Nutrition Country Profiles: Making the Most of Them
Introduction
With over 80 indicators1 for each of 193 UN member states, the Nutrition Country Profiles could be a valuable tool for those wishing to improve nutrition within their country. This note presents some ideas for how to make the most of the Profiles.
The note describes four broad areas that the Profiles can help advance: (1) understanding the nature and distribution of nutrition within the country, (2) identifying opportunities for action to accelerate improvements in nutrition, (3) identifying key data gaps that need to be filled, and (4) engaging with decision makers.
We use the Ethiopia data as our example of how to use a Profile . Any country could have been chosen.
Before exploring the four areas, it is useful to review the different blocks of indicators in each Profile.
Different Types of Data in the Profile
The data cover undernutrition outcomes (poor height attainment, thinness, micronutrient deficits) and outcomes related to other forms of malnutrition such as overweight, obesity and some diet related non-communicable disease. All age groups are covered: children and women of childbearing and all other adults. The drivers of good nutrition are covered at the nutrition specific level (intervention and practice coverage) and the underlying level (poverty, inequality, food security, water and sanitation, health access and girls enrollment rate). Finally the Profiles describe how enabling the environment is for nutrition improvement (policies, legislation, spending, institutional transformation and levels of government commitment).
The indicators were selected by the Independent Expert Group based on their ability to measure the things that the evidence tells us are the most important forms of malnutrition (in terms of mortality and wellbeing) and the factors that the evidence tells us are the most important drivers of malnutrition. [2]
Situation Analysis
The first thing to do is to get a picture of what the latest outcome data are telling us. Page 1 of the Profile does this.
The Economics and Demography section of the Profile tells us that extreme poverty rates in Ethiopia have almost halved in that past 10 years although under 5 mortality has declined only by about 10%. From the child anthropometry section (there are 14 million under 5’s) we can see that stunting is a severe problem (44%), wasting (10%) is well above the WHA target of 5% but under 5 overweight is only 2%. For the 2000-2010 period stunting has declined at a slower rate than extreme income poverty (57% to 44%). All socioeconomic groups show declines in stunting, but the better off groups show faster declines than the poorer groups. Anemia in women of reproductive age is 19% (East African average is 28%) and thinness is serious at 24%. Other micronutrient data (vitamin A, Iodine) are very old. Indicators on diet related non-communicable disease show relatively low levels of raised blood glucose and blood cholesterol, but 40% of the population is estimated to have raised blood pressure. Adult overweight rates are still below 10%.
So, the issues in Ethiopia are primarily related to undernutrition, although issues of high blood pressure are significant. The national declines in stunting are quite rapid and steady, but they are faster than the declines for the lowest socioeconomic groups. If we were to apply the global WHA targets to Ethiopia then the country would be off course for stunting, wasting and women’s anemia and only on course for under 5 overweight.
Identifying Opportunities for Action
Page 2 of the Profile is where we begin to get clues on opportunities for action. Which interventions and practices have low uptake and coverage? Which underlying drivers (food, water, sanitation, girls education) drivers and interventions seem to be relatively weak?
The first section of the intervention coverage reviews the continuum of care—practices and interventions during the first 1000 days that the evidence suggests make a positive contribution to healthy growth in a wide range of settings. For Ethiopia only 10% of births have skilled attendants while antenatal care rates are low at 19%. Exclusive breastfeeding is just above the WHA 2025 target of 50%. But more is better, and the rate of exclusive breastfeeding has not increased for the past 11 years. The coverage of other interventions ranges from 20% for iodized salt consumption to 75% for geographic coverage of severe acute malnutrition, so there is plenty of scope for getting those rates up to the target of 90%. Family planning is meeting 74% of need. But the real vulnerability is the state of infant and young child feeding, with both indicators at 5% or less suggesting that 95% of children 6-23 months of age do not eat enough food (quantity and quality).
At the underlying level—i.e. drivers that are not interventions or practices per se, but are known to be strongly linked to nutrition status—estimates of hunger have declined significantly in the past 14 years (from 56% to 35%) as has the quality of food supply as estimated by the % of calories from non-staple crops and the availability of fruits and vegetables in the food supply. These improvements do not seem to have translated into improved feeding of children 6-23 months of age. Women’s empowerment scores seem low. Female secondary enrollment rates for the most recent year are only at 11% in 2000 (compared to over 30% for Africa) and 22% of Ethiopian 18 year olds have already given birth. Ethiopia ranks 121 (out of 151) in the UNDP Gender Inequality Index. On health systems Ethiopia has below all-Africa average population densities for doctors and nurses & midwives. On access to improved water and sanitation progress is rapid but the levels of improved sanitation (37%) and improved water (52%) are low. The decline in stunting is impressive given the unpromising levels of underlying determinants. The latter are improving quickly but from a very low base. Strong and positive trends in government spending on social protection and education suggest the improvements in underlying determinants will improve.
Opportunities for action are clear: improve infant and young child feeding through complementary feeding programmes; dramatically improve secondary enrollment rates of girls and strengthen the population density of doctors and nurses/midwives. Other opportunities for action relate to policy and legislation: few provisions of the international code of marketing of breast milk substitutes are enshrined in law; nutrition does not feature as much in national development plans and economic policies as it does in many other countries (68th out of 83), wheat fortification legislation is rated as in the planning phase, and maternity protection, so crucial for child feeding of working mothers is still “partial”.
Identifying the Key Data Gaps
Ethiopia is actually one of the best performers when it comes to having data on many of these indicators. The data gaps are in the area of adolescent overweight and obesity rates and guidelines on diabetes and hypertension. The challenge for Ethiopia will be to continue conducting these surveys when external funding diminishes as Ethiopia’s economy grows (per capita GDP has doubled in past 10 years).
Engaging with Decision Makers
If there is an abundance of data to identify and guide priority actions, how to get the attention of key decision-makers? First, identify them. This requires talking with a balanced set of stakeholders. Think about them both as individuals and within their institutional context. Then think about how to influence them. Are they influenced by data? If so, think of key ways to get their attention on the extent and nature of the malnutrition problem (e.g. 5 key facts, 10 key myths, 3 things you did not know etc.). Then think about areas in which action seems obvious. Try to connect these to popular policy debates. If the decision makers are not influenced by numbers then try to think of stories (personal or otherwise), images and infographics that will connect.
Whether or not these decision makers use data, how to engage them? Both directly via face to face meetings with their staff, conversations with them at the fringes of meetings, inviting them to be on panels, indirectly via tweets, op-eds, blogs and by writing letters to newspapers. All of this takes effort and expertise. The nutrition country profiles should be a goldmine for those who seek to influence the policy process. The profiles also help to expose those who are seeking to influence the policy process in ways not supported by the data. If there are big data gaps, don’t despair, these can serve as good starting points for discussion: are the gaps because policymakers think there is no problem? Do they think the data will be low quality or not helpful for policymaking? They may well be right—we may be collecting data not because it is what is needed but because it is convenient. The absence of data can be as powerful a launching pad for policy dialogue and engagement as the presence of data, however the latter helps to identify areas for action.
Final Note
The Nutrition Country Profiles can be a useful tool, but like all other tools they only have value when used. We will be launching a country by country series of reports on the profiles, written by interested potential users who work in the country in question. They will reflect on the stories the profiles tell, compare them with the reality they see, and offer ideas for using the profiles and ways of making them more useful. If you are interested in writing one for your country write to [email protected]
[1] The data sources for each indicator are listed at http://www.globalnutritionreport.org/files/2014/11/gnr14_tn_n4g_01nutrition_country_profile.pdf
[2] The detailed rationale behind the selection of indicators is provided here http://www.globalnutritionreport.org/files/2014/07/Country-Profile-Indicators-Table.pdf