MI - FINAL REPORT - SITUATIONAL ANALYSIS FOR ADVOCACY PROJECT

FINAL REPORT

SITUATIONAL ANALYSIS FOR THE NUTRITION ADVOCACY PROJECT

“Advocacy to Secure Policy and Financial Commitments for Nutrition from the Government of Pakistan”

SUBMITTED TO

Pakistan

BY

Dr. Moazzam Khalil Dr. Muhammad Khalid


Acknowledgements

The researchers wish to express their gratitude to the Micronutrient Initiative Pakistan for providing the

opportunity to conduct this study.

We furthermore thank the entire team of Micronutrient Initiative for the successful completion of this study.

Our thanks are due to Dr. Naseer Muhammad Nizamani, Country Director MI and Mr. Muhammad Irshad

Danish, National Coordinator Scaling Up Nutrition Civil Society Alliance Pakistan (SUNCSA,Pak), who

guided us with their extensive knowledge and experience. We are also grateful to Micronutrient Initiative

home office officials for their valuable comments and feedback.

Ownership

All the ideas, know-how, processes, information, drawings, documents, designs, models, inventions,

copyrightable material and other tangible and intangible materials included in this document, including

without limitation computer programs, computer systems, data and documentation, (collectively, the

“Works”) are the sole and exclusive property of Micronutrient Initiative Pakistan. All rights for the Works are

reserved. No part of the Works may be reproduced or transmitted in any form or by any means, electronic

or mechanical, including photocopying, recording, or by any information storage or retrieval system, without

the written permission from Micronutrient Initiative Pakistan, except for the inclusion of quotations in a review.

List of Notations

Team: Dr. Moazzam Khalil, Dr. Muhammad Khalid

Client: Micronutrient Initiative, Pakistan, the Secretariat of SUNCSA, Pak

Study: Baseline Situational Analysis for Nutrition Advocacy

Report: Draft Report

Disclaimer: We have made every effort to provide the most accurate information, data, statistics, facts,

figures, drawings and procedural descriptions contained in this document. The limitations of the accuracy of the information at the source, however, remain. The document may thus contain human or mechanical errors or omissions. No liability for such errors, or omissions, or un-intentional misrepresentations will be accepted. The Development Strategies Pakistan reserves the right to make corrections and changes in any information contained in this and in subsequent versions of this document.

Either as part of this document or any other written material produced by the researchers, wherever a reference is made to any person using ‘He’ please read it as ‘He/She’.


Abbreviations

ACF Association for Charitable Foundations

ADB Asian Development Bank

BISP Benazir Income Support Program

CSO Civil Society Organization

DFID Department For International Development

DG Health Director general Health

DS Development Strategies

FATA Federally Administered Tribal Areas

GAIN Global Alliance for Improved Nutrition

GFSI Global Food Security Index

IDI In Depth Interview

IDP Internally Displaced People

KP Khyber Pakhtunkhwa

LHWs Lady Health Workers

MI Micronutrient Initiative

MQSUN Maximizing Quality of Scaling up Nutrition Programme

N4G2 Second Nutrition for Growth summit

NFA National Fortification Alliance

NHSRC National Health Services Regulation and Coordination

NNS National Nutrition Survey

NVF New Venture Fund

ODF Open Defecation Free

P&DD Planning and Development Department

PARC Pakistan Agricultural Research Council

PC Planning Commission

PDMA Provincial Disaster Management Authority

PFA Provincial Fortification Alliances

PHNP Provincial Health and Nutrition Programme

PINS Pakistan Integrated Nutrition Strategy

SDG Sustainable Development Goals

SUN Scaling up Nutrition

SUNCSA Scaling up Nutrition Civil Society Alliance

TWGs Technical Working Groups

UN United Nations

WB World Bank

WFP World Food Program

WHO World Health Organization

WINS Women & Children Improved Nutrition in Sindh


CONTENTS

Acknowledgements ...................................................................................................................... 2

Abbreviations ............................................................................................................................... 3

1 INTRODUCTION .................................................................................................................. 5 1.1 Background ................................................................................................................ 5 1.2 Context of Assignment ............................................................................................... 6 1.3 Study Objectives and Key Determinants..................................................................... 7

1.3.1 Objective ........................................................................................................................ 7 1.3.2 Key Determinants .......................................................................................................... 7

1.4 Methods ..................................................................................................................... 7 1.5 Scope of Work ............................................................................................................ 7

1.5.1 Review of relevant documents ....................................................................................... 7 1.5.2 Development of data collection tools ............................................................................. 8 1.5.3 Data collection – In-Depth Interviews (IDIs) .................................................................. 8

2 FINDINGS ............................................................................................................................. 9 2.1 Role of Public and Private Sector, and Civil Society ................................................... 9

2.1.1 Nutrition specific interventions ....................................................................................... 9 2.1.2 Nutrition sensitive interventions ................................................................................... 10

2.2 Key Nutrition Stakeholders for Multi-Sectoral Approach ........................................... 13 2.2.1 Federal Level ............................................................................................................... 13 2.2.2 Provincial Level ............................................................................................................ 15 2.2.3 Development Partners for Nutrition Group .................................................................. 18

2.3 Policy and Legislative Environment for Nutrition & Food Security ............................. 18 2.4 Financial Commitment at Federal and Provincial Level ............................................ 20

2.4.1 Provincial overview ...................................................................................................... 20 2.5 Mechanisms to Monitor Policy and Financial Commitment ....................................... 22 2.6 Awareness and Capacity of Opinion Makers, Media & Civil Society ......................... 23 2.7 Findings from In-depth Interviews (IDIs) ................................................................... 24

2.7.1 Key actors working on nutrition issues in Pakistan ...................................................... 24 2.7.2 Perceptions around nutrition policy and food security ................................................. 25 2.7.3 Legislations to translate national policies into action ................................................... 26 2.7.4 Financial commitment for nutrition at federal and provincial level ............................... 26 2.7.5 Monitoring mechanisms at federal and provincial level ............................................... 26 2.7.6 Role of legislators, opinion makers, media and CSOs ................................................ 26

3 CONCLUSIONS .................................................................................................................. 27

4 RECOMMENDATIONS ....................................................................................................... 29

REFERENCES .......................................................................................................................... 30

List of Tables Table 1: Nutrition specific interventions given in the Provincial Nutrition PC-1s .......................................... 10 Table 2: Nutrition sensitive interventions by main actors .............................................................................. 12

List of Figures Figure 1: Comparative ranking of Pakistan by GFSI (Source GFSI 2016) ..................................................... 5


1 INTRODUCTION

1.1 Background

Food is a basic need of everyone and therefore, access to adequate nutritious food is the

fundamental right of every human being. Malnutrition results from either eating too little or

eating an unbalanced diet. Adequate nutrition not only benefits the individual health and

survival, but it also enhances collective human capital and economic development, which is

particularly true for children [1].

Food is different from other usual commodities in that there is no substitute. All humans require

adequate food for survival and with security over the next meal. The 1996 World Food Summit

defined food security as “when all people at all times have access to sufficient, safe, and

nutritious food to maintain a healthy and active life”. Food security, according to the World

Health Organization (WHO), rests on three pillars [2]:

1. Food availability covers the supply side, and is determined by food production and

technology, inventory, efficiency of supply chains, and local and international trade.

2. Food access is the ability to obtain

adequate quantities of food, the

purchasing power needed, and

adequate delivery mechanisms,

including social safety nets; and

3. Food utilization refers to the need

to meet dietary needs and cultural

preferences.

Pakistan is facing a silent crisis of

malnutrition and has not improved for

decades. According to GFSI, Pakistan

scored 47.8 in 2016 which was slightly

higher than its score (43.7) in 2012 however it secured 78th position in 2012 as well as in 2016

amongst the 113 countries [3]. Figure 1 compares position of Pakistan with the best GFSI

(United States) and the worst GFSI (Burundi) in 2016.

Results from the 2011 National Nutrition Survey (NNS) indicated minimal change over the last

decade in terms of core maternal and childhood nutrition indicators in Pakistan. Among

children under 5 years of age, 43.7% were found stunted as compared to 41.6% in 2001;

15.1% were found wasted compared to 14.3% in 2001, and 31.5% were underweight

compared to 42% in 2001.

Vitamin A status has been deteriorated and there has been little or no improvement in other

micronutrients e.g. Iron Deficiency Anemia 61.9%, zinc deficiency 39.2%, and Vitamin D

deficiency 40.0%. The only success story has been iodine status which has improved

nationally as the survey indicates. Currently about 69% of the households are using iodized

salt as compared to 17% in 2001. This has also led to the conclusion that sincere efforts carried

down from the policy to the implementation level could have positive impact.

SUN (Scaling up Nutrition) is a distinctive movement founded on the principle that all people

have a right to food and good nutrition. It unites and works through people, from governments,

0

25

50

75

100

1)AFFORDABILITY

2) AVAILABILITY3) QUALITY AND

SAFETY

Pakistan

Best

Worst

Figure 1: Comparative ranking of Pakistan by GFSI (Source GFSI 2016)

SITUATIONAL ANALYSIS FOR THE NUTRITION ADVOCACY PROJECT INTRODUCTION

FINAL REPORT 6

civil society, the United Nations, donors, businesses and researchers, and focusses at

collective efforts to improve nutritional status.

Pakistan joined the Global SUN Movement in 2013. Government of Pakistan signaled its

commitment to scaling up nutrition; Ministry of Planning Development and Reform is

spearheading the movement in the country and has established SUN movement Unit for

coordination among all SUN stakeholders, alliances/networks at international, national and

sub-national level. Currently, government, civil society alliance, donors, UN business networks

and SUN Academia and Research network have been established with support from

development partners. Similarly, all provincial governments have developed and endorsed

multi-sectoral nutrition strategies while Pakistan multi-sectoral nutrition Strategy is under

process of development by the federal government.

In Pakistan, funding for nutrition interventions mainly comes from donors and much of this is

project-based and goes directly to the provinces. The overall share of funding for nutrition from

federal and provincial governments is meager, which is a major challenge in ensuring state

leadership and ownership. Nutrition-specific interventions are key to accelerating progress but

it is also critical that other sectors namely agriculture, food, education, WASH and social

welfare, develop nutrition-sensitive interventions. A truly multi-sectoral approach will achieve

optimal nutrition outcomes through greater coverage, and will also help other programs in

achieving much better results.

The share of government expenditure in annual budget is the key indicator to evaluate the

government priorities in real term. This may also be used as a tool that enables us to monitor

and hold government accountable for the service delivery which lead to reforms in public

policy, establish a path for transparent, effective and efficient budgeting principles and

capacitate to provide concrete recommendations for program improvement. Solutions to

malnutrition are practical and basic but the desired improvement in current status of nutrition

cannot be achieved unless a sufficient amount is allocated in the budget.

Keeping in view the poor nutrition indicators in Pakistan, federal and provincial governments

will have to demonstrate their political will by investing more financial resources for

implementation of multi-sectoral nutrition interventions which can translate into a demographic

dividend in socio-economic development in the long run.

1.2 Context of Assignment

Micronutrient Initiative (MI) as Secretariat of Scaling Up Civil Society Alliance Pakistan

(SUNCSA, Pak) received a grant from New Venture Fund (NVF), to secure political and

financial commitments from government of Pakistan during the Second Nutrition for Growth

(N4G2) Summit scheduled in August 2016 in Rio de Janeiro, Brazil. This summit provides a

platform of global visibility for these governments, especially compared to prior summits that

placed less emphasis on governmental pledges. Specific objectives of the project for which

this assignment was conducted included:

Sensitize policy makers to the challenge of malnutrition and the need for additional

financial resources for nutrition.

Generate public debate on the impact of malnutrition on the social and economic

development of the country.

Improve capacity of civil society organizations on nutrition advocacy.


FINAL REPORT 7

Promote accountability on the delivery of policy and financial commitments.

This situation analysis was conducted to establish a baseline status of awareness of various

stakeholders regarding nutritional issues, financial allocations by the government, the policy

and legislative environment, and advocacy efforts on nutrition.

1.3 Study Objectives and Key Determinants

1.3.1 Objective

The main study objective was to establish baseline indicators for the project.

1.3.2 Key Determinants

Following key determinants were considered for conducting the assignment:

1. The landscape of civil society organizations, public sector agencies, and private entities

working on nutrition-related issues, to understand the role and contribution of different

actors in addressing malnutrition.

2. Policy and legislative environment for nutrition and food security.

3. Current level of financial commitment by federal government around scaling up nutrition

program.

4. Mechanisms to monitor policy and financial commitment at federal level.

5. Awareness and capacity of opinion makers, media and civil society to generate demand

for additional resources for nutrition.

1.4 Methods

This study gathered both the primary and secondary data. The primary data was collected

through interviewing the federal level key personnel whereas secondary data was gathered

through reviewing the project documents, and national and international relevant publications.

1.5 Scope of Work

Following key activities were undertaken to achieve assignment objectives:

1.5.1 Review of relevant documents

All the relevant documents for the project including policies, plans, project proposal,

performance measurement framework, and detailed implementation plan, etc. were reviewed

to understand the nature of the proposed interventions for the project and to ascertain the key

areas/themes to be explored in the baseline assessment. The following documents were

reviewed in this regard:

1. Pakistan Food Fortification Scoping Study - Maximizing the Quality of Scaling up

Nutrition Programmes (MQSUN);

2. The Political Economy of Undernutrition National Report: Pakistan;

3. Punjab Province Report: Nutrition Political Economy, Pakistan;

4. Sindh Province Report: Nutrition Political Economy, Pakistan;

5. Nutrition Policy Guidance Note – Balochistan;

6. Inter-sectoral Nutrition Strategy Sindh;

7. Inter-sectoral Nutrition Strategy KP;


FINAL REPORT 8

8. Strategic Plan (2016 – 2020) SUN CSA Pakistan;

9. Mapping of Nutritional Initiatives in Pakistan.

10. GFSI Model 2016

11. Asian Development Bank, Food Security in Asia and Pacific, 2013

1.5.2 Development of data collection tools

Data collection tools were developed in line with the study objective and key determinants and

were finalized after incorporation of the feedback and inputs from MI team.

1.5.3 Data collection – In-Depth Interviews (IDIs)

In-depth interviews were conducted with the federal level authorities to explore the key

determinants of the assignment. A total of 6 IDIs were conducted:

1. Chief Nutrition, Ministry of Planning Development and Reforms / SUN Focal Point

2. DG Health / Director Nutrition, Ministry of National Health Services, Coordination and

Regulations;

3. Secretary / DG Ministry of National Food Security and Research;

4. Representative from media;

5. Member of Standing Committee on health;

6. Representative from UN agencies; and

7. Representative from Civil Society

***********


2 FINDINGS

The findings are structured to give description on each of the study key determinants.

2.1 Role of Public and Private Sector, and Civil Society

The recent move towards nutrition, led by international donors, is positioned towards cross-

sector action on nutrition contrary to the initiatives in the past which were mainly

operationalized within the Health sector. This emerging move has gained momentum in the

post-devolution period and involves the provincial Planning and Development Departments

(P&DD) as the focal point for coordinated actions. Pressure by development partners has also

resulted in the establishment of provincial Inter-Sectoral Nutrition Committees headed by the

P&DD.

Regular and frequent data is required to quantify and monitor the problem, and motivate

political action, whilst disaggregation is necessary for planning and targeting. Unfortunately,

the data collection efforts greatly suffer from low frequency, compromised quality, and limited

detail.

At the provincial level, among all relevant departments, Department of Health has most

elaborately defined its role around nutrition through employing preventive health strategies

specifically targeted towards women and children.

After becoming signatory to the Global SUN Movement, the process of moving towards multi-

sector approach has been initiated in Pakistan. At this stage, other related sectors have only

recently been drawn into the loose nutrition coalition, and role of each sector is still emerging.

The coordination and liaison between donors to avoid redundant initiatives, has improved in

the post-devolution scenario, however the partnerships between donors have not grown

enough to pool funds and have a unified initiative for nutrition sector [4].

In order to understand the role and contribution of different actors, the landscaping of these

actors is provided by the nature of the interventions i.e. a) Nutrition specific and b) Nutrition

sensitive interventions.

2.1.1 Nutrition specific interventions

The government has progressively increased funding through health sector–related nutrition-

specific interventions; however, sustainability of these interventions is an area of concern. A

larger share of nutrition-related funds is contributed by the development partners in all

provinces. This leads to concerns regarding continued funding stream beyond the project life.

For nutrition-specific interventions, the provincial health department is the major actor

supported by the development partners in implementation. The governments of Punjab and

KP, have developed Minimum/Essential Health Service Package and the nutrition specific

interventions are part of the overall package. As the lead funding is provided by the

government, hence it is more likely that these interventions would be sustainable beyond the

project life. The scope of these interventions is also wider and these would be implemented

across all the districts [5] [6].

DFID, under its Provincial Health and Nutrition Programme (PHNP), does contribute to the

health PC-1s in Punjab and KP. In Sindh and Balochistan, the funding is in siloes and is

restricted to a separate nutrition programme within the respective provincial Health

Departments and is supported mainly by donor funding. This poses greater risk of discontinuity

SITUATIONAL ANALYSIS FOR THE NUTRITION ADVOCACY PROJECT FINDINGS

FINAL REPORT 10

after the project life. Table 1 presents a summary of nutrition-specific interventions by province

[7].

Lady Health Workers (LHWs) have a great responsibility in delivering many of the nutrition

specific interventions outlined in Table 1, especially for the rural population. However, the

evaluation of LHW programs indicates that LHWs have effectively implemented some of these

nutrition specific interventions such as management of diarrhea.

Table 1: Nutrition specific interventions given in the Provincial Nutrition PC-1s

INTERVENTIONS BAL’N KP PUNJAB SINDH

Iron-folic acid supplementation in Pregnancy ✓ ✓ ✓ ✓

Infant and Young Child Feeding (IYCF) practices ✓ ✓ ✓ ✓

Vitamin A supplementation ✓ ✓ ✓ ✓

Expansion of salt iodization program ✓ ✘ ✓ ✘

Wheat flour fortification program (with iron and folate) ✓ ✘ ✓ ✘

Fortification of edible oil/ghee ✓ ✘ Un clear ✘

Use of micronutrient powders through LHWs and CHWs ✓ ✘ ✓ ✓

Zinc supplementation during treatment of diarrhea ✓ ✓ ✓ ✓

Community-based management of acute malnutrition (CMAM) ✓ ✓ ✓ ✓

Deworming ✘ ✘ ✓ ✘

Behavior Change Communication Strategies ✓ ✓ ✓ ✓

The development partners have been contributing to the implementation of nutrition specific

interventions for some time now. Merlin, Save the Children, and Association for Charitable

Foundations (ACF) are conducting activities in three districts of Sindh to provide social

protection alongside nutrition-specific interventions, under the European Union (EU) Women

and Children/Infant Improved Nutrition in Sindh (WINS) program.

World Food Program (WFP) is implementing a pilot project in one district of Sindh to determine

relationship between provisions of nutritious foods and chronic malnutrition (stunting).

International Medical Corps (IMC) is treating people with acute malnutrition among Internally

Displaced Persons (IDPs). HANDS is operating in most of the areas of Pakistan, with activities

around nutrition and IYCF education [8].

DFID is supporting a food fortification program that aims to reduce anemia and vitamin A

deficiency in women and children under five. This program intends to improve access and

consumption of wheat flour fortified with at least iron and folic acid, and edible oil/ghee with at

least vitamin A. This program targets to reach 85% of the urban and 65% of the rural population

in consuming fortified wheat flour, and 85% of the urban and 75% of the rural population in

consuming fortified edible oil/ghee. In addition, a GAIN-supported project aims to develop a

roadmap for a sustainable, and effective large-scale food fortification program at national level,

a functioning regulatory monitoring system, and increased consumption of fortified foods in the

country.

2.1.2 Nutrition sensitive interventions

In order to have cross-sectoral action on nutrition, in contrast to only health sector initiatives

in the past, it is important to ensure inter-sectoral coordination and a concerted effort to make

these interventions nutrition sensitive across all relevant sectors.

Pakistan has approved Integrated Nutrition Strategy and in all four provinces, the Steering


FINAL REPORT 11

Committees have been established. Moreover, provinces have increased social sector

spending after the devolution. However, the provincial planning for nutrition-sensitive

interventions has a slow pace.

A few schemes (currently in draft form) have been proposed by two of the provinces i.e., Sindh

and Punjab, for this year’s annual budgetary cycle, with financing entirely from provincial

government funds. While this indicates initiation of commitment towards nutrition-sensitive

interventions, proper technical designing is needed to better position the schemes towards

undernutrition, geographical convergence with nutrition-specific interventions, and scaling up.

Provincial support for nutrition-sensitive interventions for two sectors was planned for year

2015-16 in Sindh with support from government funds. Similar modality was followed for

nutrition specific interventions and involved a PC-1, supported by annual development funds

in the concerned sectors. Punjab developed draft PC-1s in the areas of WASH, livestock

support, and school feeding for 2015-16 budgeting cycle. However, it is not clear whether

these projects converged on the same districts which are being targeted by the nutrition-

specific interventions in Punjab.

KP had an uncertain situation in this regard, as draft PC-1s to be supported by government

funds, were not finalized till late part of 2014. As in Sindh, the PC-1s in KP intend to be specific

to the respective sectors and the possibility of moving towards developing a joint PC-1 seemed

weak [9].

Balochistan is positioned to target the 2016-17 Annual Development Plans (ADPs) and is open

to launching a multi-sectoral nutrition-sensitive program in the districts being targeted by the

health-focused nutrition-specific interventions [7].

It is important to discuss here the federal coordination structures especially in the post-

devolution scenario. There is low buy-in from provinces for a federal role in view of the

provincial autonomy over the social sector, provided by the constitutionally supported

devolution. The desired role for the federal platform is overall coordination rather than policy

steering or monitoring. Important areas required for coordination include: 1) bringing together

provinces for sharing updates; 2) mutual sharing of ideas and experience; 3) provision of

technical capacity in required areas; and 4) implementation of evaluation surveys.

The placement of a federal nutrition platform in the Planning Commission, rather than the

Health Ministry or Food Security Ministry, intends to have buy-in of the federating units. The

Planning Commission is believed to provide a cohesive link with the provincial P&DDs, but its

capacity remains a major constraint. With limited staff dedicated to nutrition and a lack of direct

programmatic experience of Planning Commission, would contribute to more nuanced

technical understanding.

Table 2 provides a detailed landscaping of the nutrition sensitive interventions being carried

out by the provincial departments with the support of the development partners in nutrition

related sectors.


FINAL REPORT 12

Table 2: Nutrition sensitive interventions by main actors

INITIATIVES IMPLEMENTING

PARTNER(S) EDUCATION AND RELATED INITIATIVES, INCLUDING

School feeding schemes; Early Childhood Development (ECD); Female enrolment schemes

Sindh government initiatives:

Recruitment and development of female teachers

Improved facilities in schools such as separate toilets for girls

Assistance to Girls Primary Education in Sindh (AGPES): provision of edible oil and milk powder are to girl school children in 500 schools in five rural districts with low enrolment ratios

Department of Education, Sindh

government

KP government initiatives:

Introduction of gender training of teachers and school curricula

Stipends to girl students in seven backward/low-literacy districts

Establishment of 199 Girls Community Schools with community participation

Establishment of 116 Community Learning Centers for women empowerment through income-generation and adult-literacy schemes

Department of Education, KP government

Punjab government initiatives:

Provision of nutrition facilities to the children in primary schools in District Muzaffargarh (pilot project)

Department of Education, Punjab

All provinces:

Early childhood education is being phased in for preschool children Varied implementation

in all provinces

WATER, SANITATION, AND HYGIENE (WASH) INITIATIVES

Public-sector water and sanitation schemes Sindh government’s scheme:

Sindh government’s sanitation scheme for Open Defecation Free (ODF) villages in districts where nutrition-specific interventions are underway 2015 budgetary

Municipal Services Delivery Program and Sindh Cities Development Program are primarily hardware-focused support and do not cover villages.

Provincial government Public Works

Department initiatives USAID and ADB;

principally urban in Sindh

Punjab government’s scheme

to rehabilitate 100 dysfunctional water treatment facilities for brackish water targeted at rural poor 2015 budgetary cycle

For revitalization of ODF Phase II scheme for rural areas—2015 budgetary cycle.

Changa Pani Scheme and Saaf Pani Scheme are already underway but are primarily targeted towards urban areas. There are plans for a scheme for reduction of open defecation in four districts of Punjab, but as yet there has not been movement towards an action plan.

City/Local government initiatives Go of Punjab

DFID-funded project

DFID’s humanitarian program DFID’s humanitarian program includes WASH activities for internally displaced persons (IDPs) in KP/FATA under the Predictable Emergencies Program (PEP) 2013-2015 and WASH activities for people displaced by flooding and conflict under the Multi-Year Humanitarian Program (2015-2019). DFID is also supporting the provision of WASH interventions to reduce vulnerability in the Building Disaster Resilience in Pakistan program (2015-2021) in Sindh, with one of the objectives being to increase access to safe drinking water and reduce open defecation and unhealthy hygiene practices, thereby contributing to improvements in the nutritional status of women and children.

DFID

Pakistan component of DFID-UK’s WASH Results Program

WASH interventions by Plan International in Ghotki, Bahawalpur, Lodhran, Muzaffargarh,

Rahim Yar Khan, Mardan, Swabi, Umerkot, and Islamabad districts.

WASH interventions by WaterAid in Badin, Thatta, and Rajanpur districts.

Unilever working on “school of five” hygiene promotion campaigns in schools in 21 districts.

DFID

AGRICULTURE INITIATIVES, INCLUDING HOME GARDENING

Sindh government’s nutrition-sensitive agriculture scheme for 2015 budgetary cycle, Agriculture & Food PC-1, promotes milk and meat through livestock promotion and support to small land holders for vegetable and fruit growth for local consumption in districts where nutrition-specific interventions are active.

Agriculture Department, Sindh

Punjab government’s livestock support scheme for women, in 2015 budgetary cycle, involving provision of heifers, sheep, and goats in Punjab.

P&DD, Government of Punjab

Harvest Plus project is in the process of developing and implementing a zinc-enriched wheat program in Pakistan

DFID and Harvest Plus


FINAL REPORT 13

The South Asia Food & Nutrition Security Initiative (SAFANSI) aim is to increase the commitment of governments in South Asia and development partners (such as donors, the United Nations, and NGOs) to tackle undernutrition. It is implemented by the World Bank, as part of the Multi Donor Trust Fund. The Australian Department of Foreign Affairs and Trade (DFAT) co-funded the first phase with DFID, which ends March 2015. The second phase is co-funded by DFID and EC

World Bank (WB), DFID, DFAT, European

Commission, Government of

Pakistan

The Leveraging Agriculture for Nutrition in South Asia (LANSA) program, funded by DFID, aims to understand the apparent “disconnect” between agriculture and nutrition in the region, since agriculture growth in South Asia has not translated into improvements in nutrition outcomes.

DFID and EC

The government launched a kitchen garden project in 1999 to 2001 that was focused on urban areas of Islamabad Capital Territory but this did not yield any significant results. Recently the National Ministry of Food Security and Research has launched a further pilot project on kitchen gardening in Islamabad and Rawalpindi. Project implementation is through imparting training on vegetable growing and is primarily focused on urban populations.

Food Security and Research through the PARC, Collective for

Social Science Research

FOOD SAFETY MEASURES

Safe food is an essential requirement for meeting nutritional requirements. All the provinces are required to enact their food laws. Punjab has already promulgated Food Laws and established a Food Authority.

Provincial governments

SOCIAL PROTECTION AND CASH TRANSFER PROGRAMS

Benazir Income Support Program (BISP) BISP targets women in eligible households. Provinces post devolution have control over design and implementation of Zakat and Bait-ul-Mal departments, but these are yet to be effectively targeted to support nutrition-sensitive interventions, and systematic targeting of low-income women and children is missing.

Government of Pakistan

The DFID-funded Research on Food Assistance for Nutritional Impact (REFANI) project is currently conducting a study to test the effectiveness and cost-effectiveness of different cash transfer programs on reducing the risk of undernutrition in children 6 to 59 months old and their mothers in Dadu District, Sindh Province, using ACF’s program as a vehicle for the research.

DFID and ACF

2.2 Key Nutrition Stakeholders for Multi-Sectoral Approach

Nutritional status is not only an outcome of economic or dietary factors alone, rather multiple

socio-economic factors including hygiene-sanitation, education, individual life style,

knowledge, behavior, awareness and access to safe food and drinking water are associated

with it. Hence, nutrition has close linkages to a number of sectors and requires a cross-sectoral

approach to deal with chronic and persistent malnutrition. The key stakeholders belonging to

nutrition related sectors that play critical role in having a holistic approach to address the issue

of malnourishment are discussed below.

2.2.1 Federal Level

2.2.1.1 Nutrition Section, Ministry of Planning, Development and Reforms

In April 2010, the parliament of Pakistan passed the 18th Amendment, which devolved 17

ministries from the center to the provinces, including the Ministries of Agriculture, Education,

Food, Health, Women’s development and Social Welfare.

The federal nutrition section is established in the Ministry of Planning, Development and

Reforms and is housed at National Institute of Health (NIH) in Islamabad. The role of Nutrition

Section is to provide overall coordination between provinces, share updates and experiences

with provinces, and provide technical support. The 18th constitutional amendment does not

give it powers to monitor or steer the provincial governments in this regard [10] [11].

The main functions of nutrition section are the following [12]:

1. Prepare annual and long term plan for nutrition and consumption.


FINAL REPORT 14

2. Prepare national food balance sheets including per capita food intake, food supply

and demand projections.

3. Study and analyze existing data on food consumption pattern and nutrition status in

Pakistan.

4. Support and initiate research studies in food consumption, dietary intake and nutrition

status for policy development.

5. Develop and maintain adequate database for realistic nutrition planning.

6. Identify and justify empirically proven set of nutrition interventions/ tested projects

7. Development of indicators for evaluation and impact assessment of food and nutrition

situation and plans.

8. Study and evaluate ongoing food and nutrition programme and to recommend

additional programmes in the field of food consumption and nutrition.

9. Formulate long term plans, annual plans, and annual development programmes for

food and nutrition programmes.

10. Monitoring and evaluation of projects in the field of food and nutrition.

11. Prepare policy papers and recommendations and/or comments thereon.

12. Secretariat of the federal nutrition syndicate (high level inter-ministerial coordination

body for nutrition).

13. Act as focal point for all national and international agencies in the field of food and

nutrition.

14. Support nutrition education on a mass media campaign.

15. Coordinate inter-sectoral food and nutrition programmes across sectors/regions.

16. Capacity building for food and nutrition programmes

2.2.1.2 Politicians, Media and Civil Society Networks

In order to prioritize and scale up any issue of public importance, it is pivotal to have political

will at the top. During the events, such as flash floods in recent years, food shortages in interior

Sindh, and IDPs in KP, the media has played its role in sensitizing the political representatives

of different parties about the issues of malnourishment and the nutrition related issues.

The past experiences reflect that politicians tend to have a reactionary approach to the social

issues, as and when they are brought up on the media. Unfortunately, the prominence of the

malnourishment, as an issue on the print and electronic media, quickly fades away the moment

natural or manmade disaster is over.

It is important that the politicians, media and civil society networks are sensitized about the

issue and importance of nutrition as a national development goal to wither the misconception

of nutrition being an issue during natural or manmade disaster.

2.2.1.3 SUN Unit at Federal Level

In 2013, Pakistan became signatory to the Scaling Up Nutrition (SUN) Movement. The SUN

focal point for the government is Chief of Nutrition in the Planning and Development Division

of the Planning Commission. Different development partners are supporting the development

of SUN coordination structures and planning documents at federal and provincial level; the

UN’s World Food Programme (WFP) is providing support at the federal level while UNICEF,


FINAL REPORT 15

the Micronutrient Initiative (MI), and FAO are supporting provincial structures. The SUN

structures yet to be made operational at provincial level, which is critical given that social sector

responsibility and interventions are devolved to the provinces.

2.2.1.4 SUN CSA (Scaling Up Nutrition Civil Society Alliance)

In 2014, Civil Society Alliance (SUN-CSA) was launched in Islamabad, and adopted a Civil

Society Declaration on Nutrition and Food Security. In order to ensure the creation of a strong,

coordinated and vibrant civil society constituency to promote multi-sectoral developmental

approaches to support nutrition agenda, the SUN CSA Pakistan has defined four broader

areas of focus: 1) Advocacy and Awareness Raising; 2) Monitoring and Accountability; 3)

Networking; and 4) Capacity Building. The establishment of the SUN-CSA spanned throughout

2014 starting with membership in response to the advertisements [13]. The number of SUN

CSA members have increased to 108 by September 2015 and had representation from all

federating units of Pakistan.

2.2.1.5 National Fortification Alliance (NFA)

National Fortification Alliance (NFA) constituted under the Ministry of NHSR&C play a key role

in policy making, coordination, over sight and monitoring of food fortification programs in the

country. It is an important body to address the issue of harmonization and collaboration and

serves as a platform for bringing together all the provincial governments, UN agencies,

nutrition partners and stakeholders. Provincial Fortification Alliances (PFA) were established

in May 2016, which are the provincial chapters of the National Fortification Alliance. These

PFAs will act as a platform for coordination and oversight of fortification activities at the

provinces [14].

2.2.2 Provincial Level

2.2.2.1 Structures and Capacity

Provincial Planning and Development Departments (P&DDs) are responsible for coordinating

subjects across departments to develop a common provincial development framework, acting

as counterparts to the federal level’s planning commission and nutrition section. In all four

provinces, there is a consensus for a central provincial Nutrition Section within the provincial

P&DD. The establishment of a Nutrition Section in the P&DD offers not only structural space

and authority for coordinating across nutrition-relevant sectors on project design and

monitoring, but also provides opportunity to follow up the implementation of Integrated

Nutrition Strategy (INS) [10].

The progress with regards to P&DD as the lead for multi-sectoral nutrition interventions, varies

across the provinces and there are also variances in terms of structures, designs, and

responsibilities. Sindh is leading the progress in this regard and has preferred to have specific

nutrition cell to coordinate across different sectors and develop/modify programs. Punjab and

Balochistan are also inclined to set up a separate nutrition cell within the P&DD, for effective

coordination and making program adjustments across all sectors. KP has followed a different

approach and considers the placement of nutrition as an added responsibility within the health

section of the P&DD, while involving loose coordination across other sections of P&DD [7].

Moreover, there are two particular areas of concern that are highlighted. Firstly, as one

respondent put it, “the administrative structure is still trying to catch up with devolution”, which

is most evident in provincial governments’ ability to plan, design, and implement large nutrition


FINAL REPORT 16

programmes, and even if staff positions were to be increased, “expertise on nutrition is at a

premium in Pakistan”. Secondly, the network of sub-provincial staff for implementation is weak,

and the bureaucracy’s limited capacity to deliver social services predates devolution.

In 2002, the Ministry of Health (MoH) established a Nutrition Wing with the responsibility to

implement and monitor health-related nutrition activities. This wing itself had no direct role or

presence in the districts for the actual implementation. This is the crucial missing link in any

effort to reduce undernutrition, because greater coordination at the federal and provincial

levels, in the absence of effective delivery systems at the district level and below, will not bring

any change.

2.2.2.2 Politicians, Media and Civil Society Networks

Low civil society and media activism on nutrition, as well as lack of championing by politicians,

further weaken nutrition’s place on the list of provincial priorities. Politicians at the provincial

level have tended to pay more attention to food distribution than to nutrition, and food

distribution continues to be a political priority at the federal and provincial level. For instance,

during the flash floods in 2011, Provincial Disaster Management Authority (PDMA) distributed

food rations to flood victims in Balochistan, and it was continued beyond the flood recovery

period with popular support from elected representatives [15] [16].

There is a definite need to raise awareness of the media and civil society networks to highlight

the issue of malnourishment as one of the development need for the country and pitch it as

one of the performance indicators for the political parties in government. The media and civil

society projection of social issues has shown to be effective in attaining political action and

response.

Recently, pressure by development partners has resulted in some preliminary moves towards

provincial integrated nutrition strategies and the establishment of provincial intersectoral

nutrition committees headed by the P&DDs. Levels of interest vary across the respective

P&DDs, with Punjab having made the fastest progress in constituting an intersectoral nutrition

committee. However, there is low level of acceptance within the P&DDs to take primary

responsibility for nutrition. In at least two provinces the new momentum is being interpreted as

multi-sectoral coordination for health activities rather than the larger agenda of cross-sectoral

action with visible pro-nutrition planning in each sector.

2.2.2.3 Intersectoral Steering Committees and Technical Working Groups (TWGs)

All the four provinces have established Intersectoral Steering Committees presided over by

the provincial P&DD. The Steering committees are supported by Intersectoral Technical

Working Groups (TWG). These TWGs advise on the design of nutrition-related interventions;

however, their meetings have been infrequent and are not synchronized with the government

planning and budgeting processes. In Sindh, Punjab, and Balochistan, the provincial Health

Departments coordinate the activities of TWGs. Whereas in KP, there is a TWG specific for

each sector rather than an over-arching TWG, and these essentially involve public-sector

officials [10].

2.2.2.4 Health Department

The role of the provincial health departments has been more pronounced in the nutrition

specific interventions. In Sindh and Balochistan, there are PC-1s funded district level positions

of District Nutrition Coordination Officer/Focal person reporting to the District Health Officer


FINAL REPORT 17

[10].

The interim period during which the specified Nutrition Coordination posts are realized, all the

provinces need to make interim arrangements to fill these posts. There is also need to have

structures at the district level for coordinating a multi-sectoral approach.

2.2.2.5 Food Department

The role of the food department is critical in ensuring quality of foods that conform to the

nutritional standards. In order to assert this role, all the provinces need to enact food quality

and safety laws. Market quality assurance of fortified foods and pricing has overlapping and

unclear roles between Health and Food. Punjab is the only province to have set up a Food

Regulation Authority to pull together quality assurance functions under single entity [10].

2.2.2.6 Agriculture Department

While nutrition is an outcome of complex processes, and has come to be framed largely as a

health sector concern, a broader range of factors, including food adequacy and quality, play

an important role to improve nutrition outcomes.

Agriculture has a direct impact on household food security through drivers such as food

availability and income distribution. The agricultural sector plays an important role in the

availability of diverse and nutrition-dense foods. After the devolution in 2011, much of

agricultural policymaking have been shifted to the provincial level of government while

retaining some food security-related issues at the federal level.

Agricultural policy, moreover, has not paid explicit attention to nutrition or food consumption

until relatively recently [17]. In the current scenario, the provincial Agriculture departments

need to be sensitized regarding the importance of making nutrition sensitive agriculture

policies and work on the apparent Agriculture-Nutrition disconnect.

2.2.2.7 Public Health Engineering Department (PHED)

It is the responsibility of the provincial Public Health Engineering Departments to design,

operate, and maintain drinking water and sanitation facilities in the rural areas. After the

development of Integrated Nutrition Strategy by provinces, a number of WASH-related

nutrition-sensitive projects for rural, low-income areas have been planned (Table 2) [7].

2.2.2.8 Education Department

After the devolution, education sector plans and strategies for 2013-17 have been developed

by all the provinces; however, these plans and strategies did not include nutrition sensitive

interventions. The provincial education departments do not envision nutrition as one of the

considerations for intervention designing. As a consequence, nutrition is not one of the

targeted outcomes of existing education sector strategies. Provinces lack expertise on

designing nutrition-sensitive interventions. Some recent and ongoing initiatives have

attempted to address undernutrition but lack effective design and positioning (Table 2).

2.2.2.9 Benazir Income Support Program (BISP)

BISP is a cash transfer program started in 2008 for low-income women in all four provinces,

aiming to reduce poverty by cushioning the impact of food inflation and financial crises. An

impact evaluation of the BISP program was conducted by Oxford Policy Management which

showed that the BISP beneficiaries largely spend the cash transfer on food (56%), followed by

fuel (9%) and housing expenses (6%). The evaluation did not find that the BISP had an impact


FINAL REPORT 18

on food consumption expenditure. However, when regularity of consumption of specific items

was investigated a positive impact of the BISP was found on the consumption of fish, eggs

and wheat for households.

The BISP beneficiary households had reduced rates of malnutrition amongst girls (aged 0-59

months) as measured by wasting, a measure of short-term malnutrition [18]. These findings

indicate that targeting the low-income households does help in providing some cushion to the

inflation of food prices and thus contribute indirectly to better nutrition outcomes.

2.2.3 Development Partners for Nutrition Group

The provincial devolution of 2011 gave development partners an opportunity to have easier

direct coordination and interaction with implementers, avoiding the centralized and slower

planning processes. A number of initiatives by the development partners have been put in

place in collaboration with the provincial governments. The summary of the initiatives is

provided in the Table 2. The key development partners that are contributing to the nutrition

sector are mentioned below:

UNICEF

World Food Program

Food and Agriculture Organization

World Health Organization

World Bank

DFID

Government of Australia

Government of Canada through Micronutrient Initiative (MI)

International NGOs such Micronutrient Initiative, Save the Children, ACF, GAIN, Islamic Relief, etc.

2.3 Policy and Legislative Environment for Nutrition & Food Security

The earliest institutional presence for nutritional interventions in Pakistan, goes back to 1970

in the National Planning Commission (NPC), when it was considered a subject rather than a

sector. To consider nutrition as a sector, required multi-sectoral ownership and close linkages

with other sectors like Agriculture, Education, Health, Social Protection, Water and Sanitation,

and Women’s Development.

From 1970s through 2000, there were hardly any holistic initiative that focused at addressing

the issue of malnourishment. Prior to 2011, Pakistan even lacked national nutrition policy,

however had a National Nutrition Strategic Plan 2002 which was, unfortunately, never

implemented.

The Planning Commission (PC) had a mandate to mainstream nutrition across different

sectors but its operations were housed in the nutrition wing of the Ministry of Health in 2005.

This arrangement was reflective of the understanding that nutrition was a sub-set of health

and thus it remained confined to the Health Sector [10].

A number of events in the recent past have highlighted the nutrition on the policy agenda. The

flash floods of 2010 and 2011 provoked a coordinated response by the development partners

across provinces. In affected areas, mother and child under-nutrition was highlighted to

stakeholders during recovery efforts that fostered the development of Pakistan Integrated


FINAL REPORT 19

Nutrition Strategy (PINS) at the federal level with support from UNICEF. PINS envisage linking

of all social sectors (agriculture, health, social welfare, public health engineering and

education) and having inter-sectoral planning and implementation with strong coordination,

monitoring and evaluation.

The findings of the last National Nutrition Survey 2011, supported with unusual media publicity,

further brought under-nutrition into policy prominence. It generated a lot of deliberations

among researchers, media, and development partners. Finally, the provincial devolution of

2011 gave development partners an opportunity to have direct and easier engagement with

implementers, avoiding the centralized and slower planning processes.

However, the devolution also witnessed a transition state with vague role of federal and

provincial actors. After devolution, a Nutrition Wing was established in the Planning

Commission (PC), which faced issues since PC was not an implementing agency. Moreover,

there was still no nutrition policy to guide in addressing the issue within the regular working of

ministries. Nutrition is still dealt with through the development budget of the PC rather than as

an integrated part of the recurrent budget of the Ministry of Finance [7].

Globally, the realization to prioritize the nutrition sector has led to the Scaling Up Nutrition

(SUN) Movement. SUN is a unique movement founded on the principle that all people have a

right to food and good nutrition. It unites people from governments, civil society, the UN

agencies, donors, businesses, and researchers in a collective effort to improve nutrition.

Pakistan became signatory to the SUN movement in 2013.

This multi-stakeholder platform, developed as a result of joining the Scale Up Nutrition (SUN)

movement, shows a high-level of commitment for nutrition at the national and provincial levels

with all partners on board. The provincial Nutrition Policy Guidance Notes and Strategy and

SUN roadmaps have been developed and approved within the scope of Vision 2025. The

multi-sectoral nutrition strategy is in a development stage through a consultative process,

which is based on the provincial policy guidance notes, inter-sectoral nutrition strategies, and

national and global commitments.

The SUN Units at national and provincial levels are being established at the respective

planning and development departments. This arrangement intends to enhance coordination

and collaboration at implementation levels for multi-sectoral strategy and also to develop

linkages among all public-sector departments, provinces, SUN Networks, and the Global SUN

Movement Secretariat. In Pakistan, government, donors, UN, Civil Society Alliance (CSA) are

functioning, whereas business, and research and academia networks have been established

recently to streamline SUN Movement innovative approaches [19].

Protection and Promotion of Breastfeeding laws have been enacted by federal and all

provincial governments. These legal frameworks are meant to ensure safe and adequate

nutrition for infants and young children. It has framed laws to regulate marketing and promotion

of certain designated products. The implementation of these laws can only be ensured by the

active participation and persistence of all the stakeholders especially the civil society. Other

legislative measures are limited to food regulations which deal with the adulteration and food

safety related to food supply or some others related to the consumer protection as does for

consumers of any other commodity [20].

In an event of disaster, to guide the actions of all partners in the nutrition sector, another policy

level response is reflected in the form of “National Nutrition Cluster Preparedness and


FINAL REPORT 20

Response Plan”. It provides focus and coherence to the various levels of planning that are

required to respond effectively but does not replace the need for planning by individual

agencies in relation to their mandate and responsibilities within clusters [20].

The Annual Plan (2016-17) of the Planning Commission envisage to develop a national plan

of action on food and nutrition/Pakistan’s Multi-Sectoral Strategic plan with an emphasis on

national nutrition priorities [1].

2.4 Financial Commitment at Federal and Provincial Level

Prior to 2011, Pakistan lacked a national nutrition policy and National Nutrition Strategic Plan

2002 was never implemented. The Pakistan Integrated Nutrition Strategy (PINS) 2011,

however, sets out an incremental plan for the implementation of nutrition-related interventions.

Each of the four provinces and three regions of Pakistan have begun drafting inter-sectoral

nutrition strategies.

Global Nutrition Report, 2016 reports that in 2013 Pakistan spent 1.06 percent of the general

government expenditure on nutrition-specific and nutrition-sensitive interventions and stood at

15th position among 24 countries. Whereas among the South Asian countries Pakistan ranked

last as Nepal spent 3.59 percent and Bangladesh’s spending was at 3.31 percent. In Pakistan,

around 35 percent of the nutrition budget was nutrition specific, while the remaining 65 percent

was nutrition sensitive, and among 24 countries, Pakistan was better than only 4 countries.

Whereas amongst South Asian countries Pakistan was at the bottom. Furthermore, a

comparison of the budget allocations to nutrition-relevant sectors were compared for 16

countries, including Nepal, Bangladesh and Pakistan from South Asia, where Pakistan had

allocated only 5 percent of general government expenditure to nutrition-relevant sectors,

compared to 41 percent by Nepal and 37% by Bangladesh [21].

Nutrition is still managed through the development budget of the PC rather than as an

integrated part of the recurrent budget. Donors view good nutrition as a means to achieving

growth, the PC frames nutrition as a social outcome of economic growth, whereas the

legislature is focused on food security.

The scarce funding has resulted in compromised capacities at federal and provincial levels.

The overall capacity of provincial departments is limited both in terms of availability of nutrition

staff as well as their capacity to deliver.

2.4.1 Provincial overview

Historically, provinces lacked consistent planning for nutrition and therefore followed tailored

initiatives designed by development partners and the federally supported Lady Health Worker

(LHW) Programme. However, the post devolution scenario provides more fiscal and strategic

space to provinces to prioritize nutrition.

2.4.1.1 Punjab

Punjab has surplus food production, lower poverty levels, and better access to water,

sanitation, and preventive health. However, Southern Punjab districts have inequitable land

distribution, greater poverty, and less access to social services, so they are the main source

of under-nutrition and call for district-focused strategies. Punjab has a supportive executive

bureaucracy, strong administrative control over implementation, and has integrated nutrition

within health, hence enhanced sustainability.


FINAL REPORT 21

2.4.1.2 KP

In Khyber Pakhtunkhwa (KP), low outreach access in certain districts, social exclusion of

women, and conflict are the largest contextual issues. However, it is not food-insecure

because of a more equitable land distribution and greater crop diversification. Therefore, KP

has lower levels of under-nutrition than Sindh and Balochistan. Moreover, it has reorganized

the health department around nutrition-related issues, and sustainability and reforms are high

on the provincial development agenda. The nutrition improvement is following a slow but

deliberative process, being carefully tied to the provinces’ post-devolution development vision.

In the Punjab and Khyber Pakhtunkhwa (KP), integrated health reforms programmes with

strong nutrition component, have started implementation and are going to be further

strengthened.

2.4.1.3 Sindh

Despite being the second most food-producing province, Sindh faces considerable under-

nutrition and the highest level of food insecurity. They result from contextual issues of

inequitable land ownership, poverty, patriarchy, and poor delivery of social-sector services.

Weak cross-sectoral coalition, low district accountability, and weak governance in Sindh is

likely to undermine both the horizontal coordination and implementation of nutrition. Sindh also

has the most promising non-state sector, but there is lack of cooperation by the state.

2.4.1.4 Balochistan

Balochistan is the most vulnerable, faces high food insecurity, chronic water shortage,

vulnerable to both drought and flooding, inadequate outreach of social-sector services, and a

has patriarchal and tribal power structure. This is reflected in high level of under-nutrition. It is

also constrained by weak political leadership and low district capacities for implementation.

However, Balochistan is better positioned than Sindh due to stronger coalition building

amongst key sectors and cohesive working led by P&DD [22].

2.4.1.5 Planning Commission

Planning Commission has planned various nutrition specific and nutrition sensitive projects

under Annual Plan 2016-17, which include:

An amount of Rs100 million in PSDP 2015-16 has been allocated for a project titled

‘National Initiative for SDGs/ Nutrition’ [23]. Nutrition Specific Interventions will be launched

in each province through approved projects under National Initiative for SDGs.

Nutrition Support Programme for Sindh (NSP), costing Rs 4,118 million, has been

approved and will be implemented during this year. The overall goal of the project is to

improve the nutritional status of male and female children under five years and that of

pregnant and lactating women in nine selected districts.

The Balochistan Nutrition Programme for Mothers and Children (BNPMC), costing Rs

1,493 million, has also been approved and it will be implemented this year. The overall

goal of the project is to improve the nutritional status of male and female children under

five years of age, including women of reproductive age, by improving the coverage of

effective nutrition interventions in the selected seven district.

Universal Salt Iodization (USI) Programme is being implemented with the assistance of

the development partners like Micronutrient Initiative (MI), WFP, UNICEF and Global


FINAL REPORT 22

Alliance for Improved Nutrition (GAIN). This will continue in 110 districts to benefit almost

174 million population of the country. A technical and financial review of the programme

will be conducted.

The National Food Fortification Alliance has been re-established at the Ministry of National

Health Services, Regulation and Coordination to restart fortification programme which was

abandoned due to devolution. Hence wheat flour fortification with iron and folic acid is

being revitalized to overcome micronutrient deficiency disorders with the support of the

UN agencies and Nutrition Development Partners.

Nutrition Sensitive Agriculture Project: This is a three-year project, approved in 2016 to

improve nutrition status in three districts of Sindh, i.e., Umerkot, Jacobabad and Sanghar.

The project will follow the community development approach and will establish fund to

support nutrition related agriculture activities. The cost of the project is Rs 582 million of

which 85 per cent will be funded by the DFID.

The Khud Kafalat Scheme will generate economic activities through provision of interest

free loans and Islamic Microfinance Facility. Moreover, the Insaaf Agricultural Loans are

aimed at provision of affordable loans to small farmers. Protection of infant and child

nutrition through provincial and district level regulatory committees has also been initiated

to improve nutritional outcomes. The Sehat Ka Etihad scheme is aimed at eradication of

polio from the province. Moreover, subsidized healthcare assistance will be provided to

over one million patients and grant of Rs 2,700 as cash grant to 50,000 mothers.

The Balochistan government has allocated ample resources to socially uplift the province.

Given its budget constraints, the federal government is providing Rs10 billion per annum

since 2010-11 under the Aghaz-e-Huqooq-e-Balochistan for its contribution to develop

Balochistan. Additionally, 142 development projects are being supported through the

Federal Development Programme in the province. The provincial government has

increased subsidies on tube-wells to Rs 8 billion for promotion of the agriculture sector,

but the province needs subsidies directly targeted to the vulnerable. The government has

allocated Rs 10 billion for education and Rs 8 billion for the health sector. However, no

direct allocation for Nutrition specific programme is planned.

Nutrition sensitive approaches are:

Benazir Income Support Programme (BISP) will continue as an effective social safety Net

Measure by providing cash to the poor segments of population throughout the country.

National Zero Hunger Programme, a joint collaboration between public sector and UN

agencies, is being devised to address hunger and malnutrition.

Various Scaling Up Nutrition (SUN) Movement Networks (government, UN, donors, CSA,

business and research and academia) will be streamlined. The SUN secretariat and units

at all levels will start functioning to deliver the desired results.

All four provinces in Pakistan have promulgated laws on breastfeeding. During 2015-16,

it will be carrying out follow up activities for the implementation of the laws on

breastfeeding in all provinces and at the federal level.

2.5 Mechanisms to Monitor Policy and Financial Commitment

The devolution has brought major actors responsible for nutrition specific and nutrition

sensitive intervention such as health, education, food, agriculture, women development and


FINAL REPORT 23

social welfare departments, under provincial control. At the same time, there were significant

changes in funding modalities with a shift of funding responsibilities to the provinces. This

scenario has limited the role of federal ministries, such as Ministry of Planning, Development

and Reforms and Federal Ministry of Health Services Regulation to only coordination,

conducting surveys and providing technical assistance.

The provinces have formulated their respective integrated nutrition strategies. Some steps

have been taken by provinces to improve the oversight of nutrition projects and develop inter-

departmental coordination mechanisms.

Punjab and Sindh Provinces have institutionalized the roles of provincial oversight committees

under their policy framework. These committees have the representation from relevant

departments and P&DD under the overall supervision of top offices in the provinces. In Punjab,

Provincial Steering Committee is established under leadership of Chief Minister, while in Sindh

and KP, provincial P&DD and offices of ACS are leading these mechanisms, respectively.

Government of Sindh has also institutionalized inter-district nutrition group to increase

coordination and monitoring of nutrition interventions.

These frameworks though promise continued oversight and ownership by major governmental

offices, the efficacy of these mechanisms is dependent on multiple factors. These include

prioritization of nutrition as major developmental need, political will and commitment, and

capacities of relevant departments to develop nutrition sensitive interventions. Most

importantly, these mechanisms are intrinsic to the respective provincial governments and the

ability to attain financial commitment remains subjective to provincial priorities.

Punjab and Sindh provinces have approved nutrition PC-1s and have made financial

commitments for nutrition specific and sensitive interventions. However, the decision on actual

financial allocation to these projects is dependent on the commitment of provinces to these

projects and real term progress made by each project.

2.6 Awareness and Capacity of Opinion Makers, Media & Civil Society

Civil Society Organizations (CSO) and opinion makers can play an important role in educating

the communities and building consensus to bring forth nutrition on development agenda. The

understanding of cross functional role of nutrition demands continued political and financial

commitments for nutritional interventions.

Over the last one and a half decade, CSOs have been more active in promoting community

participation on various development issues, and increasing outreach of various services to

marginalized segments. These CSOs occupy a strategic space through mediating the gaps

between perceived needs and governmental priorities. Although, many organizations have

been advocating on sociopolitical issues including gender, health, family spacing, education

and rights, however, due to a limited understanding of nutritional issues, it is generally

perceived as a sub-sector of health.

The Constitution of Pakistan already recognizes the right of food under the article 38: “The

State shall provide basic necessities of life, such as food, clothing, housing, education and

medical relief”. The right to food is recognized in the 1948 Universal Declaration of

Human Rights as part of the right to an adequate standard of living, and is enshrined in the

1966 International Covenant on Economic, Social and Cultural Rights.

Adoption of Sustainable Development Goals (SDG) provides a new phase of global


FINAL REPORT 24

development framework. SDGs emphasize on Improved Nutrition as the outcomes. SDG Goal

2 (End Hunger, Achieve Food Security, Improved Nutrition, and Sustainable Agriculture)

directly targets the issue of the hunger and malnutrition while SDGs 1, 3, 4, 5, 6, 12 & 17

address interacting processes linking health care, education, sanitation and hygiene, access

to resources, and women empowerment.

The provincial integrated nutrition strategies, agriculture and food security policies, and the

legislations around breastfeeding shows increased government commitment to nutrition and

would further pave way for CSOs to strongly advocate for financial commitments.

However, in order to achieve optimal results through this opportunity, it is essential to build the

capacity of CSOs and opinion makers (including print, electronic and social media) on issues

related to nutrition, policy and legislative framework, social beliefs and challenges that

contribute to malnutrition, etc.

In recent years, electronic and social media has emerged as powerful tools for raising issues

and generating awareness, facilitating policy debates and shaping public opinion in Pakistan.

The audience of electronic and social media has drastically increased due to wide spread

proliferation of TV channels and internet connectivity in both the urban and rural areas. There

were some attempts to raise public awareness on use of micronutrients such as iodine and

vitamin A & D. Private sector has also successfully use electronic media for advertisement of

fortified edible products. However, there is still a lot of potential for using these mediums for

advocacy on nutritional issues.

Opinion makers in print and electronic media can significantly promote involvement to protect

the right to adequate food and nutrition. These mediums have the potential to reach out to the

communities and establish the food security and nutrition as priority areas in developmental

arena. The challenges of nutrition have been effectively addressed by promoting effective

political and social leadership in countries like Peru, Brazil, Thailand, and India.

CSOs and media can potentially increase the demands for nutrition specific and sensitive

interventions in Pakistan by engaging with parliamentarians at national and specifically

provincial level.

2.7 Findings from In-depth Interviews (IDIs)

The in-depth interviews, conducted with various federal stakeholders, UN agencies and media

representatives, revealed that the realization of nutrition issues in Pakistan has greatly

increased after dissemination of findings of National Nutritional Survey in 2011. Various actors,

including government planning agencies, are more inclined to address the underlying causes

of malnutrition, and the nutrition sensitive programming is being focused as development

agenda.

2.7.1 Key actors working on nutrition issues in Pakistan

The participants identified a variety of actors working for nutrition related issues in Pakistan.

Planning commission is primarily the federal body that is responsible for allocations of public

sector development projects through PSDP. Within planning commission, three sections deal

with nutrition specific programing: population, nutrition and food security. The nutrition section

of planning commission is also the focal point for SUN movement in Pakistan. P&DDs are

mainly responsible for planning and making financial commitments for nutrition specific and

nutrition sensitive development projects in the provinces.


FINAL REPORT 25

Ministry of National Health Services, Coordination and Regulation and provincial health

departments are the main stakeholders in nutrition specific interventions. MoNHSCR is mainly

responsible for coordination of PHC and nutrition activities. Nutrition section in MoNHSCR is

directly involved with nutrition projects including National Fortification Alliance. At the provincial

levels, National Programme for Family Planning and Primary Healthcare has been providing

extensive outreach to the communities especially for health education on nutrition.

The new provincial nutrition strategies demand Agriculture, Food, Public Health Engineering,

Education and Social Welfare and Women Development departments to design nutrition

sensitive projects in their respective domains.

National Agriculture Research Center, University of Agriculture Faisalabad and University of

Arid Agriculture are among leading academic and research institutions that provide technical

assistance in agriculture, food security and nutrition to conduct pilot projects.

WFP, FAO, WHO and UNICEF were identified as main UN agencies working on nutrition and

food security. World Bank, DFID, AUSAID and JICA were among main bilateral donors which

fund nutrition interventions.

There are various INGOs that are funding nutrition intervention in Pakistan. These include

Micronutrient Initiative, ACF, Merlin, GAIN, Save the Children, Concern Worldwide,

Johanniter, Shifa Foundation, Amman Foundation, CDO and HANDS. In addition, SUN Civil

Society Alliance has registered 108 civil society organizations which have adopted Civil

Society Declaration on Nutrition and Food Security.

Private sector is also contributing to the cause of nutrition in Pakistan especially in fortification

of food products. Small and large scale salt producers in private sector have adopted iodization

practices. Punjab Floor Mills association is promoting wheat fortified with iron and folic acid in

Punjab under GAIN project. SUN business network includes fast moving consumer groups,

pharmaceuticals, salt, confectionary, rice, flour, food commodities, plastics, packaging,

agriculture, consumer services, logistics, mill owners, etc. Engro foods have started some

school based nutrition projects in Sindh.

2.7.2 Perceptions around nutrition policy and food security

Mostly the participants mentioned that there was currently no nutrition policy at national or

provincial level. Nutrition guidance notes and Vision 2025 provides some policy guidance

regarding nutrition. The Planning Commission is in process of developing Pakistan Multi-

Sectoral Strategic Plan that intends to bridge the gaps in the national and provincial Integrated

Nutrition Strategies.

In lieu of SDGs, a dire need was recognized to prepare the framework for nutrition planning,

emphasized on SDG 2 and including vulnerable groups with respect to gender and age.

The participants also highlighted that the indicators for measuring hunger were collected at

household level in Pakistan Social and Living Standard Measurement survey, and suggested

that they should be measured for individuals living in the household.

There was a mixed reaction on food security issues. It was emphasized that there was

abundant production of wheat and government was taking adequate measures to subsidize

the supply chain of wheat. However, the issue of scarcity of appropriate storage facilities was

a big concern. It was also highlighted that government’s subsidy on wheat procurement was

inequitable and small farmers were unable to avail these benefits. Benazir Income Support

http://e.thenews.com.pk/pindi/12-31-2014/page14.asp

http://e.thenews.com.pk/pindi/12-31-2014/page14.asp


FINAL REPORT 26

Program was identified as a single significant intervention providing relief to the poor

households.

2.7.3 Legislations to translate national policies into action

Most of the study participants were unaware of the legislations with respect to nutrition. Only

a few participants made a brief mention of breast feeding laws, iodized salt and food safety

laws.

2.7.4 Financial commitment for nutrition at federal and provincial level

The participants unanimously agreed that considering the extent of nutritional issue, the

available funding for nutrition projects is inadequate, and there were huge gaps in available

and required resources.

Federal Government has not allocated budget in recent years for nutrition but there is strong

political will to start advocacy interventions for nutrition. Some participants identified that

nutrition projects were only driven by donor funding and were governed by the donor agenda.

These donor-funded programs benefit only a segment of population.

In addition to the financial gaps, the capacities of institutions working for nutrition also need

strengthening in terms of trained human resources, improved governance, and monitoring and

supervisory mechanisms. The components of research, knowledge management, and

communication systems also need further strengthening.

2.7.5 Monitoring mechanisms at federal and provincial level

It was informed that there was no organized mechanism that could monitor and follow up a

policy implementation or financial commitment. The provincial nutrition cell within P&DD, is the

key to monitor nutrition interventions and policy implementation in the provinces. But no

mechanism is evident in the province to monitor financial commitment.

However, it was pointed out that there was a strong need to monitor policy interventions within

the federal and provincial structures.

2.7.6 Role of legislators, opinion makers, media and CSOs

The participants stated that media could play strong role in creating awareness on nutritional

issues. The media coupled with nutritional experts can effectively raise awareness among

policy makers and the political leadership. The school nutrition messages can improve the

dietary patterns among students and general population if adequately communicated.

Advocacy with legislators and opinion makers needs special attention and can potentially

increase political commitment to nutrition. The opinion makers, researchers, media personnel

and civil society have been engaged in SUN networks and need to have continued capacity

building support.

The participants also identified the need to roll out capacity building opportunities for CSOs for

advocacy, nutrition implementation, and conducting research.

***********

SITUATIONAL ANALYSIS FOR THE NUTRITION ADVOCACY PROJECT CONCLUSIONS

FINAL REPORT 27

3 CONCLUSIONS

1. In Pakistan, multi-sectoral approach is recently adopted to address the nutrition issues

after Pakistan became signatory to Global SUN Movement.

2. After devolution, at the federal level, nutrition section is established in the Ministry of

Planning, Development and Reforms however its role is limited to only coordination

between provinces, sharing updates and experiences with provinces, and providing

technical support. At the provincial levels, the multi-sectoral approach is led by P&DD

instead of health departments. The federal level has no role in monitoring of either policy

or financial commitments.

3. In Punjab, Provincial Steering Committee under leadership of Chief Minister, while in

Sindh and KP, provincial P&DD and offices of ACS constitute the monitoring

mechanisms, respectively. Government of Sindh has also institutionalized inter-district

nutrition group for monitoring of nutrition interventions.

4. Although, at the provincial level, this has resulted into improved coordination but the

partnerships with donors have not grown enough to pool required funds. Moreover,

limited staff dedicated to nutrition and a lack of direct programmatic experience, limit the

capacity of P&DDs.

5. In the provinces, although the governments have gradually increased funding through

health sector related nutrition-specific interventions, development partners still contribute

a major share through specific projects. This poses risks to sustainability of these

initiatives beyond the projects duration.

6. Under support from DFID, the governments of Punjab and KP, have developed

Minimum/Essential Health Service Package and nutrition specific interventions are part

of the overall package. It is more likely that being part of the government system, these

interventions would better sustain in these two provinces.

7. At provincial levels, the efforts to plan for multi-sectoral interventions around nutrition are

evident through preparation of relevant PC-1s. However, within the P&DDs, the

acceptance level is low to take primary responsibility for nutrition.

8. There are issues in understanding when separately interpreting health and nutrition,

because in half of the provinces the multi-sectoral approach for nutrition is being

interpreted as multi-sectoral coordination for health activities.

9. The politicians, media personnel, and Civil Society Networks are generally not much

aware of the complexity of nutritional issues in Pakistan. Moreover, the elected

representatives commonly follow the visible approach of food distribution.

10. The SUN Movement is seen as a lead agency in providing guidance in nutrition

interventions. It is well supported by the government and the development partners, and

has established a successful alliance with large number of civil society organizations.

11. The SUN Units at national and provincial levels are established at the respective P&DD.

This arrangement would enhance coordination and collaboration at implementation

levels, and linkages among partners. The government, donors, UN, and CSA

collaborations are functioning, whereas business, research and academia networks are

established recently.

SITUATIONAL ANALYSIS FOR THE NUTRITION ADVOCACY PROJECT CONCLUSIONS

FINAL REPORT 28

12. After the devolution, the provinces have developed education sector plans and strategies

for the period 2013-17 however they lack nutrition sensitive interventions. Therefore,

nutrition is not amongst the targeted outcomes of education sector strategies. Moreover,

provinces lack expertise in designing nutrition-sensitive interventions.

13. The role of the food department is critical in ensuring nutritional standards of foods. So

far only Punjab has set up a Food Regulation Authority for quality assurance functions.

14. Nutrition is an outcome of complex processes and agriculture has a direct impact on

household food security through food availability and income distribution. After the

devolution, agricultural policymaking has been shifted to the provinces. Agricultural

policy, however, has not paid much attention to nutrition or food consumption.

15. The facts, that prior to 2011 Pakistan lacked a national nutrition policy and the National

Nutrition Strategic Plan 2002 was also not implemented, clearly reflect that the

respective governments in Pakistan never committed any nutrition specific funds. In

2013, government spending (only spent 5% of general government expenditures) on

nutrition was much less (6 to 8 times) than the spending of its neighboring countries.

***********

SITUATIONAL ANALYSIS FOR THE NUTRITION ADVOCACY PROJECT RECOMMENDATIONS

FINAL REPORT 29

4 RECOMMENDATIONS

1. There is need to advocate political and administrative authorities, to further convince

them to add nutrition among the top priorities of the governments, translate policies into

actions and ensure allocation of funds for nutrition interventions. If they are not convinced

enough they would never prioritize nutrition on their agenda and hence will not allocate

financial resources.

2. With the adoption of sustainable development goals, efforts should be directed to

develop multi-sectoral nutrition specific and nutrition sensitive development programs

with the involvement of Health, Social Welfare, Education, Food, Agriculture, and Public

Health Engineering departments.

3. The government, donors and development partners should focus at building capacities

of respective departments in provision of trained staff and of personnel in understanding,

planning and implementation of nutrition related interventions, at federal, provincial and

district levels.

4. The governments should establish mechanisms to monitor policy interventions and

financial commitments. Technical and financial assistance should be provided to federal

and provincial governments in establishing such mechanisms.

5. Structured and well planned efforts should be directed to raise understanding regarding

nutritional issues among the legislators, policy makers, media and implementers.

6. SUN SCA should advocate Federal and Provincial Governments for nutrition sensitive

and nutrition specific projects and improving the financial commitments.

7. Scaling Up Nutrition Civil Society Alliance at federal level has the potential to influence

the monitoring mechanisms of policies and financial mechanisms. This should be

achieved through taking concrete steps to influence the financial commitments at

provincial level through continued advocacy for financial allocation.

8. The capacity of CSOs should be enhanced for developing and implementing effective

advocacy programs and nutrition sensitive interventions.

9. The beneficial outcomes of BISP on nutrition outcomes should be enhanced through

sensitizing the beneficiary households on rational spending and benefits of prioritizing

spending on nutritious food.

***********

SITUATIONAL ANALYSIS FOR THE NUTRITION ADVOCACY PROJECT REFERENCES

FINAL REPORT 30

REFERENCES

1. Annual Plan, Planning Commission of Pakistan, 2016-17

2. Asian Development Bank, Food Security in Asia and Pacific, 2013

3. Global Food Security Index, 2016

4. The Political Economy of Undernutrition National Report: Pakistan, March 2013

5. Essential Package of Health Services for Primary Health care, Punjab, 2013

6. Minimum Health Service Delivery Package for Primary Health Care, KPK, 2012

7. Preventing Undernutrition Through Multi-Sectoral Initiatives in Pakistan - A Landscape

Analysis, July 2015

8. The Political Economy of Undernutrition National Report: Pakistan, March 2013

9. Multi-sectoral Integrated Nutrition Strategy, Khyber Pakhtunkhwa, Dec 2014

10. Zaidi et al. Nutrition Policy in the Post-Devolution Context in Pakistan: An Analysis of

Provincial Opportunities and Barriers, May 2013

11. http://www.nih.org.pk/Nutrition.asp

12. http://pc.gov.pk/organization/sections/nutrition.pdf

13. http://scalingupnutrition.org/news/the-sun-civil-society-alliance-launches-in-pakistan-

and-adopts-a-declaration-to-mark-the-occasion-2#.VfZ6qNKqqko

14. http://nhsrc.gov.pk/news_details.php?news_id=197

15. Baluchistan Province Report: Nutrition Political Economy, Pakistan

16. Khyber Pakhtunkhwa Province Report: Nutrition Political Economy, Pakistan

17. Agriculture and Nutrition in Pakistan: Pathways and Disconnects, IDS Bulletin Volume

44 Number 3 May 2013

18. Benazir Income Support Program; First follow-up impact evaluation report, Oxford Policy

Management, April 2014

19. Strategic Plan, Scale Up Nutrition-Civil Society Alliance 2016 -2020

20. Pakistan National Nutrition Cluster Preparedness and Response Plan 2013

21. Global Nutrition Report, 2016

22. Pakistan National Synthesis – PEA

23. Strategic Plan - SUN CSA 2018-2020

***********

http://www.nih.org.pk/Nutrition.asp

http://pc.gov.pk/organization/sections/nutrition.pdf

Documents

MI - FINAL REPORT - SITUATIONAL ANALYSIS FOR ADVOCACY PROJECT