being of mothers and their children.

Source

ILO. Maternity protection database. http://www.ilo.org/travaildatabase/servlet/maternityprotection.

Further reading

Maternity protection indicators (GNMF compliance)

Maternity protection indicators

What do these indicators tell us?

These indicators provide information on national policies for legal entitlement to maternity protection, including leave from work during pregnancy and after birth, as well breastfeeding entitlements after return to work.

Since the International Labour Organization (ILO) was founded in 1919, international labour standards have been established to provide maternity protection for women workers. The ILO Maternity Protection Convention, 2000 (No. 183) represents the minimum standards, whereas the accompanying ILO Maternity Protection Recommendation, 2000 (No. 191) encourages additional measures. Key elements of maternity protection include:

·         Maternity leave duration: The mother’s right to a period of rest in relation to childbirth is a crucial means of safeguarding health and nutrition of the mother and her child. Convention No. 183 states that maternity leave should not be less than 14 weeks, while Recommendation No. 191 suggests that maternity leave be at least 18 weeks.

·         Amount of maternity leave cash benefits: The right to cash benefits during absence for maternity leave is intended to ensure that the woman can maintain herself and her child in proper conditions of health and with a suitable standard of living. Maternity leave cash benefits aim to replace a portion of the income lost due to the interruption of the woman’s economic activities, giving practical effect to the provision for leave. Convention No. 183 states that cash benefits should not be less than two-thirds of the woman’s earnings prior to taking leave, while Recommendation No. 191 encourages raising the benefits to the full amount of previous earnings.

·         Source of maternity leave cash benefits: The source of benefits is important due to potential discrimination in the labour market if employers have to bear the full costs. Convention No. 183 stipulates that cash benefits shall be provided through compulsory social insurance or public funds, and that individual employers shall not be liable for maternity leave benefits without that employer’s specific agreement.

·         Breastfeeding breaks and breastfeeding facilities: The right to continue breastfeeding a child after returning to work is important since duration of leave entitlements generally is shorter than the WHO recommended duration of exclusive and continued breastfeeding. Convention No. 183 states that women shall have the right to one or more daily breaks or a daily reduction of hours of work for breastfeeding, which is to be counted as working time and remunerated accordingly. Recommendation No. 191 states that where practicable, provision should be made for the establishment of facilities for nursing under adequate hygienic conditions at or near the workplace.

A composite indicator on maternity protection is included as a policy environment and capacity indicator in the core set of indicators for the Global Nutrition Monitoring Framework. It currently uses the ILO classification of compliance with Convention 183 on three key provisions (leave duration, remuneration and source of cash benefits), but an alternative method taking into account higher standards as stated in Recommendation 191 as well as breastfeeding entitlements is under development. 

How are they defined?

The ILO periodically publishes information on the above key indicators, including the assessment of compliance with Convention No. 183, as part of the TRAVAIL Database of Conditions of Work and Employment Laws and the NATLEX Database of National Labour, Social Security and Related Human Rights Legislation. The legislative data are collected by ILO through periodical reviews of national labour and social security legislation and secondary sources, such as the International Social Security Association and International Network on Leave Policies and Research; as well as consultations with ILO experts in regional and national ILO offices around the world

The composite indicator on maternity protection included in the Global Nutrition Monitoring Framework is currently defined as whether the country has maternity protection laws or regulations in place compliant with the provisions for leave duration, remuneration and source of cash benefits in Convention 183. However, an alternative method is under development which may use a scale to indicate the degree of compliance is under development. This method will also take into account higher standards for leave duration and remuneration in Recommendation 191, as well as breastfeeding entitlements within both the Convention and Recommendation. 

 What are the consequences and implications?

Pregnancy and maternity are potentially vulnerable time for working women and their families. Expectant and nursing mothers require special protection to prevent any potential adverse effects for them and their infants. They need adequate time to give birth, to recover from delivery process, and to nurse their children. At the same time, they also require income security and protection to ensure that they will not suffer from income loss or lose their job because of pregnancy or maternity leave. Such protection not only ensures a woman's equal access and right to employment, it also ensures economic sustainability for the well-being of the family. Returning to work after maternity leave has been identified as a significant cause for never starting breastfeeding, early cessation of breastfeeding and lack of exclusive breastfeeding. In most low- and middle-income countries, paid maternity leave is limited to formal sector employment or is not always provided in practice. The ILO estimates that more than 800 million women lack economic security around childbirth with adverse effects on the health, nutrition and well-being of mothers and their children.

Source

ILO. Maternity protection database. http://www.ilo.org/travaildatabase/servlet/maternityprotection.

Further reading

Monitoring and enforcement of the International Code on Marketing of Breast-milk Substitutes

Monitoring and enforcement of the International Code of Marketing of Breast-milk Substitutes

What does this indicator tell us?

This indicates whether a government has adopted legislation to monitor and enforce the International Code of Marketing of Breast-milk Substitutes, which helps create an environment that enables mothers to make the best possible feeding choice, based on impartial information and free of commercial influences, and to be fully supported in doing so.

How is it defined?

This indicator is defined on the basis of whether a government has adopted legislation for effective national implementation and monitoring of the International Code of Marketing of Breast-milk Substitutes. The Code is a set of recommendations to regulate the marketing of breast-milk substitutes, feeding bottles and teats. The Code aims to contribute "to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution" (Article 1).

What are the consequences and implications?

Improper marketing and promotion of food products that compete with breastfeeding often negatively affect the choice and ability of a mother to breastfeed her infant optimally. The Code was formulated in response to the realization that such marketing resulted in poor infant feeding practices, which negatively affect the growth, health and development of children and are a major cause of mortality in infants and young children.

Breastfeeding practices worldwide are not yet optimal, in both developing and developed countries, especially for exclusive breastfeeding under 6 months of age. In addition to the risks posed by the lack of the protective qualities of breast milk, breast-milk substitutes and feeding bottles are associated with a high risk for contamination that can lead to life-threatening infections in young infants. Infant formula is not a sterile product, and it may carry germs that can cause fatal illnesses. Artificial feeding is expensive, requires clean water, the ability of the mother or caregiver to read and comply with mixing instructions and a minimum standard of overall household hygiene. These factors are not present in many households in the world.

Source

WHO. Department for Child and Adolescent Health and Department of Nutrition for Health and Development.

Further reading

WHO. The International Code of Marketing of Breast-milk Substitutes. Frequently asked questions, 2008. http://www.who.int/nutrition/publications/Frequently_ask_question_Internationalcode.pdf.

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Degree training in nutrition and nutrition in medical curricula

Degree training in nutrition and nutrition in medical curricula

These indicators reflect the capacity of a country to train professionals in nutrition. As nutrition is an important part of health staff activities, adequate training of health professionals is essential to ensure that nutrition activities are part of the health system. Unfortunately, there are no readily available data on these indicators. The indicators are maintained in the NLIS to encourage countries to collect and compile data on these aspects in order to assess their national capacity.

Degree training in nutrition and nutrition in medical curricula

Degree training in nutrition and nutrition in medical curricula

These indicators reflect the capacity of a country to train professionals in nutrition. As nutrition is an important part of health staff activities, adequate training of health professionals is essential to ensure that nutrition activities are part of the health system. Unfortunately, there are no readily available data on these indicators. The indicators are maintained in the NLIS to encourage countries to collect and compile data on these aspects in order to assess their national capacity.

Density of nutrition professionals

Trained nutrition professionals density

What does the indicator tell us?

The indicator ‘Density of trained nutrition professionals per 100 000 population’ reflects the capacity of a country to design and implement nutrition policies and programmes effectively.

The focus of the nutrition professional indicator is on individuals trained to pursue a nutrition professional career, described in most countries as dieticians or nutritionists (including nutrition scientists, nutritional epidemiologists and public health nutritionists). These individuals are trained sufficiently in nutrition practice to demonstrate defined competencies and to meet certification or registration requirements of national or global nutrition or dietetics professional organizations. This training at universities or other tertiary or higher education institutions may occur at Bachelor, Post-graduate certificate or Diploma, Masters and /or PhD degree levels.

Dieticians and nutritionists may complete the same training and perform the same functions in some countries but not others. Likewise, professional registration or accreditation of dieticians and/or nutritionists may be joint or separate, and may occur in some countries but not others. Countries are encouraged to implement professional registration or accreditation of dieticians and/or nutritionists to provide a guarantee of appropriate training and professional competence.

Number of trained nutrition professionals/100 000 population is included as a policy environment and capacity indicator in the core set of indicators for the Global Nutrition Monitoring Framework.

How is it defined?

This indicator is defined as the number of trained nutrition professionals per 100,000 population in the country in a specified year.

What are the consequences and implications?

Trained nutrition professionals work at facilities including health facilities as well as at population and community levels and may influence nutrition policies, and designing and implementation of nutrition intervention programmes at various levels. They also play an important role in training of other health and non-health cadres to plan and deliver nutrition interventions in various settings. The requirement for a ‘trained nutrition professionals’ indicator is based on the recognition that availability, within a country, of sufficient workforce with appropriate training in nutrition will lead to better outcomes for country-specific nutrition and health concerns. Validation of the indicator defined in this guidance has shown that it can predict several maternal, infant and young child nutrition outcomes.

Source

WHO. 2^nd Global Nutrition Policy Review (forthcoming).

Further reading

Hughes R, Shrimpton R, Recine E, Margetts B. A competency framework for global public health nutrition workforce development: A background paper. 2011. World Public Health Nutrition Association. Accessible http://wphna.org/competency-standards/

Association for Nutrition. Registering as Registered Nutritionist. The UK Voluntary Register of Nutritionists Registration http://www.associationfornutrition.org

Ellahi B, Annan R, Sarkar S, Amuna P, Jackson AA. Building systemic capacity for nutrition: training towards a professionalised workforce for Africa. Proc Nutr Soc. 2015 Nov;74 (4):496–504.

Nurse and midwife density

Density of nurses and midwives

What does the indicator tell us?

Nurse and midwife density indicates whether nurses and midwifery personnel are available to address the health care needs of a given population.

How is it defined?

It is the number of nursing and midwifery personnel and density per 10 000 population. These personnel include professional nurses, professional midwives, auxiliary nurses, auxiliary midwives, enrolled nurses, enrolled midwives and other personnel, such as dental nurses and primary care nurses. Traditional attendants are not counted here but as community or traditional health workers.

What are the consequences and implications?

There is no gold standard for a sufficient health workforce to address the health care needs of a given population. It has been estimated, however, that countries with fewer than 25 health-care professionals (counting only physicians, nurses and midwives) per 10 000 population fail to achieve adequate coverage rates for selected primary health care interventions that are priorities in the Millennium Development Goals.

Source

WHO. Global Health Observatory (GHO). http://apps.who.int/ghodata/.

Further reading

WHO. The World Health Report 2006. Working together for health. Geneva, World Health Organization, 2006. http://www.who.int/entity/whr/2006/en/index.html.

WHO. The World Health Report 2006 papers. Follow-up to The World Health Report 2006 Geneva, World Health Organization, 2006. http://www.who.int/hrh/documents/whr06_background_papers.

The WHO Indicator and Measurement Registry (IMR). http://apps.who.int/gho/indicatorregistry/App_Main/browse_indicators.aspx.

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Gross domestic product per capita and annual growth rate

Gross domestic product per capita and annual growth rate

What do these indicators tell us?

Gross Domestic Product (GDP) per capita and GDP per capita annual growth rate are widely used by economists to gauge the health of an economy.

How are they defined?

GDP per capita (purchasing power parity) is the GDP divided by the midyear population, where GDP is the total value of goods and services for final use produced by resident producers in an economy, regardless of the allocation to domestic and foreign claims. It does not include deductions for depreciation of physical capital or depletion and degradation of natural resources. Purchasing power parity indicates the rate of exchange that accounts for price differences across countries, allowing international comparisons of real output and incomes. The purchasing power parity US$ 1 has the same purchasing power in the domestic economy as US$ 1 in the United States. Purchasing power parity rates allow standard comparisons of real prices among countries, just as conventional price indexes allow comparisons of real values over time; use of normal exchange rates could result in over - or undervaluation of purchasing power.

GDP per capita annual growth rate is defined as the least squares annual growth rate, calculated from constant price GDP per capita in local currency units.

What are the consequences and implications?

Higher income is usually associated with lower rates of malnutrition. Improving income however, reduces malnutrition to only a small degree (World Bank 2006). For example, when the gross national product [GDP plus the net factor income residents receive from abroad for factor services (labour and capital), less similar payments made to  who contribute to the domestic economy] per capita in developing countries doubled, the nutrition situation did improve, but reductions in underweight rates were only modest-from 32% to 23%. On the basis of the correlation between growth and nutrition, it is estimated that a sustained per capita economic growth of 2.5% between the 1990s and 2015 would reduce malnutrition by 27%-only halfway towards the Millennium Development Goal target 3. These estimates suggest that countries cannot depend on economic growth alone to reduce malnutrition within an acceptable time.

Source

GDP per capita and GDP per capita annual growth rate

Gross domestic product per capita and annual growth rate

What do these indicators tell us?

Gross Domestic Product (GDP) per capita and GDP per capita annual growth rate are widely used by economists to gauge the health of an economy.

How are they defined?

GDP per capita (purchasing power parity) is the GDP divided by the midyear population, where GDP is the total value of goods and services for final use produced by resident producers in an economy, regardless of the allocation to domestic and foreign claims. It does not include deductions for depreciation of physical capital or depletion and degradation of natural resources. Purchasing power parity indicates the rate of exchange that accounts for price differences across countries, allowing international comparisons of real output and incomes. The purchasing power parity US$ 1 has the same purchasing power in the domestic economy as US$ 1 in the United States. Purchasing power parity rates allow standard comparisons of real prices among countries, just as conventional price indexes allow comparisons of real values over time; use of normal exchange rates could result in over - or undervaluation of purchasing power.

GDP per capita annual growth rate is defined as the least squares annual growth rate, calculated from constant price GDP per capita in local currency units.

What are the consequences and implications?

Higher income is usually associated with lower rates of malnutrition. Improving income however, reduces malnutrition to only a small degree (World Bank 2006). For example, when the gross national product [GDP plus the net factor income residents receive from abroad for factor services (labour and capital), less similar payments made to  who contribute to the domestic economy] per capita in developing countries doubled, the nutrition situation did improve, but reductions in underweight rates were only modest-from 32% to 23%. On the basis of the correlation between growth and nutrition, it is estimated that a sustained per capita economic growth of 2.5% between the 1990s and 2015 would reduce malnutrition by 27%-only halfway towards the Millennium Development Goal target 3. These estimates suggest that countries cannot depend on economic growth alone to reduce malnutrition within an acceptable time.

Source

Official development assistance (ODA)

Official development assistance

What does this indicator tell us?

Official development assistance received (net disbursements as a percentage of Gross Domestic Product (GDP)) is a measure of the flow of aid, private capital and debt in comparison with the value of goods and services produced within the country.

How is it defined?

This indicator is official development assistance received as a percentage of the GDP. Net official development assistance consists of grants or loans to countries or territories from the official sector, with the main objective of promoting economic development and welfare, at concessional financial terms. GDP is the total value of final goods and services produced within a country's borders in a year, regardless of ownership.

What are the consequences and implications?

When official development assistance makes up a large proportion of the GDP, a country is highly aid dependent, with the risk of unpredictable aid and donor-driven aid programmes. This can affect the resources allocated to nutrition, which are often not a donor priority in the sector-wide aid strategies promoted by the Paris Declaration (2005).

Low-Income Food-Deficit Countries (LIFDC)

Low-income food-deficit countries

What does this indicator tell us?

This indicator identifies countries with low income and food inadequacy.

How is it defined?

A country is classified by the UN Food and Agriculture Organization (FAO) as 'low-income food-deficit' for analytical purposes on the basis of low income and food inadequacy, and the status is agreed by the country itself. The classification applies to countries that have a per capita income below the ceiling used by the World Bank to determine eligibility for International Development Association assistance and for 20-year terms determined by the International Bank for Reconstruction and Development, applied to countries included in World Bank categories I and II. The second criterion is based on the net (i.e. gross imports less gross exports) food trade position of the country, averaged over the preceding 3 years. Trade volumes of a broad range of basic foodstuffs (cereals, roots and tubers, pulses, oilseeds and oils other than tree crop oils, meat and dairy products) are converted and aggregated by the calorie content of individual commodities. The third criterion, which is self-exclusion, is applied when countries that meet the above two criteria specifically request to be excluded from the low-income food-deficit category. In order to avoid too frequent changes of low-income food-deficit status, usually reflecting short-term, exogenous shocks, an additional factor is taken into consideration. This factor, called 'persistence of position', postpones the 'exit' of a country from the list even if it does not meet the low-income or the food-deficit criterion, until the change in its status is verified for 3 consecutive years. In other words, a country is taken off the list in the fourth year after confirming a sustained improvement in its position. During these 3 years, the country is considered to be in a transitional phase.

What are the consequences and implications?

The rationale behind the low-income food-deficit classification is that being both food deficit and having a low income at the same time means that the country lacks the resources not only to import food but also to produce sufficient amounts domestically. It is the combination of these two factors that makes these countries both food insecure and susceptible to domestic and external shocks, which could affect the nutritional status of vulnerable populations. The low-income food-deficit list is intended to capture this aspect of the food problem.

In comparison with countries in other classifications commonly used for analytical and operational purposes, e.g. 'least-developed countries', the World Bank's 'low-income countries' and 'heavily indebted poor countries', countries that are low-income food-deficit have demonstrated better nutrition and health related outcomes.

Source

FAO. Country profiles. Low-income food-deficit countries. http://www.fao.org/countryprofiles/lifdc.asp?lang=en.

Further reading

Committee on World Food Security. Twenty-eighth Session. Rome, 6-8 June 2002. The LIFDC classification-an exploration, 2002. http://www.fao.org/docrep/meeying/004/y6691e/y6691e00.htm.

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Averaged aggregate governance indicators

Averaged aggregate governance indicators

What does this indicator tell us?

The world governance indicators of the World Bank Institute define governance as the traditions and institutions by which authority in a country is exercised. This includes the process by which governments are selected, monitored and replaced; the capacity of the government to formulate and implement sound policies effectively; and the respect of citizens and the state for the institutions that govern economic and social interactions among them. The world governance indicators measure six broad definitions of governance, capturing the key elements of this definition:

·   Voice and accountability: the extent to which a country's citizens are able to participate in selecting their government, as well as freedom of expression, freedom of association and free media;

·   Political stability and absence of violence or terrorism: the likelihood that the government will be destabilized by unconstitutional or violent means, including terrorism;

·   Effectiveness: the quality of public services, the capacity of the civil service and its independence from political pressures and the quality of policy formulation;

·   Regulatory quality: the ability of the government to provide sound policies and regulations that enable and promote private sector development;

·   Rule of law: the extent to which agents have confidence in and abide by the rules of society, including the quality of contract enforcement and property rights, the police and the courts, as well as the likelihood of crime and violence; and

·   Control of corruption: the extent to which public power is exercised for private gain, including both petty and grand forms of corruption, as well as 'capture' of the State by elites and private interests.

How is it defined?

The averaged aggregate governance indicators in the NLIS country profile represent the aggregated average of the six world governance indicators. The indicators represent the views of thousands of stakeholders worldwide, including respondents to household and firm surveys and experts from nongovernmental organizations, public sector agencies and providers of commercial business information. The NLIS averaged aggregate governance indicators are calculated from the average of the z scores (a measure of standard deviations away from the mean) of the six world governance indicators. Each of the six indicators are expressed as the standard normal units, ranging from around -2.5 to 2.5. The higher the score a country has, the better the assessment has it received regarding the six governance elements.

What are the consequences and implications?

Policy-makers, civil society groups, aid donors and scholars around the world increasingly agree that good governance affects development. This consensus has emerged from a proliferation of empirical measures of institutional quality and governance, the investment climate and research (World Bank Institute, 2008).

For nutrition, the importance of good governance is reflected in the UNICEF conceptual framework of factors in the "control and management of resources influenced by political and ideological structures in society'' (Jonsson 1995). The SCN 5th Report on the World Nutrition Situation (SCN 2004) further shows how a nutrition perspective can help improve governance. Good governance is also recognized by countries themselves in the Voluntary Guidelines to support the progressive realization of the right to adequate food in the context of national food security (FAO 2004) as an essential factor for sustained economic growth, sustainable development, the eradication of poverty and hunger and the realization of all human rights, including the right to adequate food.

Source

World Bank. Worldwide governance Indicators. http://info.worldbank.org/governance/wgi/index.asp.

Further reading

FAO. Voluntary guidelines to support the progressive realization of the right to adequate food in the context of national food security, 2004. http://www.fao.org/righttofood/VG/vgs_en.htm.

Jonsson U. Towards an improved strategy for nutrition surveillance. Food and Nutrition Bulletin 1995, 16.

United Nations Standing Committee on Nutrition. The fifth report on the world nutrition situation: nutrition for improved development outcomes, 2004. http://www.unscn.org/layout/modules/resources/files/rwns5.pdf.

World Bank Institute. Governance matters.. http://info.worldbank.org/governance/wgi/resources.htm

Kaufmann D, Kraay A and Mastruzzi M. The Worldwide Governance Indicators: Methodology and Analytical Issues (September 2010). World Bank Policy Research Working Paper No. 5430. http://ssrn.com/abstract=1682130

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Gender Inequality Index (GII)

Gender inequality index (GII)

What does this indicator tell us?

The Gender Inequality Index (GII) provides insights into gender disparities in health, empowerment and labour market. Unlike the HDI, higher values of the GII indicate worse achievements.

How is it defined?

The Gender Inequality Index is a composite measure reflecting inequality in achievements between women and men in three dimensions: reproductive health, empowerment and the labour market.

·   The health dimension is measured by maternal mortality ratio and the adolescent fertility rate.

·   The empowerment dimension is measured by the share of parliamentary seats held by each sex and by secondary and higher education attainment levels.

·   The labour dimension is measured by women's participation in the work force.

It varies between zero (when women and men fare equally) and one (when men or women fare poorly compared to the other in all dimensions). The Gender Inequality Index is designed to reveal the extent to which national human development achievements are eroded by gender inequality, and to provide empirical foundations for policy analysis and advocacy efforts.

What are the implications?

Low status restricts women's opportunities and freedom, giving them less interaction with others and fewer opportunities for independent behaviour, restricting the transmission of new knowledge and damaging their self-esteem and expression. It is a particularly important determinant of two resources for care: mothers' physical and mental health and their autonomy and control over household resources. Low status restricts women's capacity to act in their own and their children's best interests. There is a demonstrated association between women's status and malnutrition in children.

Source

UNDP. Human Development Report. http://hdr.undp.org/en/statistics/.

Further reading

UNDP. The Gender Inequality Index (GII). http://hdr.undp.org/en/statistics/gii/

UNDP. Human Development Report 1995. Gender and Human Development. New York, United Nations Development Programme, 1995. http://hdr.undp.org/en/reports/global/hdr1995/

United Nations Standing Committee on Nutrition. Challenges for the 21st century: a gender perspective on nutrition through the life cycle, 1998 (Nutrition Policy Paper No. 17). http://www.unscn.org/layout/modules/resources/files/policy_paper_No_17.pdf.

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Gender Parity Index in primary level enrolment

Gender Parity Index in primary level enrolment

What does this indicator tell us?

This indicator of gender equality is also an indicator of Millennium Development Goal 3: to promote gender equality and empower women.

How is it defined?

The ratio of girls to boys, the gender parity index, in primary education is the ratio of the number of female students enrolled at the primary level of education to the number of male students. To standardize the effects of the population structure of the appropriate age groups, the gross enrolment ratio for each level of education is used. The gross enrolment ratio is the number of students enrolled in primary, secondary and tertiary education, regardless of age, as a percentage of the population of official school age for the three levels.

What are the implications?

Low status restricts women's opportunities and freedom, giving them less interaction with others and fewer opportunities for independent behaviour, restricting the transmission of new knowledge and damaging their self-esteem and expression. It is a particularly important determinant of two resources for care: mothers' physical and mental health and their autonomy and control over household resources. Low status restricts women's capacity to act in their own and their children's best interests. There is a demonstrated association between women's status and malnutrition in children. 

Source

Millennium Development Goals indicators database. http://mdgs.un.org/unsd/mdg/Default.aspx.

Further reading

United Nations Standing Committee on Nutrition. Challenges for the 21st century: a gender perspective on nutrition through the life cycle, 1998 (Nutrition Policy Paper No. 17). http://www.unscn.org/layout/modules/resources/files/policy_paper_No_17.pdf.

United Nations Statistics Division. Millennium Development Goals indicators. Goal 3. Promote gender equality and empower women. Target 3A: Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015. Indicator: 3.1 Ratio of girls to boys in primary, secondary and tertiary education. http://mdgs.un.org/unsd/mdg/Metadata.aspx?IndicatorId=0&SeriesId=611.

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Global Hunger Index

Global Hunger Index

What does this indicator tell us?

The global hunger index is a means of monitoring whether countries are achieving the hunger-related Millennium Development Goals. It can be used for international ranking.

How is it defined?

The global hunger index captures three dimensions of hunger: insufficient availability of food, shortfalls in the nutritional status of children and child mortality, which is to a large extent attributable to undernutrition. Accordingly, the index includes three equally weighted indicators: the proportion of people who are food energy-deficient, as estimated by FAO, the prevalence of underweight in children under the age of 5 as compiled by WHO and mortality rate of children under 5 as reported by UNICEF. In order to identify countries that are notably better or worse off with regard to hunger and undernutrition than would be expected from their gross national income per capita, a regression analysis is made of the global hunger index on gross national income per capita. Countries are ranked on a 100-point scale, with 0 and 100 being the best and worst possible scores, respectively.

What are the consequences and implications?

Hunger is one of the world's major problems and therefore one of its most important challenges. Hunger and undernourishment form a vicious circle, which is often 'passed on' from generation to generation: The children of impoverished parents are often born underweight and are less resistant to disease; they grow up under conditions that impair their intellectual capacity for the whole of their life. As of 2009, FAO estimates that 1.02 billion people are undernourished worldwide. This is the highest number since 1970, the earliest year for which comparable statistics are available.

The factors that contribute to a high global hunger index are:

·   Low income and poverty: Countries with high hunger indexes are overwhelmingly low- or low- to middle-income countries with high levels of poverty. Sub-Saharan Africa and South Asia are the regions with the highest global hunger indexes and the highest poverty rates.

·   War and violent conflict: These have been major causes of widespread poverty and food insecurity in most countries with high global hunger indexes.

·   General lack of freedom: The 15 countries with the highest global hunger indexes were consistently rated by the 'Freedom House Index' as non-free or partially free (with regard to political rights and civil liberties) in the period 2006-2008.

·   Women's status (in South Asia): Low women's status is an important contributor to child malnutrition, which in turn accounts for high global hunger indexes for South Asian countries.

·   Poorly targeted and delivered health and nutrition programmes: Well-designed, well-implemented health and nutrition services can reduce child malnutrition substantially. Many of the countries with high global hunger indexes, especially in South Asia, do not have effective health and nutrition services that reach the most vulnerable age groups (pre-pregnancy through 2 years of age).

GHI Severity Scale

Reference: IFPRI, 2012

Source

International Food Policy Research Institute. 2012 Global Hunger Index. http://www.ifpri.org/publication/2012-global-hunger-index.

Further reading

IFPRI. 2011 Global Food Policy Report. International Food Policy Research Institute, 2012. http://www.ifpri.org/publication/2011-global-food-policy-report

FAO. The State of Food Insecurity in the World 2009. Economic crises - impacts and lessons learned. Rome, Food and Agriculture of the United Nations, 2009. http://www.fao.org/publications/sofi/en/.

International Food Policy Research Institute and Concern Worldwide, 2008. http://www.ifpri.org/pubs/cp/ghi08.asp#rel.

von Grebmer K et al. The challenge of hunger 2008. Global Hunger Index. Bonn, Welthungerhilfe,

Welt-Hunger-Life, International Food Policy Research Institute and Concern Worldwide. The challenge of hunger 2007. Global hunger index: facts, determinants, and trends. Measures being taken to reduce acute undernourishment and chronic hunger. Bonn, 2007. http://www.zukunftsdorf.net/fileadmin/media/pdf/Pressemitteilungen/DWHH_GHI_english.pdf.

Wiesmann D. A global hunger index. Bonn, International Food Policy Research Institute, 2006. http://www.ifpri.org/divs/fcnd/dp/fcndp212.asp.

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Human development index

Human development index

What does this indicator tell us?

The human development index is a summary measure of human development.

How is it defined?

The human development index is a summary composite measure of a country's average achievements in three basic aspects of human development: health, knowledge and a decent standard of living. It is a measure of the average achievements in a country in three dimensions of human development:

·   a long and healthy life, as measured by life expectancy at birth;

·   knowledge, as measured by mean years of schooling and expected years of schooling; and

·   a decent standard of living, as measured by GNI per capita in purchasing power parity terms in US$.

The HDI sets a minimum and a maximum for each dimension, called goalposts, and then shows where each country stands in relation to these goalposts, expressed as a value between 0 and 1. The higher a country's human development, the higher its HDI value.

What are the consequences and implications?

The human development index is used to capture the attention of policy-makers, the media and nongovernmental organizations and to draw it away from the usual economic statistics to focus on human outcomes. It was created to re-emphasize that people and their capabilities should be the ultimate criteria for assessing the development of a country, not economic growth.

The human development index is also used to question national policy choices, to determine how two countries with the same level of income per person can have widely different human development outcomes. For example, two countries may have similar income per person, but the life expectancy and literacy differ greatly, so that one of the countries has a much higher human development index than the other. These contrasts stimulate debate on government policies on health and education, to determine why what is achieved in one country is beyond the reach of the other.

The human development index is also used to highlight differences within countries, between provinces or states, across genders, ethnicity and other socioeconomic groupings. Highlighting internal disparities along these lines has raised national debate in many countries.

Source

UNDP. Human Development Report. http://hdr.undp.org/en/statistics/.

Further reading

UNDP. The human development index. http://hdr.undp.org/en/statistics/hdi/.

Klugman J, Rodríguez F and Choi HJ. The HDI 2010: New Controversies, Old Critiques. Human Development Research Paper 2011/01. http://hdr.undp.org/en/reports/global/hdr2011/papers/HDRP_2011_01.pdf

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Seats held by women in national parliament

Seats held by women in national parliament

What does this indicator tell us?

This is an indicator of gender equality and empowerment of women and reflects Millennium Development Goal 3, to promote gender equality and empower women. Women's representation in parliaments is one aspect of their opportunities in political and public life, and it is therefore linked to women's empowerment.

How is it defined?

The proportion of seats held by women in national parliaments is obtained by dividing the number of parliamentary seats occupied by women by the total number of seats occupied. National parliaments consist of one or two chambers. For international comparisons, generally only the single or lower house is considered in calculating the indicator.

What are the implications?

Women are underrepresented in all decision-making bodies and political parties, particularly at the higher echelons. Women still face many practical obstacles to the full exercise of their role in political life. Low status restricts women's opportunities and freedom, giving them less interaction with others and fewer opportunities for independent behaviour, restricting the transmission of new knowledge and damaging their self-esteem and expression. It is a particularly important determinant of two resources for care: mothers' physical and mental health and their autonomy and control over household resources. Low status restricts women's capacity to act in their own and their children's best interests. There is a demonstrated association between women's status and malnutrition in children.

Source

Millennium Development Goals indicators database. http://mdgs.un.org/unsd/mdg/Default.aspx.

Further reading

Smith LC, Haddad L. Explaining child malnutrition in developing countries: a cross-country analysis. Bonn, International Food Policy Research Institute, 1999 (Food Consumption and Nutrition Division Discussion Paper No 60).  http://www.ifpri.org/publication/explaining-child-malnutrition-developing-countries.

United Nations. Indicators for monitoring the Millennium Development Goals. Definitions, rationale, concepts and sources. United Nations Development Group (United Nations Population Fund, United Nations Development Programme, Department of Economic and Social Affairs), New York, Statistics Division, United Nations, 2003 (ST/ESA/STAT/SER.F/95). http://mdgs.un.org/unsd/mdg/Resources/Attach/Indicators/HandbookEnglish.pdf.

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