Pakistan Integrated Nutrition Strategy Operational Plan

1. Pakistan Integrated Nutrition Strategy Operational Plan

2. Nutrition Situation Preliminary 2011 NNS latest indication Global Acute Malnutrition = 13-19%(serious to critical)

3. Micro-nutrient Deficiency Disorders Latest indication (Preliminary 2011 NNS) Iron Deficiency Anaemia ( children)- 44% (Severe Public Health Problem)

4. Causes of malnutrition - multi-faceted • 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

5. 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)

6. CMAM implementation to date

7. Recovery by weeks of enrolment in SFP

8. Province wise recovery rates

9. 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 Short Term Medium Term Long Term

10. Geographical Convergence 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!

12. 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

13. 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

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

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

16. 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

17. PINS Action Area 1: Indicators and Targets

18. PINS Action Area 1 – Partnerships 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

19. 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

20. 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.

21. PINS Action Area 2: Indicators and Targets

22. PINS Action Area 2 – Partnerships 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

23. Action Area 3 – Leadership, Coordination, Advocacy, Policy, Planning and Financing 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. Provide support to include nutrition into health care providers’ and food security specialists’ educational curriculum, post-graduate training Establish and/or reinforce common nutrition information, monitoring and evaluation system including nutrition surveillance system in all high risk (of malnutrition) areas. Build national capacity to produce medically certified RUTF (already producing RUSF & FBF) by providing technical assistance to one or two food processing companies.

24. PINS Action Area 3– activities 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!

25. PINS Action Area 3: Indicators and Targets

26. PINS Action Area 3 – Partnerships 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)

27. Funding Gap (US$)

28. Next steps 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!!!