This document discusses the creation of relevant monitoring and evaluation (M&E) frameworks for Nutrition Assessment, Counseling, and Support (NACS) programs. It outlines the need for harmonized global indicators to measure NACS interventions internationally. Steps are provided for developing a NACS M&E framework, including assessing program effectiveness, identifying best practices, and reporting results. Thematic areas and examples of NACS indicators are given. The document concludes by addressing gaps in NACS M&E and next steps, such as measuring quality of services and strengthening community linkages.

1. How Are We Measuring Up?
Creating Relevant M&E Frameworks for NACS
Amie N. Heap
Nutrition Advisor, Office of HIV/AIDS
SI Liaison to OGAC, Food and Nutrition TWG
U.S. Agency for International Development

2. Some Thoughts on M&E…
“If you are not confused, you are not paying attention.”
Tom Peters
“True genius resides in the capacity for evaluation of
uncertain, hazardous, and conflicting information.”
Winston Churchill
“We have an important opportunity to integrate
nutrition into care, and we should get lost in the
weeds.”
Anonymous Colleague

3. Session Objectives
• Global indicators and
tools for monitoring and
evaluation of NACS
programs
• Steps for creating a
relevant NACS M&E
framework
• Gaps and future
directions for monitoring
and evaluation of NACS

4. Global NACS Reporting Landscape
Identified Need: A harmonized set of core indicators available for
international donors, national governments, and program implementers

5. Creating a Needed and Useful
M&E Framework
Assess the effectiveness Inform and improve
Inform and improve
of interventions Training program design
program design
Identify successful
approaches Report results to
Identify successful
national
approaches governments, donors
Referral Links &
and others
Tracking
NACS
NACS
Human Resources Quality Improvement
Advocate for support and expansion of activities

6. Thematic Areas for NACS M&E Frameworks

7. Nutrition Assessment, Counseling, and Support M&E Framework
Revision or
Development
Revised
of Policy and Policy and
Guidelines Guidelines
Surveillance,
Policies Monitoring M&E
and Evaluation System INCREASED
Design • Knowledge
Guidelines Capacity
Capacity of nutrition
Building Built and
& QA/QI • Number of Reduced
QA/QI Support clients with
Human, Econ Planned Reduced Morbidity
functional
omic, working Malnutrition and
Infrastructure Clients status Mortality
Provide
and Technical Nutrition Counseled
Resources Assessments and IMPROVED
and Counseling Assessed • Dietary
practices
Nutrition Nutrition
Commodities Support to
Eligible Clients Support
Received
Formalized
Referrals to Clients
ES/L/FS Referred
Services
INPUT PROGRAM OUTPUTS OUTCOMES IMPACT
ACTIVITES

8. Creating Relevant NACS Indicators
What data would data would be most
needed and useful?
Impact
Is an indicator the best method to Outcomes
capture the data?
Outputs
If so, how can we create indicators Program Activities
that are technically sound and feasible
to measure? Inputs
Does the indicator set provide data that
is relevant at multiple levels within the
health system?

9. Nutrition Care Indicators
Indicator Definition
Undernutrition in PLHIV: Number and proportion of PLHIV in care
and treatment who were identified as undernourished at any point
Impact during the reporting period.
Provision of Therapeutic or Supplementary Food to Undernourished
PLHIV: The number and proportion of undernourished PLHIV who
received therapeutic or supplementary food at any point during the
reporting period.
Nutrition Assessment for PLHIV: The number and proportion of
PLHIV in care and treatment who were nutritionally assessed during
Output the reporting period.
Nutrition Counseling for PLHIV: The number and proportion of PLHIV
in care and treatment who were nutritionally assessed with
anthropometric measurement who also received nutrition counseling
at any point during the reporting period.

10. PMTCT Indicators
Indicator Definition
12-Month Infant HIV-Free Survival (HFS): The percentage of
infants born to HIV positive women in PMTCT programs who are
Impact alive at 12-months of age and HIV-negative.
Maternal Nutrition Status at Postnatal Care: The number and
Outcome percent of HIV positive women who have a mid-upper arm
circumference (MUAC) of less than 22cm at the first postnatal
visit.
Infant Nutrition Status: The number and percentage of HIV-
exposed infants with acute malnutrition at 12-months of age.
Infant Feeding Status: HIV-exposed infants who are: 1)
exclusively breastfeeding at 3-months of age, 2) replacement
feeding at 3-months of age, and 3) mixed feeding at 3-months of
age

11. Food Access and Referral Indicators
Indicator Definition
Food Security of PLHIV: The number and proportion of PLHIV
Impact receiving care and treatment services whose households have poor
access to food based on the household hunger scale
Per Capita Household Expenditures in HIV-affected Households: The
percentage change in average per capita household expenditures
among HIV-affected households
Outcome
Percentage of Total Expenditures Spent on Food in HIV-affected
Households: The average percentage of total household expenditures
that are spent on food in HIV-affected households
Referral to Food Security Services: The number and percentage of
HIV care and treatment clients vulnerable to food insecurity who are
referred from clinical facilities to food security services
Receipt of Food Security Services: The number and percentage of
Output HIV-affected households that receive food security services
Referral from Food Security Services to HIV Clinical Services: The
number and percentage of clients receiving food security services
who are referred to HIV clinical services

12. Country progress with NACS Indicators
NACS at the National Level
System Development Early Stages of Collection Established Data Collection
Mozambique Malawi Kenya
Ethiopia Uganda
NACS Pilot Sites
System Development Early Stages of Collection Established Data Collection
Vietnam Ghana Cote d’Ivoire
Haiti Namibia
Zambia Tanzania
South Africa

13. Creating a Tailored NACS Framework
• Is the data needed to measure
performance against goals/strategies?
• How will the data be used to manage
the program/national response?
• Will the indicator reliably measure what
it is intended to measure?
• How should the data be aggregated and
reported(site, region, district, national)?
• What advocacy and resources are
required to integrate nutrition data
collection into the broader system?
• How can data be made relevant and
useful to those collecting it?

14. Gaps and Next Steps for NACS M&E
• Measuring quality of service
• Utilizing quality improvement to
strengthen M&E systems
• Strengthening the capacity
establish, monitor, and evaluate links
between clinical and community
services
• Utilizing data to inform and improve
service delivery at the site level
• Creating a system for sharing best
practices within NACS programs

15. Resources For NACS M&E
Guidance for Harmonized Monitoring and Evaluation of Nutrition and HIV Activities (FANTA-3)
Still in press—will be available on FANTA-3 website in June 2012
GFATM Monitoring and Evaluation Toolkit: HIV, Tuberculosis, Malaria and Health and Community
Systems Strengthening (GFATM) http://www.theglobalfund.org/en/me/documents/toolkit/
A Guide to Monitoring and Evaluation of Nutrition Assessment, Education, and Counseling of PLHIV
(FANTA-2) http://www.fantaproject.org/publications/NAEC.shtml
Indicator Standards: Operational Guidelines for Selecting Indicators for the HIV Response (UNAIDS)
http://www.unaids.org/en/media/unaids/contentassets/documents/document/2010/4_3_MERG_Indicator_Standards.pdf
UNAIDS Indicator Registry: www.indicatorregistry.org