Pakistan Integrated Nutrition Strategy

Operational Plan


Nutrition Situation
Indicators Pakistan Sindh Punjab KP Baloch Cut-offs
Acute malnutrition
(NNS, 2001)
(FANS 2010)

13%

18%
21.2%

12%
13.9%

11%
7.3%

14%
8.9%
> 15% critical
> 10% serious
Stunting
(NNS, 2001)
(FANS 2010)

37%


44%
51.8%

32%
50%

43%
47.8%

39%
59.1%
> 40% very high
30-39% high
Low birth weight -
(NDHS 2006)
31.1% 27.4% 24% 34% 43% 15% sub-Saharan
Africa
27% Asian region

Preliminary 2011 NNS latest indication
Global Acute Malnutrition = 13-19% (serious to critical)
Latest indication (Preliminary 2011 NNS)
Iron Deficiency Anaemia ( children)- 44%
(Severe Public Health Problem)

Indicators

Pakn Sindh Punjab KP Baloch Cut-off
Iron Deficiency
anaemia (children)
(NNS, 2001)
67%

68% 72% 56% 36% > 40% severe
problem
> 20% public health
significance
Iron Deficiency
anaemia (mothers)
(NNS, 2001)
45% 47% 45% 44% 55% Same
Iodine Deficiency
Disorder Mothers
( NNS 2001)
69% 71% 56% 53% India = 38%
Micro-nutrient Deficiency Disorders
Inappropriate IYCF practices; late initiation breast
feeding - only 37% exclusively breastfed.
Household food insecurity has deteriorated since
2003 (VAM 2009), (61% districts or 80 out of 136
districts)
Household income minimal - subsistence
Poor quality and insufficient amount clean water
Poor sanitation - 48 million people practice open
defecation
Early and frequent childbearing
Low literacy rate - 47%
Frequent emergencies
Causes of malnutrition - multi-faceted
To date

Before 2010 floods, CMAM implemented in KP(good
coverage), Baluchistan, Sindh & Punjab ( 11 out of 57
districts)
Flood response from August 2010 different scale:
Establishing and running programmes at 629 CMAM
sites
7 types of capacity strengthening - DoH & NGO staff
Counseling of caregivers in IYCF and hygiene promo.
Nutrition information systems for decision making
(surveillance, NIS by site, FANS, NNS)




Province
Baseline
Children
treated
(Aug 2010)
Targets based on
FANs surveys and
Response Plans
# Children enrolled
Sep 2010 - April 2011
Baseline Sites
(Aug 2010)
current
CMAM sites
# SAM # MAM # SAM # MAM # SAM # MAM

OTP/SFP

SC
OTP/SFP
Punjab 0 0 71,091 177,734 29,582 73,930 0 6 207
Sindh 0 0 86,758 283,384 28,133 67,985 0 7 163
KP 0 0 4,788 30,164 8,959 42,858 0 10 202
Baluchistan 0 0 1,940 5,909 7,566 14,785 0 2 57
Total/Flood 0 0 164,577 497,191 74,240 199,558 0 25 629
KP/FATA
Displacement
1,555 6,416 18,669 63,504 9,849 46,643 135 7 202
G/Total 1,555 6,416 183,246 560,695 84,089 246,201 135 32 831
CMAM implementation to date
Recovery by weeks of enrolment in
SFP

7.01%
10.83%
26.48%
31.23%
16.74%
7.71%
7.01%
17.83%
44.31%
75.55%
92.29%
100.00%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
Two Weeks Four Weeks Si x Weeks Ei ght Weeks Ten Weeks El even Weeks or more
Province wise recovery rates
93%
77%
94%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bal ochi stan Si ndh KPK
Cured





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PINS: Conceptual Integration
Conceptual integration guided by causality analysis that informed the
strategy and Punjab & Sindh response plans
Operational plan divided into immediate, underlying and basic causes
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Targeting criteria
High levels of acute, chronic and micro-nutrient
malnutrition
Emergency affected areas ( Flood & conflict)
Severely food insecure districts (3 in Sindh and
4 Baluchistan and 3 in KP)

Achievements
WASH, food & health, nutrition interventions are
implemented in 207 out of 237 union councils in 26
districts. Now looking at 54 districts!


Geographical Convergence
Programme complementarity

Integrated approach of different programmes

OTP, SFP sites established in BHUs
SCs placed in hospitals next to other services
including ANC, Obstretric, etc.
Micro-nutrient supplementation integrated to
EPI, Mother & Child week
Programme complementarity - new
Screening for malnutrition during immunization
Immunization of all children attending feeding
centers (not just CMAM)
Nutrition counseling in Diarrhea Treatment
Centres (not just treatment)
Provision of water, jerry cans, soap, hygiene
education to be provided along with CMAM in
BHUs
Nutrition, health counseling expanded to include
kitchen gardens




Going forward
PINS Operational Plan
Three action areas:
1. Actions to prevent and treat acute and chronic
malnutrition
2. Interventions that address the underlying causes
of malnutrition with a multi-sector approach
3. Interventions that address basic causes -
advocacy, awareness raising, policy and planning,
coordination, M&E, financing

4 key elements: all to be continued and scaled up
CMAM including clinical life saving treatment of
complicated cases of severe acute malnutrition
(SC, OTP, SFP)
Promoting good nutritional practices (IYCF) and
hygiene practices
Increasing intake of vitamins and minerals
(Multi micro-nutrient, Vitamin A ,de-worming)
Food fortification -Wheat with iron and salt with
iodine.

PINS Action Area 1 actions to prevent and treat
acute and chronic malnutrition

PINS Action Area 1 activities

IYCF counselling services in health facilities at community
level through LHWs, CHWs, including maternal nutrition.
Communication for behaviour change, social
mobilization. Mother to mother support groups.
Community outreach, home visits, strengthening referral
system.
Lifesaving emergency treatment of SAM. Providing
therapeutic and supplementary foods & medicines
Training service providers in CMAM- NIE.
Providing multiple vitamins and minerals powder
(sprinkles), iron/folate micro-nutrient supplements to all
PLW, de-worming, zinc and ORS supplements, iodized salt
and iron fortified flour consumption
PINS Action Area 1: Indicators and Targets
Outcome indicators Baselines Targets
1 -Therapeutic feeding (GAM)
(SAM)
13%
3% ( NNS 2001)
9%
2%
2-IYCF ( Exclusive breastfeeding) 37%
(PDHS 2006-7)
60%

3- Micro-nutrient supplementation
( Mothers Iron Deficiency Anemia)
45%
( NNS 2001)
35%
4- Micronutrients fortification
( Iodine Deficiency Disorder)
76%
(NNS 2001)
50%
For all 3 key elements

P-DOHs already signed MoUs or work plans with WHO
and UNICEF on nutrition response plans
WFP has partnership with DoH in mother and child
health WHO, UNICEF and WFP MOUs clarify UN agency
roles
WFP , UNICEF & WHO have partnership/field level
cooperation agreements with over 100 national and
international NGOs
PDMAs, P-DOHs partner with ERWGs
Early Recovery Working Groups should transition to
sector working group led by government coordinating
body
PINS Action Area 1 Partnerships

PINS Action Area 2 Interventions that address the
underlying causes of malnutrition with a
multi-sector approach


3 key elements to be continued and scaled up
Food - diversification through household education,
homestead food production, livelihood support e.g.
food for training, food voucher scheme, micro-credit,
etc
WASH - improve access and use of safe drinking
water and sanitation through provision of water
purification tablets, containers, soap and hygiene
education
Health - increased access and use by most vulnerable
to vaccination, PHC, ANC, obstetric and newborn care



PINS Action Area 2 activities

Provide small holder farmers vegetable seeds, fertilizers, tools,
equipment, animals. Support cleaning/repairing fish ponds, provide
fish feed. Training of trainers/ extension workers, farmers, women,
community leaders, animal health workers, producer-marketing
managers.
Provide meals of High Energy Biscuits to primary school children; take-
home rations of flour and vegetable oil conditional on minimum
monthly attendance.
Provision of safe water storage containers to CMAM sites and target
families. Sanitation facilities, hygiene promotion, hygiene kits follow
up hygiene activities at homes and in community groups.
Training of health staff, increase awareness among mothers and
families for improved health practices and disease prevention of
diarrhea, ARI, malaria and measles. Provide adequate treatment
services with antibiotics. Strengthen health facilities by provision of
equipment and supplies.
PINS Action Area 2: Indicators and Targets
Outcome indicators Baselines Targets
1- Food: Proportion of pop. below
minimum level dietary energy
consumption
30%
NNS(2001)
23%
2- WASH: Reduced prevalence of
diarrhea in children < 5
21.8%
(PDHS 06/7)
10%
3- Health: Under five mortality 94/1,000
live births
90/live
births
For 3 key elements
WFP has partnership with and DOE for school
feeding programme
FAO and WFP have partnership with Ministry
of Food, Agriculture and Live stock (MINFAL)
WFP and FAO have partnership/field level
cooperation agreements with national and
international NGOs
UNICEF and WHO have agreement with
Ministry of Environment and Local bodies for
WASH activities

PINS Action Area 2 Partnerships


1. Advocate for leadership and commitment; give technical
assistance to provincial governments to update/finalise
nutrition PC-1 s and provide budget allocations.
Establish/support Government led Coordination.
2. Provide support to include nutrition into health care
providers and food security specialists educational
curriculum, post-graduate training
3. Establish and/or reinforce common nutrition information,
monitoring and evaluation system including nutrition
surveillance system in all high risk (of malnutrition) areas.
4. Build national capacity to produce medically certified
RUTF (already producing RUSF & FBF) by providing
technical assistance to one or two food processing
companies.





Action Area 3 Leadership, Coordination, Advocacy,
Policy, Planning and Financing

5 PC-1s developed to be updated for PINS, adopted and
approved; advocate for budget allocation.
Create high level National and Provincial Nutrition
Coordinating Councils
Strengthen DoH Nutrition Units or Cells in Provinces;
Advocate for legislation for universal salt iodization, wheat
flour fortification
Support the review of LHWs/CMW training
material/curriculum in line with IYCF priorities, update
integrated curriculum for health providers, put nutrition
into training and school curriculum
Expand sentinel site surveillance & increase frequency
nutrition surveys. Expand Nutrition Information
management system (NIS) to all nutrition intervention
sites, agree common process and impact indicators,
establish joint monitoring system
Root causes to be addressed by more than PINS!

PINS Action Area 3 activities

PINS Action Area 3:
Indicators and Targets
Indicators Baselines Targets
1 Provincial PC1s and budgets
prepared
0 5
2- Nutrition included in medical training
curriculum ( Number of institutions)
0 3
3- Functional Nutrition Surveillance
System(districts)
18 54
4- Certified RUTF produced by local
factory
0 1
For Leadership and coordination:
Planning Commission & MOH, P-DOH; link with other
departments such as Education, Agriculture, food, livestock
etc. to coordinate and prepare PC1
For Capacity Strengthening:
DOHs and MOE will facilitate partnership with private and
public Institutes (e.g. AKU, Health Services Academy,
Institute of Public Health) with financial and technical
support from UN for nation wide capacity strengthening
For Sustainability:
DOH in collaboration with UN will work with private sector
for RUTF and RUSF production ( latter already happening)
PINS Action Area 3 Partnerships
Funding Gap (US$)
Action area 18 months 6 months
1. Immediate interventions: 4 elements 107 mill.
1.1 CMAM 90 mill.
1.2 IYCF 10 mill.
1.3 MicrN, supl 5 mill.
1.4 Fortif 2 mill.
78,600,000 20,000,000
2. Interventions that address the underlying causes
of malnutrition 171 mill.
2.1 Food intake + School feed 116 mill.
2.2 WASH 25 mill.
2.3 Health 30 mill.
110,000,000 60,000,000
3. Advocacy, policy, surveillance 10 mill.
3.1 leadership and policies 4 mill.
3.2 National CB 2 mill.
3.3 NIS, Surveil, monitorring 4 mill.
8,000,000 3,000,000
Total 196,600,000 83,000,000

Finalize the Operational Plan through consultative
process at national and Provincial levels, bringing in
ministries and departments
Finalize Joint funding proposals (already in process)
Monthly briefings convened by the RC/HC
Monthly technical meeting of the Early Recovery
Working Groups to transition to sector working
group led by government by 2012
Scale up implementation now!!!




Next steps