Measuring and monitoring child health and wellbeing: recommendations for tracking progress with a core set of indicators in the Sustainable Development Goals era

Abstract

Although great improvements in child survival were achieved in the past two decades, progress has been uneven within and across countries, and the COVID-19 pandemic threatens to reverse previous advances. Demographic and epidemiological transitions around the world have resulted in shifts in the causes and distribution of child death and diseases, and many children are living with short-term and long-term chronic illnesses and disabilities. These changes, plus global threats such as pandemics, transnational and national security issues, and climate change, mean that regular monitoring of child health and wellbeing is essential if we are to achieve the Sustainable Development Goals. This Health Policy describes the three-phased process undertaken by the Child Health Accountability Tracking technical advisory group (CHAT) to develop a core set of indicators on child health and wellbeing for global monitoring purposes, and presents CHAT's research recommendations to address data gaps. CHAT reached consensus on 20 core indicators specific to the health sector, which include 11 impact-level indicators and nine outcome-level indicators that cover the topics of: acute conditions and prevention; health promotion and child development; and chronic conditions, disabilities, injuries, and violence against children. An additional six indicators (three impact and three outcome) that capture information on child health issues such as malaria and HIV are recommended; however, these indicators are only relevant to high-burden regions. CHAT's four research priorities will require investments in health information systems and measurement activities. These investments will help to increase data on children aged 5–9 years; develop standard metadata and data collection processes to enable cross-country comparisons and progress assessments over time; reach a global consensus on essential interventions and associated indicators for monitoring emerging priority areas such as child development, chronic conditions, disabilities, and injuries; and implement strategies to increase the uptake of data on child health to improve evidence-based planning, programming, and advocacy efforts.

Introduction

The global community affirmed its commitment to end preventable child deaths and to support child development with the adoption of the Sustainable Development Goal (SDG) framework in 2015.¹ Although children have a better chance of survival now than they did two decades ago, progress has been inconsistent around the world. Latest estimates indicate that 54 of the 193 UN member states will need accelerated action to achieve the SDG 3 target of reducing mortality in children younger than 5 years to at least as low as 25 per 1000 livebirths by 2030.² Most of these countries are in sub-Saharan Africa and central and southern Asia. Children everywhere are facing an uncertain future given the disruptions to services, schools, and economies caused by the COVID-19 pandemic and climate change. Many children are also affected by conflicts, rapid urbanisation, and other forms of mass migration; online harassment and harmful online content; and predatory commercial practices.³ Each country's ability to meet the health needs of its children is affected by its available resources, the strength of its health system, and its demographic and epidemiological profile. Continued high rates of birth and child mortality in many sub-Saharan African countries, for example, suggest that these countries might face serious challenges with scaling up high-quality, essential child health and nutrition services to meet growing demand.4, 5 The proportion of child deaths due to chronic conditions and injuries is increasing in many countries, and more children than before are living with short-term and long-term disabilities, placing pressure on already over-stretched health systems to adequately respond.⁶ These complex challenges highlight the importance of regular monitoring of child health to promote action and accountability at global, regional, national, and subnational levels, and to ensure adequate resources are efficiently and equitably allocated to support comprehensive child health policies and programmes.

Key messages.

• •Regular monitoring of core child health and wellbeing indicators is essential for holding governments and partners to account for meeting the needs of children, addressing pervasive inequities and health threats, and making progress towards global goals
• •The Child Health Accountability Tracking technical advisory group (CHAT) group undertook a three-phased process from 2018 to 2020 to reach a consensus on a core set of indicators for global monitoring that would keep the reporting burden on countries manageable and comprehensively cover key dimensions of child health and wellbeing
• •The CHAT group has recommended 20 indicators for capturing information on the topics of acute conditions and prevention; health promotion and child development; and chronic conditions, disabilities, injuries, and violence against children
• •The CHAT group has proposed four research recommendations to address data gaps and to increase the uptake of child health and wellbeing data for decision making, which will require investments in measurement activities and in country health information systems
• •Next steps for the CHAT group are to develop guidance materials on how countries can adapt the recommended core indicators to their specific contexts, and a companion set of paediatric quality-of-care indicators informed by WHO-led efforts

Numerous global initiatives have been launched in the SDG era, and many include monitoring frameworks with indicators relevant to child survival and development.⁷ Although these initiatives have helped raise the visibility of child health, they have inadvertently contributed to widespread use of inconsistently defined indicators and non-standard data collection approaches. Consequently, the reporting burden on countries has increased, and tracking the progress of child health over time and within and across countries has become challenging.⁸ To help address these problems, WHO and UNICEF, with support from the US Agency for International Development, co-convened the Child Health Accountability Tracking technical advisory group (CHAT) in 2018. The aims, objectives, and membership of CHAT and the companion advisory groups on maternal and newborn health (Mother and Newborn Information for Tracking Outcomes and Results [MoNITOR]) and adolescent health (Global Action for Measurement of Adolescent Health [GAMA]) are described elsewhere.7, 9, 10 CHAT set out to map child health and wellbeing indicators included in global accountability initiatives, prioritise a core set of standard indicators on child health and wellbeing, and propose a research agenda to address identified gaps. This Health Policy paper describes how CHAT completed these tasks and presents the group's recommendations.

How the priority indicators were selected: a three-phased approach

CHAT arrived at its indicator and research recommendations through a three-phased approach undertaken between November, 2018, and January, 2020. This approach comprised: (1) mapping existing child health and wellbeing indicators from the most salient global initiatives launched in the SDG era between 2015 and 2020; (2) organising the indicators into three domains covering major aspects of child health and wellbeing; and (3) developing selection criteria and prioritising the indicators (figure ). CHAT reaffirmed its recommendations in July, 2021.

Figure.

Phases for the selection of priority child health and wellbeing indicators and research recommendations

Phase one: mapping and review of indicators in relevant global health initiatives

The first step involved mapping and review of indicators for children aged 1 month to 9 years, to complement similar exercises conducted on the first month of life by MoNITOR and the 10–19 year age group by GAMA. Phase one also covered the survive, thrive, and transform dimensions as defined in the Global Strategy for Women's, Children's, and Adolescents’ Health.11, 12 The review component focused on relevant global accountability initiatives introduced between 2015 (the start of the SDG era) and 2020 that include indicators on child health and are used for regular progress assessments and comparisons across countries and time. These initiatives include the SDGs, the WHO core list of 100 indicators, Global Strategy, Countdown to 2030, and the Nurturing Care Framework.1, 12, 13, 14, 15 A total of 149 indicators were identified and compiled into an Excel file that includes information on the metadata for each indicator (appendix pp 1–15).

Phase two: organising indicators into three main domains

CHAT organised the 149 indicators into three domains that cover major areas of child health and wellbeing: acute conditions and prevention; health promotion and child development; and chronic conditions, disabilities, injuries, and violence against children. Separate working groups covering these three domains were established. These groups met face to face and virtually to agree which indicators from the mapping exercise were relevant for their area; develop a set of criteria and a scoring system to rank the indicators; apply the criteria; discuss, refine, and agree on the results; and identify gap areas for future research.

Phase three: prioritisation

The prioritisation phase started with a reconvening of the three groups to reach a consensus on the distribution of indicators by domain using a Delphi process, to identify cross-cutting indicators that were relevant to more than one of the three domains, and to discuss the scoring systems and initial results of each group. After this step, CHAT developed exclusion and inclusion criteria applicable to all three groups. CHAT agreed to select indicators that only capture information on the health sector. Therefore, transform indicators (eg, completion of secondary education and elimination of discrimination) were excluded because they capture information beyond the health sector. In addition, the underlying constructs for transform-related indicators are often poorly defined, and most have little or no available data or collection mechanisms. Indicators on health and social determinants such as poverty, conflict or humanitarian disasters, and pollution were excluded because they are context-specific, are outside the scope of the health sector, and require complex measurement. Assessments of the core indicators should be followed by in-depth investigations that include information on determinants and other factors to understand why a country is progressing or falling behind.

Most (131 [89%]) of the 149 indicators are outcome or impact measures. These types of measures are the most appropriate for global monitoring because greater consensus has been reached on standard definitions and data collection approaches for them, enabling comparisons over time and across settings.¹⁶ Input, output, and process indicators were excluded because these three types of measures generally capture programme-specific data, country-specific information on financial flows or human resource issues, or are adapted to a given context and are not as useful for global monitoring. Input, output, and process indicators are essential for understanding health system readiness and other aspects of quality of care, and should be considered for in-depth national and subnational monitoring exercises. CHAT also agreed to exclude indicators for which there is evidence of invalidity, such as the collection of information on antibiotic treatment for children with diagnosed or suspected pneumonia through household surveys.¹⁷ Indicator validation studies have been conducted for only a handful of child health indicators, making it unrealistic to insist upon evidence of validity as an inclusion criterion.

CHAT reached consensus on the following inclusion criteria: (1) related to a leading cause of child death, disease, disability, or injury within the age range of 1 month to 9 years; (2) for outcome indicators, effective in addressing one or more of these causes and with programmatic relevance (ie, changes in the indicator can be detected in a timely manner to inform a programmatic response); (3) consensus on a standard definition and data collection approach; (4) feasibility (ie, a reliable mechanism is in place for regular data collection across most countries); (5) stability (ie, making it possible to track trends); and (6) child specific or child centred.

CHAT members agreed that after application of the first list of inclusion criteria, an additional set of inclusion criteria would be applied: (1) elimination of duplicates; (2) ensuring a balance across all leading causes of child death, disability, disease, or injury; and (3) consideration of equity through recommending disaggregation as appropriate (eg, by age, sex, geographical location, wealth quintile, and maternal education) and by ensuring that indicators for diseases associated with poverty (ie, diarrhoea and pneumonia) were included so that the most disadvantaged children are not left behind. Each of the working groups developed some additional criteria specific to their domain area and prepared detailed reports of their deliberations (appendix pp 16–32).

Recommendations for a core set of child health and wellbeing indicators

This section presents the CHAT indicator recommendations. Table 1 shows the 20 recommended core indicators that cover the three domain areas and are relevant to all countries. Table 2 presents six additional recommended indicators that should be regularly collected and reported on by countries in high-burden regions. Both tables include information on indicator definitions, associated domain area (more than one domain is relevant for some indicators, such as nutrition indicators), and measurement activities needed.

Table 1.

Child Health Accountability Tracking recommendations for a core set of indicators for global monitoring of child health and wellbeing

	Definition	Indicator type	Domain and subdomain area	Data sources	Measurement uses	Areas for measurement improvement
Mortality rate of children younger than 5 years (SDG 3.2.1)	Probability of dying between birth and exactly 5 years of age, per 1000 livebirths	Impact	Acute and prevention (mortality)	Estimate from UN-IGME; can be disaggregated by age to include 1–11 months (postneonatal mortality rate) and 1–4 years (child mortality rate)	Monitoring progress at country and global level towards SDG 3.2.1 (reducing child mortality and ending preventable child deaths)	Strengthen CRVS systems in all LMICs
Mortality rate of older children (aged 5–9 years)	Probability of dying at age 5–9 years expressed per 1000 children aged 5 years	Impact	Acute and prevention (mortality)	Estimate from UN-IGME	Monitoring progress towards the reduction of mortality among older children	Strengthen CRVS systems in all LMICs
Causes of death (children younger than 5 years and children aged 5–9 years)	Number of deaths in children (younger than 5 years and aged 5–9 years), by cause; proportion of deaths due to specific causes; cause of specific rates of death	Impact	Acute and prevention (mortality)	Estimates from WHO and Maternal and Child Epidemiology Estimation Group	Targeting programmes and policies, and for evidence-based resource allocation	Strengthen CRVS systems in all LMICs
Neural tube defect (prevalence)	Prevalence of disorders that occur during gestation, involving specific elements of the neural tube; consensus needed on a definition of prevalence for children younger than 5 years and for children aged 5–9 years	Impact	Chronic condition and disability	WHO Global Health Estimates; IHME Global Burden of Disease modelled data on prevalence of moderate and severe neural tube defects at birth	Represents one of the most common congenital malformations; important information for planning prevention and treatment services and anticipating needs	Improve measurement of burden of disease and consensus on definition; develop indicators on effective interventions
Uncorrected refractive error (prevalence)	Prevalence of refractive errors (eye disorders impeding the full development of good visual function) that have not been corrected; consensus needed on a definition of prevalence for children younger than 5 years and for children aged 5–9 years	Impact	Chronic condition and disability	WHO Global Health Estimates	One of the top ten conditions with the highest YLDs globally; important to ensure children can learn effectively in schools	Improve measurement of burden of disease and consensus on definition; develop indicators on effective interventions
Asthma (prevalence)	Percentage of children younger than 5 years and children aged 5–9 years with asthma	Impact	Chronic condition	WHO Global Health Estimates; IHME Global Burden of Disease modelled data	One of the top ten conditions with the highest YLDs globally; important to ensure children can participate fully in school and extracurricular activities	Improve measurement of burden of disease and consensus on definition; develop indicators on effective interventions
Road traffic accidents (YLDs)	YLDs due to road traffic accidents among children aged 0–9 years (deaths due to road traffic accidents are captured in the cause of death indicator)	Impact	Injury	WHO Global Health Estimates	One of the top ten conditions with the highest YLDs globally, and a leading cause of older child mortality	Improve measurement of burden of disease; develop indicators on effective interventions (regulations and behaviours)
Anaemia prevalence in children	Percentage of children aged 6–59 months with a haemoglobin concentration of <110 g/L, adjusted for altitude	Impact	Chronic condition (including sickle cell when appropriate); health promotion and child development (nutrition and growth)	WHO global database on anaemia	A leading cause of YLDs for children in LMICs; important for school performance and child health	Improvements in burden of disease estimates on nutrition deficiencies and sickle cell anaemia
Stunting prevalence among children younger than 5 years (SDG 2.2.1)	Prevalence of stunting (height-for-age more than 2 SD below the median of the WHO Child Growth Standards) among children younger than 5 years	Impact	Acute and prevention (nutrition); health promotion and child development (nutrition and growth)	Household surveys (DHS, MICS); population surveys; surveillance systems	Monitoring progress on the reduction of chronic or recurrent undernutrition in early childhood	Improvements in input data for models; strengthen routine information systems in LMICs and regularity of population-based surveys
Wasting prevalence in children younger than 5 years (SDG 2.2.2)	Prevalence of wasting (weight for height more than 2 SD below the median of the WHO Child Growth Standards) among children younger than 5 years	Impact	Acute and prevention (nutrition)	Household surveys (DHS, MICS); population surveys; surveillance systems	Monitoring progress on acute malnutrition resulting from poor nutrient intake or disease that increases susceptibility to infection and death	Improvements in input data for models; strengthen surveillance systems and regularity of population-based surveys
Overweight prevalence among children younger than 5 years (SDG 2.2.2)	Prevalence of overweight (weight-for-height more than 2 SD above the median of the WHO Child Growth Standards) among children younger than 5 years	Impact	Health promotion and child development (nutrition and growth)	Household surveys (DHS, MICS); population surveys; surveillance systems	Monitoring progress on overweight to reduce short-term and long-term health risks for children	Improvements in input data for models; strengthen routine information systems in LMICs and regularity of population-based surveys
Exclusive breastfeeding	Percentage of children aged 0–5 months who are fed exclusively with breastmilk	Outcome	Acute and prevention (nutrition); health promotion and child development (nutrition and growth)	Household surveys (DHS, MICS); population surveys	Monitoring progress	Ensure consistent use of standard definition; regularity of population-based surveys
Vitamin A supplementation (full coverage)	Percentage of children aged 6–59 months who received two doses of vitamin A supplements approximately 4–6 months apart in a given calendar year	Outcome	Acute and prevention (nutrition); health promotion and child development (nutrition and growth)	UNICEF global databases based on administrative reports from countries submitted through UNICEF NutriDash system	Monitoring progress is crucial in countries where there is high child mortality and vitamin A deficiency	Strengthen routine information systems in all vitamin A priority countries
Full vaccination coverage (SDG 3.b.1)	Proportion of the target population covered by all vaccines included in their national programme	Outcome	Acute and prevention (vaccines)	Estimates from WHO and UNICEF (combining administrative system and population-based survey data)	Monitoring coverage of immunisation services and to guide vaccine preventable disease eradication and elimination efforts; used as an indicator of health system performance	Strengthen routine information systems in all LMICs, and further develop approaches to identify children who have not received all recommended vaccinations (including children who have had no vaccinations)
Measles vaccination	Percentage of children who have received two doses of measles-containing vaccine in a given year, according to the nationally recommended schedule	Outcome	Acute and prevention (vaccines)	Estimates from WHO and UNICEF (combining administrative system and population-based survey data)	Monitoring coverage to guide measles eradication and elimination efforts	Strengthen routine information systems in all LMICs, and further develop approaches to identify children who have not received all recommended vaccinations (including children who have had no vaccinations)
Care-seeking for children with symptoms of acute respiratory infection	Percentage of children younger than 5 years with symptoms of acute respiratory infection (cough and fast or difficult breathing due to a problem in the chest and not due to a blocked nose only) in the 2 weeks preceding the survey for whom advice or treatment was sought from a health facility or provider	Outcome	Acute and prevention (pneumonia and diarrhoea)	Household surveys (DHS, MICS); other population-based surveys	Reducing child deaths from pneumonia, a leading cause of death in children	Children aged 5–9 years; improve measurement of antibiotic treatment for children with pneumonia
Care-seeking for fever in children younger than 5 years	Percentage of children younger than 5 years with fever in the 2 weeks preceding the survey for whom advice or treatment was sought from a health facility or provider	Outcome	Acute and prevention (all causes of fever, including meningitis)	Household surveys (DHS, MICS); other population-based surveys	An essential aspect of making sure children are receiving life-saving services	Children aged 5–9 years; improve availability through regular population-based surveys
Diarrhoea treatment	Percentage of children younger than 5 years who had diarrhoea in the 2 weeks preceding the survey and who received oral rehydration salts (packets or prepackaged fluids) and zinc	Outcome	Acute and prevention (pneumonia and diarrhoea)	Household surveys (DHS, MICS); other population-based surveys	Reducing child deaths from this preventable and treatable disease; diarrhoea remains a leading cause of death in young children	Children aged 5–9 years; improve availability through regular population-based surveys
ECDI2030	Recommended measure for reporting on SDG 4.2.1, which is defined as the proportion of children younger than 5 years who are developmentally on track in health, learning, and psychosocial wellbeing	Outcome	Health promotion and child development (learning and responsive caregiving)	UNICEF custodial agency, household surveys	Ensuring children everywhere reach essential cognitive, social, emotional, and physical developmental milestones	Improve measurement of each component of the indicator and data availability through population-based surveys
Maltreatment, harsh punishment by caregivers (SDG 16.2.1)	Proportion of children aged 1–17 years who experienced any physical punishment or psychological aggression by caregivers in the past month	Outcome	Health promotion and child development (safety and security)	UNICEF custodial agency (MICS and DHS)	Ensuring that children's human rights are not violated, and that they do not have short-term or long-term damage from maltreatment	Improve data availability through regular population-based surveys including large enough sample sizes to disaggregate by more granular age categories

Further information on the recommended indicators is available in the appendix (pp 16–32). Because of overlaps in some of the indicators across the three domains, the indicators in the table are organised by impact indicators followed by outcome indicators, rather than by domain area. Domain area is specified for each indicator. All indicators are to be disaggregated by stratifiers (eg, wealth quintile, urban or rural location, maternal education, and sex) as relevant. Although scored as moderate priority, ECDI2030 is an SDG indicator and included in three of the global accountability initiatives included in the mapping. Birth registration is not included in the core list because it is not exclusively a health intervention although the health sector often facilities birth registration in many countries. However, it is an essential indicator of child rights and should be part of country-level analyses on progress. SDG=Sustainable Development Goal. UN-IGME=UN Inter-agency Group on Mortality Estimation. CRVS=civil registration and vital statistics. LMIC=low-income and middle-income country. IHME=Institute for Health Metrics and Evaluation. YLD=years lived with disability. DHS=Demographic and Health Surveys. MICS=Multiple Indicator Cluster Surveys. ECDI2030=Early Childhood Development Index 2030.

Table 2.

Child Health Accountability Tracking recommendations for regionally specific indicators in areas of high endemicity or burden

	Definition	Indicator type	Domain and subdomain area	Data sources	Measurement uses	Areas for measurement improvement
New HIV infections in children (estimated paediatric HIV incidence)	Estimated number of new HIV infections per 1000 uninfected population at risk of HIV infection (available for children aged 0–9 years)	Impact	Chronic conditions (infectious cause)	UNAIDS estimates	Crucial for assessing progress in eliminating maternal-to-child transmission of HIV and paediatric infections	Build country capacity to collect and analyse data from Spectrum models
Tuberculosis (incidence)	Estimated number of sputum-smear-positive cases of tuberculosis in a population in a year or given period of time; expressed as the number of sputum-smear-positive cases per 100 000 population in a given year	Impact	Chronic conditions (infectious cause)	WHO Global Tuberculosis Programme estimates	Monitoring paediatric tuberculosis epidemics in countries	Strengthen country surveillance systems and burden-of-disease estimates to improve data quality and to enable disaggregation by the child population
Thalassaemia (prevalence)	Prevalence of an inherited blood disorder caused when the body does not make enough haemoglobin; consensus needed on a definition of prevalence of thalassaemia in children younger than 5 years and children aged 5–9 years	Impact	Chronic conditions	International and national surveillance systems for birth defects and genetic diseases	Determination of service needs	Strengthen country surveillance systems and burden-of-disease estimates
Use of insecticide-treated bednets for children younger than 5 years	Percentage of children younger than 5 years who slept under an insecticide-treated mosquito net	Outcome	Acute and prevention (malaria)	Household surveys (DHS, MICS), malaria indicator surveys, and other population-based surveys	Crucial for understanding progress in reducing malaria infection, a leading cause of death in children	Improve regularity of population-based surveys, including malaria-specific surveys
Malaria diagnostics in children younger than 5 years	Percentage of children younger than 5 years with fever, for whom advice or treatment was sought, and who had blood taken from a finger or heel for testing	Outcome	Acute and prevention (malaria)	Malaria indicator surveys	Crucial to ensuring that febrile children in endemic countries are properly diagnosed, and that only febrile children diagnosed with malaria receive antimalarials	Improve regularity of population-based surveys, including malaria-specific surveys; strengthen routine information systems in all LMICs
Malaria treatment—first-line treatment for children younger than 5 years	Percentage of febrile children younger than 5 years receiving first-line antimalarial drug, among those receiving any antimalarial drugs	Outcome	Acute and prevention (malaria)	Household surveys (DHS, MICS), malaria indicator surveys	Determining whether these children are receiving effective treatment for malaria	Improve regularity of population-based surveys, including malaria-specific surveys; strengthen routine information systems in all LMICs

Further information on the recommended indicators is available in the appendix (pp 15–32). Because of overlaps in some of the indicators across the three domains, the indicators in the table are organised by impact indicators followed by outcome indicators, rather than by domain area. Domain area is specified for each indicator. All indicators are to be disaggregated by stratifiers (eg, wealth quintile, urban or rural location, maternal education, and sex) as relevant. DHS=Demographic and Health Surveys. LMIC=low-income and middle-income country. MICS=Multiple Indicator Cluster Surveys.

Of the 149 indicators from the mapping exercise, 79 were related to the domain of acute conditions and prevention. After applying the predefined criteria, these 79 indicators were narrowed down to 16, covering five subdomains: mortality; nutrition; immunisation; pneumonia and diarrhoea; and malaria and all other causes of fever, including meningitis. 50 of the 149 indicators were considered applicable to health promotion and child development, which were reduced to ten indicators once the selection criteria were applied. These indicators covered three subdomains consistent with the Nurturing Care Framework: nutrition and growth (including anthropometry, infant and young child feeding, micronutrients, and anaemia); early learning and responsive caregiving; and safety and security.

The four topic areas of chronic conditions, disabilities, injuries, and violence against children have historically received little global visibility. For example, of the top ten conditions afflicting children according to WHO's latest evidence on years lived with disability (iron deficiency anaemia; skin diseases; congenital anomalies; asthma; uncorrected refractive error; diabetes, endocrine and blood disorders; other neurological problems; autism spectrum disorder; unintentional injury; and hearing loss),¹⁸ only two (anaemia and road traffic injuries [a specific type of unintential injury]) were included in the 149 indicators. This observation is not surprising given that global guidance on a recommended set of effective interventions and supportive policy measures for these conditions in children is still under development. Review of the cause of child death and data on years lived with disability for 2019 showed that disabilities, injuries, violence, and congenital malformations are of equal relevance for children younger than 5 years and for children aged 5–9 years. Chronic infections and non-communicable diseases are proportionally more impactful on the health of older children. CHAT recommended focusing on the highest burden conditions for the two age groups, starting with tracking conditions for which prevalence data are available. CHAT also recommended that WHO and UNICEF undertake a consultative process to reach consensus on a core set of essential interventions for these conditions and associated indicators. Once this step is completed and data become available for these indicators, these data can be added to monitoring efforts.¹⁹

Research recommendations

CHAT identified four research priorities to address data gaps (panel ). The first area involves improving data availability for children aged 5–9 years. Increasing data on all dimensions of child health and wellbeing for older children will require greater investments in country health information systems, civil registration and vital statistics systems, and household survey programmes. These investments will also improve data availability for children younger than 5 years.

Panel. Research priorities.

Investments in measurement activities and country health information systems are needed to:

• •Improve data availability for children aged 5–9 years
• •Develop standard indicator metadata and data collection procedures so that child health constructs are correctly captured, and to ensure indicators are harmonised across global initiatives and in global databases
• •Reach consensus on essential interventions and associated indicators for the topic areas of child development, chronic conditions, disabilities, injuries, and violence
• •Build country capacity to collect, analyse, and use data, and to increase the use of child health data for decision making at global, regional, and national levels

The second area concerns investments in measurement activities to improve how indicators are defined and collected, so that constructs (including all relevant equity dimensions) are correctly captured. The mapping exercise found numerous duplicates for the same domain and indicator (eg, care-seeking for symptoms of acute respiratory illness, diarrhoea treatment, and exclusive breastfeeding). These duplicates might lead to inconsistencies in measurement and challenges in interpretation. Efforts are needed to ensure that standard definitions for child health and wellbeing indicators available in the SDG and UN agencies global databases are used across monitoring efforts, and that the best data collection platform (eg, household surveys, facility surveys, or administrative systems) for each indicator is identified.

A third area involves reaching consensus on essential interventions and associated indicators for child development, chronic conditions, disabilities, injuries, and violence. Although there are robust indicators for anthropometry and for infant and young child feeding, standard indicators on nutrition interventions such as counselling need to be regularly included in data collection processes. Initiatives such as the WHO–UNICEF Child Health Redesign and the Nurturing Care Framework are helping to spearhead consensus building efforts.

A final research area is developing strategies to increase the uptake of available data on child health and wellbeing for informing policies and programmes and for promoting accountability. This work includes building country capacity to collect, analyse, and use data on child health and wellbeing for monitoring and resource allocation purposes.

Implications for global monitoring

CHAT enacted a multiphased approach to prioritise a core set of child health and wellbeing indicators for global monitoring. Starting with mapping indicators from relevant global accountability initiatives, the group developed exclusion and inclusion criteria and a scoring system for selecting indicators that covered major dimensions of child health and wellbeing—acute conditions and prevention; health promotion and child development; and chronic conditions, disabilities, injuries, and violence against children. Through this exercise, CHAT reached consensus on a core indicator set and research recommendations to address major data gaps. Similar prioritisation exercises should be done periodically so that the core set remains reflective of global and national priorities and accounts for new evidence on effective interventions, measurement advancements, and changes in the causes and geographical distribution of child deaths, diseases, and disability. The core indicator set should be regularly monitored and used as a starting point for in-depth analyses exploring factors such as social determinants, supportive policies, and health system elements that contribute to or detract from progress within and between countries.

The COVID-19 pandemic has highlighted the importance of strong information systems for enabling countries to mount rapid responses to crises while also maintaining essential services. The pandemic also threatens to reverse the major advances the world has made in improving children's lives, through service disruptions that leave many children without the care they need, school closures, and economic declines that increase children's risk of poverty, poor health, and exposure to violence. Fulfilling the CHAT recommendations will require greater investments in health information systems and improvements in measurement and monitoring of child health and wellbeing—two actions that are essential to making sure children are not left behind in the pandemic's wake. CHAT's next tasks are to help WHO and UNICEF develop guidance materials on how countries can use and adapt the core indicator set to their specific contexts, and to develop recommendations on a companion set of paediatric quality-of-care indicators, which are now under development by WHO and partners. The work on quality of care will be informed by the WHO Quality of Care Network²⁰ and the recently established WHO advisory group on quality of care across the life course.

Search strategy and selection criteria

This study did not involve a systematic or scoping review of the literature. The search strategy for the indicator mapping phase of the study involved identifying global initiatives launched between 2015 and 2020, which included indicators for monitoring child health and wellbeing. The selection criteria for prioritising the indicators were agreed upon through a consensus-based process involving all CHAT technical experts and on the basis of epidemiological considerations as well as programmatic implications.

Declaration of interests

We declare no competing interests.