Transforming the nutrition information system
Ethiopia has transformed its information system for nutrition.
Ferew Lemma, Senior Advisor, Office of the Minister of Health and SUN Government Focal Point
provides an update of how routine information is bolstering the system…
A discussion of the national Nutrition Information System (NIS) for Ethiopia as it was in early 2011 is presented in the box on page 33. In the last few years the system has been strengthened, extended and some of the challenges addressed. These changes are described by the author below.
Main achievements of the Nutrition Information System
The national Nutrition Information System (NIS) has been strengthened as part of the 2008-2013 National Nutrition Programme (NNP), which was updated for 2013-2015. The Health Extension Programme (HEP) has ensured that the NIS is widely recognized by all partners as the source of reliable information. This information also serves Emergency Nutrition Coordination Units (ENCU) of the Ministry of Agriculture (MoA) established at national and regional level13. This has progressively reduced the duplication in data collection and ensured optimised sharing and use of available information.
Inclusion of routine nutrition data in the NIS and the early warning system
Due to the consistent reporting and wide coverage of routine data collected through the HEP – therapeutic feeding programme (TFP), trends have been established for several years. The trend data provide information on what happens with admissions for severe acute malnutrition during the hungry seasons, as well as during times of crises and normal periods. TFP trend data is incorporated in the early warning system and is the critical component in triggering immediate response that may arise. This means that the capacity of the health system determines the emergency response: if the health system is not able to absorb the increase of caseloads then additional support is required.
Better management of data
Under the MoA food security Directorate, there is an Emergency Nutrition Coordination Unit (ENCU), which is responsible for the national multi-agency nutrition task force (MANTF) coordination meetings, information sharing and discussion of technical issues among nutrition partners working in Ethiopia.
In addition to this, the health management information system of national Ministry of Health (MoH) collects six or seven nutrition indicators, including growth monitoring and promotion data, information on the community management of acute malnutrition (CMAM) plus its outcomes, micronutrient data (on vitamin A, de-worming, iron and folic acid supplements) and low birth weight. These information are collected monthly and reported quarterly.
Ethiopia has introduced a child survival score card in an effort to reduce child mortality. The scorecard consists of three components: input indicators that relate to policy issues and availability of resources; process indicators; impact and outcome indicators that outline the data results. Nutrition indicators such as stunting, breastfeeding practices, vitamin A and de-worming capsule coverage are included on the score card.
Furthermore, the National Nutrition Coordination Body (NNCB) led by MoH is currently working to develop a multisectoral nutrition scorecard that would facilitate high level decision making.
Improvements in the use of decentralised nutrition data
At ‘woreda’ level, the information system serves all sectors and is called ‘woreda net’. Health and nutrition information is included in this system and is compiled by ‘woreda’ health offices. For programmes such as the productive safety net programme14, the ‘woreda’ administration triangulates agriculture, climatic, nutrition and other data with vulnerability to decide who requires support.
Data from the information system is now available in computerized form in most ‘woredas’. The capacity of district officials to perform data quality checks and analysis has also been strengthened with college or university trained information technicians now employed at ‘woreda’ and zonal level. Hence decentralization of the system has facilitated local interpretation and use of information.
Trust in frontline staff as the main source of information
Frontline workers in Ethiopia have been gathering nutrition information (particularly data for CMAM) since 2004. Over the years, the skills of these workers have been developed and data have become very reliable. For instance, in 2011 when the Horn of Africa was hit by food shortages, the situation was picked up by frontline workers in Ethiopia very early and corrective measures were put in place – hence the number of affected children was minimised and the death rate remained very low.
- It is necessary to work on developing the health system before embarking on an information system for nutrition which is reliable and able to inform decision making.
- When scaling up an information system, quality can be compromised and it is important to put mechanisms in place (continuous capacity building) to address these shortcomings.
- Getting a reliable comprehensive nutrition information which addresses timely warning, plus informs about the progress of national plans and multiple sectors is very, very difficult and takes time.
- Country’s need to look at their context, be patient and build the capacity of frontline workers continuously.
Discussion of Ethiopia Nutrition Information System in early 2011
In Ethiopia, the role of the national Nutrition Information System (NIS) has been clearly stated in the Ethiopian National Nutrition Programme (NNP). There are three constituent parts to this role. These provide a ‘comprehensive’ and holistic structure to NIS design: to support timely warning and adequate interventions at woreda and higher levels, to develop, manage and evaluate the NNP at all levels, and to inform other sectors like agriculture, water/sanitation and economic development. This comprehensive vision for the NIS is to inform understanding of the nutritional situation with respect to chronic and newly occurring problems, as well as the causes of these problems, and how these change over time in order to help in decision-making at all levels. However, while the NIS can effectively accommodate and be ‘open’ to an unlimited amount of data, the ability to trigger an effective and appropriate response requires that the information is timely, reliable and consistent. These conditions ultimately determine the basic parameters upon which the initial choice of information for the NIS is made. Put simply, all data should be trusted and continuously available,
data should be triangulated to generate ‘contextspecific’ and evidence-based information and there should be a clear process, agreed by all actors, to feed information into decision-making.
Unique data situation in Ethiopia
Ethiopia is in quite a unique position because, over the last thirty years, large amounts of data have been collected by the Early Warning System (EWS), including health and nutrition information. However, the nutrition information collected by the EWS provides only scattered data – mostly alert signals based upon ‘observable’ degeneration. Data is collected directly from health workers at ‘critical times’ and without systematic comparison with what would be ‘normal’ for a given time of year. Nutritional assessments are required during these critical times to confirm ‘emergencies’ but the seasonality of these critical times creates a widespread, simultaneous demand for assessments, which rarely can be adequately met. In recent years, targeting of surveys has been improved through increased use of routine data sources, at least to indicate where an assessment is most urgently needed. Nutrition data are now available and accessible on a monthly and quarterly basis at the lowest levels due in large measure to three programmes: The Community Based Nutrition programme (CBN), the Therapeutic Feeding Programme (TFP) and Community Health Days (CHD). These routine systems are the monitoring backbone of the NNP, which – at least theoretically – can be combined to inform timely warning and be shared with other sectors. Similarly, a number of diseases are also currently being tracked on a weekly basis through the Public Health Emergency Management (PHEM) system. Thus, there is a very real potential for the EWS to systematically tap into specific data from existing health information sources and vice-versa. This will be most effective if a consensus is reached on key indicators, in particular for timely warning. The key question, ultimately, is whether decision-makers from all sectors are willing to exchange and use available routine data to inform their decisions and response.
Nutrition data management
While there are ‘trust’ issues on data quality and credibility, the administrative decentralisation and existence of a widespread health network, creates the rare opportunity to build capacities, accountability and transparency at lower levels like the woreda and the kebele. Initial data collectors are volunteers and frontline health practitioners. Many report that data collection is an additional burden to their already crowded agenda. After the initial collection, data flows up through various levels via supervisors and health officials. However, little feedback is given through the system so that people directly involved have a limited sense of what is actually done with the information provided. The sheer volume of reports stored testifies to the regularity of data collection undertaken and the immediate priority that should be given to improve the ‘efficiency’ of the process. Currently, asking for nutrition information from a woreda official leads to a paper-chase given the amount of report forms collated. Where officials have been provided with a computer, data appears to have been regularly updated. Given the increased requirements for information
management, it seems inevitable that woreda Health Offices will move from a paper-based system to a computerised one, allowing them to perform data quality checks that otherwise are time consuming and prone to mistakes if done manually. The implication here is that woreda level officials are mostly young, often computer-literate, professionals with degrees. Provision of adequate tools/software to practically manage information can help build their capacity to implement the system. If information is not properly valued at
woreda level, where most data are collated and ‘checked’, then the task of quality assurance at higher levels is nigh-on impossible.
Added value of NIS: triangulation of data
What is ‘new’ in the NIS paradigm is the requirement for ‘triangulation’ to provide evidence-based information for decision making. This implies that collected data are not interpreted in isolation but are brought together from different sources. The strength of triangulation is the ‘contextualisation’ of the data, meaning numbers and/or standardised observations are grounded in ‘local knowledge’. Frontline practitioners in health-posts have access to nutrition and health information through regular contact with patients. With nutrition, for example, they are in the best position to judge if the deteriorating weight of a child during monthly growth monitoring or his/ her admission in the Outpatient Therapeutic Programme (OTP) is linked to lack of food in the family or to other causes like illness, inappropriate feeding practices, etc. It is this ‘proximity’ that allows for the triangulation to be most helpful at community level whereby root causes of malnutrition can be identified. An example where this could be used is in chronically food
insecure areas supported by the Productive Safety Net Programme (PSNP) where risk financing mechanisms exist to address new chronic or temporary food insecurity. By monitoring increases in underweight (as an early indicator) and OTP admissions (as a late indicator), frontline health practitioners, who are members of the Food Security Task Forces (FSTF), can play a crucial role in providing information for appeal processes.
However, the credibility of their information will depend on their full understanding that risk financing mechanisms are only accessible when malnutrition is linked to food insecurity. Thus, triangulation of data at source is a kind of check by key people before information is fed into the decision-making processes or reported to higher levels.
Trust, accountability and transparency
In Ethiopia, in line with governmental decentralisation, woreda and kebele level administrations have been given increased power to analyse, assess and act on their own changing situation. They are therefore more responsible and accountable for both development and emergency response. Addressing the challenges of how information can feed into decision-making will ensure the credibility and sustainability of the NIS. At the moment, available data from routine sources are not adequately linked to information use. The main challenge for data utilisation at higher levels is that sources are not fully trusted while at lower levels there are
limitations over capacities and mandate. While data quality assurance can be built into the system,
especially by improving lower-level capacity, more emphasis needs to be given to the human aspect. ‘Trust’ cannot be built without attention to the role played by each stakeholder, starting with frontline practitioners. ‘Accountability’ cannot be acquired if there is no hand over of responsibility. ‘Transparency’ cannot be promoted without making response and feedback more visible. The NIS in Ethiopia can be built upon coupling available data sources with adequate technical support provided throughout the health system.
However, technical inputs are not enough to ensure its sustainability. A sense of ‘value’ is what motivates people and without it, the simple transmission of data to higher levels will not provide incentive to stakeholders for their input. ‘Triangulation’ is most effective at community level where individual data sets can be compared at source and understood within a given context. Frontline practitioners play a crucial role in building the credibility of the NIS but this can only come about with increased recognition of the role they play in informing decision-making. As the process of decentralisation continues within Ethiopia, important decisions to be taken at the lowest levels, risk financing mechanisms being an example, will require bringing together available data from different sources. This, in turn, will rely increasingly on key people accountable for informing this process at the frontline. Before trusting the Nutrition Information ‘System’, a vote of confidence should be given to empowering the information ‘Source’. Credibility, after all, should always start with the people.