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Table 1 Three case studies of nutrition surveillance system administration in low-income countries

From: A perspective on the development and sustainability of nutrition surveillance in low-income countries

Case study The Nutrition Surveillance Project (NSP) and the Food Security and Nutrition surveillance Project (FSNSP), Bangladesh 1990–present ([70, 142, 143], and Tuffrey, V. Nutrition surveillance systems: their use and value. London: Save the Children and Transform Nutrition, forthcoming.). The Nutrition Surveillance Programme (NSP), Ethiopia 1986–2001 [95, 144]. The Integrated Nutrition and Food Security Surveillance System (INFSS), Malawi 2003–2008 [77, 93, 145, 146].
Governance There has been a national surveillance system in Bangladesh covering most of the country for the last 25 years, except for a break between 2006 and 2009. The Nutrition Surveillance Project (NSP), which operated between 1990 and 2006 was established by the NGO Helen Keller International (HKI) in partnership with the national Institute of Public Health Nutrition (IPHN) and a variable number of mostly national NGOs who employed staff to collect and enter the data. The successor to the NSP, the Food Security and Nutrition Surveillance Project (FSNSP), has operated since 2009 as a partnership between HKI, the James P Grant School of Public Health (JPGSPH) of BRAC University and the Bangladesh Bureau of Statistics, part of the Ministry of Planning. The FSNSP collects anthropometric, food security, socio-economic and environmental data. Save the Children UK funded and implemented a surveillance system between 1986 until 2001 which generated data on anthropometry and food security. Fifteen survey areas were purposively selected to include the most famine-prone areas of the country. The NSP provided information for the Ethiopian government’s Early Warning System (EWS) within the Relief and Rehabilitation Commission (RRC). The EWS had its own Nutrition Unit, but this was poorly resourced and the EWS was mainly dependent upon NGOs such as Save the Children and Care for nutrition data. This clinic-based sentinel system was designed and coordinated by ACF and implemented between 2003 and 2008 in partnership with the Ministry of Health and Ministry of Agriculture. The INFSS system provided information on trends in nutrition among children aged less than 5 years and their households’ food security situation, and the system covered most of the country (26 out of 28 districts).
Financial support Funded by USAID between 1990 and 2002, the Dutch government between 2002 and 2006, and the EU from 2009 to present day. Save the Children both funded and implemented the system. Funded by the EU, with technical support from UNICEF and the FAO.
Objective Initially timely warning, but as the number of regions covered increased, the system became more of a tool for national and local policy and planning. Timely warning. Timely warning, and a tool for national planning.
Methods of information dissemination • Bulletins providing information on a specific topic.
• Presentations to the government, NGO partners, donors and at national and international scientific conferences.
• Scientific papers, for example on vitamin A capsule distribution, homestead food production, rice prices and malnutrition.
• A book.
• From 1995 there were two publications: NSP Reports and NSP Focus. These were distributed to around 20 donors, NGOs and other external agencies, and within the Disaster Prevention and Preparedness Commission (DPPC) and other government agencies.
• Staff members from Save the Children participated in the federal DPPC Early Warning Group, attended meetings and contributed to discussions about needs.
• Each month a bulletin was issued, with the results of the data analysis presented by district and livelihood zone showing trends over time for information on both nutrition and food security.
• Reports and bulletins were shared with government ministries and other interested institutions.
• Findings were sent to the district representatives of ministries, and presented at Nutrition and Food Security meetings.
Comment from evaluation [68]: Some stakeholders found the bulletins were appropriate for nutrition experts only. It was suggested that an additional short and simple report in the local language, Bangla, should be produced. Comment from evaluation [93]: Information was presented regularly in a format that was easy to understand, but not enough attention was given to ensuring a response. Comments from evaluation (van der Heide A. Evaluation of the sustainable nutrition rehabilitation project (SNRP) and review of the integrated nutrition and food security surveillance system (INFSSS). Action Against Hunger, Unpublished.) The bulletin was often published late, and while it was very readable for people with knowledge of the subject, staff at district level found it difficult to understand. Interviewers and health surveillance assistants never saw the bulletin.
Note: These points refer to the NSP after 2000.
Transfer of institutional base The NSP was never transferred to the government. HKI tried to build capacity in the IPHN through secondment of staff, but this had little effect since government policy is to regularly transfer personnel between functions after a number of years. When the FSNSP started in 2009, the process of institutionalisation was not delineated, but at least this time it was identified as an activity in the programme that needed separate support. So the EU separately funded a programme within Bangladesh Bureau of Statistics (BBS) called the “Nutrition Surveillance Component Project” through which the BBS conduct Post-Enumeration Checks (PECs) for quality control and arrange training programmes for capacity-building. Thus the process of transferring the FSNSP from BRAC University and Helen Keller International to the BBS has started, although the exact manner remains to be finalised, if the system finds a donor to sustain it. One model is for the BBS to take over the data collection and reporting from the JPGSPH, with HKI still being involved with data analysis and training, and JPGSPH being responsible for quality control including PECs. Alternatively health workers at community level could undertake data collection. The institutional base was transferred from Save the Children UK to the Disaster Prevention and Preparedness Commission (DPPC), Ministry of Agriculture. In 1998, Save the Children UK decided to stop collecting data and, despite a 3-year plan to transfer skills, the system was not sustained after 2001. This was due to a lack of human and financial resources within the DPPC, formerly the RRC, to deal with nutrition. The intention was to transfer the institutional base from ACF to the Ministries of Health and Agriculture, and training and materials were provided to enable this. However, from the start the system was perceived as belonging to ACF rather than the government, and this perception did not change during the operational period. One reason was that no single government structure was responsible for the INFSSS and no physical place was available to “house” the project within one of the two ministries or other governmental agency. When funding for the system ended and ACF withdrew support, the system quickly began to decline. There was a lack of ownership, a lack of human resources to undertake data entry and analysis, and unclear roles and responsibilities among government employees.
Present-day surveillance is still coordinated by the Ministry of Agriculture and there are three main sources of information: existing programme data systems; ad hoc surveys using SMART methods in regions where early warning information indicates that the nutrition situation is deteriorating; and bi-annual nutrition surveys in vulnerable regions, which are supported by UNICEF and partly funded by the UK Department for International Development. The use of Rapid SMS technology was piloted in three clinics in 2009, and now a ‘rapid surveillance system’ for health facility and community screening is being established, supported by UNICEF and the EU.