Balochistan An Inter-Sectoral Nutrition Strategy...development of “Provincial intersectoral...

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Balochistan –An Inter-Sectoral Nutrition Strategy

February, 2013

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Contents

Executive summary .................................................................................... 34

1. Introduction ............................................................................................. 36

1.1 Nutrition- a development and human rights agenda ................................................................ 36 1.2 Nutrition Situation in Balochistan ............................................................................................................. 37 1.3 Response to the nutrition problems ......................................................................................................... 38 1.4 Challenges of working in Balochistan ...................................................................................................... 39

2. Background of the Strategy .................................................................. 41

2.1 Framework of Determinants of Child Nutrition UNICEF (1992)............................................... 41 2.2 Pakistan Integrated Nutrition Strategy, March 2011 .................................................................... 43 2.3 Dissemination of Findings of National Nutrition Survey 2011, Quetta, October 2011 . 44 2.4 Balochistan Nutrition Policy Note and Strategic Framework Workshop, Quetta, July 2012 ............................................................................................................................................................................... 45 2.5 Multi-sectoral Review Workshop on Nutrition Policy Guidance Notes and Strategy Development, Islamabad, November 2012 .............................................................................................. 47

3. Logical Framework, Objectives, Outcomes/Outputs, Actors, programme planning and implementation mechanisms ..................... 49

Goal: Achieving human development through enhanced nutrition status of mothers and children in Balochistan ..................................... 49

4. Sectoral roles in Strategy ................................................................... 52

4.1 Planning & Development Department .................................................................................................. 52 4.2 Women Development Department ......................................................................................................... 53 4.3 Agriculture, Food and Livestock Sectors ............................................................................................ 54 4.4 Health Sector .................................................................................................................................................... 60 4.5 Water, Sanitation and Hygiene ................................................................................................................ 64 4.6 Social Welfare, Special Education, Literacy/ Non-formal Education Department .......... 66 BISP ............................................................................................................................................................................... 68 4.7 Education Sector ............................................................................................................................................. 68

Annexure ...................................................................................................... 70

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Note

This draft strategy has been developed under a consultancy assignment for the

development of “Provincial intersectoral nutrition strategy (PINS)”. The draft strategy

is based on the findings from local and international literature review and discussions

and deliberations of representatives from various departments of Government of

Balochistan in local and national level policy dialogues and meetings. As such it

provides a sketch to the stakeholders and the technical working group (TWG) is the

appropriate forum to make amendments in this draft before approval from the

competent authority.

Muhammad Suleman Qazi Consultant, Provincial Inter-sectoral Nutrition Strategy for Balochistan

[email protected]

mailto:[email protected]

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Executive summary

The recent advancement in scaling up nutrition (SUN) movement has successfully

made the case that good nutrition is not just about healthier food, though that is part

of it; that it is not just about ensuring a good health\ service, though that is part of it

too; and that it is not just about sound labour laws, nutrition sensitive agri-

businesses, or effective sanitation. SUN is demonstrating that good nutrition can be

achieved when all these elements are brought together in a cohesive plan.

The stagnation and decline in the GDP growth and rise in income inequality in the

country has a bearing on the consumption patterns of the population segments

whereby share of lowest quintile in consumption is only 9.6% against 40.3% for the

highest quintile. According to SPDC 2010, among the 20 poorest districts of

Pakistan, sixteen belong to Balochistan.

The human and economic costs of malnutrition are enormous. Malnutrition interacts

with repeated bouts of infectious disease causing preventable maternal and child

deaths and its economic costs in terms of lost national productivity and economic

growth are huge. But before succumbing to these ailments there are a number of

measures that can serve a preventive purpose. These measures come under the

sphere of work of diverse institutions within public sector and civil society.

Interventions aiming reduction in under nutrition have a special relevance to

Millennium Development Goals (MDGs).

A poor nutrition status of children and mothers is both a consequence of a range of

determinants and also has multiple short to long term ramifications for the socio

economic development. Managing malnutrition not only contributes towards

alleviation of poverty but also provides most effective and sustainable solutions in

the developmental context. In 2004 under the “Copenhagen Consensus Initiative”,

eight of the world’s most distinguished economists agreed that controlling HIV/AIDS,

malaria, and providing micronutrients would yield returns comparable with those of

the best economic policies at that time. Revisiting the issue in May 2008 this eminent

team of economists commissioned by Copenhagen Consensus Centre, reviewed

and prepared a list of the most promising solutions to ten of the most pressing

challenges facing the world today. Five out of the ten most cost effective and

sustainable solutions directly relate with nutrition and the conclusion of the 2008

Copenhagen Consensus Conference was that combating malnutrition in

undernourished children provides the most beneficial return on investment.

The very grim picture of Balochistan depicted by the National Nutrition Survey (NNS)

2011 indicates that the prevalence of chronic malnutrition is 52.2 % and maternal

anaemia is 47.3%. Similarly the prevalence of acute malnutrition among children is

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16.1%. According to the WHO if this percentage exceeds 15% it becomes

emergency state. As such Balochistan is facing a nutritional emergency.

Being the largest province of Pakistan with a low population density and remoteness

of some districts, Balochistan has peculiar challenges in addressing the maternal

and child malnutrition. The multi-sectorial causality of malnutrition includes hygiene

practices; access to safe water and sanitation and health services, household’s food

security, access to a diversified diet, socioeconomic constraints and level of literacy.

This multi-causality implies that there is clearly a role for key sectors such as Food,

Agriculture, Fisheries and Live stock (in addressing widely prevalent food

insecurity), WASH (for the association of stunting with water, sanitation and hand

washing), Education (for the strong association between mother’s education and

child stunting), Social Protection (for the extremely poor and marginalized), and

Health (for the delivery of key interventions for prevention and treatment of

malnutrition) etc,. In order to effectively address these diverse issues related to

malnutrition, the Balochistan multi-sectoral nutrition strategy is being developed.

Such a multi-sectoral approach requires high level commitment, effective

coordination and above all informed leadership for its success. Only focused, results

oriented, evidence-based and fully implemented strategies can make a real

difference.

This document is hoped to bring the under-nutrition in the radar of various actors in

human development. To begin with, the active engagement of the stakeholders

should at least translate in terms of refinement of their draft action plans to

incorporate or scale up, nutrition sensitive and nutrition specific interventions. A

participatory consultative process is required to reach a consensus on the overall

goal, to which all the key departments and ministries shall make their contributions

to. Each stakeholder should define its own strategic objective, outcome and outputs,

as well as activities, including a list of all the key indicators and costing. Given the

diversity and multi-sectorality in addressing the multilevel causes of under-nutrition,

a separate section or secretariat might be required, housed in P&D with

accountabilities for all key levels.

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1. Introduction

1.1 Nutrition- a development and human rights agenda

Pakistan’s economy has been facing stagnation and a decline in the GDP growth from 5.7% to 3% (Pakistan: Framework for Economic Growth April 2011)i. The income inequality is on rise in the country, whereby share of lowest quintile in consumption is only 9.6% against 40.3% for the highest quintileii. According to SPDC 2010, among the 20 poorest districts of Pakistan, sixteen belong to Balochistan. The human and economic costs of malnutrition are enormous. Malnutrition interacts with repeated bouts of infectious disease causing preventable maternal and child deaths and its economic costs in terms of lost national productivity and economic growth are huge. Interventions aiming reduction in under nutrition have a special relevance to Millennium Development Goals (MDGs).iii

1. MDG 1: “eradicate extreme poverty and hunger” a. Reducing “prevalence of underweight children under five years of age”

is an agreed target for MDG 1. Reducing under nutrition increases economic growth.

2. MDG 2: “achieve universal primary education” a. Reducing under nutrition increases cognitive development and

contributes to learning and school completion rates. 3. MDG 3: “promote gender equality”

a. Promoting better nutrition practices contributes to empowering women and to reducing discrimination against girls in family feeding practices.

4. MDG 4: “reduce child mortality” a. Enormous impact, explained in text, of lower under nutrition on child

mortality. 5. MDG 5: “improve maternal health”

a. Improved maternal nutrition and reduced maternal mortality through programmes of behaviour change and iron and folic acid supplementation.

6. MDG 6: “combat HIV/AIDS, malaria and other diseases” a. Reduces maternal and child mortality caused by the interaction of

under nutrition with HIV/AIDS and other infectious diseases. 7. MDG 7: “ensure environment sustainability”

a. Better nutritional practices mean more effective use of available food and so better adaptation to environmental stress (Target 7A), increased health impact from improved access to water and sanitation (Target 7C), and improvement in lives of slum dwellers (Target 7D).

8. MDG 8: “global partnership for development” a. Addressing hunger and malnutrition around the world is a key element

of, and argument for, the global partnership for development. This applies particularly for the least developed countries (Target 8B), where levels of under nutrition are highest.

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A poor nutrition status of children and mothers is both a consequence of a range of

determinants and also has multiple short to long term ramifications for the socio

economic development of any region. Managing malnutrition not only contributes

towards alleviation of poverty but also provides most effective and sustainable

solutions in the developmental context. In 2004 under the “Copenhagen Consensus

Initiative”, eight of the world’s most distinguished economists agreed that controlling

HIV/AIDS, malaria, and providing micronutrients would yield returns comparable with

those of the best economic policies at that time. Revisiting the issue in May 2008 this

eminent team of economists commissioned by Copenhagen Consensus Centre,

reviewed and prepared a list of the most promising solutions to ten of the most

pressing challenges facing the world today. Five out of the ten most cost effective

and sustainable solutions directly relate with nutrition and the conclusion of the 2008

Copenhagen Consensus Conference was that combating malnutrition in

undernourished children, specifically providing vitamin A and zinc, provides the most

beneficial return on investment. Micronutrient fortification with iron and iodine ranked

3rd even above such critical interventions like expanded immunization coverage for

children.

1.2 Nutrition Situation in Balochistan

The National Nutrition Survey (NNS) 2011iv has shown that nutrition status of women

and children of Pakistan in general and that of Balochistan province in particular is

far from satisfactory. The very grim picture of Balochistan depicted by NNS 2011

indicates that the prevalence of chronic malnutrition is 52.2 % and maternal anaemia

is 47.3%. Similarly the prevalence of acute malnutrition among children is 16.1%.

According to the WHO if this percentage exceeds 15% it becomes emergency state.

As such Balochistan is facing a nutritional emergency.

Child Malnutrition

Underweight Stunted Wasted

NNS 2001-02

NNS 2011

NNS 2001-02

NNS 2011

NNS 2001-02

NNS 2011

Pakistan 38 31.5 36.8 43.7 13.1 15.1

Balochistan 35.1 40 39 52 13.9 16

Maternal Child

Micronutrient Status

NNS 2001 NNS 2011 NNS 2001 NNS 2011

Pakistan Balochistan Pakistan Balochistan Pakistan Balochistan Pakistan Balochistan

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Vitamin A deficiency (severe+mild)

5.9 16.6 42 61 12.5 19.6 54 74

Anemia (severe + moderate)

29.4 26.9 51 49 50.9 35.7 62 57

Urinary Iodine deficiency

76.3 52.6 36 29 42.4 29.3 37 35

Zinc deficiency

41.4 52.6 42 44 37.1 37.8 39 40

Being the largest province of Pakistan with a low population density and remoteness

of some districts, Balochistan has peculiar challenges in addressing the maternal

and child malnutrition. The multi-sectorial causality of malnutrition includes hygiene

practices; access to safe water and sanitation and health services, household’s food

security, access to a diversified diet, socioeconomic constraints and level of literacy.

This multi-causality implies that there is clearly a role for key sectors such as Food

and Agriculture (in addressing widely prevalent food insecurity), WASH (for the

association of stunting with water, sanitation and hand washing), Education (for the

strong association between mother’s education and child stunting), Social Protection

(for the extremely poor and marginalized), and Health (for the delivery of key

interventions for prevention and treatment of malnutrition) etc,.

In order to effectively address these diverse issues related to malnutrition, the Balochistan multi-sectoral nutrition strategy is being developed. Such a multi-sectoral approach requires high level commitment, effective coordination and above all informed leadership for its success.

1.3 Response to the nutrition problems

Prior to 18th Constitutional Amendment the nutrition was mostly absent from the development radar. Nutrition specific activities were being implemented in a piecemeal fashion, largely in the form of short-term projects with the assistance of UN or bilateral INGOs. These projects have mostly focused on:

Infant and young child feeding (IYCF), o Baby Friendly Hospitals Initiative (BFHI) for promotion of newborn

breastfeeding, o Nutrition corners at public sector hospitals for nutrition related advice,

Community based management of acute malnutrition (CMAM) projects for flood affected areas. The community based nutrition screening and referrals were through CSOs and INGOs whereas the health department’s facilities and basic health units (BHUs) under Peoples’ Primary Health Care Initiative (PPHI) provided institutional support for CMAM.

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Vertical programs like EPI, LHW, and MNCH served in Vitamin A supplementation and de-worming in children, iron and folate provision to pregnant and lactating mothers, and breastfeeding counseling services.

Multiple micro-nutrients (Sprinkles) were piloted in one district

Salt iodization was implemented throughout Balochistan

School feeding projects such as Tawana Pakistan Project under the Ministry of Women’s Development and Social Welfare was run and half way halted. Funds for this initiative were channelized from Pakistan Bait-ul Mal. Later some other pilot projects funded by the World Food Program were implemented through Education Department involving provision of edible oil and milk powder to girl school children.

Currently, like other provinces, Balochistan has neither a nutrition policy nor a nutrition strategic plan for addressing malnutrition. The strategic clarity on the underlying causes of malnutrition, beyond health department’s mandate has yet to be realized and this strategy serves as a means towards integrating the multi-disciplinary programs.

1.4 Challenges of working in Balochistan

An environmental scan of Balochistan indicates that there are a number of challenges in the design and implementation of inter-sectoral strategies. These can be described as follows: General Challenges in External Environment

Vast area and scattered population: With population of 8.8 million and a population density of 19 persons/ sq km (National166 persons/ sq km) and lower levels of Urbanization (Balochistan 23.9% vs National 32.5%), Balochistan faces severe challenges of coverage and access to services.

High levels of poverty: In Balochistan the MDG 1 (eradicating extreme poverty and hunger), targets are lagging far behind other provinces. The headcount index (where the national goal is 13 percent by 2015), Balochistan’s poverty incidence was found at 48 percent in 2001/02, 15 percent higher than the national average. By 2005/06 poverty incidence worsened at around 51 percent, compared to a national average of around 22 percent. Pakistan Microfinance Network (PMN) study based on the HIES 2005/06 data indicates that the rural poverty exceeds urban poverty levels by approximately 24.2 percentage points. Only 2 percent of the rural households in Balochistan were classified as non-poor,17 percent of the rural poor in Balochistan were classified as “ultra- poor”, while 26 percent were classified as “poor” and 19 percent were classified as “vulnerable”.v

Poor infrastructure to support: Balochistan faces severe issues of water sufficiency which has full range of implications ranging from safe drinking water, food production and sanitation. According to PSLM 2010-11, 35 percent of the population in Balochistan had access to tap water supplied by the local government as a main source of drinking water, 13 percent have no toilets or sanitation system. ‘Water washed’ diseases are more prevalent than ‘water borne’ diseases.

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Limited agriculture: Most of Balochistan is an arid zone and rugged mountainous terrain, which makes it unsuitable for agriculture with the exception of small pockets in far flung valleys. According to Federal Bureau of Statistics (FBS), the Agriculture Statistics of 2009-10 indicate that only 17% of the land is arable; and only 3% is cropped in Balochistan.

Repeated disasters: Having different ecological zones increases Balochistan’s vulnerability to various forms of natural disasters such as droughts and floods. Recent droughts (1997-2002) were the longest dry spells in many years. The districts affected were that of Kalat, Chaghi, Nokundi, Zhob, Kharan, Sibi, Killa-Saifullah. Balochistan was affected by monsoon floods 2010 and 2011 with losses to life and property in Barkhan, Sibi, Kohlo, Kachi, Naseerabad, Jafferabad, Quetta and other areas in northern and central Balochistan.

Large variation in the districts: Wide variations exist with respect to geography, socio-cultural, literacy levels, service delivery, income support and employment opportunities, etc. Hence in terms of developmentindicators , all 30 districts demonstrate yawning inter-district gaps.

Security compromised areas: In majority of the districts security situation remains unpredictable with constrained access

General Challenges in Internal Environment

Status of PSDP: Trends in allocation of funds, with an inclination of investing in physical infrastructures instead of ‘soft’ aspects of development. For instance, between 2009-11, although development and current allocations to health sectors doubled, yet most of these allocations were absorbed in the increase in salaries and cost escalation of drugs, supplies, etc and increase in population served; however, overall contribution is not proportionate to required improved allocations.

Perception of mandate: Nutrition is generally thought of a Health Department’s responsibility and has yet to be considered a development priority and needs mainstreaming into the sectoral policies.

Technical capacity: Historically low base of professionals & skilled persons and other technical capacity related issues offer hurdles to the realization of nutrition as a cohesive inter-sectoral construct.

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2. Background of the Strategy

This strategy is guided by the following frameworks and discussions:

Determinants of Child Nutrition UNICEF1992

Pakistan Integrated Nutrition Strategy, March 2011

Dissemination of findings from NNS 2011

Balochistan Nutrition Policy Note and Strategic Framework Workshop, Quetta

Multisectoral Review Workshop on Nutrition Policy Guidance Notes and Strategy Development Islamabad, 8 November 2012

A chronology of the landmarks in the development of the strategy is given at Annex: whereas a brief description of these is given below:

2.1 Framework of Determinants of Child Nutrition UNICEF (1992)

The nutrition conceptual framework presented below offers a causal analysis of

malnutrition at various levels – immediate, underlying, and basic.

Figure 1: The Conceptual Framework of Malnutrition, adapted from UNICEF – 1992

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The figure indicates that malnutrition is the direct result of two ‘Immediate Causes’:

inadequate diet that is intake of food/nutrients and/or result of infectious disease

which lead to body’s inability to properly absorb the nutrients consumed. Two way

arrows between disease and inadequate dietary intake imply that both might

predispose rather further accentuate each other.

Inadequate food and nutrient intake in part are the result of inadequate access to

food (food insecurity), while “disease” often results from some combination of

inadequate provision of health services and poor environment (water, sanitation and

hygiene practices or WASH). Both inadequate food intake and poor health are

importantly affected by deleterious maternal and child care practices (an underlying

determinant of malnutrition along with food insecurity and inadequate provision of

WASH and health services.) Inadequate education, particularly of females, has

important negative effects on caring and self-care practices, on the utilization of

health services, on family hygiene and on food security. And all of these are affected

by economic status, governance and other “basic causes.”

Using this conceptual framework, the relationship with nutrition with various sectors

becomes clear. On strategic level this framework implies that in order to address the

causes of malnutrition long term, mid-term and short term strategies are required:

Figure 2: The Strategic Dimensions in the Conceptual Framework of Malnutrition

Nutrition Conceptual Framework

Social, economic

and political context

Lack of capital: financial, human, physical, social and

natural

Inadequate education

Income poverty:

employment, self-employment, dwelling,

assets, remittances,

pensions, transfers etc

Inadequate care for

Women and Children

Insufficient health

services & unhealthy

environment

Household food

insecurity

DiseaseInadequate dietary intake

Short-term consequences:

Mortality, morbidity, disability

Long-term consequences:

Adult size, intellectual ability, economic productivity,

reproductive performance,

metabolic and cardiovascular disease

Maternal and child undernutrition Immediatecauses

Basiccauses

Underlying causes

Pakistan Integrated Nutrition Strategy

Sho

rt Term

Me

diu

mTe

rm

Lon

g Term

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As can be ascertained, the short term strategies address the immediate causes of

malnutrition and basically foster prevention and treatment of acute and chronic

malnutrition (these include clinical life saving treatment of complicated cases of

severe acute malnutrition, promotion of good nutritional (IYCF) and hygiene

practices, increasing intake of vitamins and minerals (Multi micro-nutrient, Vitamin A

,de-worming); and food fortification (wheat with iron and salt with iodine).

The medium term strategies address the underlying causes of malnutrition with a

multi-sector approach. These include 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) and Health (increased access and use by

most vulnerable to vaccination, PHC, ANC, obstetric and newborn care).

The interventions that address basic causes (e.g. the political ideology, socio

economic, infrastructure related factors and other resources) can be addressed

through long term strategies and approaches such as advocacy, awareness raising,

policy and planning, coordination, M&E, nutrition surveillance and financing.

On these grounds, scaling up nutrition (SUN) movement has established the need

for multi-sectorality. By breaking down barriers separating different disciplines, SUN

galvanises experts in agriculture, health, social protection, and finance. It

successfully made the case that good nutrition is not just about healthier food,

though that is part of it; that it is not just about ensuring a good health\ service,

though that is part of it too; and that it is not just about sound labour laws, nutrition

sensitive agri-businesses, or effective sanitation. SUN is demonstrating that good

nutrition can be achieved when all these elements are brought together in a

cohesive plan (Scaling up nutrition, 2013).vi

2.2 Pakistan Integrated Nutrition Strategy, March 2011

During response to massive floods in 2011, need for nutrition promotion through inter-sectoral approach was recognized as an important strategy to achieving improved nutritional outcomes in a holistic manner. As a result Pakistan Integrated Nutrition Strategy was developed with support from partners (UN and non-UN partners) to address the issue of malnutrition effectively. Using multifactor causality analysis, it advises the policy makers to understand the need for urgent and immediate intervention as well as to take a holistic view for developing future strategy. It was increasingly felt that while a number of partners and sectors have been mobilized for addressing the malnutrition among children and women, there are three avenues of synergizing their efforts and programmatic approaches i) conceptual integration, ii) programmatic complementarity, and iii) geographic convergence.

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The conceptual integration was based on the framework discussed above and emphasized on realizing the importance of “The Window of 1000 Days” i.e., the fate regarding stunting and low birth weight is decided in utero, starting around conception and the first trimester. In utero Malnutrition predisposes children to adult-onset diseases (e.g., CVD, diabetes, obesity) and that stature at 2 years of age predicts adult stature and is irreversible. The “Window” is from -9 months to 24 months but to reach women at conception or in the first trimester means reaching them before they are pregnant. Evidence suggests that investing in nutrition leads to greater adult height, improved scores on tests of intelligence and reading, greater income, and better physical and cognitive growth, development and productivity

The programmatic complementarity callsfor intersectoral support to achieve the common objective. For instance effective nutrition and health education/promotion requires the four critical sectors: Agriculture, Food, Nutrition and WASH working together and complementing the related outputs of the health sector

The geographic convergence (i.e., more than one sector operating in the same place at the same time) is a must for synergy. It implied that nutrition being a multi-faceted, multi-sectoral problem needs multifaceted sectoral response. Unless and until the vulnerable individuals and families are supported through other interventions, sectoral responses including livelihood support, income generation, microcredit schemes, health care, hygiene promotion, water and sanitation related interventions and especially education enhancing measures, sustainable solutions can never be attained. As the conceptual framework implies, the Pakistan Integrated Nutrition Strategy (PINS) fostered three action areas: 1. Addressing direct and indirect causes of malnutrition in an intersectoral manner 2. Supporting the development of adequate leadership, and 3. The technical and managerial capacities to plan and implement effective nutrition programmes. After the 18th constitutional amendment, a number of ministries having stakes in this framework have been devolved. The new situation offers an opportunity to provincial governments to design and implement their own province specific policies and strategies.

2.3 Dissemination of Findings of National Nutrition Survey 2011,

Quetta, October 2011

The first important strategic landmark for the provincial level intersectoral engagement for nutrition in Balochistan was the dissemination ceremony of findings of the National Nutrition Survey (NNS) 2011 held at Balochistan Civil Secretariat, Quetta, on 18th October 2011. Chaired by the Chief Secretary Government of Balochistan the event witnessed participation by the secretaries of P&D, Education, Food, Agriculture, Population Welfare, Social Welfare, Livestock, PHE and the

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representatives of health programs, Donor and UN agencies as well as Local, national and international NGOs.

The discussions and deliberations at the dissemination of findings of the NNS 2011 highlighted the need of raising profile of nutrition and recognized an inter-sectoral approach as an important strategy to address the grave concerns regarding malnutrition. The analysis of NNS 2011 for Balochistan shows that there is clearly a role for key sectors such as Food, Livestock and Agriculture (in addressing widely prevalent food insecurity), WASH (for the association of stunting with water, sanitation and hand washing), Education (for the strong association between mother’s education and child stunting), Social Protection (for the extremely poor and marginalized), and Health (for the delivery of key interventions for prevention and treatment of malnutrition) etc,.

2.4 Balochistan Nutrition Policy Note and Strategic Framework

Workshop, Quetta, July 2012

Provincial Multi-Sectoral Workshop for Nutrition Policy Guidance Note and Strategic/Operational Planning held on 9-10 July 2012 at Quetta was chaired by the worthy ACS and was attended by P&DD, Finance, Education Department, Health Department, Agriculture Department, Food Department, Planning Commission Islamabad, BISP, UN Agencies and other nutrition development partners. The Workshop was organized with the following Objectives:

i. Develop a common understanding on the province specific multisectoral causes and potential priority activities within each sector to address malnutrition.

ii. Provide the foundation for developing a policy guidance note on the multi-sectoral aspects of nutrition in Balochistan.

iii. Complete next steps in the development of the intersectoral nutrition strategy and the operational plan.

iv. Define roles, agree on clear objectives, nominate focal persons, and agree on next steps and timelines.

It was recognized that poverty and malnutrition are components of a vicious cycle as both reinforce each other. Malnutrition reduces productivity with and results in an overall loss to the economy of 2-3% of GDP annually. Investments in interventions to address malnutrition are very cost-effective. Balochistan needs to chalk out an Inter-sectoral Nutrition Strategy in line with the evidence from countries like Nepal, Afghanistan, Thailand, Peru and Brazil which shows that a centrally-placed coordination mechanism is imperative for ‘planning multi-sectorally, Implementing sectorally, and reviewing programs multisectorally’. The centrally-placed coordination mechanism should be equipped to manage horizontal integration across sectors and vertical integration among levels of government. Such a mechanism requires results-based monitoring tools and results based budgeting, focusing not solely on provincial “average” figures but also e.g. on poorest wealth quintiles. There is need to target the neediest areas and, within them, neediest

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population groups. In order to raise the profile of nutrition there is need to initiate and maintain active advocacy.

From sectoral group discussions following points emerged:

i) The education sector can play a role in creating awareness. The sector requires teaching aids and materials on nutrition, chipping in nutrition in curriculum, promoting nutrition in life skills education for adolescent girls and nutrition sensitization campaigns. The education sector deems capacity building necessary for its teachers, sensitization of department of education staff and SMC sensitization/training program. The sector also offered venues of direct nutrition interventions such as school feeding programs, supplement provision for adolescent girls i.e. iron, deworming, and schools as entry points for effective nutrition targeting i.e. households.

ii) After Sindh, Balochistan is most affected by food insecurity where 63% of households are considered food insecure (18% food insecure with hunger and 11.5% food insecure with severe hunger). Ten of Pakistan’s most food insecure districts are situated in Balochistan. The agriculture sector plays a key role in ensuring good nutrition for example through supporting the development of resilient food systems, crop systems, improving the use of foods e.g. home stead food production, food processing, food preparation, child feeding, nutrition promotion. Agriculture extension services are an ideal structure to work towards better nutrition.

iii) Benazir Income Support Programme (BISP) with a robust dataset on the household level poverty can introduce malnutrition risk factors in the targeting mechanisms for cash transfers. The cash transfer platforms can also serve as ways to transfer information and create knowledge. (e.g. cell phone messages specifically targeting BISP recipients). Besides that vouchers for the purchase of nutrition-specific products (e.g. nutritious food, soap, and micronutrient powders) can be tried.

iv) WASH and PHED asserted the needs in short, medium and long term support. Short term interventions such as capacity building of staff and the users in water testing ensuring that the water being consumed is clean for drinking, provision of water testing kits at the tehsil level and IEC material at the UC level; Medium term interventions such as rehabilitation of water supply schemes, Technical and financial assistance for alternate energy sources and focus on BCC component in training and long term interventions such as coordination mechanisms at higher level, Involvement of legislators, parliamentarians etc.

v) Health department indicated four areas (strengthening governance & institutional mechanisms, service delivery, coordination, and supplies) where it is already working in the domain of nutrition, the department indicated requirement of development of nutrition policy and strategy, integration of nutrition in medical curricula, standardization of curricula for community and facility level service providers, local production of RUTF, vertical and horizontal integration of nutrition program, strategic coordination, BCC and advocacy, disaster preparedness and response and support for Surveillance systems and MIS

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2.5 Multi-sectoral Review Workshop on Nutrition Policy Guidance

Notes and Strategy Development, Islamabad, November 2012

This workshop provided a venue to all provinces to exchange the notes and share the experiences and ideas in design and implementation of a strategy for tackling malnutrition challenges multi-sectorally. Multitude of development partners insisted on the importance of addressing nutrition through multi-sectoral approaches and indicated commitment to support nutrition sensitive planning as their priority. The workshop called provinces to develop mechanisms to come together with donors through one national plan, and to ponder upon the mechanism at federal level in order to ensure funding.

Reflecting on the historical development of multi sectoral program in nutrition Mr. Mohammad Ayub, Sr. Chief of Planning Commission in his address shared that the whole process so far adopted and today’s workshop are a follow up of meeting of ‘Friends of Pakistan’ followed D-10 forum meeting; both specifically focused on nutrition. During these meetings wide consultations were done with 03 key decisions:

a) All provinces will undertake needs assessment, plan and identify resource gaps and develop strategies

b) Planning Commission will help in planning on a one by one basis to come up with a national strategy, based on the provincial strategies, and submit to EAD

c) World Bank, DFID and ADB to coordinate a cohesive response from the development partners

The participants were apprised that since September 2011, substantial progress has been made and there is a broad understanding that there are certain ‘nutrition specific’ strategies that can be implemented through the health sector whereas certain ‘nutrition sensitive’ strategies can be best implemented through other sectors. Both these are being adapted in the provinces at two levels.

All provinces are at advanced stages of PC1s. Two provinces, that is Balochistan and Sind, have nutrition specific PC-1s whereas Punjab and KPK have incorporated nutrition in their broader health sector reform programs.

The four provinces and three regions are developing multi sectoral strategies under Pakistan Integrated Nutrition Strategy (PINS) for nutrition direct and sensitive actions.

The workshop was informed that Pakistan Nutrition Development Partners Group (founded in October 2011) is meeting every month and is chaired by WB. In October, 5th D 10 meeting, chaired by the Minister of Finance with participation from senior officials from Planning Commission, EAD, provincial governments and donors, noted the good progress on planning for a response to the malnutrition challenge in Pakistan but also the need to accelerate action.

Sectoral working groups (Planning and Development, Agriculture, Education, Health, Social Protection and Water and Sanitation sectors) discussed on the policy notes

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and strategies at length and came up with various recommendations. Provinces had a good chance of learning from each other.

It was emphasized that there is currently an important “window of opportunity” with the support and alignment at the federal level through the D-10 group and the Pakistan Nutrition Development Partners Group and at the provincial level through the planning process discussed during the day. Provinces were encouraged to accelerate the finalization of their plans so as to be able to benefit from this window of opportunity.

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3. Logical Framework, Objectives, Outcomes/Outputs, Actors, programme planning and implementation mechanisms

Goal: Achieving human development through enhanced nutrition status of mothers and children in Balochistan

1. STEWARDSHIP

No. Outcomes of Multi-sectoral Nutrition Strategy

1. STEWARDSHIP: To improve policy environment and organization for the multisectoral response to nutrition situation in Balochsitan

2. SYSTEMS STRENGTHENING: human and institutional Capacity building for better service delivery

3. LIVELIHOOD & SOCIAL SAFETY NET for better targeting and ensuring access to the poor and marginalized

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Strategy: Ensuring Overall Stewardship of Multi-sectoral Nutrition Strategy (P&D)

Strategy: Ensuring Gender sensitivity of the multisectoral nutrition strategy (Women Development Department) Strategy: Creating a conducive legal and political environment (DoH)

Strategy: Policy and capacity development (PHED)

2. SYSTEMS STRENGTHENING FOR BETTER SERVICE DEIEVRY

Strategy: Capacity building and institutional strengthening (Live Stock Department ) Strategy: Technical support for agriculture extension services in food sciences (Agriculture department) Strategy: Institutional strengthening for better management of nutrition programs (DoH) Strategy: Human resource capacity building to raise profile of nutrition (DoH)

Strategy: Institutionalization of nutrition into Education Sector (Education department) Strategy: Scaling up and expansion of nutrition services

Strategy: Improved nutrition service delivery (DoH) Strategy: Services to improve access and use of safe drinking water and proper sanitation (PHED) Strategy: Flour fortification and value addition (Food Department)

Strategy: Household level capacity building to enhance quality and quantity of homestead food (Agriculture department)

Strategy: Direct nutrition support to children through education sector

(Education department)

3. LIVELIHOOD & SOCIAL SAFETY NET

Strategy: Strengthen livelihood of the poor producers (Agriculture department)

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Strategy: Livelihood generation in agriculture sector (Agriculture department) Strategy: Social safety nets in agriculture sector (Agriculture Department) Strategy: Better targeting of the poor and marginalized (BISP) Strategy: Creating opportunities for the marginalized (BISP) Strategy: Women focused capacity building in agriculture sector (Agriculture Department)

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4. Sectoral roles in Strategy

4.1 Planning & Development Department

Introduction A premier planning body in the province, with a mission “to judiciously plan the scarce financial resources to improve socio-economic conditions of the masses of the province”, Planning and Development (P&D) Department formulates all development, planning policy matters and plans to execute the policy and ensures that line departments, in accordance with the policies of the Provincial Govt, achieve set targets. Situation P&D secured commitment from government for 20% provincial contribution, as per the WB requirement, for the Nutrition Program PC-1 and the token allocation for 2 years was also reflected in PSDP 2012-13. Rationale P&D has to play a dual role of multi-sectoral planning and advocacy across sectors to implement the strategy sectorally. Effective coordination, both vertically and horizontally, would be a key to integration of nutrition concerns across sectors and policy paradigm. Balochistan, like Sindh, has developed nutrition specific PC1 for the department of Health, Punjab and KPK have developed ‘multi-sectoral PC1s’ with integration of nutrition into sectoral PC1s. The latter approach has certain advantages such as creating incentives for workers, enabling strong coordination, opportunity to leverage large funds and simple financial flow. However there are challenges like, integration of financing and lead role of P&D need to be addressed during planning. Representatives from Balochistan proposed four tiers of coordination mechanism for Balochistan at a national level meeting.vii A provincial steering committee, chaired by ACS development and secretaries of relevant departments as members, a departmental technical working group chaired by secretary of concerned department, while deputy secretary/director and deputy director as members. For monitoring the implementation, two committees at the level of division and district will be constituted. Divisional implementation committee will be chaired by respective Commissioner and heads of line departments will be members. Similarly the district implementation committee will be chaired by the Deputy Commissioner, while district heads of line department will be members. Strategic areas

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Strategy: Ensuring Overall Stewardship of Multi-sectoral Nutrition Strategy

Activities Sector Task Output Indicator Key stakeholders

P&D Establish Multisectoral Coordination Committee for Nutrition (MCCN)

MCCN established

Members of the MCC

P&D Regular coordination between sectors

Regular quarterly meetings

Members of the MCC

P&D Development of Joint nutrition program monitoring and evaluation framework

M&E framework implemented by Dec. 2014

TA

4.2 Women Development Department

Introduction Women Development Department (WDD) plays a vital role in economic, social, legal and political empowerment of women and elimination of gender discrimination. Among its prime functions are to mobilize awareness and sensitize the society for women rights, to look after women related issues at grass root level by way of planning, and keeping liaison with various departments, NGOs, National & International Agencies involved in development for women. Situation The poverty has a women face in Balochistan. From various development parameters the poor status of females can be well ascertained.

Women related development Indicators in Balochistan

Female literacy rate

According to PSLM 2010-11, female literacy rate in Balochistan is just 19% where as that of men is 60%

According to Balochistan MDGs Report 2011, in 2008/09 the gender parity Index (GPI) for primary education was 0.58 for Balochistan, 0.26 percentage points below the national levels of 0.84.

Unemployment rate

According to Labor Force Survey 2010-11, unemployment among women is at 8.08% and that of men is at the tune of 2.41%. For livelihood in Balochistan only 35-46 percent women are allowed whereas at national level this figure is 47-49% (USAID 2012)

Economic autonomy

According to Balochistan MDGs Report 2011 the share of women in wage employment in the non-agricultural sector was poor in Balochistan even compared to other provinces. Female labor force participation (including the

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agricultural sector) was officially recorded at just 11.4 percent compared to 66.2 percent for males without rural/urban variations in 2009.

Economic autonomy: 8-10% women have bank accounts (USAID 2012)

Patriarchy NNS 2011 has shown that when it comes to decision making, men have the power within households to take decisions. Under the patriarchal system men are served meals first.

Rationale At present WDD is developing Gender Equality Policy Framework where nutrition dimension can be incorporated. The department has a stake in assessing the strategies from gender and equity lens and advocating for the same in multi-sectoral nutrition policy, strategy and guidelines. Strategic areas

Strategy: Ensuring Gender sensitivity of the multisectoral nutrition strategy


WDD Assess gender sensitivity of the proposed actions in the nutrition strategic framework and action plans

Gender mainstreaming of sectoral plans

WDD TA

WDD Advocacy and sensitization with the partners on gender aspects of respective strategies

Sector specific sessions organized

TA

WDD Synergizing efforts with the Women Division of Agriculture and Cooperative Department

Number of joint ventures initiated

Women Division of Agriculture and cooperative department

4.3 Agriculture, Food and Livestock Sectors

Introduction According to FAO “Food security exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life”. Food security is built on the following pillars:

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Food availability: The availability of sufficient quantities of food of appropriate quality, supplied through domestic production or imports (including food aid), on a consistent basis. Food access: Access by individuals to adequate resources (entitlements) for acquiring appropriate foods for a nutritious diet. Entitlements are defined as the set of all commodity bundles over which a person can establish command given the legal, political, economic and social arrangements of the community in which they live (including traditional rights such as access to common resources). Food access is also about having sufficient resources to obtain appropriate foods for a nutritious diet. Utilization: Utilization of food through adequate diet, clean water, sanitation and health care to reach a state of nutritional well-being where all physiological needs are met. This brings out the importance of non-food inputs in food security. Stability: To be food secure, a population, household or individual must have access to adequate food at all times. They should not risk losing access to food as a consequence of sudden shocks (e.g. an economic or climatic crisis) or cyclical events (e.g. seasonal food insecurity). The concept of stability can therefore refer to both the availability and access dimensions of food security (FAO, 2006)viii. Literature indicates that most districts of Balochistan have very low values of carrying capacity and do not have a variety of food crops, except Nasirabad, Jaffarabd, Sibi and Lasbela. Ziarat leads in carrying capacity although it has only one crop i.e. potato which has low energy. Balochistan’s nutritional condition is not supportive or adequate for maintenance of good health. Balochistan depends on other provinces for its requirements of wheat, rice and other food crops for subsistence. One of the basic causes of low carrying capacity apart from natural infertility of the soil is the shortage of water, because the province depends on traditional canal systems i.e. ‘karezes’ and tube wells for irrigation to supplement its scarcity of water due to inadequate rainfall and inland drainage. No rivers carrying a large permanent flow of water are found in the province. Since water is the limiting factor of agriculture in Balochistan, this problem must be given top priority in order to facilitate agricultural productivity (Burke. F, Huda. SN, Hamza. S, and Azam M, 2005).ix Rationale Since food security ensures access to essential nutrition enabling the household or country to provide future physical and economic access to sufficient, safe, and nutritious food that fulfils the dietary needs and food preferences for living an active and healthy lifestyle,x these three departments have a direct stake in ensuring the food security and livelihood. Inadequate access to food is one of the underlying causes of malnutrition as it leads to inadequate dietary intake. Situation

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Around 68 per cent of households in Balochistan are exposed to food insecurity, with 18 per cent of these being food insecure with hunger while 11.5 per cent are food insecure with hunger and malnutrition. Livestock & Dairy Development Introduction The mission of Livestock & Dairy Development Department is promoting livestock to provide safe and quality products at competitive prices, covering entire value chain with focus on market & poverty reduction. The contribution of livestock to the economy in Balochistan is more than 40% towards agriculture share and 52% share in province GDP. The Livestock is the mainstay of more than 75% of the people inhabiting in the countryside of Balochistan. Livestock raising continues to be the major occupation for over 70 % rural population of the province. The nomadic people solely depend on livestock whereas; the trans-shipments and sedentary people derive up to 40 % income from livestock. Livestock is considered as financial security and generate ready cash to meet family and farm needs. It also provides a cushion to agro-pastoralists in case of crop failures. Around 80% population is directly or indirectly involved in livestock rearing activities which contributes about PKR20 billion. The department has the following aims and objectives:

- Conservation of indigenous pure breeds. - Identification of quality stock on performance basis. - Multiplication of superior germ plasm and its dissemination. - Technical training in the field of animal Husbandry / Management. - Evolvement of new breeds. - Study on nutrition requirements of Livestock and Chemical composition of

feed. - Study on different economic traits of Livestock.

Strategic areas

Strategy: Capacity building and institutional strengthening of the Live Stock Department


Livestock & Dairy Dev.

Strengthening of Directorate of Planning

PC-1 submitted

P&D Finance TA


PC-1 for Development of Data Base and Information Technology systems

PC-1 submitted

P&D Finance TA


Development of PC-1 for the establishment of livestock research institute

PC-1 submitted

P&D Finance TA

Livestock & Dairy

Development of PC-1 for the strengthening of animal

PC-1 submitted

P&D Finance

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Dev. sciences institute: biological production including semen embryo production

TA

Strategy: Strengthen livelihood of the poor producers


Development of PC-1 for provision of feed mills

PC-1 submitted

P&D Finance TA


Development of PC-1 credit program for livestock farming

PC-1 submitted

P&D Finance TA


Development of PC-1 on improvement in marketing: e.g. meat packing industry

PC-1 submitted

P&D Finance TA

Agriculture and Cooperative Department Introduction Agriculture and Cooperative Department works for the development of agricultural land, construction of dykes / sailabi bunda, harness the runoff of rainfall, thus conserving moisture for utilization in Sailabi (flood) cultivation. The department provides agricultural machinery to farmers on subsidized rates for harvesting and threshing of wheat and paddy. Strategic areas

Strategy: Technical support for agriculture extension services in food sciences

Activities Sector Task Output Indicator

Key stakeholders

Agriculture & Cooperative Dep.

Promotion of research based extension services in indigenous food preservation, processing and value addition, storage and marketing to enhance food security and reduce malnutrition


TA on assessment of designs of agricultural programmes in improving access and utilisation (nutrition promotion, awareness raising, women empowerment aspects)

Strategy: Household level capacity building to enhance quality and quantity of homestead food

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Promotion of kitchen gardening and homestead food production; for ensuring family food security and safety


Capacity building on food diversification, reduction in nutrients losses during food processing, preservation and post harvest losses and to improve market services


Improve supply of agricultural inputs and provision of subsidies


Food fortification and micronutrient supplementation

Strategy: Livelihood generation in agriculture sector


TA on exploring venues of income through the agriculture sector


Small business enterprises, local marketing, income generation


Promote crops/products to meet the population’s nutritional needs (quantity & quality, diversification, food processing)

Strategy: Social safety nets in agriculture sector


Establishment of food safety net to target households and communities at risk of malnutrition


Livelihood support to food insecure households (i.e., gardens, livestock, fisheries)

The Women Division of Agriculture and Cooperative Department Strategy 4.3.7: Women focused capacity building in agriculture sector

Women Div of Agriculture

TA on Introduction of the concept of balanced diet in the curriculum

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& Cooperative Dep.

Women Div of Agriculture & Cooperative Dep.

Capacity building of women groups in fruit and vegetable preservation, sericulture, floriculture, bee keeping, kitchen gardening, calf rearing, soap making, tailoring, embroidery, and home baking; toy making and other handicrafts based on local raw materials available.


Awareness sessions on healthy nutrition and use of fortified foods especially for anaemia in women.


Adolescent girls’ education in nutrition

Food Department Introduction The Food department is mainly focused on wheat supply and storage and regulation of price. Its role is to stabilize open market prices by releasing wheat from reserves as and when the prices of the open market reported to be on higher side, hence it controls and regulates price hike in market. The department is responsible for the maintenance of three month′s reserves to ensure smooth and steady supply of wheat/atta and to eliminate possible artificial shortage and breakdown in supplies. Strategic areas

Strategy: Flour fortification and value addition


Food Department

Mandatory fortification of wheat flour with micronutrients

Food Department

Restart wheat flour fortification to control

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micronutrient deficiencies in vulnerable population

Food Department

Strengthening of food storage facilities

Food Department

Strengthening of food quality laboratory

Food Department

Support to develop resilient food systems (diversification)

4.4 Health Sector

Introduction The department of health has several functions and manifold responsibilities to improve the health standards. Functions of health department include delivery of health care services, health planning, management and development, development of human resource and regulatory functions. Among the provincial offices of the health department, Nutrition Cell is tasked with the nutrition projects, mostly implemented with the donor’s assistance. Situation Under-nutrition levels in children of Balochistan are higher than national level. Similarly there are high levels of micro-nutrient deficiency. Majority of women (61%) and children (73.5%) have Vitamin A deficiency. The NNS 2011 has shown that the mothers had limited knowledge about the essential micronutrients. In children <5years, 70 percent were stunted (1/3rd severely stunted), 38 percent wasted (9 percent with severe wasting) and 62 percent under weight (20 percent severely underweight), and 57.6 percent haemoglobin deficient. At present the PC-1 of Balochistan Nutrition Program for Mothers and Children is under process. It addresses general malnutrition, micronutrient deficiency and promote healthy practices. Health department’s main focus is on pregnant and lactating mothers and children (<5). PC-1 has pooled/ coordinated funding mainly from GoB, WB, UNICEF, MI and WFP (July 1, 2012 – June 30, 2017). The nutrition program will focus on IYCAF & CMAM, micronutrient through fortification (salt and wheat) and supplementation (Vit A, IFA tablets, Zinc&ORS), awareness of stakeholders, strengthening institutional capacity, research and M&E systems. Nutritional status of mothers and children can be a result of the issues surrounding the access to nutrition/food and/or behaviours secondary to lack of information or prevailing myths and wrong beliefs. The second reason requires a behaviour change strategy through which interpersonal and behavioural communication personnel are

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required to disseminate the nutrition messages among communities. However the Department of Health has only 13 health and nutrition education officers for 30 districts. And even these have no training in BCC techniques. In the absence of funds they are unable to deliver the needed services. Thirty-six percent (36%) children age 0-23 months were bottle fed at the time of MICS 2010 survey. The practice was slightly higher among male children and children in the urban areas whose mothers had higher level of education and those in the richest wealth quintile. As low as 38 percent children age 6-8 months were receiving supplementary food; the proportion was higher among males compared to females, but was almost similar on the basis of rural-urban residence.

Indicator MICS 2003/04

MICS 2010 PDHS 2006/07

Exclusive breastfeeding <6 months 24% 39.70% 37.10%

Continued breastfeeding at 1 year 92% 85.70% 79.00%

Continued breastfeeding at 2 years 71% 62.30% 54.90%

Predominant breastfeeding <6 months 57.00%

Duration of breastfeeding 23.9 month

Bottle feeding 34% 36%

Introduction of solid, semi-solid or soft foods

37.70%

Minimum meal frequency 20.30%

Age-appropriate breastfeeding 44.30%

Strategic areas

Strategy: Creating a conducive legal and political environment


Key stakeholders

Health Review of laws and their implementing mechanisms for breast feeding, food fortification and salt iodization.

TA

Health Mandatory legislation on oil and ghee fortification with Vitamin A, Wheat Flour Fortification with iron and salt fortification with iodine

Health Advocacy to enhance political commitment and ownership in nutrition

Health Citizen voice: More visible

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face of community involvement with emphasis on vulnerable groups

Strategy: Human resource capacity building to raise profile of nutrition

Health Capacity building of community health workers in IYCF & CMAM

Health In-service training for BHU and RHC staff on facility based and community-based delivery of key nutrition services

Health Introducing nutrition education in school and college curricula,

Education Department

Health Inclusion of nutrition component as a compulsory part of curricula for all cadres of health care providers;

Health Expand opportunities for enrolling local human resource in accredited post graduation programs in nutrition from recognized Universities of Pakistan

Strategy: Scaling up and expansion of nutrition services

Health Scaling up of CMAM in the food insecure districts

Health Expansion of salt iodization program

Health Expansion of wheat flour fortification with Departments of Food and Agriculture and in partnership with Wheat Flour Mills Association

Private sector Food Department Agriculture Department

Health Zinc/ ORS supplementation through LHW program & PPHI

Health Coverage of non LHW Program covered areas though CMWs and NGOs

Health Integration of nutrition in disaster and emergency plan

PDMA

Health Initiate local production of high density complementary feeding diet

Private sector

Strategy: Institutional strengthening for better management of nutrition programs

Health Inclusion of nutrition indicators in DHIS

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Health Establishment of nutrition surveillance system at hospitals, and institutions, i.e. IDD, Anemia, Malnutrition and micro nutrient deficiencies.

Health Development of BCC strategy to address malnutrition, promotion of exclusive breast feeding for six months, dietary diversity for young children, intensified self-care and IYCF counselling of pregnant women and mothers in the community and facility levels

Health Revision of ToRs of various care providers at facility and community levels and raising the priority in the light of nutrition services

TAs

Health Inclusion of nutrition related role of health care providers in their ToRs by the competent authority

Directorate of HRD, Health Department

Health Revision of school nutrition services

TA

Strategy: Improved nutrition service delivery

Health Increase coverage of Micro nutrient supplementation:

-Zinc to children for treatment of diarrhoea,

-Iron/folic acid supplementation,

-Continued twice yearly vitamin A supplementation through NIDs and measures to increase its coverage,

-Micronutrient powder for young children and increased coverage of salt iodization.

Health High quality dissemination of the priority nutrition messages via media- and also cell phones, as part of a behavior change strategy that includes inter-personal communication (e.g. through LHWs and NGOs)

Health High energy biscuits, powders, ready to use foods, rich energy foods for very poor

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pregnant women and children identified by LHWs.

Health Conditional social transfers for positive nutrition behaviours

Health Pilot and research studies to implement nutrition interventions (e.g. CMAM, PLW and children and treatment of MAM);

4.5 Water, Sanitation and Hygiene

Introduction Public Health Engineering Department (PHED) of the government of Balochistan is the responsible department for providing access to the safe drinking water in the rural as well as in urban slums of the province. Presently the department is maintaining its data regarding water supply schemes and coverage at provincial as well as at the district. Water and Sanitation Authority (WASA) provides services to Quetta City whereas Quetta (tribal) is under PHED. While PHED is providing water and sanitation facilities of most of the rural and some urban areas of Balochistan, WASA (as per WASA, Act 1989) is responsible for the management and supply of safe and clean drinking water according to the requirements of inhabitants of the area and to provide hygienic and pollution free environment from the effects of sewerage and dirty water and to combat also the requirements of the consumers of WASA. Situation According to PSLM 2010-11, 35% population uses tap water for drinking water (urban 87%; rural 21%). As of March 2012 the PHED was providing 61 percent population of Balochistan with drinking water through 2650 schemes with marked variations between districts. However, the MICS 2009/10 reported this proportion as 74.6 percent. MICS reported that around 70 percent of households had access to sanitary means of excreta disposal in 2009/10. WASA has undertaken huge projects and the new water resources are being developed, in and around the mountainous range of Quetta. WASA has currently has 406 tube wells from which 3 Carore gallons of water is supplied through 67000 connections in Quetta, out of which 64000 are domestic and rest are commercial. WASA and PHED work with local govt, P & D, health, municipal corporation, sanitation dept, forest dept, rural development dept and WAPDA. PHED has established 6 labs with UNICEF financial support and hired 6 lab assistants to check

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water quality. The department also has laboratories to test water periodically. The water testing kits are provided by WHO. Rationale The unsafe drinking water and poor hygiene practices and sanitation conditions (Water, Sanitation and Hygiene - WASH) are important underlying determinant of malnutrition. Poor WASH conditions lead to diarrheal diseases, one of the leading causes of child mortality in Pakistan. Diarrhoeal diseases lead to a decrease in the absorption of nutrients consumed and hence even if consumption of food is sufficient, the diarrhoea can lead to malnutrition in children. Open defecation and improper sanitation facilities and unsanitary waste disposal contaminate food in the household as well as food production. The objectives of PHED are to facilitate the rural and urban population of Balochistan with the potable drinking Water. The Department is responsible for the following matters:

Strategy: Policy and capacity development


PHED Policy and strategy

dialogues to define roles

and responsibilities

between LGRDD, PHED

and Municipal

corporations for efficient

and effective

implementation and

accountability.

PHED Developing capacities for

water testing laboratories

PHED TA to assess equity

concerns for water supply

and sanitation rights of

the districts followed by

advocacy with political

leaders

Strategy 4.5.2: Services to improve access and use of safe drinking water and proper sanitation

66

PHED Protection of water sources

from contamination by

continuous water treatment,

stream pollution control etc.

Chlorination of water at the

source

PHED Installation of tube wells and

establishment of sources for

construction of drinking water

supply schemes.

PHED Improved sanitation,

Household water treatment

and storage, improvement of

sewerage system and sanitary

conditions.

PHED Levying regular revenue to

cover all costs of operations

and maintenance.

PHED Issue of notification for water

rates.

PHED Construction and

maintenance of drinking water

supply schemes.

PHED Social mobilization for

awareness on open

defecation free areas, hand

washing with soap, hygienic

preparation of complementary

food and caring for children.

4.6 Social Welfare, Special Education, Literacy/ Non-formal

Education Department

Introduction Optimal development of persons with disabilities for the realization of their full potential in all walks of life, especially in the areas of health, education, social, economic and vocational needs to provide better social facilities socially disadvantaged people and especially to empower women. Major focus of the

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department is on orphanages, special education, rehabilitation of poor and the aged through training / rehabilitation centres, coordination of social welfare schemes etc,. Rationale The human rights based approach demands that the marginalized and the people with the special needs are not excluded. The role of the department hence is advocacy for policy, strategy and development of guidelines to ensure that the rights holders are included in the nutrition sensitive and nutrition specific strategies. Benazir Income Support Program Introduction The primary mandate of Benazir Income Support Program (BISP) is poverty alleviation. In recent past 90 percent of Zakat funds were diverted to BISP. Enrolled families are paid cash assistance @ Rs.1000 per month on quarterly basis; apart from benefits provided under graduation strategy like: long term interest free returnable financial assistance, vocational & technical training, health & life insurance coverage. BISP has also established a small Social Policy Research Unit in order to strengthen research activities related to social policy social protection and cash transfers. Special initiatives of BISP include:

Waseela-e-Haq: To promote self-employment among women beneficiaries (or their nominees as in Balochistan, trainees are usually men to improve their livelihood. Soft loan of PKR 300,000 on 15 years terms for business+10 days fully covered training on entrepreneurship and business management are being offered.

Waseela –E- Rozgar: To empower female beneficiary or her nominee through acquiring a skill; become economically independent by acquiring vocational training through dynamic and Intersectoral technical education and vocational training service -Beneficiaries are given vocational training in one of 52 different trades (check for nutrition relevant!) -Waseela E Sehat: Health Insurance program with an annual maximum limit of Rs. 25,000 per family through Benazir Sehat cards Conditional Social Transfers

Strategic areas

Better targeting of the poor and marginalized


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BISP Identification of the

marginalized households

from poverty score cards

from a nutrition lens

TA

BISP Finance and food stamps to

the dependent families,

disables, poor

Creating opportunities for the marginalized

BISP Livelihood generation through training and marketing of food items and establishment of small business enterprises

4.7 Education Sector

Introduction The Department of Education is working on next 5 years “Balochistan Education Sector Plan (BESP)” which will include training of teachers, curriculum review and research. The department is working on EC (early childhood) education and Kindergarten students or nursery students come under this program till 5 years of age. Other relevant initiatives include hygiene education with UNICEF support. The Education Department has a plan to work with Peoples Primary Healthcare Initiative (PPHI) where children would be observed in classrooms and recommended for treatment from PPHI doctors. At policy level, after the 18th Constitutional Amendment, Department has taken lead on Compulsory Education Act. The Article 25-A of this that declares free education to 5 year old children also guarantees provision of school meals. Strategic areas

Strategy: Institutionalization of nutrition into Education Sector


Key stakeholders

Education Inclusion of nutrition in Informal education,

Education Inclusion of nutrition in pre teaching course

Education Inclusion of nutrition in curriculum in medical colleges, nursing and paramedic schools

Education Development of teaching aids and materials on nutrition

Education Life skills education for adolescent

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girls

Education Teacher training on education

Education Sensitization of Department of education staff

Education Child to family approach: Access of women and girls to micronutrient supplements

Strategy: Direct nutrition support to children through education sector

Education Deworming for all children

Health

Education Weekly supplement of iron for adolescent girls

Health

Strategy: Research based advocacy on nutrition

Education Piloting LHWs program for out of school children

Health

Education TA on School feeding programs: Learning from previous projects

P&D

Education School feeding programs for attracting, enrolling and keeping girls in schools Incentive based programs

Education Nutrition campaigns and nutrition promotion through agents of change

Education Inclusion of out of school children through employing PTSMC

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Annexure

Major landmarks in the development of the Balochistan Multi-sectoral Nutrition strategy

October 2011: Dissemination of Findings of National Nutrition Survey 2011, Quetta

July 2012: provincial Consensus building workshop for developing multisectoral nutrition policy guidance notes and strategies, Quetta

November 2012: Multi-sectoral Review Workshop on Nutrition Policy Guidance Notes and Strategy Development, Islamabad

January 2013: P&D Notification for the constitution of Inter-sectoral Nutrition Co-ordination committee and Technical Woking Group (TWG) for Intersectoral strategy

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References

i Government of Pakistan. Planning Commission Pakistan: Framework for Economic

Growth April 2011

ii Ghauri I. “Millenium Development Goals- Pakistan to miss MDGs due to slow

growth”, Tribune Pakistan, 4th July 2012.

iii Scaling Up Nutrition: A Framework for Action – (2010). UNSCN

iv NNS, National Nutrition Survey, 2011 by Aga Khan University, PMRC and Cabinet

Division

v Pakistan Micro-finance Network (PMN). 2010. Profiling Pakistan’s Rural Economy

for Microfinance.

vi Scaling up nutrition (2013). SUN movement progress report 2011-2012

vii Multisectoral Review Workshop on Nutrition Policy Guidance Notes and Strategy

Development, Islamabad, 8 November 2012

viii FAO (2006). Policy Brief- Issue 2. Agricultural and Development Economics

Division

ix Burke. F, Huda. SN, Hamza. S, Azam. M, (2005). Disparities of Agricultural

Productivity in Balochistan A GIS Perspective. Pakistan Geographical Review, Vol.

60, No. 1

x FAO 2008. The Four Dimensions of Food Security. Published by the EC - FAO

Food Security Programme. Accessed from URL:

http://www.fao.org/docrep/013/al936e/al936e00.pdf

http://www.fao.org/docrep/013/al936e/al936e00.pdf

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