Availability of national policies, programmes, and survey‐based coverage data to track nutrition interventions in South Asia

Abstract Progress to improve nutrition among women, infants and children in South Asia has fallen behind the pace needed to meet established global targets. Renewed political commitment and monitoring of nutrition interventions are required to improve coverage and quality of care. Our study aimed to assess the availability of national nutrition policies, programmes, and coverage data of nutrition interventions for women, children, and adolescents in eight countries in South Asia. We reviewed relevant policy and programme documents, examined questionnaires used in the most recent rounds of 20 nationally representative surveys, and generated an evidence gap map on the availability of policies, programmes, and survey data to track progress on coverage of globally recommended nutrition interventions. Current policies and programmes in South Asian countries addressed almost all the recommended nutrition interventions targeted at women, children, and adolescents. There was a strong policy focus in all countries, except Maldives, on health system platforms such as antenatal and postnatal care and child growth and development. Survey data on nutrition intervention coverage was most available in India and Nepal, while Bangladesh and Bhutan had the least. Though countries in South Asia have committed to national nutrition policies and strategies, national surveys had substantial data gaps, precluding progress tracking of nutrition intervention coverage. Greater attention and effort are needed for multisectoral collaboration to promote and strengthen nutrition data systems.

Over recent decades, countries in South Asia have undergone profound demographic and epidemiologic transitions, drastically changing the patterns of disease burden (Vicziany, 2021).Growing rates of malnutrition, both under-and overnutrition, continue to threaten the region's economic and social growth.According to United Nations Children's Fund (UNICEF) estimates, at least 30% of children under-5 years are stunted and 14% are wasted in South Asia, bearing the highest prevalence globally (UNICEF, WHO, The World Bank, 2021).Equally alarming, the prevalence of micronutrient deficiencies (Stevens, Beal, et al., 2022), anaemia in women of reproductive age (Owais et al., 2021;Stevens, Paciorek, et al., 2022), and noncommunicable diseases among adults are increasingly contributing to morbidity and mortality in the region (World Health Organization, 2022b).As a result, reducing malnutrition has become an international development priority in South Asia, with political momentum and alignment of country strategies to meet the World Health Assembly 2025 targets and sustainable development goals (SDGs) by 2030 (Sachs et al., 2021).At a regional level, the South Asian Association for Regional Cooperation (SAARC), provides a platform for countries to work collaboratively, advocate, and work in partnership to address common issues such as nutrition that transcend political and geographical borders (South Asian Association For Regional Cooperation, 2014).In 2014, SAARC developed the Regional Action Framework for Nutrition, which highlights that optimal nutritional outcomes for children in the region can be achieved by building an enabling environment and supporting the scale-up of sustainable nutrition interventions (South Asian Association For Regional Cooperation, 2014).Four strategic pillars were proposed including: (i) soliciting political commitment to improve nutrition governance, strengthen programme planning, and implement multisectoral policies and plans; (ii) scaling up cost-effective evidence-based, sustainable nutrition-specific and nutrition-sensitive interventions for all; (iii) increasing human and institutional capacity to manage nutrition programmes nationally and subnationally; and (iv) increasing effectiveness and accountability of nutrition intervention implementation stakeholders through monitoring and knowledge translation mechanisms (South Asian Association For Regional Cooperation, 2014).Within member countries, policies and programmes need to be in place to support these nutritional actions (Pike et al., 2021;World Health Organization, 2019).
Effective nutrition interventions, including a combination of direct (nutrition-specific) and indirect (nutrition-sensitive) interventions that are delivered within and outside the health care sector, are required to address malnutrition (Keats et al., 2021;Vaivada et al., 2022).These strategies must work across the continuum of care to reduce disparities and reach at-risk and neglected populations such as women, children, and adolescents (Keats et al., 2021;Vaivada et al., 2022).Key interventions across the life course include counselling and support for exclusive breastfeeding and appropriate complementary feeding, antenatal care, school food policies and programmes, and regulations and enforcement around marketing for unhealthy foods and breast milk substitutes (Keats et al., 2021;Vaivada et al., 2022).Research on which platforms are best suited to deliver packages of care to beneficiaries that are both age-appropriate and timely is ongoing (Janmohamed et al., 2019).
Importantly, there is much dialogue on improving integration and scaleup of nutrition interventions within health systems (Holschneider et al., 2022;Salam et al., 2019;Subandoro et al., 2021).These various policy and programmatic decisions related to the design, adaptation, and implementation of comprehensive evidence-based nutrition actions then must be informed continually by information about intervention coverage and performance at the population level.
However, studies from low-and middle-income countries have shown that nutrition interventions are often either not delivered consistently or are not of sufficient quality during critical maternal and child health contact points (Gillespie et al., 2019;Menon et al., 2014).This shortcoming is in part due to poor data integration, reliability, availability, and granularity in standardised surveys that collect nutrition data such as Demographic and Health Surveys (DHS), National Nutrition Surveys (NNS) or Multiple Indicator Cluster Survey (MICS).This, in turn, has hindered the analysis and interpretation of actionable coverage indicators to improve the delivery and quality of interventions (Amouzou et al., 2019;Gillespie et al., 2019).
The objective of this paper was to assess the availability of and gaps between policies, programmes, and survey-based coverage data on essential nutrition interventions in eight South Asian countries (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka).

| METHODS
This study was conducted under the Data for Decisions to Expand Nutrition Transformation (DataDENT) initiative, which aims to transform the availability and use of nutrition data by addressing gaps in nutrition measurement and advocating for stronger nutrition data systems (Institute For International Programmes, International Food Research Policy Institute, Results For Development Institute, 2022).The study was conducted in close collaboration with the UNICEF Regional Office of

Key messages
• Most South Asian countries had several policies and programmes in place which considered or addressed nutrition interventions across the life course.
• Nationally representative surveys provide coverage data for evidence-based recommendations to improve policy and programme actions.
• Significant coverage data gaps remain in nationally representative surveys around counselling during pregnancy, interventions targeted for newborns, infant, and young child feeding, and counselling on and identification and treatment of severe and moderate acute malnutrition.
• Mobilising political commitment and increasing multisectoral collaboration are required for an enabling environment in support of nutrition data systems in South Asia.
South Asia (ROSA) and its country offices in the region, particularly to gather all relevant documents and validate findings along the document and data review process.

| Data collection
To identify the existing policies and programme documents related to nutrition from eight countries in South Asia (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka), we searched online and contacted the UNICEF ROSA and its country offices.We maintained a broad definition of policies and programmes to ensure that all relevant documents were captured in the search.Documents included any direct or indirect nutrition policy, strategy, legislation, regulation, or guidelines applicable at the national, state, or regional levels that were endorsed by the government.If a recommended nutrition intervention was addressed by a policy, directly or indirectly, we assessed if a programme was in place, which means operational as of February 2022.
We identified policy and programme gaps (or the lack of a policy or a programme) for interventions that are applicable based on the epidemiological context of each country.For example, iron and folic acid (IFA) supplementation for adolescents is recommended by WHO only if the anaemia prevalence among women of reproductive age is more than 20%; therefore, we did not consider IFA supplementation for adolescents as a recommended intervention in a country where anaemia among women was <20%.We determined the applicability of interventions in each country based on the prevalence estimates from nationally representative population-based surveys and Global Nutrition Report country profiles, recommendation for all settings, and/or existence of the programme in the country (Supporting Information: Table S1).
Then, to examine the availability of intervention coverage data, we reviewed questionnaires used in the most recent rounds of 20 nationally representative population-based surveys (i.e., DHS, NNS, MICS, and micronutrient national surveys conducted in the eight countries between 2012 and 2019).We did not include routine administrative data or programme monitoring data as part of this study because a separate review of examining these data sources in South Asia was conducted by UNICEF.The review of nutrition policies, programmes, and survey data were conducted between January 2021 and February 2022.

| Data extraction and synthesis
To generate an evidence gap map on the existence of policies and programmes, information from policy and programme documents related to the applicable interventions was extracted for each of the eight countries.We extracted the name of the policy document, the name of programme(s) which addressed one or more nutrition interventions, and any programme implementation guidelines.The final data results were synthesised to generate an evidence gap map of the policies, programmes, and survey-based coverage data.
Of the total 54 recommended interventions, the number of applicable interventions ranged from 52 in Bangladesh, India, and Pakistan to 49 in Bhutan (Figure 1).Fifty-two nutrition interventions were applicable in the Maldives, but policies in the country only covered 34 of these interventions (policy gap of 16), programmes covered 32 (programme gap of 18), and data were available for 24 (data gap of 26) (Figure 1).Bangladesh and Bhutan had the largest data gaps of 32 and 31, respectively.Although India presented the smallest policy/programme and data gaps, there were still 19 interventions for which coverage data were not available in either of the two national surveys.

| During preconception
We did not find any policy gap during preconception in Afghanistan, Bhutan, India, Nepal, and Sri Lanka ( 3.2 | Country-specific policy, programme, and data gaps

| Afghanistan
Afghanistan's policies and programmes did not address food supplementation during adolescence and during early childhood (Tables 2 and 3).Programmes did not address IFA supplementation

| Bangladesh
Bangladesh's policies and programmes did not address deworming during preconception or IFA supplementation during early childhood.
Food supplementation for complementary feeding was addressed by policies, but not by programmes (Tables 2 and 3).None of the surveys contained data on counselling on breastfeeding/complementary feeding, iron-containing MNP, and inpatient management of SAM.

| India
In India, policies and programmes did not address iron-containing   1).
Surveys did not contain data on advising on the consumption of IFA during pregnancy; support for early breastfeeding and immediate skin-to-skin contact, advising on optimal feeding of low-birthweight infants and counselling on KMC during delivery and the postnatal period; IYCF counselling, growth monitoring, and counselling after growth monitoring during early childhood (Table 3).

| Nepal
No policies or programmes in Nepal addressed calcium supplementation and advice on consuming calcium during pregnancy, or IFA supplementation during early childhood.Programmes did not address IFA supplementation during preconception.Of the 46 nutrition interventions addressed in policies and programmes, surveys provided coverage data on 30 interventions.These included two each during adolescence and preconception, eight for pregnant women, seven during delivery and the postnatal period, and eight for early childhood (Figure 1).
Surveys did not include data on food supplementation during adolescence, energy and protein dietary supplementation, weight monitoring, or on the various types of counselling (Table 3).There

| Sri Lanka
Sri Lanka's policies and programmes did not address food supplementation during adolescence or for complementary feeding during early childhood.Programmes did not address IFA supplementation during preconception.Of the 46 nutrition interventions that were addressed by policies and programmes, surveys provided coverage data on 23 interventions (Figure 1).
There was no data on nutrition counselling for pregnant women, including advice on a healthy diet; counselling about gestational weight gain after weighing; advice on consuming calcium, IFA, and additional food; and counselling on birth preparedness and exclusive breasting (Table 3 | 11 of 14 determinants of nutrition.What people eat is an important determinant of their nutritional status, but dietary intake is infrequently measured in nationally representative surveys in South Asia, particularly for women of reproductive age, and consumption of unhealthy foods is also poorly assessed (Scott et al., 2022).Though some surveys have captured counselling for consuming healthy diets, counselling on avoiding unhealthy food was only captured among adolescents in Nepal and should be expanded to other life stages.
Furthermore, South Asian countries have social protection programmes that aim to improve diets such as cash or food transfers.
However, measurement gaps exist for coverage of social protection schemes in South Asia (Neupane et al., 2022).
This review is not without limitations.First, our approach to reviewing policy and programming documents focused on those within the health and nutrition sector.Owing to the multisectoral and crosscutting nature of nutrition, it is possible that policy and programme documents in related sectors, for example, agriculture, education, and social protection, may consider nutrition in their national policies, strategies and plans, which would contribute to our findings (World Health Organization, 2013).Second, the existence of policy and The most prominent policy and programme gaps were for food supplementation during adolescence; IFA supplementation and T A B L E 1 List of 54 recommended nutrition interventions by life stage.
and deworming during preconception, calcium supplementation during pregnancy, and IFA supplementation during early childhood.Out of the 45 nutrition interventions that Afghanistan's policies and programmes addressed, surveys provided coverage data on 22 interventions; this included two aimed at women during preconception, nine during pregnancy, five during delivery and postpartum, and six interventions for early childhood (Figure 1).None of the surveys contained data on interventions during adolescence.For interventions during pregnancy, data were missing on advice about gestational weight gain after weighing; advice on consuming calcium, IFA, and additional food; and advice on birth preparedness.For interventions during delivery and at postpartum, data were not available for early initiation of breastfeeding, care of low-birthweight babies, breastfeeding counselling, IFA supplementation, or food supplementation for malnourished lactating women.There was no coverage data on counselling on nutritional status or MAM management during early childhood.
Of the 49 nutrition interventions that Bangladesh's policies and programmes addressed, surveys provided coverage data on 20 interventions; this included two aimed at women during preconception, six during pregnancy, six during delivery and at postpartum, and six interventions for early childhood (Figure 1).None of the surveys contained data on nutrition interventions for adolescents.For interventions during preconception, data were missing on IFA supplementation.For interventions during pregnancy, data were missing on maternal nutrition counselling, calcium T A B L E 2 (Continued) MNP supplementation and outpatient management of SAM during early childhood.Of the 50 nutrition interventions addressed by policies and programmes, 33 interventions had coverage data in the surveys.During adolescence, IFA supplementation had no data, and T A B L E 3 (Continued) was no data on nutrition interventions during delivery and in the postnatal period, delayed umbilical cord clamping, support for breastfeeding and immediate skin-to-skin contact, or interventions for low-birthweight newborns.There were also no data on interventions during early childhood, including IYCF counselling, counselling after growth monitoring, or inpatient management of SAM.
in Pakistan did not address IFA supplementation and deworming during preconception, and food supplementation and IFA supplementation during early childhood.Of the 48 nutrition interventions addressed in policies and programmes, surveys provided coverage data on 26 interventions: two during preconception, 11 during pregnancy, six during delivery and the postnatal period, and six during early childhood (Figure 1).None of the surveys contained data on interventions during adolescence, data on advice about gestational weight gain after weighing, advice on consuming calcium and IFA, or advice on birth preparedness (Table3).There was no data on interventions during delivery and the postnatal period, including delayed umbilical cord clamping, support for early breastfeeding and immediate skin-to-skin contact, interventions for low-birthweight infants, IFA supplementation, and food supplementation.Surveys did not contain data on counselling IYCF, growth monitoring, and counselling, and identification and management of SAM and MAM.
programme documents does not ensure that programmes and interventions are implemented and monitored; our review did not examine implementation.Third, our review considered nutrition intervention data from primarily DHS and MICS.We recognise that there are other sources of data from administrative and nongovernmental programmatic surveys which could be leveraged to provide a more holistic picture of available nutrition data.Fourth, we recognise that our review could not adequately examine associated prevention and treatment interventions, including how countries are responding to the burden of diet-related noncommunicable diseases, and instead relied on a proxy indicator of counselling on healthy diets.5 | CONCLUSIONSNutrition policies and programmes in South Asian countries are aligned with recommended nutrition interventions, but large gaps in available coverage data in national surveys remain.Given the increased interest in scaling up and sustaining nutrition interventions, there is a need for concerted efforts to coordinate across national and subnational levels, to ensure coherence with nutrition and quality-related policies and standards, and to avail supporting data.Improving the availability of quality and timely nutrition data and strengthening monitoring systems is key to modelling, designing, and implementing relevant nutrition policies and programmes, and would potentially lead to programme cost savings.While our review reflected that nationally representative surveys help to provide data for monitoring nutrition intervention coverage and provide the foundation for evidence-based recommendations to improve policy and programme actions, data gaps need to be addressed by incorporating missing indicators into the surveys or other existing data systems.Mobilising political commitment and increasing multisectoral collaboration are required for an enabling environment in support of nutrition data systems and data use for decision-making in South Asia.

Table 2
Availability of policy, programme, and data on nutrition interventions recommended from adolescence through pregnancy by country.Table 3).Policies and programmes in Maldives addressed 56% of the interventions, which were the lowest among all eight countries.The data gap was highest in Bhutan and Maldives; only 27% of the interventions in Bhutan and 25% in Maldives had survey data.Data were available for less than 50% of the interventions in Afghanistan, Bangladesh, Pakistan, and Sri Lanka.
).There was no programme gap in India; however, in Bhutan and Maldives, only one out of three interventions was addressed by programmes.In all countries, at least 50% of the interventions had survey-based coverage data.3.1.3|DuringpregnancyAtotal of 18 interventions were recommended during pregnancy; 16 were applicable in five countries and 15 in three countries (Table2).Policies and programmes inBangladesh, India, Pakistan, and Sri Lanka addressed all recommended interventions.In Afghanistan and Bhutan, there was no policy gap, and programmes did not address one intervention.In Maldives and Nepal, policy and programme gaps were three and one interventions, respectively.We observed a large data gap during pregnancy; only 37% of the interventions in Bangladesh and 44% in Bhutan had coverage data in the surveys.Out of the total 16 recommended interventions during early childhood, policies and programmes in six countries addressed more F I G U R E 1 Numbers of nutrition interventions applicable and policy, programme, and data available by country.T A B L E 2 Availability of policy, programme, and data on nutrition interventions recommended from delivery through childhood by country.