Beyond the Demographic and Health Survey: on the past and future of population health surveillance

Summary box.

• At the start of 2025, the Demographic and Health Survey (DHS) programme was paused due to the defunding of USAID, illustrating the fragility of the international data infrastructures on which many national health systems rely.

• Detailing the history of the DHS and its role in Malawi’s health system, this commentary outlines what the DHS programme provides national health systems, what it may have cost them and how these shortcomings might be addressed going forward.

• Our four discrete suggestions for the future of health surveillance are national ownership and oversight; community involvement; the streamlining of surveys; and the continuation of international collaboration around accessibility and standardisation.

• We conclude by arguing that greater consideration of the history of the DHS, and a more critical analysis of donor-driven cross-sectional surveillance, is essential for the future reorientation of population health.

Introduction

The Demographic and Health Survey (DHS) programme was paused at the start of 2025 following deep cuts to the United States’ Agency for International Development (USAID). Since the middle of the 1980s, with financial support coming primarily from USAID, the DHS programme has provided nationally representative surveys of households and health facilities for low-income and middle-income countries (LMICs) around the world. Over the course of nearly 40 years, the DHS had grown into a vital source of data for both research and administration. The abrupt cancellation of the DHS contract undermined this pillar of population health while, at the same time, illustrating the fragile foundations on which many national health information systems have been built.

In Malawi, where the first authors have been researching the historical and contemporary production of global health data, the USAID shutdown has meant that, at the time of writing, in late 2025, the final report and finalised datasets from the 2024 survey have not yet been released. Although data were collected and cleaned in 2024—primarily by Malawian staff at the government’s National Statistical Office (NSO)—USAID contracts a US-based consultancy, currently part of ICF International, to oversee data collection, processing and publication. The stop-work order came just as the staff based at ICF International headquarters in Maryland were finishing up work on the 2024 Malawi data and, although a preliminary report was released in January 2025, as of November 2025 the finalised Malawian dataset has not been released. Zimbabwe’s 2024 data have likewise still not been published, while the release of datasets from Zambia, Nigeria and the Democratic Republic of the Congo was all also significantly delayed.¹

The stoppage of a survey programme may be more banal, less immediately impactful, less outwardly cruel than the sudden disruption of other USAID-funded projects, such as the President’s Emergency Plan for AIDS Relief (PEPFAR), a vital source of HIV/AIDS medication worldwide.² Yet DHS data are also an essential part of international action against HIV: essential for the mapping of HIV prevalence and risk; for understanding social and infrastructural barriers to care; and for the ongoing monitoring, evaluation and future planning of interventions.

This is another commentary which emphasises the necessity of this data and the need for the DHS, or a programme like it, for national health systems and global health equity.^{1 3} However, the authors also recognise that this moment of disruption should also be a moment for reflection. That this is an opportune time to consider the affordances of the DHS programme—the quality, breadth and consistency of the surveys—as well as its shortcomings—its limited utility for interventions, or that it does not always complement national health systems. We argue that these longstanding problems can only be understood through some consideration of the programme’s history and that the the future development of population data must also reflect on this past.

Affordances

Over the course of more than 400 surveys, the DHS programme has grown to become an indispensable source of population health data for governments, researchers, funding agencies and non-governmental organisations (NGOs). To date, DHS surveys have been conducted in more than 90 countries, almost all of which are in Africa, Asia, the Pacific and South and Central America, with the intention that surveys should be repeated every 5 years or so. Produced in close collaboration with national statistical bureaus, DHS data are statistically robust, with demographic and socioeconomic indicators standardised to allow for international comparison and for tracing change over time. For many countries, the DHS acts as baseline data for the entire health system. The measurements generated by DHS surveys have helped illuminate areas of epidemiological progress or concern, have illustrated the success or failure of public health policies and programmes and have offered direction to subsequent interventions. As a result, these data are also crucial for monitoring progress towards the sustainable development goals and Agenda 2063.

A nationally representative, cross-sectional household survey, the DHS programme and NSOs select a random sample of communities across the country. The number of communities or ‘clusters’ in each area is relative to the size of the population within the ‘enumeration areas’ defined by the national census. In each cluster, enumerators visit a random selection of around 30 households, collecting data on everything from household size to ethnicity, level of literacy to household ownership of specific assets. Epidemiological variables include the self-reporting of symptoms and diagnoses; questions on tobacco and alcohol use; information on gendered violence; data on intimate relationships and the employment of contraceptives; and ‘verbal autopsies’ for recent deaths in the family. Surveys have routinely collected anthropometric data from children and adults and, more recently, have taken blood samples to test for HIV, malaria, anaemia or micronutrient deficiencies.⁴

The remarkable breadth of this data has offered both practical and theoretical insight into the social, economic and environmental determinants of health and has provided a means to correlate diverse variables across time and space. Although variables have changed, and many new questions have been added, Ghanaian data from the 1988 DHS can, for instance, be easily compared with Bangladesh’s 2017 survey. This utility, and the fact that data have been made freely accessible through the programme’s data portal, made DHS data a fixture in academic and NGO research. Recently, cross-sectional surveys like the DHS have seen competition from more sophisticated statistical modelling, such as that pursed by the Gates Foundation-funded Institute for Health Metrics and Evaluation (IHME). Employing data from various sources, including the DHS, IHME models impute missing values or predict future trends. However, such modelling efforts would have been, and will be, far less accurate without DHS data.

Shortcomings

For all the good data that have been assiduously collected and freely distributed, the production and employment of DHS data have never been without its problems, the most obvious being that such an important programme was susceptible to sudden shutdown at all. As recent events have made clear, reliance on a sole foreign stakeholder left the DHS programme innately fragile and a threat to national sovereignty. The abrupt cancellation of the DHS contract meant that, in Malawi and other countries waiting for finalised datasets, stakeholders inside and outside of government were left without the data necessary for the informed allocation of scant national resources or the evidence necessary for health system planning. The erstwhile reliability of USAID, and the historical accessibility of data directly from the DHS programme, has also meant that governments have had little impetus to develop national repositories for the data produced in-country and by national bureaus of statistics. Without such a repository in Malawi, even the NSO had only piecemeal access to the earlier DHS surveys which remain an important source of information for future planning.

Beyond this obvious shortcoming, population-level health surveillance suffers from other, less noticeable problems, such as those resulting from the sheer scale of surveillance in many countries, including Malawi. Here, the DHS is only one of the longitudinal surveillance programmes operating under the aegis of international or supranational organisations. Other surveys of note include the World Bank’s Living Standards Measurement Study (LSMS) and UNICEF’s Multiple Indicator Cluster Surveys (MICS). Alongside these large surveys are the numberless other smaller-scale surveys conducted by universities, NGOs or private consultancy firms which usually do not engage national statistical bureaus. This proliferation of surveys has meant that communities and even households may be visited several times a year by enumerators, contributing to the phenomenon of ‘survey fatigue’. Variations in terms of expectations and remuneration likewise contribute to scepticism and hesitancy. In the case of the DHS, these issues are compounded by the invasive nature of the surveys—the collection of blood samples, anthropometric data and sensitive personal information, such as that which relates to participants’ sex lives, abortions or deaths in the family.⁵ The length of the DHS is also pertinent; in the last round, the women’s module—the set of questions reserved for adult women in each household—could take several hours to finish. Research into how the scale of contemporary surveillance contributes to the accuracy and reliability of data has been inconclusive.⁶ However, beginning in the 1970s with some of the earliest cross-sectional demographic surveys, anthropological research has illustrated that respondents are rarely entirely forthcoming and that the practices of enumerators can differ vastly even when engaged on the same project.^{7 8}

The size and scope of the DHS questionnaire is a result of the programme’s success, illustrating its value for a wide range of national and international stakeholders. Although today DHS data are used primarily for epidemiological insight, a large part of the survey still pertains to drivers of population dynamics. This is the core of the questionnaire and reflects the programme’s origins in an earlier USAID-funded project, the World Fertility Survey, which began in the early 1970s as a response to widespread, although predominantly Western anxieties around ‘overpopulation’.^{9 10} Over the years, the DHS has swelled through the addition of questions and modules added at the behest of various, often international actors. In last year’s Malawi survey, for instance, UNICEF requested the addition of a micronutrient module which would require larger blood samples and more sophisticated laboratory analysis. The addition of this module significantly increased the cost of the survey, with additional training and the procurement of reagents also contributing to a notable delay. While in this case the rising costs of the survey were met by UNICEF and the World Bank, the scale and scope of the DHS reinforces reliance on international partners for its implementation. At the same time, for indicators with significant variation—such as child anthropometry—or for events which are relatively rare—like maternal mortality—sample sizes are rarely large enough to illustrate the granular spatial or demographic differences necessary for targeted interventions.^{11 12} In this respect, some indicators produced by the DHS are only reliable at the regional or national level, with limited explanatory or practical value beside charting national-level change and facilitating international comparison.

The size and scope of the DHS also speaks to an absence of the national infrastructures which elsewhere provide reliable routine health data and vital statistics. Attempts are, however, being made to remedy this. In Malawi, the digitisation of routine health data through the open-source DHIS2 system now provides the government with regular, continuous data from health providers around the country. From 2010, Malawi’s National Registration Act has also made the registration of births and deaths compulsory. However, in time-poor and resource-poor healthcare settings—where accurate data collection is not always a priority—concerns persist around the quality of routinised data.¹³

That routinised data collection remains underdeveloped in many countries is at least partly due to the presence of hegemonic data collection programmes, such as the DHS.¹⁴ The utility and quality of cross-sectional data—and its affordability relative to universal vital registration or reliable nationalised health registers—somewhat deny the necessity of national health information systems. The history of the DHS also suggests that this is not entirely coincidental. As with other important population-level surveys, the DHS emerged from the middle of the 1980s alongside the structural adjustment programmes (SAPs) which, prescribed by the World Bank and the International Monetary Fund (IMF), encouraged small governments and the prioritisation of cost-effective interventions in healthcare. Offering efficient, targeted interventions without contradicting neoliberal ideals, surveys like the DHS, the LSMS and later the MICS became essential for tracking and mediating the deleterious social and health effects which accompanied the early SAPs.¹⁰ These surveys, and the period from which they emerged, started the ongoing fragmentation of data landscapes in many LMICs, in which external donors prioritise their own, parallel data collection programmes rather than investing in the often pre-existing national health information systems which could also readily collect such data.¹⁵ If programmes like the DHS continue to negate investments in routine data collection, they may actually represent a barrier to the development of better national-level infrastructures.

Solutions

The DHS repository is now back online, thanks to stopgap funding from the Gates Foundation; interim funding has also been secured for the completion of unfinished surveys, including Malawi’s. However, this period of transition is also the moment to consider the shape and orientation of future surveys. After the DHS was shuttered in February, the United Nations Statistical Division (UNSD) began a ‘task force on sustainable demographic and health statistics’.¹⁶ The World Bank and the Gates Foundation have been proposed as sources of longer-term funding.¹⁷ Grassroots efforts to independently secure older datasets have also emerged.¹⁸ Alongside the broad consensus that the DHS should be saved, and that surveys half-finished should be quickly finished, are conversations around what happens next. Drawing from the authors’ ongoing research, we offer four discrete suggestions for the future of these statistics.

National ownership and oversight

As a vital national resource and the product of national labour, national governments and statistical agencies—with assistance from local universities and civil society groups—must lead the design, implementation, analysis and publication of any future surveys. Completed datasets should likewise be made available through national statistical agencies and secured against the loss of international assistance. There should be commitments from development partners in country and outside to support the financing of these foundational aims.

Capacity strengthening and community involvement

Rather than negating the need for routinised data, any future DHS programme should work to complement the national production of routine health data and universal vital statistics. Here, cross-sectional surveys can be developed to provide more insight into the quality of routinised data. This may also be an opportune time to experiment with the integration of routine and extraordinary data collection. In Malawi, for instance, health surveillance assistants or disease control surveillance assistants—community members tasked with generating health data from remote areas—might also be employed to support larger survey programmes.¹⁹ As well as potentially reducing the cost of cross-sectional surveillances, greater community involvement may also improve data quality and mitigate survey fatigue.

Streamlining

Given the burden of overlapping surveys and associated survey fatigue, health systems should prioritise surveys that serve national needs rather than external interests. At the global level, commissioning organisations must prioritise discussions around the integration and timetabling of comparable surveys. Removing certain modules, stripping questions which could be easily or more reliably answered through routine data collection may also reduce costs and facilitate greater national autonomy. If funding were to remain at a similar level, however, such streamlining may instead allow for larger sample sizes and the more granular insight necessary for the planning and assessment of interventions.

Accessibility, standardisation and international collaboration

While prioritising national requirements, the international perspective of the DHS programme should also be preserved. International comparison remains valuable for policy and analysis, a way to learn from success and failures elsewhere and to advocate for interventions which have worked in other places. Standardisation offers economic efficiencies, allaying the duplication of efforts and expenditure by individual governments and facilitating the transfer of materials and expertise between countries. To safeguard the old DHS’s values of openness and accessibility going forward, and as a means to further secure national data, old and new datasets and technical supporting documents should still remain freely accessible through a centralised repository, as well as through national-level repositories. Where technical support is required from international partners, this should emphasise capacity building at the national level.

Conclusion

The recent loss of USAID funding will have consequences for the provision of healthcare and for population health around the world. It will take some time before the precise effects of the shutdown become apparent and, ironically, the DHS will probably be the best way to understand the effects of these recent events. Although the cancellation of the DHS contract interrupted the production of reliable population health data and compromised the health systems which rely on it, the fact that these surveys have become so important for national health systems is the result of a longer history. Although not the principal intention of those working within the DHS programme, the DHS first emerged and first became valuable in the context of structural adjustment and deep cuts to healthcare spending. Offering cost-effective alternatives to routine data collection—as well as a means to targeted, economical public health interventions—the DHS complements a broadly neoliberal approach to healthcare. The survey’s shortcomings are rooted in this history and, as the next iteration of the DHS is decided, a deliberate break from this past will make for a better future.

Data availability statement

No data are available.