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NUTRITIONAL ANTHROPOMETRIC SURVEY Final report Rawalpindi City Pakistan 4th to 16th June 2007

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NUTRITIONAL ANTHROPOMETRIC SURVEY

Final report

Rawalpindi City Pakistan

4th to 16th June 2007

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 2

TABLE OF CONTENTS 1. EXECUTIVE SUMMARY ...............................................................................................................4 2. INTRODUCTION ...........................................................................................................................7

2.1 Structures of Power..................................................................................................................7 2.2 Demography ............................................................................................................................8 2.3 Migration Features ...................................................................................................................9 2.4 Rawalpindi Demographic Features ..........................................................................................9 2.5 Access to Infrastructures........................................................................................................11

2.5.1 Health facilities ..............................................................................................................11 2.5.2 Educational Facilities .....................................................................................................11 2.5.3 Water and Sanitation Facilities ......................................................................................11

2.6 Morbidity and Mortality ...........................................................................................................12 2.7 Childcare Practices ................................................................................................................12 2.8 Malnutrition ............................................................................................................................12

3. SURVEY OBJECTIVES...............................................................................................................12 4. METHODOLOGY ........................................................................................................................13

4.1. Selection of Survey Area within Rawalpindi City ................................................................13 4.2. Survey Methodology ..........................................................................................................16 4.3. Sample size and sampling procedure for anthropometric and mortality data .....................16

4.3.1. Sample size for anthropometric data .............................................................................16 4.3.2. Sample Size for Household and Mortality Data .............................................................17 4.3.3. Selection of Clusters......................................................................................................17 4.3.4. Selection of Households and Children ...........................................................................17

4.4. Key informant Interviews and secondary data collection....................................................18 4.5. Data collection and measurement techniques ...................................................................19

4.5.1. Anthropometric data ......................................................................................................19 4.5.2. Household and Mortality Data .......................................................................................19

4.6. Training and supervision....................................................................................................20 4.7. Data analysis .....................................................................................................................20 4.8. Indicators and Formulae ....................................................................................................21

4.8.1. Acute Malnutrition..........................................................................................................21 4.8.2. Chronic Malnutrition.......................................................................................................21 4.8.3. Mortality.........................................................................................................................21

5. FIELD WORK ..............................................................................................................................22 6. RESULTS....................................................................................................................................22

6.1. Anthropometric results .......................................................................................................22 6.1.1. Age and sex distribution of the sample population.........................................................22 6.1.2. Anthropometric analysis (based on Z-scores)................................................................23 6.1.3. Anthropometric analysis (based on Percentage of the Median).....................................24 6.1.4. Anthropometric analysis (comparison of Z-score and Percentage of Median) ...............25 6.1.5. Anthropometric analyses – Risk of Mortality: Children’s MUAC.....................................25

6.2. Visited Households’ description .........................................................................................26 6.3. Results of retrospective mortality survey............................................................................27 6.4. Results of Key Informant Interviews and Secondary Data .................................................27

6.4.1. National and District Level Key Informant Interviews .....................................................27 6.4.2. Union Council Level Key Informant Interviews...............................................................28 6.4.3. Secondary Data Collection ............................................................................................29

7. DISCUSSION AND RECOMMENDATIONS................................................................................29 8. ACKNOWLEDGEMENTS............................................................................................................31 9. APPENDICES .............................................................................................................................32

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 3

List of Acronyms AAH Action Against Hunger ACF Action Contre la Faim ADB Asian Development Bank CI Confidence Interval DCO District Coordination Officer EDO Executive District Officers GAM Global Acute Malnutrition HFA Height for Age IDP Internally Displaced Person KG Kilogram LHW Lady Health Worker MUAC Mid Upper Arm Circumference NCHS National Center for Health Statistics NGO Non Governmental Organizations NWFP North Western Frontier Province SMART Standardized Monitoring and Assessment of Relief and Transitions TB Tuberculosis UC Union Council WASA Water and Sanitation Agency WFH Weight for Height WHO World Health Organization

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 4

1. EXECUTIVE SUMMARY Rawalpindi is located in Punjab Province, North-East Pakistan, in the close vicinity of Islamabad. Rawal city has an estimated population of about 1 million in 20071. Four union councils out of 46 within Rawalpindi City were chosen for a joint nutritional and food security survey based on an analysis of indicators for vulnerability which included density, minority population, secure tenure, housing conditions, water and sanitation, impact of natural disaster, accessibility to food markets and sustainable employment. It was felt that these four union councils were the most vulnerable out of the 46 and relatively homogeneous in regards to their vulnerabilities. The union councils are Dhok Hassou North Union Council 5, Fauji Colony Union Council 8, Mohallah Eidgah Union Council 16 and Pirwadhai Union Council 7. Dhok Hassou North is located in the northern part of Rawalpindi, across the road defining the administrative boundary between Rawalpindi and Islamabad. One of the specificities of Dhok Hassou is that it encompasses a large population from Pathan origin (these are Pashto speakers versus the native district Punjabi speakers). The Pathan populations living in Dhok Hassou North are from longstanding in-migrations. Such a significant proportion of Pathans in this union council is related to economic opportunities. Wholesale or retail markets are strongly handled by Pathans, notably involved in the nearby Sabzi Mandi (vegetable and fruits wholesale market). Men are mainly daily-wage workers. The estimated population in 2007 is 18,503. Dhok Hassou North is bordered by Lai Nulla River on its Eastern, Southern and Western part, increasing its exposure to flooding during the monsoon period. Fauji Colony Union Council 8 had to face an influx of population following the eviction of Afghan refugees from a nearby camp. About 30,000 people lived in this informal settlement and had no choice than move in September 2005. They were requested to return to Afghanistan but part of them are said to have stayed in the neighboring union councils for economic reasons: Consequences of migrations since the eighties are mainly related to the pressure on facilities and resources (accommodation, water, sanitation). Similarly to Dhok Hassou, Pathan communities also constitute a large proportion of the population of Fauji Colony. About 72% are longstanding residents (27% natives from Rawalpindi and 45% settled for more than 16 years) and a minority arrived less than 2 years ago in Fauji Colony. The estimated total population in 2007 is 24,841 Mohallah Eidgah Union Council 16 is mainly populated with residents, although the UC had to face longstanding migrations: one wave of migrations occurred in 1947 in the aftermath of the Independence (people mainly settled in an area known as ‘Satellite Town’); another one took place in 1973 as a consequence of a destructive earthquake in Kashmir. There is not a Pathan migration pattern to this UC as with the above two union councils. Water and sanitation is a main concern among this population, although situation undoubtedly improved in the last few years. Housing units are now directly connected whereas 10 years ago, water was collected in street taps. Living conditions in the ward inhabited by Christians are certainly more problematic as they are highly exposed to flooding and sanitation system is clearly ineffective leading to an unhealthy environment. In addition, Christians have a limited access to sustainable work. Survey will thus be restricted to the section populated by Christian community. The estimated total population of the entire union council in 2007 is 20,719. Pirwadhai Union Council 7 has a total estimated population in 2007 of 24,615. It is located on the adjacent southern side of Fauji Colony. It is mainly populated with residents and a large majority of the dwellers are Punjabi speakers. Pirwadhai is bordered on the western side by the Lai Nulla River, hence actual flooding is a recurrent theme to many of the inhabitants in this union council. In the near vicinity of the surveyed union councils, there are several government hospitals which are mandated to provide affordable services to the general public, these include: Holy Family Hospital, Rawalpindi General Hospital and District Headquarter Hospital. Government T.B. Hospital provides treatment for patients diagnosed with tuberculosis free of charge. One other hospital is the Islamic International Medical College Trust Railway Hospital which provides free treatment to railway employees and their families, but charges fees for the general public accessing their services. There is one private hospital, Margalla Welfare Hospital, which is located close to Fauji Colony UC 8. One

1 Estimations for demographic data have been calculated using the National census of 1998 increased by 4% per annum (growth rate used by ADB in 2003 for Rawalpindi).

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 5

maternal child center is located in Dhok Hassou, two municipal medical centers (one in Dhok Hassou and one close to Mohallah Eidgah) and a total of five Lady Health Workers (LHWs) for the entire population of these areas. A wide variety of private practitioners have clinics in these union councils and many people stated that there was a private “doctor” on “every street”, some with proper certification and others without. There are no dedicated nutritional centers in the surveyed area. The nutritional anthropometric survey and retrospective mortality survey were conducted over 10 days starting on June 4 and continuing until June 16, 2007. An AAH food security survey was conducted in conjunction with the anthropometric survey from May 14th to June 16th in the same geographic areas. Some results from this survey are reported in this document, as they provide a broader understanding of the nutritional situation in these union councils, but are detailed in a separate report. The SMART methodology was applied. A three stage cluster sampling was used for this survey with 40 clusters of 23 children between the ages of 6 to 59 months. All the children from 6 months to 59 months in the randomly selected household were included in the survey. A retrospective mortality survey over the past 150 days was undertaken alongside the anthropometric survey using SMART methodology. Nutrition and mortality data were analyzed using NutriSurvey version December 2006 software.

Table 1: Rawalpindi City (surveyed areas) Acute Malnutrition Results

The GAM rate of 5.9% (C.I. at 95%: 4.4%-7.4%, in Z-scores, reference NCHS) shows that the nutrition situation in councils surveyed in Rawalpindi City is not alarming. Similarly, the crude death rate of 0.23 is significantly below the alert level of 1/10,000 persons/day and the 0-5DR of 0.83 is also below the alert level of 2/10,000 persons per day. The one child with measurements indicating severe malnutrition had a past medical history of chronic diarrhea. Similarly, 100% of the moderately malnourished children that were interviewed had some type of underlying illness. It is important to note that most of these illnesses were not diagnosed by a health care practitioner, but were reported by the caretaker. Other surveys have shown that of the children who are taken to health care practitioners when they are ill, 40% go to the private sector2 and that many of these practitioners are poorly trained and have grossly inadequate diagnostic facilities3.

2 District-Based Multiple Indicators Cluster Survey 2003-04, Punjab Province, Government of Punjab Planning and Development Department, the Federal Bureau of Statistics and UNICEF. 3 National Health Survey of Pakistan 1990-1994.

Index INDICATOR RESULTS(n =930)

Global Acute Malnutrition W/H< -2 z and/or edema

5.9% [4.4%-7.4%] Z-score

Severe Acute Malnutrition W/H < -3 z and/or edema

0.1% [0.0-0.3%]

Global Acute Malnutrition W/H < 80% and/or edema

2.6% [1.6%-3.5%]

NCHS

% Median Severe Acute Malnutrition W/H < 70% and/or edema

0.0% [0.0%-0.2%]

Global Acute Malnutrition W/H< -2 z and/or edema

6.3% [4.7%-8.0%] Z-score

Severe Acute Malnutrition W/H < -3 z and/or edema

0.5% [0.1%-1.0%]

Global Acute Malnutrition W/H < 80% and/or edema

1.3% [0.6%-1.9%]

WHO

% Median Severe Acute Malnutrition W/H < 70% and/or edema

0.0% [0.0%-0.2%]

Total crude death rate (last 150 days) /10,000/day 0-5 death rate last 150 days) /10,000/day

0.23 [0.10-0.36] 0.83 [0.30-1.36]

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 6

The GAM rates disaggregated for sex are 6.6% for boys and 5.3% for girls. Interviews with several key informants mentioned gender preference (mothers serving high quality or protein based food to boys before serving girls) as a potential cause for malnutrition rates to be higher among girls in Pakistan (and in Rawalpindi City). The nutritional data in this survey does not support these preliminary viewpoints. In conclusion, the nutritional status of children in these union councils is not alarming. Even so, the nutritional problems, observed in these councils can be explained by the following factors:

• Childcare Practices and Health Education: A large part of the underlying causes of malnutrition are related to inadequate childcare practices: breastfeeding, weaning and health seeking. The introduction of liquids, and therefore water of unknown quality, predisposes children, especially infants, to malnutrition. Simply implementing education sessions is not necessarily the right answer for this area. An example: in many cases the caretakers know that they should boil water before giving to their children, but choose not to do so for various reasons. Many women who had children with a history of illness did not know the diagnosis of the child and were not aware of the treatment given to the child.

• Water and Sanitation: Water in the surveyed area seems to be of poor quality resulting in continuous bouts of water borne diseases, such as gastroenteritis causing diarrhea and hepatitis. Chronic illness in children contributes to malnutrition4.

• Health Care Infrastructure and Utilization: There are multiple providers of care in the area, but there seems to be a lack of regulation and knowledge at national, district and local level regarding private practitioners in these councils. Government hospitals and clinics which should be providing appropriate care at affordable prices are not adequately utilized by the population in these councils. Government primary health centers or community based strategies (such as lady health workers) are not available in these councils in adequate numbers. Poor health care provider practice, leads to misdiagnosis and mistreatment of simple illnesses (such as gastroenteritis) predisposing children to malnutrition.

Recommendations that could improve the nutritional situation in these Union Councils of Rawalpindi City:

• Childcare Practices and Health Education: − Initiate health education programs in schools, the community and other institutions at union

council level focusing on general knowledge, prevention and treatment of water borne illnesses, as well as improving hygienic practices.

− Initiate water borne illness, nutrition and proper childcare practice refresher courses for the Lady Health Workers and government dispensers currently working in the union councils. These refresher courses could also include private practitioners currently staffing clinics in these union councils.

• Water and Sanitation: − Improve the water quality consumed from household taps by introducing affordable and

sustainable methods to filter water for the community. − Continue to support plans at the district and union council level to rehabilitate the water and

sewage pipes. • Health Care Infrastructure and Utilization: − Increase the quantity and quality of regulated government health facilities and health

programs (LHW) in the surveyed area. − Increase awareness in the community regarding opening hours and location of government

health services. − Support efforts for proper quality control of private clinics operating in these union councils.

These quality control measures should ensure that private clinics uphold national standards of health care service delivery.

4 Refer to ACF Urban Assessment on Food Security – Rawalpindi City written by Caroline Broudic for more information regarding the water and sanitation situation in Rawalpindi.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 7

2. INTRODUCTION5 Rawalpindi is located in Punjab Province, North-East Pakistan, in the close vicinity of Islamabad. Rawalpindi cannot, in fact, be dissociated from the foundation and development of Islamabad in the 60s’. They are both strongly interconnected as may demonstrate the spatial continuity between both cities. Although it is sometimes stated that ‘the development of Islamabad happened at the cost of Rawalpindi’ as it increased demographic pressure on the latter, it is likely that Rawalpindi took also some benefits from the ‘Capital City’ status of Islamabad.

Map 1: Islamabad and Rawalpindi

2.1 Structures of Power Pakistan is a federation of four provinces: Sindh, Balouchistan, NWFP (North Western Frontier Province) and Punjab Province. Every province is divided into districts (zila). The larger cities are run as city districts and subdivided into towns (tehsils) and these are divided into union councils. Union council is the lowest administrative unit. There are only ten cities with the status of city district which is the case for Rawalpindi since 2005. Rawalpindi city is divided into 2 towns (Rawal and Potohar) whereas Rawalpindi city district encompasses 8 towns or tehsils (Rawal, Potohar, Taxila, Gujar Khan, Kahuta, Kallar Syedan, Murree and Kotli Sattian) divided into 175 UCs. It is worth noting that administrative division was revised less than 5 years ago and consequently, the last population census (1998) did not establish any distinction between Potohar from Rawal (both included within Rawalpindi Tehsil) and Kahuta from Kaller Syedan (both included into Kahuta Tehsil). Distribution of responsibilities on district level has changed since 2000 with the introduction of the so-called Devolution of Power Plan. This administrative decentralization aimed at strengthening local power in regard with resource control and initiatives enhancement: “The essence of this system is that the local governments are accountable to citizens for all their decisions”. Each district (zila) is now headed by elected mayors (nazim) and deputy mayors (naib nazim) and assisted by an administration and elected council. Following the Devolution Plan and in order to empower those traditionally excluded from the decision-making process, 33 % of the Assembly member seats are reserved for women and 5 % for workers and peasants. Councilors are directly elected by voters above 18 years whereas nazims are elected by the Assembly. Introduction of an election system on local level, although indirect for nazim positions, endeavored to increase accountability towards citizens. Such a 5 This majority of this section was written by Caroline Broudic, ACF Food Security Officer

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 8

configuration is similar on district, town (tehsils) and UC levels. Organizational structure of Rawalpindi City District is structured as follows:

Figure 1: Organizational structure of Rawalpindi city district

District nazim is also, since 2001, assisted by a District Coordination Officer (DCO) at the top and Executive District Officers (EDOs) heading each department (Finance, Health, Agriculture, Education, Water & Sanitation, Justice…).

2.2 Demography Pakistan is the most urban country in South Asia as 34 % of its population presently live in towns. Karachi, with about 10 millions inhabitants, is one of the largest cities in Asia. The urban population of Pakistan, estimated at 45 million, is concentrated in two major Provinces: Punjab (56%) and Sindh (34%). Another demographic specificity of Pakistan and more specifically of urban areas is its fast population’s growth. Pakistan’s population increased eight-fold within a century and quadrupled in only 50 years. Urban growth is even faster as populations living in cities have grown 7.5 times in a half century, from about 6 million in 1951 to 45 million in 20046, with an annual growth rate of about 5% at the present time (estimated at 4.3% per annum in the three decades spanning from 1960 – 1992). It is worth noting however that the population census does not address Afghan refugees or immigrants from other countries, which undoubtedly leads to an under-estimation of the urban/rural distribution. Urban growth is partly due to natural increase, but is above all attributed to various forms of migrations.

Figure 2: Evolution of Urban Population in Punjab Province Evolution of urban population in Punjab Province

0

0.2

0.4

0.6

0.8

1

1.2

1951 1961 1972 1981 1998

Date of Census

%

Rural populationUrban population

6 Estimation, as the last census was completed in 1998 (urban population in 1998 was 34 million)

Rawalpindi City

District

Rawal Tehsil

Potohar Tehsil

Taxila Tehsil

Kahuta Tehsil

Murree Tehsil

Kotli Sattian Tehsil

Gujar Khan Tehsil

Kaller Syedan Tehsil

46 UC 36 UC 10 UC 14 UC 15 UC 10 UC 33 UC 11 UC

Urban population in Punjab Province has grown 6 times in less than 50 years (from 3.6 millions in 1951 to 22.7 millions in 1998). The creation of Islamabad as a capital city in 1961 and the subsequent development of Rawalpindi partly explain this demographic explosion. Rapid growth in government and administrative employment enhanced the economic dynamism of both cities, Rawalpindi and Islamabad.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 9

2.3 Migration Features It is worth noting that migrations cannot be dissociated from Pakistan’s creation and history. Pakistan experienced a massive influx of population [Muslims from India and other neighboring countries] in the immediate aftermath of its independence in 1947. Those migrations actually constitute the foundation of Pakistan as a Nation. Since independence, migrations are still widespread throughout the country following various waves and covering three different aspects: Rural-to-urban, Inter-Provincial, International (although extremely important in terms of remittances and then of economic impact, Pakistani emigrations will not be addressed in this report).

• Rural-to-urban: Rural-to-urban migrations are a longstanding trend in Pakistan and find their origin in the lack of job opportunities and perspectives in rural areas, an increasing pressure on declining resources (water, land, etc.) and a search for better living conditions.

• Inter-Provincial: NWFP and Balouchistan are the two Provinces with the highest level of out-migration, which may be explained by geopolitical, cultural and economic reasons. Migrants from NWFP are particularly numerous in the main cities of Punjab district such as Lahore and Rawalpindi.

• International: Pakistan experienced different waves of population’s influx from neighboring and/or other Muslim Asian countries. International migrations are illustrated by an important influx from Bangladesh, Burma and India in the aftermath of 1947 and then of 19727 and a steady flow from Afghanistan resulting from the Soviet Union invasion, Afghan civil war and harsh living conditions. Since the change of government in Afghanistan in 2001, a program of repatriation under the auspice of various Pakistani governmental authorities and of the UNHCR has been executed resulting in a massive return to Afghanistan. An exhaustive registration of Afghan refugees has been also carried out from October 2006 to February 2007 and the population was estimated at 2.15 million. All registered Afghans above the age of 5 received Proof of Registration cards recognizing them as Afghan citizens temporarily living in Pakistan. The cards are valid for 3 years, until December 20098. A large majority of this Afghan population live in NWFP (64%) and Balouchistan (21%), more than half (55%) live outside camps. It can be assumed that the Afghan population is however under-estimated as fear of eviction was highly dissuasive for registration.

2.4 Rawalpindi Demographic Features The population of Rawalpindi City District was estimated at about 3.36 million in 1998 (last census), corresponding to an increase of almost 60% compared to 1981. The population of Rawalpindi City reached 1.9 million in 1998 with an increase of 55 % since 1981.

Table 2: Population features in Rawalpindi district

Surface area (km²)

Population 1998

Population 1981

PopulationDensity per km²

Urban (%)

Rural (%)

Average Annual growth (81-98)

Rawalpindi DISTRICT 5,285 3,363,911 2,121,450 636.5 47% 53% 2.75%

Rawalpindi TEHSIL 1,682 1,927,612 1,065,646 1146 73% 27% 3.55%

Gujar Khan TEHSIL 1,457 494,010 360,588 339 14% 86% 1.87%

Kahuta TEHSIL 1,096 313,200 231,985 286 6% 94% 1.78%

Kottli Sattian TEHSIL 304 81,523 83,255 268 0% 100% -0.12%

Murree TEHSIL 434 176,426 157,136 406 12% 88% 0.68

Taxila TEHSIL 312 371,140 222,840 1,189 73% 27% 3.04% 7 Partition between Pakistan and Bangladesh 8 Reliefweb, May 2007

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 10

Rawalpindi City (Rawal, Potohar and cantonment) with about 57 % of the total population is the most populated tehsil. Density of the population is also largely higher than elsewhere in the district as it reaches 1,146 inhabitants per sq. km. This figure does not however reflect disparities within Rawalpindi city. Potohar is, for instance, much larger and less urbanized than Rawal9, implying that population density in Rawal city is largely higher than 1,146 inhabitants per sq. km.

Figure 3: Distribution of the population in Rawalpindi Tehsil (Census of 1998)

The present assessment only focuses on Rawal city with an estimated population of about 1 million in 2007.

Figure 3: Population Growth in Rawalpindi city from 1951 to 200610

(Source: Population Census Organization – Government of Pakistan)

This graph illustrates the dramatic increase of population in Rawalpindi city since 1951. It is worth noting that the annual growth rate considerably increased in the decade 61-72 as a consequence of the shift of the Federal Capital from Karachi to Islamabad (5.1% per annum). Since the early 1980s, population increase may be partially explained by the political situation along Pakistani borders (Kashmir, Afghanistan). Rawalpindi, as a result of its geographic position, is historically considered as a transit city, which may be illustrated by the large scope of inhabitant’s origins. Economic opportunities further enhanced since 9 In the last census, Potohar was mentioned as ‘Rural’ and its population size was estimated at 517,844 10 Population data for 2006 is only estimation as no census has been done since 1998.

RAPALPINDI TEHSIL 1,927,612

RURAL ( Potohar)

517,844

URBAN 1,409,768

Rawal City 781,927

Cantonment 627,841

Population growth since 1951 - Rawalpindi city

0

500000

1000000

1500000

2000000

2500000

1951 1961 1972 1981 1998 2006

Rawalpindi is historically an important military centre [cantonment of the British Army in 1851] and is still current houses the General Headquarter of Armed Forces and to the Presidential residency. Cantonment will as such not be included in the present assessment.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 11

the transfer of federal city capital from Karachi to Islamabad have drained migrants from the whole country and from outside Pakistan. Discrepancies between Rawal and Potohar have been underlined as the latter would encompass a higher proportion of residents.

2.5 Access to Infrastructures Urban growth has been previously highlighted and is now to be confronted with the development of basic services. Pakistan’s urbanization only reached 8% in 1947 against 35% at present time. Questions on capacities of those fast-growing cities to absorb an accelerated influx of people are thus highly relevant. Access to infrastructures is indeed not to be regarded solely but put into perspective with population size and growth, with environmental conditions and with possible economic hindrances. Availability of health centers or schools, for instance, does not systematically imply an easier access for all the population. Social or economic factors may hamper some of the inhabitants accessing to basic services. Access to water and sanitation facilities requires also an integrated approach as high concentration of inhabitants and of economic activities dramatically increases risks of contamination. Not only should be considered the proportion of people having access to tap water or latrines, but also – and above all - water quality and efficiency of the sewerage system. 2.5.1 Health facilities 1% of the federal budget is allocated for health care expenditures for Pakistan for fiscal year 2007-2008. This equals approximately 18 billion rupees and is a 14.5 % increase from the 2006-2007 fiscal year budgets. Most of the federal health budget in previous years has been spent on paying for public sector hospital services. A large range of medical facilities exists in Rawalpindi City. Besides several private hospitals and many clinics which have varying user fee schemes, there are seven government hospitals, seven government maternal/child health centers and multiple dispensaries, which have nominal consultation fees (1-2 rupees) and have a list of free medications available at the facilities. There is also a specialized TB Hospital which provides all services free of charge. Qualified medical practitioners that can prescribe allopathic medications are M.B.B.S. doctors, which have the equivalent of 12 years of primary/secondary school, five years of medical school and a six month minimum of practical training as a house doctor in a teaching hospital. A dispenser, which requires a Pharmacy – B degree, can also diagnose, prescribe and dispense medications. Lady Health Workers can also diagnose, prescribe and treat a limited number of diseases (such as malaria) and usually only have antipyretics, oral re-hydration salts and vitamins at their disposal. These are legally the only health practitioners that can diagnose and prescribe allopathic medications. In Pakistan, there is a wide variety of private practitioners, some with proper certification and others without. The government attempts to regulate the private practitioners and close those businesses that are prescribing allopathic medications illegally. Rawalpindi also ranks quite low in urban Pakistan for number of doctors and number of nurses per 20,000; 6th and 10th from the bottom of the ranking respectively11 (out of 112 urban cities in Pakistan). 2.5.2 Educational Facilities Significant choice of educational facilities for males and females is available in Rawalpindi district, as illustrated below:

Table3: Educational facilities in Rawalpindi

Institutions Total Male Female Universities 3 2 1 Degree Colleges 13 6 7 Intermediate Colleges 19 9 10 Higher Secondary School 7 4 3 Secondary High School 53 23 30 Middle School 29 10 19 Primary School 106 44 62 Technical Training Institutions 3 2 1 Mosque Madressa 12 12 -

(Source: Directorate of Education, Rawalpindi, 1998) 2.5.3 Water and Sanitation Facilities The water supply system has been introduced in Rawalpindi in 1926 and the sewage system in 1953 with an extension in 1969. The sewerage system was said in 2005 to only cover 30% area of the city. 11 Obtained from a discussion with WFP Pakistan on a working paper for “Food Security in Urban Pakistan”

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 12

2.6 Morbidity and Mortality12 In Punjab Province, 40% of the children interviewed in a survey undertaken by the government had a recent illness (in the last 2 weeks). Diarrhea was the most common morbidity at 22%. 15% of the children had cough with difficult breathing and 17% of children had a high fever. The under five mortality rate (which is the probability of a child dying before his fifth birthday) for the entire province is 112 per 1000 live births and the rate for major cities in Punjab province is 75 per 1000 live births.

2.7 Childcare Practices Studies have shown that urban populations show a trend toward less breastfeeding and earlier weaning than rural populations. Earlier onset of growth faltering in urban populations was related to decreased breastfeeding in Pakistan (Pakistan was part of a multi-country study including El Salvador, Thailand, India and Papua New Guinea)13. In the National Nutrition Survey-Pakistan 2001-2002, 13.3% of mothers offered the first solid food to their children during the first 3 months of their life and 35.4% of mothers in urban areas of Pakistan gave the first solid food at the age of 4 months. Another study shows that only 30% of infants aged 0-5 months were exclusively breastfed in the past 24 hours in Punjab Province. This same study shows that episodes of diarrhea averaged 2-3 times in a year in children under 5 years of age and that the percentage of children with recent diarrhea (in last 2 weeks) peaked in children in the first year of life which coincided with a peak for malnutrition in the same age range and a high prevalence of bottle feeding. This study suggests a link between the lack of exclusive breast feeding and number of diarrhea episodes14. More than half (59%) of children in a survey in Punjab Province with a recent illness were taken to a health practitioner, mostly to a those in the private sector (40%) and only 19% were taken to a government facility (either a hospital or clinic)15.

2.8 Malnutrition16 Nutrition in Pakistan as a whole was surveyed in 2001-2002 and the global acute malnutrition rates were 38% weight-for-age, 36.8% height-for-age and 13.1% weight-for-height in Z-score analysis. The urban differential analyzed in the survey revealed global acute malnutrition rates of 38.7% weight-for-age, 24.5% height-for-age, and 12.1% weight-for-height in percentage of the median (NCHS). As compared to the national nutritional survey from 1985-87 there is a very slow but sustained decline in stunting and underweight rates, but the prevalence of wasting has slightly increased. The prevalence of wasting is higher in urban areas as compared with rural areas in the 2001-2002 survey and this was possibly attributed to the lower breastfeeding rates in urban areas contributing to reduced disease fighting capabilities in children. Note: The results presented in the present report are not comparable to the rates displayed below, as the methodology and analysis are not similar in both surveys.

3. SURVEY OBJECTIVES

To evaluate the nutritional status of children aged 6 to 59 months in the urban context of Rawalpindi City.

To estimate the retrospective death rate among children less than 5 years of age, and the crude death rate of the total population living in the area covered by the surveys.

To make recommendations for nutritional interventions in Rawalpindi City.

12 District-Based Multiple Indicators Cluster Survey 2003-04, Punjab Government of Punjab Planning and Development Department, The Federal Bureau of Statistics, UNICEF 13 Available from: http://www.unu.edu/Unupress/food/8F144e/8F144E0a.htm 14 District-Based Multiple Indicators Cluster Survey 2003-04, Punjab Government of Punjab Planning and Development Department, The Federal Bureau of Statistics, UNICEF 15 District-Based Multiple Indicators Cluster Survey 2003-04, Punjab Government of Punjab Planning and Development Department, The Federal Bureau of Statistics, UNICEF 16 National Nutrition Survey 2001-2002, Planning Commission Government of Pakistan and UNICEF

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 13

4. METHODOLOGY

4.1. Selection of Survey Area within Rawalpindi City17 Rawalpindi city district is composed of eight tehsils. Decision was taken to only concentrate the joint food security and nutrition assessment on Rawal city and to evaluate the situation of an urban environment. Other towns are less urbanized and were considered in the 1998 population census as ‘rural’ areas. Rawal city is divided into 46 union councils (out of 175 UC for the whole district), which share main constraints (transportation, water and sanitation, density, etc.) although with different intensities. Out of these 46 UC, 4 were identified for an in-depth assessment [nutrition survey and household questionnaires]: Dhok Hassou North (UC 4), Pirwadhai (UC 7), Fauji Colony (UC 8) and Mohallah Eidgah (UC 16). Different indicators were analyzed for the selection of these UCs, such as density, minorities, secure tenure, conditions of housing, water and sanitation, natural disaster, market access and sustainable employment. Difficulties to systematically address those indicators during interviews made comparisons between UCs somehow hazardous. Finding stakeholders with a comprehensive knowledge of Rawal city was challenging as national NGOs or local authorities may have a good understanding of the situation in the areas they are operational but not of Rawal as a whole. Governmental authorities, on the other hand, may have proper knowledge of Rawal city in general, but are unable to raise specific problems. As such, the indicator framework was used more as a guideline, keeping in mind that the indicators highlighted probably constitute the main risks for food, nutrition or health insecurity.

Map 2: Satellite Image of Rawalpindi City

Presence of a slum in Rawalpindi is arguable in regard with the definition of UN-Habitat: “A slum is a contiguous settlement where the inhabitants are characterized as having inadequate housing and basic services. A slum is often not recognized and addressed by the public authorities as an integral or equal part of the city. 5 major components are considered: Insecurity residential status, Inadequate access to safe water, Inadequate access to sanitation and other infrastructure, Poor structural quality of housing, Overcrowding”. It is also worth indicating that some of those indicators were not decisive in the specific context of Rawalpindi: 17 Section 4.1 was formulated by Caroline Broudic, Food Security Officer

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 14

Secure tenure, for instance, is apparently not anymore a serious issue at macro level, as katchi abadis (illegal settlements) have been systematically regularized (or destroyed) in the last two decades. There is as such no risk of eviction, except for Afghan refugees settled in a slum in the vicinity of Rawalpindi (located on the territory of Islamabad). These refugees were given a two month notice to return to Afghanistan, but will most probably move to NWFP and possibly to Rawalpindi. As far as the residents are concerned, decision of eviction of part of the population living along the Lai Nulla River is not yet clear. There is a pending highway project which will cross the central city and could result in a massive eviction along the river. Objectives of this highway project are two-fold: 1) to decongest the central city as traffic is a serious constraint in Rawalpindi; 2) to protect the river banks against flooding and limit risks of natural disasters (huge flooding of 2001 remains a trauma throughout the city). Although not significant at a macro level for the selection of UC, secure tenure may be a so-called idiosyncratic factor18, meaning a factor that affects an individual household and not a whole community. Deprivation of land or housing ownership highly increases risks of eviction and consequently households’ vulnerability to food security. It should, thus, be further studied at household level via questionnaires. Conditions of housing: There were no significant differences in housing conditions, from an external viewpoint, between the various union councils. Most of the houses are concrete made (96% of houses according to 1998 population census), although it is said that a certain number of ‘temporary’ houses dispersed throughout the city are still remaining. The large majority of houses are supplied with tap water and sanitary facilities (92% of households are equipped with tap water - 1998). Home visits will offer additional information on the living conditions of the population and put emphasis on the major constraints.

Housing conditions did not help in the selection of UCs, but housing rent may definitively be used as an indicator of socio-economic vulnerability. Union councils located in the north of Rawalpindi (at the border with Islamabad) are said to offer the lowest housing rent, further attracting low-income dwellers. Due to the demographic pressure, housing rent has dramatically increased these last decades throughout the city and notably in the centre (commercial zone) constraining the poorest to move out. Sharing a dwelling unit with one or two other households to mitigate housing rent is also said to be a common practice. Market: Access to market places is clearly not an issue in Rawalpindi as small scale markets or shops are widespread throughout the city. There are also large market places for foodstuff in central city and in the periphery. It is thus highly unlikely that access to market places plays a role in the aggravation of food or nutrition security. Indicators that played a decisive role in the selection of UC are as follows: Density: One of the specificities of Rawal city is its high density compared to other towns of Rawalpindi district. Influx of populations may definitively adversely affect dwellers’ living conditions and increase exposure to environmental hazards if not accompanied by the correlated development of basic services and infrastructures. UCs located in the north of Rawal city [UCs numbered 1 to 9] had to face in the recent past an increase of their population as a consequence of the arrival of IDPs from NWFP and Kashmir and also of Afghan refugees (following their eviction from a nearby camp in 2005). Despite the continuous raise of housing rent, Northern UCs remains the most attractive for the lowest income. Accommodation in Islamabad or increasingly in central Rawalpindi is not affordable for households relying on daily wages.

Water and Sanitation: As above mentioned, water and sanitation has been unanimously mentioned as being the main concern of the dwellers of Rawalpindi. The water supply system has been introduced in some parts of Rawalpindi in 1926 and the sewage system in 1953. The water network obviously suffers from a lack of maintenance, displayed by many leakages all through the system. Poor conditions of pipes do not only lead to waste but also to contaminated water. Water pipes are often mixed with sewage canals (open drains) further increasing risks of bacteriological contaminations. Lack of proper waste management (from industries, hospitals or domestic) also contributes to the deterioration of the water quality. ADB-2003 “Water quality analyses done in 2002

18 Mutangadura and Makaudze, 1999

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 15

showed that 85 % of water samples analyzed for physical, chemical and bacteriological parameters were found unsafe for human consumption due to bacterial contamination”19. As far as water is concerned, quality is clearly the issue as almost every house is now equipped with water tap. Supply of water is said to have improved these last years thanks to the completion in 2003 of a large project funded by ADB. The project contributed, according to ADB, to the rehabilitation and extension of the water supply network, resulting in an increased water supply of about 34% (from 192,000m3/day to 256,000m3/day). Pipelines connected to Khanpur dam have been installed in 2002 to overcome water shortages in Rawalpindi. The city is now supplied with 3 different sources: groundwater, surface water from Rawal Lake Filtration Plant and surface water from Khanpur dam. In the UCs located in northern Rawal city, it has been clearly stated by local authorities that access to water significantly improved these 5 last years thanks to the connection to Khanpur dam. Due to the inefficiency of the whole system and of the unequal distribution, dwellers are however only supplied two hours a day on average. Quality remains however an issue. The second loan of ADB aims at improving the sewage system, as it only serves about 30% of the population. Objective is to reach 70% at the end of the project. 30% of the population will then remain with an inappropriate system, that discharges through pipes or open canal directly in Lai Nulla River or into the nearest drain. According to WASA (Water and Sanitation Agency), technical reasons impede the extension of the system to the whole population. Some detractors evoked a lack of bargaining power of some social groups as criteria of exclusion from the project. It is however still unclear whether northern Union Councils are fully included in the program to improve the sewage system. Minorities: Union Councils from 1 to 9 are mainly inhabited by IDPs or Afghan Refugees. Reasons for their establishment are various: housing rent, livelihood opportunities (vicinity of the main vegetable / fruit markets, factories, railways and bus stations) or eviction from the nearby katchi abadi in 2005.

In UC 16, more than one third of the population is Christian and faces socio-economic difficulties due to religious discrimination, living conditions (although said to have improved these last years) and access to sustainable livelihoods. Christians are often dedicated to street sanitary jobs (street sweepers, etc.) as lower castes and are as such economically disadvantaged. Sustainable employment: Access to sustainable employment is one of the critical indicators for measuring urban poverty as people mainly rely on market economy for the achievement of their basic needs (accommodation, food, health, education, transport, etc.). Daily labor is per se unpredictable in terms of monthly wages and security of employment which could be further exacerbated by a sudden population growth as it leads to an increased competition. Health status plays also a crucial role in livelihoods’ stability as any disease episode may result into a decreased work attendance and then adversely impact on households’ income. Rawalpindi offers a large range of governmental employments [Army, Civil and Military Airports, Administration, Universities, etc.] but a large segment of the population is deprived from access to such jobs (due to education, gender, status, caste, religion, etc.). Peoples’ economic activities in the Northern UCs are mainly daily labor (wholesale or retail trade, driver, workshop, etc.). Child labor is also common (garbage collection, workshop, market, etc.) as it brings substantial income to the most destitute households. Drugs addiction amongst those children and/or their parents has often been mentioned as a serious issue.

Natural disasters: Main natural risk is related to flooding as a river crosses the city from Northeast to Southwest. Heavy rains that frequently occurred throughout the monsoon season constitute a critical risk for settlements along the river. They are indeed highly exposed to water floods as tragically illustrated in 2001. In the Lai Nulla area, a total of 19 floods have been registered for the period 1944 to 2002, meaning more or less 1 flood every three years. 2001 remains however the largest devastating flooding among recorded events.

Some parts of UC 16 are particularly exposed to such a risk as located nearby the river and at low level. Floods were particularly disastrous in 2001 as water reached in some occasion the third floor of the buildings located in the Christian ward of UC 16. Some sections of Dhok Hassou, Fauji Colony and Pirwadhai are also highly exposed to flooding. 19 ADB, “Technical assistance to the Islamic Republic of Pakistan for preparing the Rawalpindi environment improvement project” – April 2003

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 16

Discussions with stakeholders have systematically pointed out Union Councils 1 to 10 as being the less secure in terms of water and sanitation, livelihoods and health. Reasons evoked were a mix of the above described indicators.

4.2. Survey Methodology A cluster sampling methodology was used. The nutritional survey and retrospective mortality survey covered four union councils in Rawal city based on the indicators mentioned above. The union councils are Dhok Hassou North (Union Council 5), Fauji Colony (Union Council 8), Mohallah Eidgah (Union Council 16) and Pirwadhai (Union Council 7).

4.3. Sample size and sampling procedure for anthropometric and mortality data

4.3.1. Sample size for anthropometric data The union council is the smallest administrative unit that can be found in Rawal City with population figures and definite boundaries. See below the estimated population size for the specific geographical units in 200720.

Table 4: Estimated Population Size

Geographical unit Population size

Dhok Hassou North UC 5 18503

Fauji Colony UC 8 25841

Mohalla Eidgah UC 1621 6837

Pirwadhai UC 7 24615 Total Population 75796

These population figures result in a total population of 75,796. Twelve percent of this population is 9096, which for this survey will be the estimated number of children in these union councils in 200722. The reference estimate for acute malnutrition for Pakistan comes from the National Nutrition Survey carried out in 2001-200223. The prevalence of wasting which was a weight for height (WFH) < -2 SD of Z-Scores was at 13.1 (11.3 – 14.9 with a CI of 95%). The prevalence of wasting (in percentage of the Median) in urban areas in the same survey was 12.124. This prevalence was used for the sample calculation. As the expected prevalence for this survey should follow the same trends, high precision is needed. Therefore a precision of 3 has been chosen. The design effect is set at 2 based on the estimate by the preliminary data collection that these union councils are relatively homogenous in nature (see indicator methodology above). After calculation, the required sample size would be 865 children. Estimating a 4% elimination rate of collected data (usually due to errant data), the final sample size should be at least 900 children.

20 Estimations for demographic data have been calculated using the National census of 1998 increased by 4% per annum (growth rate used by Asian Development Bank in 2003 for Rawalpindi). 21 Only one section of union council 16 Mohallah Eidgah is included in the survey. It is the area known as Mohallah Raja Sultan. This area comprises the buildings beside the Lai Nulla River and has definite boundaries. Approximately 33% of the population is living in this area. 22 Under 5 children in the population of Rawalpindi City was surveyed at 12% in the official census of 1998 by the Population and Housing Census - Government of Pakistan. 23 National Nutrition Survey 2001-2002, Planning Commission Government of Pakistan and UNICEF 24 Z-score analysis was not reported in the National Nutritional Survey for anthropometric data from urban residences.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 17

Table 5: Assumptions for Calculating the Sample Size for Anthropometric Data

4.3.2. Sample Size for Household and Mortality Data The household and mortality data collection used a recall period of 150 days. This corresponds to the approximate beginning of the calendar year as well as with the last major holiday in Pakistan which was Eid ul Azur25. The reference crude death rate for Pakistan is 0.22/10,000/day26. This number will be rounded up to 0.4 as the estimated prevalence rate per 10000/day for the survey. The required sample size was calculated to be 564 households.

Table 6: Assumptions for Calculating the Sample Size for Household and Mortality Data

Population size 75796

Estimated prevalence rate per 10000/day 0.4

± desired precision % 0.6

Design effect 2

Recall period in days 150

Sample size 564

4.3.3. Selection of Clusters Forty clusters were selected so that the four teams have one cluster per day with a total of approximately 23 children per day. The clusters were assigned by NutriSurvey database27.

Table 7: Assigned clusters by NutriSurvey Database

Geographical Unit Population Size Assigned Cluster

Dhok Hassou North UC 5 18503 1,2,3,4,5,6,7,8,9,10

Fauji Colony UC 8 25841 11,12,13,14,15,16,17,18,19,20,21,22,23,24

Mohalla Eidgah UC 16 6837 25,26,27

Pirwadhai UC 7 24615 28,29,30,31,32,33,34,35,36,37,38,39,40

As it was difficult to obtain detailed road/boundary maps of each union council, the survey teams and/or the nutrition/food security officers, met with the Nazims to draw and establish the boundaries of the union councils (see Appendices III – VI for maps). 4.3.4. Selection of Households and Children The survey teams began data collection in each cluster by finding a point approximately in the middle of the mapped segment for the corresponding cluster assigned for that day. They spun a pen/bottle in the middle of the road and noted the direction for the start of the survey for this cluster28. After finding 25 Recall period is from Eid ul Azur which corresponds to January 3, 2007 or approximately 150 days before the start of the survey. 26 Calculations done from 2005 UNICEF figures available at http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html 27 NutriSurvey for SMART, developed by Dr. Juergen Erhardt in cooperation with Prof. Michael Golden, December 2006: Available from www.nutrisurvey.de 28 The two stage EPI method mentioned in the SMART methodology is not appropriate for this survey as there

Children below 5 years 9096

Estimated prevalence % 12.1

± desired precision % 3

Design effect 2

Sample size 865

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 18

the approximate center of the cluster, as well as the direction in which they will walk, they put the numbers 2-5 into a hat and drew at random a number. The number chosen dictated the increment counted between doorways of each household chosen. Once the randomization of the start of the survey was done, then each doorway (counted according to the randomized number) on the right side of the road/walkway will be entered. Within each doorway, one member of the survey team recorded on a piece of paper each household unit within the building. In the context of Pakistan, a household unit will be all those who eat from the same pot within the same household unit. Each household had their name written on a piece of paper and placed into a hat and a separate member of the team drew the chosen household. This drawn household was used for the anthropometric data and the household/mortality data. All children from 6 to 59 months old in a selected household were included in the anthropometry survey. All households selected were interviewed for the retrospective mortality survey, whether or not they counted eligible children for the anthropometry survey. Once the questionnaires filled for the first household, no other household in this building (or doorway) was chosen. The team left the doorway, counted the doorways on the right hand side of the road to the random number that they drew in the beginning and entered the doorway corresponding to the random number. At the first intersection the team takes the road to the right. At the second intersection the team takes the road to the left, etc. If the team comes to a dead end before the 23 children in the cluster have been measured, then they turned around (not entering any of the doorways coming out of the dead end) took the opposite direction at the intersection where they entered the dead end road and then begin counting doorways on the right of the new road. If the doorway chosen was a business or shop (and there were no households in the building) then they left this doorway and entered the next doorway on the right (they did not count the random number for the next house). In case of temporary absence of children or informant to answer the questionnaires, the household was not omitted, skipped or substituted in the data. The team visited back the household at the end of the working day. If the child/informant was still not available at the end of the day then this was noted by the team leader. In situations where the members of a household had departed permanently/houses were locked/or no one answered the door, this particular household was recorded as such and skipped but not replaced. Each household was asked whether they would like to participate in the survey and that this was by voluntary basis only. If they refused, then this household was noted by the team leader as such, but it was not replaced.

4.4. Key informant Interviews and secondary data collection 4.4.1. Key Informant Interviews Key informant at national and district level were chosen due to their relevance in the field of nutrition. Triangulation between government offices, INGO offices and UN bodies was felt to give an overall general picture of the situation in Pakistan and/or the urban environment in Pakistan as related to nutrition. The key informant at union council level, as well, were chosen to display a wide variety of expertise as well as affiliation with different structures involved in nutrition, so private practitioners, lady health workers (government program), government dispensers, doctors working at hospital level as well as union nazims and lady counselors and national NGOs were interviewed. 4.4.2 Secondary Data Collection All hospitals used as primary referral hospitals from the government and private clinics in these four union councils were visited to obtain statistical data regarding nutrition related admissions. Random private clinics were visited in these union councils to obtain statistics regarding nutrition related clients presenting to their clinic. All government affiliated clinics within these union councils were visited to obtain statistics regarding nutrition related presentations to their clinic. are not direct routes to the edges of the grid areas and many roads are dead ends. It is also not feasible to walk in a line and count the number of doorways until the end of the grid area. The methodology for this survey was to use only the direction from the approximate center of the grid within the union council.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 19

4.5. Data collection and measurement techniques 4.5.1. Anthropometric data The following was collected for children 6 months of age to 59 months of age. Age was recorded in months (when known by mother). The team leader attempted to crosscheck the reported age with birth cards or vaccination cards. If the team leader could confirm the date of birth or the exact age in months then it was noted as a confirmed age. Sex of the child was recorded as “M” for male or “F” for female. Weight was measured using 25 kg hanging Salter scales and recorded in kilograms to the nearest 100 grams. The Salter scales were calibrated each morning by the team leader using a known weight of 2kg. The scale was hung from a stick held by two measurers, and recalibrated to zero before the child was put into the weighing pants. Although the teams attempted to weigh all children without clothing, in some households this was not culturally acceptable. In the households where clothes were left on, 0.1 kg was subtracted from the weight of the child. Height was measured in centimeters using a 1.30 meter height board graduated to 0.1cm with a movable block. Children were measured recumbent if their height was below 85cm. The children were measured standing if they measured 85 cm or above. The height was recorded to the nearest 0.1 cm. All children were measured barefoot. For children measured standing up, the measurers were trained to ensure that the child’s head, shoulder blades, buttocks, calves and heels were touching the boards and they were looking straight ahead. Children measured lying down were placed in the middle of the board with the head touching the fixed end, the knees pressed down and the heels touching the movable block. Edema was measured by applying normal thumb pressure to the anterior surface of both feet for three seconds. If an indentation remained after the pressure was removed, presence of edema was considered positive and a “Y” was entered on the data collection form. If the thumb imprint did not persist, or if the edema was not bilateral, the child was recorded as not having edema and an “N” was entered on the data collection form. The supervisor was to check all positive or questionable cases of edema. Mid upper arm circumference was measured in centimeters, to the nearest 0.1cm, using AAH MUAC measuring tape. The measurers were trained to locate the mid-point between the shoulder and the tip of the elbow on the left arm with the arm bent at a right angle and to note the mid-point. The measurement was taken at this mid-point with the arm extended and relaxed. For retrospective morbidity and childcare practices, an informal discussion with caretakers of severely, moderately or at-risk malnourished children was undertaken by the team leaders of the nutrition team. These discussions happened either immediately after the actual anthropometric data collection or on the following day in a subsequent visit. These were informal discussions with mothers and were done randomly by the team for children or families that measured as severe, moderate or at-risk of malnutrition. Vaccination status was checked during these retrospective interviews and where possible the vaccination card was visualized by the team. In many cases the family did not have the vaccination card and the team leader simply asked whether the child had been vaccinated or not. In addition, health/nutrition questions were added as a component of the food security questionnaire that was completed in conjunction with the anthropometric and mortality survey. The food security teams surveyed every fifth household that was selected at random to be a part of the nutrition (anthropometric) survey. 4.5.2. Household and Mortality Data The following information was recorded for each household selected in order to establish the 0-5 years and crude death rate. To ensure accuracy of the data collected, a household tally sheet was completed (See Appendix II) for each household visited.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 20

The head of each household was selected (regardless of whether there were any children ages 6 to 59 months living in the house) was asked to list all the household members (currently present or not) and to indicate whether each member 1) was currently living in the house, 2) was living in the house during the Eid ul Azur holiday (corresponding to January 3rd, 2007), 3) whether they were born or died in the period since Eid ul Azur, 4) the age of each family member, 5) sex of the family member. All of this information was then tallied to give us 1) how many people were currently living in the house, 2) how many of the current household members arrived since Eid ul Azur (total and under five – excluding births), 3) how many former household members left during this period (total and under 5 years – excluding deaths), 4) the number of births since Eid ul Azur, 5) the number of deaths since Eid ul Azur (total and under five years).

4.6. Training and supervision Four teams were trained for the survey and each team consisted of 4 members – two female measurers, one female team leader and one female food security team member29. All members of the team were women due to accessibility of households limited only to women in the Pakistani context. One male facilitator was hired for each team to carry equipment and assist with explanations of the survey to male members of the households. The facilitators did not measure or interview any households and they only attended a brief training explaining the rationale of the survey and their responsibilities. The nutritional team members attended a two day training conducted at Pirwadhai Council Office by technical staff from Islamabad. Half of the training sessions focused on anthropometric measurement and each trainee had to practice in the classroom and community. Attention was given in training on standardization of instruments and data recording. The team members were trained for completing the household/mortality questionnaires and quality assurance techniques. The training also covered a basic introduction to nutrition and malnutrition, explanation of the rationale for the survey and methodology, interview skills and sign and symptoms of malnutrition. During the practical classroom anthropometric measurement training session the survey teams measured ten children and compared their results. The teams offered each other constructive criticism or positive feedback on measurement techniques and introduction of the survey rationale for other teams during this session. They also discussed inter-observer error. Team leaders were chosen on the last day of the training session due to their observed organizational, public speaking and data recording skills. A pilot survey took place in the Pirwadhai community after the theoretical and practical classroom sessions were complete. The teams were supervised by two technical trainers during the pilot and data collection forms were piloted during this time. No changes needed to be made to the data collection forms based on the pilot survey. During the actual survey two persons supervised the teams, one nurse and one sociologist. The two persons provided constant supervision and monitoring to the teams in the field. Each day a debriefing session was conducted with the four team leaders and all data collected that day was reviewed for mistakes and necessary corrections were made immediately. Concurrent crosschecks of the data collected by the teams were performed by the supervisors in a random sample of households. Randomly during the survey the supervisors would also observe the team while collecting data in the households.

4.7. Data analysis Nutrition teams returned data collections forms for one cluster per day at the end of the day during debriefing sessions with the nutrition supervisors. Data entry into the NutriSurvey database was entered from these data collection forms by one supervisor only, with crosschecks of data entry performed by the other supervisor.

29 The food security team member was trained in interview techniques by the food security officer and even though she was part of the broader nutritional assessment, this team member will not be addressed in this report. The training and data collected is detailed in a separate report titled “Urban Assessment on Food Security – Rawalpindi City District”, by Caroline Broudic

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 21

4.8. Indicators and Formulae 4.8.1. Acute Malnutrition The main indicator of nutritional status used throughout this report is weight-for-height, which assesses how thin the sample population is relative to their height, compared with a reference population (in this case the National Center for Health Statistics – NCHS – reference data are used)30. Weight-for-height is expressed either in Z-score or percentage of the median. The Z-score index is usually used to measure prevalence of malnutrition at population level, while percentage of the median is used to assess the nutrition status of individuals. The classification of GAM (Global Acute Malnutriton), moderate acute malnutrition and SAM (Severe Acute Malnutrition) using Z-score and percentage of the median are as follows:31

Table 8: GAM, Moderate Acute Malnutrition and SAM using Z-Score and Percentage of the Median

% of the median Z-scores

Global Acute Malnutrition

<80% and/or oedema <-2 and/or oedema

Moderate Acute Malnutrition

<80% to ≥70%, no oedema

<-2 and ≥-3, no oedema

Severe Acute Malnutrition

<70% and/or oedema

<-3 Z-score and/or oedema

The weight for height index is the most appropriate index to quantify wasting in a population in emergency situations where acute forms of malnutrition are the predominant pattern. However the mid-upper arm circumference (MUAC) is a useful tool for rapid screening of children at a higher risk of mortality. MUAC measurements are presented for all children from 6 to 59 months, divided by height groups, as MUAC is a malnutrition indicator in children taller that 65 cm in some protocols, and children taller than 75 cm in others.

Table 9: Classification of the Nutritional Status using MUAC

Adequate nutritional status MUAC ≥ 13.5 cm

Moderate risk of malnutrition MUAC 12.5 – 13.4 cm

High risk of malnutrition MUAC 12.0-12.4 cm

Moderate acute malnutrition MUAC 11.0-11.9 cm

Severe acute malnutrition MUAC <11.0 cm

4.8.2. Chronic Malnutrition Children who have a low height-for-age (HFA) are considered stunted. Measuring the height of a child in relation to a standard child of the same age gives an indication of the growth of a child. HFA is usually used as an indicator for chronic malnutrition. This survey attempted to capture the prevalence of stunting but was not successful. In this survey, many caretakers had difficulties to determine the exact age of their children and also did not have or could not locate birth cards or vaccination cards. Because credible dates of birth could not be obtained the HFA could not be analyzed from the data collected during this survey. 4.8.3. Mortality Mortality data was collected using Standardized Monitoring and Assessment of Relief and Transitions (SMART) methodology. A prevalence of 0.4 and precision of 0.6% were used during planning. The crude death rate (CDR) is determined for the entire population surveyed for a given period. 30 There will be additional analysis based on the WHO reference population but only for informational purposes and it will be included in a separate section. The recommendations from the survey are based on the NCHS reference population figures. 31 Any children with oedema, regardless of their weight-for-height are classified as severely malnourished.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 22

The CDR is calculated using NutriSurvey for SMART software for Emergency Nutrition Assessment. The formula below is applied: Crude Death Rate (CDR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2), Where: a = Number of recall days (150) b = Number of current household residents c = Number of people who joined household d = Number of people who left household e = Number of births during recall f = Number of deaths during recall period The result is expressed per 10,000-people / day. The thresholds are defined as follows32: Total CDR:

Alert level: 1/10,000 people/day Emergency level: 2/10,000 people/day

0-5 CDR:

Alert level: 2/10,000 people/day Emergency level: 4/10,000 people/day

5. FIELD WORK The anthropometric nutritional survey and retrospective mortality survey was conducted over 10 days starting on June 4 and continuing until June 16, 2007. A food security survey was also done from May 14th – June 16th using questionnaires on 198 households. No substitutions of clusters needed to happen due to security restraints or adverse events.

6. RESULTS

6.1. Anthropometric results The field work for the survey was done from June 4th 16th, 2007. Information was recorded from a total of 983 children. 64 children were not measured in chosen households due to various reasons (out of town in local village, at school, child sleeping and mother refused to wake child, child crying and mother refused). 53 children were excluded (7 children were physically disabled, 17 children were excluded due to incoherence in the data, 1 child was excluded because the height was not recorded, 28 children were excluded because their ages were out of range). 53 children had their age modified in the dataset as the age was not congruent with the weight and height of the children. Based on that, the analysis of stunting was found to be impossible, as it is believe that the remaining data were not reliable and precise enough to provide quality information. Age groups mentioned below are provided as indicators for the description of the sample. The following analyses are based on data from 930 children ages 6-59 months. 6.1.1. Age and sex distribution of the sample population The age and sex distribution of the sample population is illustrated in Table 11 and Figure 4. The sex-ratio (males/females) is well balanced.

32 Health and nutrition information systems among refugees and displaced persons, Workshop report on refugee’s nutrition, ACC / SCN, Nov 95.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 23

Table 10: Age and sex distribution of the sample population

Figure 4: Age and sex distribution of the sample population

0 20 40 60 80 100 120 140 160

6 to 11

12 to 23

24 to 35

36 to 47

48 to 59

Age

(mon

ths)

Number of children

FemaleMale

6.1.2. Anthropometric analysis (based on Z-scores) The results of acute malnutrition based on Z-score are illustrated in Table 12.

Table 11: Prevalence of acute malnutrition by age based on weight-for-height Z-scores33 and/or Edema (NCHS Reference)

Severe

malnutrition (<-3 Z-score)

Moderate malnutrition

(≥ -3 and <-2 Z-score )

Normal (≥ -2 Z-score)

Edema Age groups

(months)

Total no.

No. % No. % No. % No. % 6-11 98 0 0.0 4 4.1 94 95.9 0 0.0 12-23 199 1 0.5 24 12.1 174 87.4 0 0.0 24-35 187 0 0.0 10 5.3 177 94.7 0 0.0 36-47 184 0 0.0 6 3.3 178 96.7 0 0.0 48-59 262 0 0.0 10 3.8 252 96.2 0 0.0 Total 930 1 0.1 54 5.8 875 94.1 0 0.0

Table 12: Distribution of acute malnutrition based on weight-for-height Z-scores (NCHS reference)

<-2 Z-score ≥-2 Z-score Edema present Marasmic kwashiorkor

0 (0.0 %) Kwashiorkor

0 (0.0 %) Edema absent Marasmic

55 (5.9 %) Normal

875 (94.1 %) 33 Confidence Interval 95%

Males Females Total Age groups N % N % N %

Sex Ratio

6-11 months 46 46.9 52 53.1 98 10.5 0.9 12-23 months 100 50.3 99 49.7 199 21.4 1.0 24-35 months 94 50.3 93 49.7 187 20.1 1.0 36-47 months 89 48.4 95 51.6 184 19.8 0.9 48-59 months 126 48.1 136 51.9 262 28.2 0.9 Total 455 48.9 475 51.1 930 100.0 1.0

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 24

Figure 5: Z-scores distribution weight-for-height (NCHS reference)

The displacement of the sample curve to the left side of the reference curve indicates a less than average nutritional situation in the surveyed population. The mean of the sample is at -0.65 Z-scores, and the Standard Deviation is 0.87. The SD is within the interval of 0.80 and 1.20, which shows that the sample is representative of the population.

Table 13: Global, Moderate and Severe Acute Malnutrition in Z-scores (comparison between NCHS reference and WHO reference)

6.1.3. Anthropometric analysis (based on Percentage of the Median)

Table14: Distribution of weight-for-height by age in Percentage of the Median (NCHS reference)

Severe wasting (<70% median)

Moderate wasting

(≥70% and <80% median)

Normal (≥80% median)

Edema Age groups (month

s)

Total no.

No. % No. % No. % No. % 6-11 98 0 0.0 0 0.0 98 100.0 0 0.0

12-23 199 0 0.0 12 6.0 187 94.0 0 0.024-35 187 0 0.0 7 3.7 180 96.3 0 0.036-47 184 0 0.0 3 1.6 181 98.4 0 0.048-59 262 0 0.0 2 0.8 260 99.2 0 0.0Total 930 0 0.0 24 2.6 906 97.4 0 0.0

Table 15: Global, Moderate and Severe Acute Malnutrition in Percentage of the Median (comparison

between NCHS and WHO reference)

34Confidence Interval of 95%

NCHS Reference34

WHO Reference

Prevalence of global malnutrition (<-2 Z-score and/or Edema)

5.9% (4.4 – 7.4)

6.3 % (4.7 - 8.0)

Prevalence of severe malnutrition (<-3 Z-score and/or Edema)

0.1% (0.0 – 0.3)

0.5 % (0.1 - 1.0)

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 25

NCHS Reference WHO Reference Prevalence of global acute malnutrition (<80% and/or edema)

2.6 % (1.6 - 3.5)

1.3 % (0.6 - 1.9)

Prevalence of severe acute malnutrition (<70% and/or edema)

0.0 % (0.0 - 0.2)

0.0 % (0.0 - 0.2)

6.1.4. Anthropometric analysis (comparison of Z-score and Percentage of Median)

Figure 6: Comparison of Z-Score and Percentage of Median by NCHS reference

NCHS Reference

2.6

2.6

0

5.9

5.8

0.1

0 1 2 3 4 5 6 7

Global AcuteMalnutrition

Moderate AcuteMalnutrition

Severe AcuteMalnutrition

Percentage of the Total Children Surveyed (n=930)CI 95%

Z-Score

Percentage ofthe Median

Figure 7: Comparison of Z-score and Percentage of Median by WHO reference

WHO Reference

1.3

1.3

0

6.3

5.8

0.5

0 1 2 3 4 5 6 7

Global AcuteMalnutrition

Moderate AcuteMalnutrition

Severe AcuteMalnutrition

Percentage of the Total Children Surveyed (n=930) CI 95%

Z-Score

Percentage ofthe Median

6.1.5. Anthropometric analyses – Risk of Mortality: Children’s MUAC According to MUAC criteria, 0% of the children surveyed are severely malnourished, 1.9% are moderately malnourished, 1.4% are at high risk of malnutrition, 11.5% are at moderate risk of malnutrition and 85.2% have satisfactory nutritional status.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 26

Table16: MUAC by height categories

MUAC (cm) < 75 cm height ≥ 75 cm to < 90 cm ≥ 90 cm Total

<11.0 0 0% 0 0% 0 0% 0 0%

11.0 to < 12.0 16 8.7% 1 0.3% 1 0.3% 18 1.9%

12.0 to < 12.5 10 5.4% 2 0.5% 1 0.3% 13 1.4%

12.5 to < 13.5 46 25% 48 12.6% 13 3.6% 107 11.5%

≥ 13.5 112 60.9% 331 86.6% 349 95.9% 792 85.2%

TOTAL 184 100% 382 100% 364 100.1% 930 100%

6.2. Visited Households’ description The table below gives an outline of households visited

Table 17: Household Status of Union Councils and Total Population Surveyed

Dhok Hassou North- UC 5

Fauji Colony UC 8

Mohallah Eidgah-UC 16

Pirwadhai UC 7 Total

N % N % N % N % N %

Household with children <5 114 60.6 165 68.2 37 61.7 186 62 502 63.5

Households without children <5 53 28.2 45 18.6 23 38.3 75 25 196 24.8

Empty/locked Houses 12 6.4 20 8.3 0 0 27 9 59 7.5

Refused to be surveyed 9 4.8 12 5.0 0 0 12 4 33 4.2

Total Households 188 100 242 100 60 100 300 100 790 100

The empty or locked houses were mainly because families had traveled out of the city to their villages for the summer months. Of the 33 households that refused to participate in the survey, 58% of them did not give a reason for refusal. The other 42% gave reasons such as:

1) children are healthy and there is no reason to survey a healthy child 2) family felt fear in general 3) thought it was a plan to send the family back to Afghanistan 4) sleeping and didn’t want to be disturbed 5) didn’t have the time 6) husband (or head of household) was not allowing the family to be surveyed 7) death in the family and did not want to be disturbed

The average composition of the households interviewed is described below:

Table 18: Average number in households

Average number of people per household

Average number of < 5 per household

Dhok Hassou North UC 5 8.3 1.6 Fauji Colony UC 8 9.5 1.9

Mohallah Eidgah UC 16 8.6 1.4 Pirwadhai UC 7 7.9 1.3

Total 8.5 1.5

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 27

6.3. Results of retrospective mortality survey The crude death rate was calculated from the figures collected from families with or without children under five years of age. The recall period was 150 days prior to survey.

Table 19: Demographic Data

Demographic Data Total

Current Resident 5949

Current Resident < 5 years old 1081

People who joined HH 123

< 5 years old who joined HH 20

People who left HH 37

< 5 years old who left HH 11

Birth 88

Death 20

Death under five years old 13

CDR (deaths/10,000 people/day

0.23 (0.10 -0.36)35

0-5DR (death in children < 5/10,000/day

0.83 (0.30 – 1.36)

The crude death rate of 0.23 is significantly below the alert level of 1/10,000 persons/day and the 0-5DR of 0.83 is also below the alert level of 2/10,000 persons per day.

6.4. Results of Key Informant Interviews and Secondary Data 6.4.1. National and District Level Key Informant Interviews Five key informant interviews were conducted on National level.

− World Food Program, Sahib Haq, Program Officer for Vulnerability Analysis Mapping (VAM)

− UNICEF, Sarita Neupane, Project Officer (Nutrition) − Ministry of Health - Nutrition Wing, Dr. Zahid Larik, M.B.B.S., M.P.H.M., Deputy Director

General − Micronutrient Initiative, Dr. Noor Ahmed Khan, National Program Manager − Concern Worldwide, Shagufta Shah, Urban Project Coordinator

Three key informant interviews were conducted on Rawalpindi District level − Rawalpindi District EDO Health Office, Dr. Zafar Iqbal, − Rabnawaz, Multipurpose Master Trainer for Rawalpindi District − Dr. Sohail, District Health Development Officer

Each of the interviewees produced information on what they considered to be key issues surrounding nutrition in Pakistan and in the urban environment. Some of the issues presented were:

• Gender preference for food distribution at household level (specifically that preference may be given to boys for quality food such as high protein food).

• Micronutrient deficiencies - specifically iron (resulting in anemia) and zinc deficiencies • Water and sanitation – quality of water contributing to high rates of gastroenteritis, diarrhea,

typhoid and hepatitis. • Breastfeeding practices – poor weaning practices including the lack of exclusive

breastfeeding up to 6 months of age and introduction of liquids (not properly prepared, i.e. 35 Rates expressed with a 95% confidence interval

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 28

boiled) to infants. • Food safety – lack of proper refrigeration • Lack of proper health education and nutrition education • Underlying medical conditions (i.e. tuberculosis, worm infestation) • Inadequate food intake during pregnancy resulting in low birth weight • Utilization of government services in urban areas – lady health workers (government strategy

for community based health services) are limited in their ability to work because of the high utilization in the urban areas of private clinics and hospitals. These private health providers are not regulated by the government and may not provide services based on recognized protocols.

On national level there are several initiatives for addressing nutritional issues in Pakistan.

• Large scale TV/Print/Media campaign for nutritional education. • Wheat flour fortification – implemented in Punjab province in June 2007 • Iodized salt campaign - to subsidize salt producers who properly iodize salt and enforcement

of quality control measures. This has been started in Punjab province June 2007. • Micronutrient sachet36 distribution to young children. The distribution will potentially take place

through the lady health worker program and will begin in June 2008.

6.4.2. Union Council Level Key Informant Interviews At union council level, many people participated in key informant interviews regarding nutritional issues in their own union council. These people included the four Nazims as well as their advisors (from each union council), a LHW from UC 8, doctors at Holy Family Hospital (public) and Margalla Hospital (private), clinic staff at a national NGO (USAID funded) clinic in UC 16, doctors at government clinics/dispensaries UC 16 and UC 5, health practitioners at private clinics and a homeopathic doctor in UC 8. The two major themes were quality of water and poor management of health care. Other issues highlighted were health problems stemming from overcrowded conditions, gender preference for quality food and inadequate breastfeeding practices (specifically weaning at a very early age and introducing “dirty water” and “buffalo milk” which causes diarrhea and vomiting in children). The interviewees felt that the quality of water, specifically broken water lines lying in open sewage areas, has led to increased disease in the community, such as hepatitis, diarrhea and gastroenteritis. From the public health perspective, many of the interviewees discussed the problem with private clinics in the urban setting. These private clinics are often staffed with “fake doctors”. These doctors are not licensed and regulated by the government and yet have a wide variety of medications at their disposal. They are used by the community more often than the government clinics or hospitals because it is conveniently located (almost one on every street) and open regularly and the patients can buy the medications that they prefer and can afford. Discussions from the key informants revealed that this often leads to inadequate treatment as many people can only afford one day of medication and this is all that they can afford. The community also frequents the “fake doctors” because they can ask for injections which may not be prescribed at the government clinic/hospital. These inadequate treatments result in resistance to medications and a continual cycle of chronic illness, as the underlying illness is not usually resolved from one day of treatment. There were concerns voiced that government clinics are understaffed and the staff present are overworked and have a lack of motivation. Other interviewees stated that clinic staff are often not present in their station or have limited hours of operation. The provision of free drugs from the government health clinics is mainly for fever and pain and if clients require other medications then they are referred to private shops to buy them. The unqualified private health practitioners that were interviewed stated that they only provided medications for fever and pain and that they did not prescribe injections. When asked about syringes and injectable medications available at the private clinic, they stated that these were prescribed by a qualified doctor who was not available at the time.

36 These micronutrient sachets are termed ‘Sprinkles’ and were developed by Dr. Stanley Zlotkin et al. at the Hospital for Sick Children in Toronto. It is a home-based strategy. The sachet is a single serving that contains 12.5mg of microencapsulated iron, 5mg of zinc, 30mg of vitamin C, 300µg of Vitamin A and 160 µg of folic acid.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 29

6.4.3. Secondary Data Collection Secondary data collected from union council level was very difficult to obtain due to procedural obstacles and absence of the appropriate persons to give “permission” to release statistical data. In the near vicinity of union councils 5, 7, 8 and 16, there are several government hospitals which are mandated to provide affordable services to the general public, these include: Holy Family Hospital, Rawalpindi General Hospital and District Headquarter Hospital. Government T.B. Hospital provides treatment for patients diagnosed with tuberculosis free of charge. One other hospital is the Islamic International Medical College Trust Railway Hospital which provides free treatment to railway employees and their families, but charges fees for the general public accessing their services. There is one private hospital, Margalla Welfare Hospital, which is located close to Fauji Colony UC 8. Out of all of these hospitals the only statistics that were available and applicable to this survey were cases of gastroenteritis that presented to Holy Family Emergency Department in June 2007, which were 337 cases to the adult ED and 335 cases to the pediatric ED37. One maternal child center is located in Dhok Hassou but this center only contributed two out of twelve reports to the district health office for 2006 and so the statistics can not be analyzed for the full year. There are two government supported dispensaries which are termed “Municipal Medical Center” located in or close to the survey area, one in Dhok Hassou and one in Mohallah Imambara (services people from Mohallah Eidgah). The statistics from the children presenting to these dispensaries are listed below:

Table 20: Morbidity of Children presenting to Municipal Medical Centers in Survey Area

Dhok Hassou Jan 2006 – May 2007

Mohallah Imambara Jan 2006-May 2007

Total Patients 5741 5101 Respiratory diseases 2513 2289 Gastrointestinal Diseases (which includes malnutrition) 1912 955 Skin Diseases 218 393 Anemias 298 246 Infestations (worm) 157 460 Fever of Unknown Origin 17 81 Other 626 677

There were varying reports on the number of actual lady health workers operating in these union councils but the final decision on the figures were gathered from the EDO health office which stated that there was one LHW employed in Dhok Hassou, no LHW employed in Fauji Colony, one lady health supervisor employed for Pirwadhai and Mohallah Eidgah (the same person) with two LHWs employed in Pirwadhai and one LHW in Mohallah Eidgah. Only one LHW could be located during this survey and she was based in Fauji Colony although she was reported by the EDO to be working in Pirwadhai. She did not have any written statistics to provide to the survey team and her interview is reported in the above section on key informant interviews. The projected goal for the Lady Health Worker program is for there to be 1 LHW for every 1000 individuals. In the urban environment in Pakistan, there is an approximate 30% coverage rate of LHW for the population38. In these union councils (with an estimated 2007 population size of 89,678), there should be a total of 90 LHWs operating. Currently there are 5 LHWs (including the supervisor). Using a 30% coverage rate, it is calculated that there should be 27 LHWs operating in these union councils. There is a clear lack of adequate coverage of the government program for LHW in the surveyed area.

7. DISCUSSION AND RECOMMENDATIONS 37 The denominator of total patients in order to calculate percentages of patients with GE compared to total patients presenting to the ED was not available from the hospital at the time of interview. 38 This information was obtained from interviews at the Nutrition Wing of the Ministry of Health.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 30

The GAM rate of 5.9% (C.I. at 95%: 4.4%-7.4%, in Z-scores, reference NCHS) shows that the nutrition situation in councils surveyed in Rawalpindi City is not alarming. Similarly, the crude death rate of 0.23 is significantly below the alert level of 1/10,000 persons/day and the 0-5DR of 0.83 is also below the alert level of 2/10,000 persons per day. The one child with measurements indicating severe malnutrition had a past medical history of chronic diarrhea. Similarly, 100% of the moderately malnourished children that were interviewed had some type of underlying illness. It is important to note that most of these illnesses were not diagnosed by a health care practitioner, but were reported by the caretaker. Other surveys have shown that of the children who are taken to health care practitioners when they are ill, 40% go to the private sector39 and that many of these practitioners are poorly trained and have grossly inadequate diagnostic facilities40. The GAM rates disaggregated for sex are 6.6% for boys and 5.3% for girls. Interviews with several key informants mentioned gender preference (mothers serving high quality or protein based food to boys before serving girls) as a potential cause for malnutrition rates to be higher among girls in Pakistan (and in Rawalpindi City). The nutritional data in this survey does not support these preliminary viewpoints. In conclusion, the nutritional status of children in these union councils is not alarming. Even so, the nutritional problems, observed in these councils can be explained by the following factors:

• Childcare Practices and Health Education: A large part of the underlying causes of malnutrition are related to inadequate childcare practices: breastfeeding, weaning and health seeking. The introduction of liquids, and therefore water of unknown quality, predisposes children, especially infants, to malnutrition. Simply implementing education sessions is not necessarily the right answer for this area. An example: in many cases the caretakers know that they should boil water before giving to their children, but choose not to do so for various reasons. Many women who had children with a history of illness did not know the diagnosis of the child and were not aware of the treatment given to the child.

• Water and Sanitation: Water in the surveyed area seems to be of poor quality resulting in continuous bouts of water borne diseases, such as gastroenteritis causing diarrhea and hepatitis. Chronic illness in children contributes to malnutrition41.

• Health Care Infrastructure and Utilization: There are multiple providers of care in the area, but there seems to be a lack of regulation and knowledge at national, district and local level regarding private practitioners in these councils. Government hospitals and clinics which should be providing appropriate care at affordable prices are not adequately utilized by the population in these councils. Government primary health centers or community based strategies (such as lady health workers) are not available in these councils in adequate numbers. Poor health care provider practice, leads to misdiagnosis and mistreatment of simple illnesses (such as gastroenteritis) predisposing children to malnutrition.

Recommendations that could improve the nutritional situation in these Union Councils of Rawalpindi City:

• Childcare Practices and Health Education: − Initiate health education programs in schools, the community and other institutions at

union council level focusing on general knowledge, prevention and treatment of water borne illnesses, as well as improving hygienic practices.

− Initiate water borne illness, nutrition and proper childcare practice refresher courses for the Lady Health Workers and government dispensers currently working in the union councils. These refresher courses could also include private practitioners currently staffing clinics in these union councils.

• Water and Sanitation: − Improve the water quality consumed from household taps by introducing affordable

and sustainable methods to filter water for the community. − Continue to support plans at the district and union council level to rehabilitate the

water and sewage pipes. 39 District-Based Multiple Indicators Cluster Survey 2003-04, Punjab Province, Government of Punjab Planning and Development Department, the Federal Bureau of Statistics and UNICEF. 40 National Health Survey of Pakistan 1990-1994. 41 Refer to ACF Urban Assessment on Food Security – Rawalpindi City written by Caroline Broudic for more information regarding the water and sanitation situation in Rawalpindi.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 31

• Health Care Infrastructure and Utilization: − Increase the quantity and quality of regulated government health facilities and health

programs (LHW) in the surveyed area. − Increase awareness in the community regarding opening hours and location of

government health services. − Support efforts for proper quality control of private clinics operating in these union

councils. These quality control measures should ensure that private clinics uphold national standards of health care service delivery.

8. ACKNOWLEDGEMENTS Appreciation is extended to World Food Program, UNICEF, Ministry of Health - Nutrition Wing, Micronutrient Initiative, Concern Worldwide and Rawalpindi District EDO Health Office for providing background information on the nutritional situation at country and district level. At the union council level appreciation is extended to the Nazims and their advisors in each union council surveyed. We extend thanks to the staff of Friends Foundation, the staff at Holy Family Hospital and Margalla Welfare Private Hospital, Agahe Drop-In center, the staff of the government dispensaries, the Lady Health Workers and the private practitioners who provided information during key informant interviews. The technical support from AAH-USA and the logistics department of AAH-Pakistan is highly appreciated. The food security survey team, survey supervisors and survey officer provided key information and assistance to this survey and report. A special acknowledgement is extended to the nutritional survey team: Irum Abbas, Sadaqat Bibi, Zeba Gul, Sobia Hafeez, Sajida Mustafa, Rubina Rasheed, Amna Sakhee, Rubina Shaheen, Saima Shaukat, Shahida, Asifa Yaqoob and Sobia Yousaf and to the nutritional assistant, Rafaqat Bibi.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 32

9. APPENDICES Appendix I: Anthropometric Data Form42 Body Measurement Survey Data Form Union Council name and Number_________Date: _________ Cluster number: _______ Team number: _______ HH #

Child #

Name Sex Birthday Age in

months

Weight (kg) ±100g

Height (cm) ±0.1cm

Oedema (Y/N)

MUAC % W/H Comments

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

42 This form was translated into Urdu for the actual survey.

Action Against Hunger, Nutrition Survey: Rawalpindi City, Pakistan June 2007 33

Appendix II: Household and Mortality Data Form43

43 This form was translated into Urdu for the actual survey.

HOUSEHOLD AND MORTALITY DATA FORM (one for every household) Survey district: Rawalpindi Village: Cluster number: _____ HH number: Date: Team number:

1 2 3 4 5 6 7

ID

HH membe

r

Present

now

Present in the household at the time of Eid ul Azur (include those not present now and indicate which members were not present at the start of the recall period )

Sex

Date of birth/or age in years

Born during recall

period?

Died during

the recall period

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Tally:

Current HH members – total

Current HH members - < 5

Current HH members who arrived during recall (exclude births)

Current HH members who arrived during recall - <5 (exclude births)

Past HH members who left during recall (exclude deaths)

Past HH members who left during recall - < 5 (exclude deaths)

Births during recall

Total deaths

Deaths < 5