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WORKSHOP REPORT ON NUTRITION INFORMATION MANAGEMENT (NIM) IN AFGHANISTAN GHAZANFAR INSTITUTE OF HEALTH SCIENCE (GIHS), KABUL, AFGHANISTAN 16 - 17 JULY 2018
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WORKSHOP REPORT ON NUTRITION INFORMATION MANAGEMENT (NIM) IN AFGHANISTAN
GHAZANFAR INSTITUTE OF HEALTH SCIENCE
(GIHS), KABUL, AFGHANISTAN 16 - 17 JULY 2018
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Table of Contents
INTRODUCTION ................................................................................................................................... 3
EXECUTIVE SUMMARY ........................................................................................................................ 3
BACKGROUND ..................................................................................................................................... 5
METHODOLOGY .................................................................................................................................. 6
SUMMARY OF WORKSHOP CONTENTS ........................................................................................... 7 OPENING REMARKS .............................................................................................................................................. 7
Session 1: Introduction to Nutrition Information Management and Data Environment in Afghanistan ............................................................................................................................................ 7
Session 2: Nutrition data sources, Methodologies and Use ............................................................... 11
Session 3: Triggering factors for conducting different assessments. ................................................ 19
Session 4: Standardization of SMART and Rapid SMART tools and templates. ............................... 19
Session 5: Data utilization and dissemination. ................................................................................... 19
Session 6: Complementarity of different sources of nutrition information for effective decision making .................................................................................................................................................. 21
ANALYSIS OF THE WORKSHOP CONTENTS................................................................................... 22 ENHANCING NUTRITION INFORMATION MANAGEMENT IN AFGHANISTAN ...................................... 22 BEST PRACTICES .................................................................................................................................................. 23 LESSONS LEARNT ................................................................................................................................................ 23
CONCLUSIONS ................................................................................................................................... 24
RECOMMENDATIONS ....................................................................................................................... 25
ANNEX 1: WORKSHOP AGENDA ..................................................................................................... 27
ANNEX 2: LIST OF PARTICIPANTS .................................................................................................... 29
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INTRODUCTION
This report is divided into seven sections namely; the executive summary, background information, methodology, summary of workshop contents, analysis of the workshop contents, conclusions and recommendations. Attached to this report are annexes for the workshop program/agenda and the list of workshop participants.
EXECUTIVE SUMMARY A two-day long workshop was organized by the Public Nutrition Directorate (PND) and Action Against Hunger-Afghanistan mission in Kabul to provide a platform for knowledge and information sharing on nutrition information management and quality assurance mechanisms. The workshop was attended by 29 participants including representatives of different departments of MoPH (EHIS General Directorate – HMIS, NDSRR directorates and PND), NGOs and BPHS partners implementing nutrition projects, Nutrition Cluster, WHO, FEWSNET, and Global Affairs Canada.
The Kabul workshop focused on issues aimed at enhancing the impact of nutrition information
management in Afghanistan with the following objectives:
1. Have an understanding of the current information management and data situation in Afghanistan
2. The difference types of population level surveys, data collected in each, frequency and use
3. Clear triggering factors/criteria for conducting different nutrition assessments in Afghanistan
4. Clearly defined standard indicators, corresponding tools and templates
5. Clarity about roles and responsibility in terms of nutrition surveillance and M&E among the different departments of MoPH, the nutrition clusters and partners.
6. The complementarity of different sources of nutrition information for effective decision making process.
It was pointed out that, nutrition information entails addressing the underlying determinants of collecting data in a standardized approach on childhood malnutrition and incorporating this evidence in setting of goals and specific activities during project design. Ensuring that BPHS projects/partners are using the most accurate and recent data on nutrition therefore entails incorporating nutrition surveys as part of the overall situational analysis on a regular basis through embedding nutrition surveys and surveillance in the MoPH Monitoring and evaluation framework, while establishing linkages with other nutrition sensitive sectors that deal with other underlying causes of malnutrition. Enhancing the Nutrition information outlook of Afghanistan will also entail strengthening multi-sectorial linkages across relevant sectors for coordinated assessments, programming design, implementation, monitoring and evaluation.
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In consideration of the multiple departments of MoPH, linkages among the relevant directorates are critical. It was particularly noted during the workshop that centralization of validation platform through the Assessment & Information Management Working Group (AIM-WG) is a central element in improving the coordination mechanism of nutrition data and information at MoPH level.
The following are some of the key recommendations that emerged from the discussions:
Considerable momentum by donors, clusters and actors towards multi-sectorial programming across sectors.
Scaling up the role of (AIM-WG) in validation of nutrition surveys and management of nutrition information.
Involving the research and evaluation department and IRB in the Assessment working group to enhance coordination of nutrition information and management.
Standardizing indicators, tools and templates for surveys at sub-national level is important to ensure consistency of data.
Complementarity of different information management systems and data collection methods is critical to be clearly articulated and embedded with the MoPH monitoring and evaluation framework
Picture: Dr. M. Homayoun “Ludin” delivering his speech
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BACKGROUND
Since National Nutrition Survey (NNS) was conducted in 2013, there has been no other nationwide assessment conducted. In 2014, Action Against Hunger in collaboration with Public Nutrition Directorate (PND) with financial support of OCHA took step and started to conduct nutrition assessments in different provinces of Afghanistan in order to provide updated information to all relevant stakeholders. So far, AAH Afghanistan mission conducted around 29 SMART assessments, 13
Rapid SMART and around 27 SQUEAC since 2014.
In 2016 the nutrition cluster, Action Against Hunger and PND organized “Multi Sectorial Data Clinic workshop” with participation of Cluster Coordinators from FSL, WASH, Nutrition and Health. In this workshop, all the clusters came up with indicators for rapid and in-depth assessments. However, as a result of turnover both at nutrition cluster, AAH and PND - there was limited follow up of the actions and recommendations from this workshop. The proposed and agreed upon indicators remain in the report of the workshop. Hence, there is need for a technical triggering from nutrition stakeholders to review all these indicators and develop standard multi-sectorial SMART indicator matrix, and necessary tools to effectively collect data at population level.
All the data collected from SMART surveys is shared with the PND and nutrition cluster at national level, as well as the BPHS partners and Provincial Public Health Directorate (PPHD) at provincial level. In Afghanistan there are different sources of data and information e.g. National and sub-national surveys, the nutrition surveillance from sentinel sites, HMIS data from HFs and community health workers (CHW), etc. These data are often not well used, compiled analyzed, and utilized. The nutrition cluster, PND and other nutrition stakeholders were brought together to review the different data sources and come up with a clearly defined approach to maximize the use of these different sources of data and information for decision making. The two days workshop was organized to facilitate a brainstorming of these different sources of data and information in order to provide a scope to guide better data utilization and sensitization to different stakeholders for efficient uptake to survey/research findings and recommendations.
The following are the main expected results of the two days’ workshop: - Develop/adapt standardized and harmonized SMART and Rapid SMART Questionnaires with
corresponding indicators. - Having standard and harmonized nutrition assessment matrix. - Standard tools as triggering factors for area prioritization process. - Standard survey reporting and analysis tools and template. - Understanding the complementarity and/or duplication of different assessments and data sources
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The Nutrition Workshop held on 16th to 17th July, 2018 at Ghazanfar institute of Health Science (HIS) was attended by 29 participants including representatives of NGOs and partners implementing BPHS and nutrition projects, Ministry of Public Health, UNICEF, FEWS-NET, Global Affairs Canada, WHO and Public Nutrition Directorate. This was a follow up of a similar workshop on multi-sectorial assessment in November 2016 at OCHA office, where participants underscored the importance of designing standardized methods for multi-sectorial rapid and in-depth assessments. While the 2016 workshop focused mostly on multi-sectorial assessments, this workshop focused on issues aimed at enhancing the impact of nutrition information management and data utilization for stakeholders working in the field of nutrition and those regularly utilizing nutrition data and information from other sectors. The workshop had the following objectives:
1. Have an understanding of the current information management and data situation in Afghanistan
2. The difference types of population level surveys, data collected in each, frequency and use
3. Clear triggering factors/criteria for conducting different nutrition assessments in Afghanistan
4. Clearly defined standard indicators, corresponding tools and templates
5. Clarity about roles and responsibility in terms of nutrition surveillance and M&E among the different departments of MoPH, the nutrition clusters and partners.
6. The complementarity of different sources of nutrition information for effective decision
METHODOLOGY
This was an interactive workshop characterized by robust discussions and active participation by participants. A mix of methods was used in facilitation including: power- point presentations, group work sessions, group work presentations and plenary discussions. Dr. M. Homayoun "Ludin", Director of Public Nutrition Directorate of MoPH, officially opened the workshop that comprised of a total of 6 sessions.
See detailed workshop agenda in Annex 1.
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SUMMARY OF WORKSHOP CONTENTS
OPENING REMARKS
In his opening remarks, the Director of Public Nutrition Directorate observed that the main investment of nutrition in Afghanistan is in ensuring collection of high quality and reliable data particularly SMART surveys at provincial level, with other major investments being in routine data and surveillance system. With respect to support towards the PND, the focus has been shifting from using the NNS 2013 to updating the nutrition sector with integrated SMART survey results that have been instrumental in giving an update of the nutrition situation and inform PND and stakeholders on where to focus their efforts and resources to combat malnutrition. The cluster coordinator spoke of the importance of data and information management for emergency response. He sighted the use of Rapid SMART methods to provide reliable data within a short timeframe. This has allowed the nutrition cluster to respond to emergencies in a timely manner as well as use the data to mobilize resources for emergency response. He sighted the use of SMART and Rapid SMART survey data for the Humanitarian needs overview (HNO) and Humanitarian response planning (HRP). The Deputy Country Director for Action Against Hunger Afghanistan, spoke about the importance of having clearly defined processes for data collection and information management. She mentioned that without clearly defined steps and processes nutrition data would not have the same of quality and reliability that can exude confidence of stakeholders to invest in nutrition. She mentioned that data and information management is a systematic process that needs to be respected from planning to utilization of data. If one of the key steps is skipped, then the reliability and confidence in the outcome will not be achieved.
Session 1: Introduction to Nutrition Information Management and Data Environment in Afghanistan This session was focused on introducing the nutrition information environment in Afghanistan. Specifically,
1. Introduction to Nutrition Information Management 2. Current Nutrition Information Management in Afghanistan 3. Contextual Analysis 4. Technical Analysis
The Nutrition Cluster Information Management Officer (IMO) presented the session. He mentioned that there are different sources of nutrition information in the country. These different sources play different roles in providing the much needed data and information for decision making at both government and cluster level.
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Figure 1: Nutrition Information Management in Afghanistan
The presenter indicated that the different sources of information and data are usually managed at different levels and with different stakeholders. Figure 1 above provides a summary of the different sources of information and data and how /who is responsible in conducting and managing that data. The main observation from the presenter is the need for coordination and understanding of these different stakeholders and information management systems so as to achieve a better and holistic understanding of the nutrition outlook in Afghanistan. Currently the system is fragmented and disconnected, with different sources not synchronized nor coordinated together. The presenter also shared the situation in relation to the nutrition information systems currently existing in Afghanistan (see figure 2 below). In the presentation the clear message was that Afghanistan has invested in diverse sources of nutrition information, however these sources do not necessarily
•Routine IMAM program
monitoring data, Supplies
•Facility and Community based
longitudinal Surveillance
through HMIS
•Sub-national level representative Assessments
(SMART, SQUEAC, KAP)
•National Surveys (DHS, MICS, NNS
etc.)
MoPH (with multiple
directorate), CSO, UN Org.
AIM-WG, PND, MoPH, Cluster
Nutrition Cluster, PND,
MoPH
PND, HMIS, MoPH
NGO, INGO,
BPHS IP
NGO, INGO,
BPHS IP
National level
HF&IP
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Figure 2: Nutrition Information systems in Afghanistan
In this session there was also a presentation on the coverage of assessments using the SMART
methodology across the country. What was visible from this presentation was the number of provinces
that are above the emergency thresholds in relation to prevalence of malnutrition as well as the number
of provinces that are yet to be assessed (using old data from NNS 2013). The summary of this information
is presented in the map below.
Nutrition Service Statistics
Nutrition Database
HMIS
Surveillance
NNSS
Localized nutrition monitoring, Surveys and
Research
Nutrition Monitoring Checklist
SMART/Rapid Survey
Nutrition Coverage Survey
National HHS
DHS
AHS
NNS
MICS
Nutrition Sensitive
Information
SFSA/ EFSA
- SMART
- ALCS/ NRVA
- IPC
- DEWS
- FEWSNET
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This session also looked at the challenges and limitation in relation to data and information management in Afghanistan. Some of these limitations and challenges were:
• Limited data accessibility. • Limited Backup and recovery. • No central storage location. • Weak data use (specifically for program management) • Weak data analysis and validation process. • No proper system for data feedback mechanism and strict accountability for different stakeholders • Weak planning of HHSs (local and national)
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Session 2: Nutrition data sources, Methodologies and Use
This session explored the different sources of nutrition information in Afghanistan, the different methodologies applied in collecting data at different levels of the country and finally the way all this information is being used to inform decision making and influence policy in relation to malnutrition. The presentation was prepared and delivered by the Nutrition Surveillance Head of Department for Action Against Hunger Afghanistan mission (Bijoy Sarkar). The session’s objectives are as indicated below.
1. National and Sub-national level surveys 2. Routing monitoring and sentinel site
based surveillance
3. Different methodologies 4. Frequency and representativeness 5. Indicators collected (Nutrition & Other
sector) 6. Advantage and Limitations
The presenter aimed to highlight the different types of surveys conducted in Afghanistan with a focus on two main levels, (a) National level surveys (b) sub-national level surveys. At the national level in Afghanistan there are a number of surveys conducted over a period of time e.g. The Demographic Health Survey which is conducted every 5 years, the Afghanistan Health survey (AHS) conducted every 4 years, the National nutrition survey (NNS) no defined period yet. All these surveys include nutrition indicators at different levels. The presenter aimed to cover how these surveys collect nutrition data, the scope of coverage, frequency and the level representativeness. Table 1 below provides a summary of the information in relation to national surveys. Sub-national surveys on the other hand are conducted mainly at provincial and district levels. The most commonly conducted sub-national level surveys in Afghanistan use the SMART methodology. These are either comprehensive multi-sectorial SMART surveys at provincial level or Rapid SMART surveys at district level. Table 2 below provides a summary of what information is collected using these 2 methodologies, the frequency, scope of coverage and the advantages and limitation of each of the
methodologies.
Picture: Group discussion by the participants
Table 1: Population level representative surveys- National level surveys
AfDHS MICS AHS NNS
Methodology Cross
sectional,
stratified two
stage sample
design with
25,974 EA as
sampling
frame.
Cross
sectional,
stratified two
stage sample
design with
21,194 EA as
sampling
frame.
Cross sectional,
two stage cluster
sampling using
NNS 2013 EA as
sampling frame
(30 cluster per
province & 23
HHs per cluster)
Cross sectional,
stratified two
stage cluster
method with
21,194
EA/cluster as
sampling frame.
30
cluster/province
and18
HH/cluster.
Representativeness National and
Provincial
Level. Further
disaggregated
by Urban &
Rural, by Sex,
by wealth
quintile
National,
Regional (8),
further
disaggregated
by wealth
quintile,
mother’s
education,
Urban vs
Rural.
Country and
provincial level
Country and
provincial level
Frequency 2015 was
the first
DHS in
AFG
1997, 2003
then 2010/11
2006, 2012,
2015 & 2018
Once done in
2013
When it was done
last?
Year 2015 2010-2011 2015 (2018 is
ongoing)
2013
Survey Coverage Whole
country (34
provinces)
Whole
country (8
regions)
Entire country
(34 provinces)
Entire country
(34 provinces)
Major Nutrition and
related Indicators
-Selected
IYCF
Indicators
-MN Suppl.
for children
and women
- Stunting,
Wasting,
Underweight
of U5
- U5MR, IYCF,
Vit-A Supple,
Salt
Iodization,
Anemia (U5 &
Women),
2015 and
previous AHS
didn’t have any
nutrition
indicators, 2018
AHS
incorporated
stunting,
wasting,
underweight,
IYCF, vitamin A
supplementation,
etc.).
The most
comprehensive
nutrition survey
that covered
almost all the
key nutrition
indicators (i.e.
Child nutrition,
micronutrient
status, IYCF,
Vit-A supple) as
well as WASH
and FSL
Advantage &
Limitation
Adv: Provide
country and
provincial
level
representative
estimate,
wider
acceptance.
Lim: Very
costly, didn’t
include
Anthro
Adv:
Providing
country level
representative
data, cover a
wide range of
health,
nutrition and
other
nutrition
sensitive
sectorial
Adv: National
and provincial
level
representative
data
Lim: Apart from
2018 AHS,
previous AHS
didn’t have any
nutrition
indicators. Even
2018 AHS only
Adv: National
level
representative
survey covering
a wide range of
nutrition
indicators.
Lim: Data
become old
already (almost
5 years now) for
decision making
indicators,
frequency is
4-5 years.
indicators.
Lim: Costly,
Provincial
level data not
available.
has five nutrition
indicators. No %
wasting by
MUAC
and resource
mobilization.
Table 2: Population level representative surveys- Sub-National level surveys
SMART Rapid SMART
Methodology Cross sectional, two stage
cluster sampling or Simple
Random Sampling (SRS) using a
defined sampling frame
Cross sectional, fixed sample
methodology using modified
SMART for a smaller geographic
location for quick assessment.
Representativeness Up to provincial level Usually a specific location (i.e.
Camp, IDP settlements) or 1-2
districts (max).
Frequency Need based (usually yearly) Need base
When it was done last? Every year in high priority
provinces
Every year in hotspot locations
Survey Coverage Entire province (All districts) Specific emergency locations (i.e.
Camp, IDP settlement, 1-2 districts
Major Nutrition and related
Indicators
- Child & PLW nutritional status
- Mortality & IYCF
- Health (Vaccine, morbidity)
- WASH & FSL
-Mainly anthropometry of children
- Few additional variables like child
morbidity and PLW MUAC
Advantage & Limitation Adv: Population level
representative data at provincial
level, standardized
methodology and tools like ENA
software.
Lim: Due to limited number of
surveys, unable to repeat survey
in same location in a yearly basis
Adv: Quick and easy to conduct
maintaining data representation at
a smaller location. Most cheaper.
Lim: Can’t cover big area like a
province due to smaller sample.
Only few indicators are collected
like Anthro and PLW MUAC.
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The other main source of nutrition information in Afghanistan is routine data collected on a regular basis from health facilities. Routine data sources in Afghanistan is mostly divided into 2 main key sources
a) Routine health facility data – PND database and HMIS b) Nutrition surveillance sentinel sites at both health facility and community level.
The routine health facility data is collected and reported on a monthly basis and covers information on screening and performance indicators (cure rate, default rate, non-response). This data is currently collected by two parallel systems. The UNICEF/PND database is the main source of information and data for nutrition actors in Afghanistan, this system is currently not integrated with the Ministry of Health information system and only serves to provide information to nutrition actors/stakeholders. On the other hand, the HMIS also collects nutrition information but at a minimal level (Screening data). The information collected in HMIS is integrated within the other sectorial indicators in the Ministry of Health. One of the main limitation to nutrition information and data use in Afghanistan is the current structure of routine data collection and reporting. The recommendation from the workshop was to ensure an integration of the IMAM database into the HMIS in order to ensure that there is one platform for integrating nutrition information with other health data collected at health facility level. The Nutrition surveillance system on the hand is a set of sentinel based surveillance at health facility and health post level that collects data on a number of indicators for children under 2 years e.g. wasting (WHZ and/or Edema) and MUAC, Stunting (HAZ) Underweight, Birth outcomes (Low birth weight, Neural Tube Defects) Hemoglobin status in pregnant women (indicator for anemia) Infant and young child feeding practices (Early Initiation of breast feeding and continuation of BF) ARI, Diarrhea Measles and Vitamin A supplementation. This session ended with a group exercise where participants were grouped into 3 main stakeholder groups
1. Donors and cluster 2. Government –MoPH 3. INGOs, NGOs and BPHS partners
Each group was tasked with the following questions?
1. How are the different nutrition information sources utilized by each stakeholder group? 2. How Effective are the different data sources in terms of decision making and resource
mobilization? 3. What are the advantages and limitations of different data sources?
The summary of each group is presented in the tables below.
Table 3: Donor and Cluster group
Utilization of different sources of nutrition information
Effectiveness (Decision making and resource mobilization)
Advantage and limitation of data sources
National Surveys (AfDHS, AHS, MICS, NNS etc.)
Mainly used by donors and cluster partners
- Effective data for decision making at national level by donors and clusters - Used for resource allocation by donors
Adv: more valid and accurate. Easy for review by donors
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Lim: Long duration (frequency), Cost effectiveness (costly)
Sub-national surveys (SMART, Rapid SMART)
Used mainly for humanitarian situation and
context
Used for update information availability in emergency situation
Adv: Small scale and complete information captured Lim: Limited representation (up to provincial level only)
Routine data (HMIS, IMAM) Used mainly for target
setting and baseline data
Mainly used for result based functioning (RBF) and performance based results
Adv: Updated semi-annually Lim: Limited nutrition information as most of the indicators are for health
Surveillance (HF & HP) Used sporadically by cluster
partner
Used for having further explanation
Adv: Quick trend Lim: Not representative, Quality of data and accuracy of the information.
Table 4: Government_ MoPH group
Utilization of different sources of nutrition information
Effectiveness (Decision making and resource mobilization)
Advantage and limitation of data sources
National Surveys (AfDHS, AHS, MICS, NNS etc.)
1. Annual strategic plan and policy
2. Target setting 3. Program scale-up 4. Fund raising 5. Multi-sectorial
collaboration is enhanced by this kind of survey
Need base planning and to estimate the nutrition status
Advantages: 1. Used for planning,
Policy making (+) 2. Information sharing
with stakeholders (+) 3. Advocacy (+) 4. Fund raising (+) 5. Make aware us of
current situation (+) Limitation: 6. Costly (-)
Sub-national surveys (SMART, Rapid SMART)
-Emergency response Appeal -Target setting -Program scale-up
Timely response and for resource mobilization
Advantage: Small scale and complete information captured Limitation: Limited representation (up to provincial level only)
Routine data (HMIS, IMAM)
Used mainly for target setting and case load calculation
Mainly used for result based functioning (RBF) and performance based results
Limitation: Accuracy and validity is a question (-)
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Surveillance (HF & HP) target setting, caseload calculation
Used for having further explanation
Limitation: Maybe not representative (-)
Table 5: Group 3- INGOs, NGOs and BPHS partners
Routine information from health facility and health posts
AF - DHS NNS, MICS, AHS Rapid SMART
Utilization
- Caseload calculation - Resources input - Functionality - HR - Decision making policy and strategy - Resource estimation and proposal writing
- Don’t used by NGO for caseload or resource input based on the AF-DHS - Very limited utilization by NGO working at the provincial or district level - Mainly used for policy and strategy at national level
- Baseline setting - Target setting - Proposal writing - Planning
- Mainly used for emergency response
Effectiveness (Decision making and resource mobilization)
- Provincial level (HF & HP) - National level
-National level - Provincial level - Nation level
Used at all level
Advantage and limitations
Time, resources, Reliability, Scope of indicators, Frequency, Workload (HF) and limited representativeness (-)
- National level figure, situation (+). - 2-5 years’ frequency (-) - Budget constraints (-) - No access to some cluster due to insecurity (-) - Community Load (-) because of the very long questionnaire
- National and provincial level representation (+) - 5-10 years for some surveys (-) - MICS is multi-sectorial (+)
- Provincial representation for SMART (+) and small area for Rapid SMART (+) - Number of days (6 days0 for the training is not sufficient to ensure quality data (+) - Reliability of RNS in some area is ? (-)
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Session 3: Triggering factors for conducting different assessments.
This session aimed to identify triggering factors that will be able to help stakeholders in Afghanistan prioritize locations where nutrition surveys need to be conducted. Due to the vast size and complex contextual situation (security and access) in most provinces of Afghanistan, it is quite complex to effectively conduct nutrition surveys at sub-national level across all provinces every year. Currently the capacity to conduct surveys in all provinces of Afghanistan is limited. BPHS partners do not have the budget nor the technical capacity to conduct surveys at sub-national level. In Afghanistan the humanitarian situation varies across regions and provinces. In order to ensure optimal targeting of provinces that are in most need of assessment the nutrition stakeholders proposed to develop a prioritization matrix. This matrix is aimed to provide technical guidance to the AIM-WG and partners based on existing data and evidence. The proposed matrix will include a number of key indicators that can be considered to define a threshold for prioritization. Some of these indicators are; GAM rate (WHZ <-2SD and/or presence of Oedema), Crude Death Rate/10000/day, U5MR/10000/day, % of infants & young children have access to acceptable diet, IPC Acute Food Insecurity, rCSI (Only if IPC data is not available) and Recurrent onset of emergencies (IDPs, Flooding, disease outbreaks etc.). Seasonality and trends of malnutrition using routine health facility data were currently not considered for Afghanistan mainly due to the quality and reliability of routine health facility data on nutrition and the fact that currently surveys conducted are not following seasonal patterns. In the future, these two criteria can be considered as part of the prioritization matrix.
Session 4: Standardization of SMART and Rapid SMART tools and templates. In this session participants were engaged in a group exercise that involved a process of building consensus on standardized tools and templates for conducting SMART and Rapid SMART surveys in Afghanistan. The aim of this exercise was to ensure that the tools used for collection of data using these methodologies were harmonized across the country. This process of harmonization involved defining which key indicators are most relevant to be collected using these methodologies, how are these indicators going to be used by the different stakeholders in the country and whether or not there are other better methods to collect these indicators aside from SMART and Rapid SMART. The session was instrumental in providing guidance to the stakeholders on streamlining and harmonizing the way sub-national surveys are conducted in order to ensure optimal use of data collected as well as make the surveys affordable, and easy to conduct.
Session 5: Data utilization and dissemination.
This session focused on defining the dissemination and utilization methods/techniques for nutrition data and information in Afghanistan. During this session, participants discussed the different ways that nutrition data is utilized in Afghanistan. Nutrition data is currently being used for Integrated phase classification, Humanitarian response planning, and humanitarian needs overview, caseload calculation, as well as for advocacy purposes. Currently data utilization has not been optimal in the country. The need to consider data management and information as a government led initiative is still weak and and not well structured. – The Public Nutrition Directorate is currently the chair of the AIM-WG in Afghanistan and takes the lead role in management of nutrition data from different sources as well as ensuring the regular and consistent use of this data for
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decision making and policy. The existence of a technical working group is a big step towards ensuring better utilization of data and information, however the structure of the AIM-WG is affected by the low level of participation from partners. Lack of a structured approach to data management and utilization. There is currently no pre-defined approach on how data is managed, stored and utilized. A recommendation was proposed to design a nutrition assessment matrix. The matrix will considerably provide a platform for collecting and sharing relevant data from surveys conducted in different parts of Afghanistan.
Session 6: Complementarity of different sources of nutrition information for effective decision making This session looked at the different sources of nutrition information and how they complement each other. Currently in Afghanistan there are many different data sources for nutrition. The aim of this session was to reflect on how these tools are complementing each other and how the complementarity can be used to provide a holistic picture of the nutrition situation in the country. Figure 2 below provides a summary of the complementarity of nutrition information and data sources in Afghanistan. Figure 3: Complementarity of nutrition sources, Afghanistan 2018
Health facility Routine data collection (PND database) NNS 2013
National Nutrition surveillance system (sentinel based. Health Facility /Community)
Health Management Information System (HMIS) MoPH hosted.
AHS 2018
Small scale surveys – SMART & Rapid
Year 1
Year 2 Year 3 Year 4 Year 5
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ANALYSIS OF THE WORKSHOP CONTENTS
ENHANCING NUTRITION INFORMATION MANAGEMENT IN AFGHANISTAN
Nutrition information management entails designing and setting up systems, tools and methods in a clearly defined way to ensure that data and information is regularly collected, analyzed and used to inform decision making from programmatic perspective, resource allocation, prioritization of vulnerable populations and policy development that deliberately incorporates nutrition goals and actions. There is ample evidence to show that direct actions to address the immediate determinants of under nutrition can be further enhanced by actions that aim to strengthen and structure nutrition information management in Afghanistan. Therefore, a perfect scenario is where nutrition data and information from the different sources both at facility and population level become delivery platforms for nutrition interventions. The double advantage in such a setting is the fact that improving nutrition information management can help nutrition program achieve better coverage and reach the most vulnerable groups in the country. Since Afghanistan applies integrated programming, it is also important to not only strengthen the nutrition information management systems, but also to ensure that there is a clear integration plan of such a system with other sectorial information sources in order to have a holistic understanding of the impact and effect of malnutrition and its contributing factors. It has been established for example that under nutrition is a key shared risk factor for morbidity and mortality associated with diarrhea and pneumonia (Bloomberg et al April 2013). Therefore, collecting multi-sectorial data using reliable and accurate methods has a significant potential to enhance other health outcomes. An Integrated nutrition information management system has ideally two broad agendas:
1. Incorporating nutrition specific information and data that deal with the immediate determinants of nutrition and;
2. Establishing linkages with other nutrition sensitive programs that deal with other underlying causes of malnutrition.
On a practical level and in general terms, enhancing the Nutrition-information systems entail strengthening multi-sectorial linkages across other relevant sectors for coordinated assessments and incorporating nutrition objectives, actions and indicators consistently in multi-sectorial assessment,
program design, implementation, as well as monitoring and evaluation.
Establishing linkages In consideration of the multiple determinants of nutrition, linkages among the relevant information systems and data sources by different players are critical. It was particularly noted during the workshop that promotion of multi-sectorial assessments and indicators is a central element in improving the integration approach to programming. Additionally, it was noted that partners like FEWSNET and IPC are working with both the Ministry of Agriculture and Ministry of Public Health to support information and data management from an integrated lens. Strong linkages are also at play when it comes to supporting processes for mobilizing resources towards the nutrition agenda e.g. HNO and HRP processes and SEHAT funded projects. Therefore, understanding the dynamics at play during the budgeting processes specifically for SEHAT-BPHS at provincial level is important. Of critical concern are the political and social interests because the entire process is normally political. In overall terms, the BPHS projects seem to be
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weak in the area of nutrition information management and data collection at population level.
BEST PRACTICES
This part of the report is lacking in-depth understanding and consensus. This is due to minimum evidence reported/presented at the workshop worthy of considering as ‘best practice’. For an aspect to be regarded as best practice there must be clear demonstration of results in line with stated objectives. Some of the content as presented below could, with further documentation, pass for best practices but for now they remain emerging best practices and they include:
Considerable momentum by donors and actors towards multi-sectorial assessment across sectors
Scaling up the role of AIM-WG in influencing nutrition data quality and dissemination mechanisms
Integrating nutrition assessments in BPHS projects and grants.
On-going studies to understand the dynamics at play in relation to use of reliable, timely and accurate data from surveys or health facility routine data during the budgeting processes for nutrition at both emergency and development situation
LESSONS LEARNT
Delivering at scale requires a combination of system resources from different players. Without collaboration and effective linkages, setting up and scaling effective and efficient nutrition information management systems generally becomes hampered and not cost effective. The assumption that the nutrition survey knowledge provided to health workers and BPHS partners translate into action in nutrition assessments is not correct. This bring into question the many capacity building sessions in form of training that have been heavily invested in Afghanistan. The best approach to ensuring optimal use of the trained expertise is a combined commitment from all relevant stakeholders to utilize these trained teams at both central level for quality assurance at AIM-WG and actual implementation at province level. Besides capacity building, another notion that is normally held is the assumption that there is no sufficient number of technical personnel to implement programs, which is likely the case. However, the PND, MoPH and partners should therefore clearly plan for these capacity gaps from the design phase. The need to be rigorous towards effective monitoring and evaluation of the existing structures and systems for information management and achievement of objectives respectively is summed up in the statement “What gets measured gets managed”. Without sufficient and timely information on programs, operations become a management crisis. Nutrition information management in Afghanistan currently faces a challenge in terms of being clearly embedded in national policies, strategies, plans and implementation. It is the role of Ministry of Public Health and Public Nutrition Directorate to realize the need to adapt such policies to include and integrate the designed information management structures and put these policies into relevant practice.
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CONCLUSIONS
With regard to improving nutrition information management in Afghanistan, there is a great need to have multi-stakeholder engagement and commitment. This 2 days’ workshop worked as a starting point of a long strategic engagement and discussions that will need to be done to ensure the optimal structure of nutrition information and data is clearly mapped and embedded within the policy framework of MoPH. Relevant multi-sectorial platforms both at national and province level are required in executing the process and methods of collecting high quality, reliable data at health facility and population levels. Currently there is poor stakeholder coordination with different sectors and players working vertically or in silos leading to inadequate data collection and utilization. This in turn has severely affected the quality of nutrition interventions in Afghanistan at all levels (designing, planning, implementation, monitoring and evaluation).
RECOMMENDATIONS Table 6 presented below contains both recommendations and ways forward discussed during the NIM Workshop, as well as in collaboration with the AIM-WG following the workshop. Table 6: Nutrition Information Management Recommendations
Identified Problem or Challenge Recommendation
1. Current nutrition information system is disconnected and fragmented
1. The functionality and existence of AIM TWG should be officially endorsed by MoPH leadership 2. Strengthening of the capacity and authority of AIM-WG by engaging all the relevant directorates of
MoPH plus all other relevant partners to ensure quality control of surveys and assessments conducted in Afghanistan
3. Involving the research department and IRB in the AIM-WG to enhance coordination of NIM 4. Standardization and harmonization of tools and templates as well as indicators for SMART surveys
and other nutritional cross sectional assessments as validated by MoPH and AIM-WG 5. The MoPH Health and Nutrition policy should have a clear strategy and way forward for conducting
subnational level nutrition surveys and assessment for better ownership and capacity. As a starting point, the complementarity of different information management systems and data collection methods is critical to be clearly articulated and embedded within the MoPH monitoring and evaluation framework
6. Nutrition Information Architecture needs to be developed and integrated within HMIS data architecture
2. Weak data analysis and validation process
7. Develop and share tools for better data analysis (i.e. documents and videos) 8. Scaling up the role of the AIM-WG in validation of nutrition surveys and management of
nutrition information 9. Partners to systematically seek validation from AIM-WG/PND/MoPH before and after
conducting an assessment to ensure a robust survey methodology and validity of results. 10. Partners to systematically consult with the Nutrition Cluster to ensure the area is of priority and
there is need of information 11. Both AIM-WG and the Nutrition Cluster to systematically utilize the Assessment Prioritization
Matrix to justify selection of a given province for a nutrition assessment
3. Limited data accessibility 12. Aggregation of all data sources (SMART surveys, Nutrition database, Nutrition, Surveillance and
HMIS) into the Nutrition Assessment Matrix 13. Addition of the the Nutrition Assessment Matrix to the MoPH’s data warehouse
14. Development of personas at all levels (personas are categories of users with their designated data need, roles, responsibilities and ability of data analysis and use)
15. Provide data access to personas with specific user-roles 4. No central storage location 16. Allocate central storage at MoPH’s IT data center and Nutrition DG
5. Limited backup and recovery 17. Development of back-up procedure and schedule 18. Designation the central storage space to be used for backing up data
6. Weak data usage (specifically for program management)
19. Development and use of Personas will help to improve data use by specifying of roles and responsibilities
20. Training users in data use guidelines 21. Better utilization of data and information by conducting meta-analysis and synthesis of the
reports
7. Nutrition survey capacity not well distributed among partners
22. Conduct national trainings for SMART and Rapid SMART nutrition surveys to increase national capacity across nutrition agencies
23. Improve field monitoring and supervision to strengthen from different stakeholders (i.e. MoPH, Cluster, Kabul and provincial level management) to ensure the validity and reliability of the data coming from the field
8. No proper system for data feedback mechanism and strict accountability for
different stakeholders
24. Development of a data flow diagram for given personas 25. Developing proper feedback mechanism from data collection level to data use level 26. Integration of nutrition data quality into HMIS data quality assurance (DQA)
9. Weak planning for HHSs (local and national)
27. Definition of the role of HHSs in nutrition information system 28. Development of schedule of HHSs
10. Capacity of BPHS partners to regularly conduct population level surveys
is limited
29. Explore engaging off-budget nutrition partners with technical capacity and experience to cover the gaps of assessments using available funds from SEHAT for population level assessments.
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ANNEX 1: WORKSHOP AGENDA
DAY ONE Time Content 9am – 9:30am 9:30 – 10:10am
Welcome Introduction of Participants. Review of Logistical and Administrative arrangements
(lunches/WC/exits). Review of Agenda, introduce Parking Lot.
Introduction of information management and data environment in Afghanistan
Introduction to the current situation o Technical and o Contextual
Existing information and data gaps 10:10 – 10:30 Tea Break 20 minutes 10:30am – 12:30pm Nutrition data sources, Methodologies and Use
1) Population level representative surveys
a. National level surveys (DHS, MICS, AHS, NNS) b. Subnational level surveys (SMART, IYCF-KAP, Rapid SMARTs)
2) Facility based Monitoring a. Routine data sources – HMIS, PND nutrition database) b. Sentinel site based surveillance system.
i. Health facility level ii. Health post level
12:30 -1:30 Lunch break
1:30pm – 1:40pm Energiser
1:40pm – 3:15pm
Triggering factors for conducting different assessments. a. Criteria for selection of priority areas
a. Roles and responsibilities of Govt, UNICEF, OCHA, Donor, Partners, AIM-WG, Cluster
b. Definition parameters for prioritization. c. Contextual factors (Humanitarian emergencies vs.
development needs) d. Data and information availability e. Access and security
b. Criteria for selection of methodology a. SMART vs. Rapid SMART b. National vs. sub-national c. Rapid assessments vs. comprehensive assessments
3:15 – 3:30pm Wrapping up Day 1
Day 2
9:00 – 9:30 Day 1 Recap
9:30am – 11: 30am (inclusive of 20 minutes
Standardization of SMART and Rapid SMART tools and templates. a. Population level surveys
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break a. Standard core indicators i. Questionnaire ii. Analysis iii. Reporting
b. Additional indicators i. Questionnaire ii. Analysis iii. Reporting
11:30am – 12:30pm Data validation and uptake a. Roles and responsibilities of Govt departments in coordination of
validation of survey results, quality control, knowledge management b. Roles and responsibilities of Cluster departments in coordination of
validation of survey results, quality control, knowledge management c. Roles and responsibilities of BPHS partners in coordination of
validation of survey results, quality control, knowledge management
12:30 – 1:30 Lunch break
1:30pm-2:00pm Data utilization and dissemination. a. Harmonized nutrition assessment matrix
a. What indicators are to be captured in the matrix b. Frequency of use and dissemination
b. Use of SMART data a. HRP & HNO b. IPC c. Fewsnet d. Caseload calculation e. Programmatic f. General advocacy
c. Accountability and follow up of survey results for decision making a. Role of BPHS Partner b. Role of PND c. Role of cluster d. Role of donor
2:00 – 3:00 Complementarity of different sources of nutrition information for effective decision making
1. Defining a nutrition information data utilization framework 3:00pm– 3:45pm Process of incorporating nutrition information management and survey
methodology into MoPHP M&E framework.
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ANNEX 2: LIST OF PARTICIPANTS
Nutrition Information Management Workshop Participants list
No Name Phone No Organization Title Email Address
1 Mohammad Haider 770801644 ORCD CBNP Project coordinator [email protected]
2 Zahidullah Walizada 796009614 FHI 360 M&E Manager [email protected]
3 Zia Dashti 785598999 MOPH/PND NiE officer [email protected]
4 Dr. Khalil Samadi 799734370 MOPH/PND Nut M&E officer [email protected]
5 Dr. Noor 777666525 MOPH/PND RNSC [email protected]
6 Dr. A. Wahedd Hassan 785060705
FEWS NET Nut Officer [email protected]
7 Dr. Temor Shah Yarghal 774050249 BARAN Technical Manager [email protected]
8 Abdul Qadir 765197616 AADA Nut Program manager [email protected]
9 Dr. Hamza 787001919 AADA Technical Manager [email protected]
10 Dr.Baidar Bakht habib 772604336 AAH SMART PM [email protected]
11 Admire Chinjekure 784916419 WHO Technical Officer chinjekurea@who….
12 Zar Badshah Jabarkhil 796999340 AHC Nutrition specialist [email protected]
13 Sahar Sayedy 798740022 PND Data Manager [email protected]
14 Lutfullah 700005128 HMIS HMIS manager [email protected]
15 M. Khalid 787651644 PU-AMI Senior Nut Officer [email protected]
16 Dr. Asef Ghyasi 729880507 CAF Senior Nutrition Manager [email protected]
17 Dr. Seddiqi 789093797 MEDAIR Nut PM [email protected]
18 Dr. Rangeen Ahmadzai 776864880 MRCA M&E Officer [email protected]
19 Ahmad Shaheer Rasikh 786868607 OHPM M&E [email protected]
20 Dr. Homayoun Ludin 700604649 PND Director [email protected]
21 Dr. M. Ghani 706771727 IRC Nutrition specialist [email protected]
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22 Dr. Naqeeb 778282136 SCA S.O [email protected]
23 Hasina 780902873 PND intern [email protected]
24 Dr.Afzal Khosti 799277105 MOPH/EHIS NDSR coordinator [email protected]
25 Dr. Azimi 730717622 UNICIEF IMS [email protected]
26 Dr.Fatema 797597578 AKHS NPO [email protected]
27 Sayed Rahim 776040704 ACF Surveillance DHOD [email protected]
28 Bijoy SERKER 730709193 ACF Surveillance HOD [email protected]
29 Hassan Ali ACF-Ca Snr. Project Manager [email protected]
