pins operational plan final version 2 14 june (1)

8/12/2019 PINS Operational Plan Final Version 2 14 June (1)

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Pakistan Integrated Nutrition Strategy

Operational Plan


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Nutrition SituationIndicators Pakistan Sindh Punjab KP Baloch Cut-offs

Acute malnutrition

(NNS, 2001)

(FANS 2010)

13% 18%

21.2%

12%

13.9%

11%

7.3%

14%

8.9%

> 15% critical

> 10% serious

Stunting

(NNS, 2001)

(FANS 2010)

37% 44%

51.8%

32%

50%

43%

47.8%

39%

59.1%

> 40% very high

30-39% high

Low birth weight -

(NDHS 2006)

31.1% 27.4% 24% 34% 43% 15% sub-Saharan

Africa

27% Asian region

Preliminary 2011 NNS latest indicationGlobal Acute Malnutrition = 13-19% (serious to critical)


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Latest indication (Preliminary 2011 NNS)Iron Deficiency Anaemia ( children)- 44%

(Severe Public Health Problem)

Indicators Pakn Sindh Punjab KP Baloch Cut-off

Iron Deficiencyanaemia (children)(NNS, 2001)

67% 68% 72% 56% 36% > 40% severeproblem

> 20% public health

significanceIron Deficiencyanaemia (mothers)(NNS, 2001)

45% 47% 45% 44% 55% Same

Iodine Deficiency

Disorder Mothers( NNS 2001)

69% 71% 56% 53% India = 38%

Micro-nutrient Deficiency Disorders


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Inappropriate IYCF practices; late initiation breast

feeding - only 37% exclusively breastfed. Household food insecurity has deteriorated since

2003 (VAM 2009), (61% districts or 80 out of 136

districts)

Household income minimal - subsistence

Poor quality and insufficient amount clean water

Poor sanitation- 48 million people practice open

defecation Early and frequent childbearing

Low literacy rate - 47%

Frequent emergencies

Causes of malnutrition - multi-faceted


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To date

Before 2010 floods, CMAM implemented in KP(goodcoverage), Baluchistan, Sindh & Punjab ( 11 out of 57districts)

Flood response from August 2010 different scale:

Establishing and running programmes at 629 CMAMsites

7 types of capacity strengthening - DoH & NGOstaff

Counselingof caregivers in IYCFand hygiene promo.

Nutrition information systems for decision making

(surveillance, NIS by site, FANS, NNS)


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Province

Baseline

Childrentreated(Aug 2010)

Targets based on

FANs surveys andResponse Plans

# Children enrolledSep 2010 - April 2011 Baseline Sites(Aug 2010) currentCMAM sites

# SAM # MAM # SAM # MAM # SAM # MAM OTP/SFP SC OTP/SFP

Punjab 0 0 71,091 177,734 29,582 73,930 0 6 207Sindh 0 0 86,758 283,384 28,133 67,985 0 7 163

KP 0 0 4,788 30,164 8,959 42,858 0 10 202

Baluchistan 0 0 1,940 5,909 7,566 14,785 0 2 57

Total/Flood 0 0 164,577 497,191 74,240 199,558 0 25 629KP/FATA

Displacement1,555 6,416 18,669 63,504 9,849 46,643 135 7 202

G/Total 1,555 6,416 183,246 560,695 84,089 246,201 135 32 831

CMAM implementation to date


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Recovery by weeks of enrolment inSFP

7.01%10.83%

26.48%

31.23%

16.74%

7.71%

7.01%

17.83%

44.31%

75.55%

92.29%

100.00%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

Two Weeks Four Weeks Six Weeks Eight Weeks Ten Weeks Eleven Weeks or more


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Province wise recovery rates

93%

77%

94%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bal ochi stan Si ndh KPK

Cured


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MediumTerm

LongTerm

PINS: Conceptual Integration Conceptual integration guided by causality analysis that informed the

strategy and Punjab & Sindh response plans Operational plan divided into immediate, underlying and basic causes

ShortTerm


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Targeting criteria High levels of acute, chronic and micro-nutrient

malnutrition

Emergency affected areas ( Flood & conflict)

Severely food insecure districts (3 in Sindh and4 Baluchistan and 3 in KP)

Achievements WASH, food & health, nutrition interventions are

implemented in 207 out of 237 union councils in 26districts. Now looking at 54 districts!

Geographical Convergence


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Programme complementarity

Integrated approach of different programmes

OTP, SFP sites established in BHUs

SCs placed in hospitals next to other servicesincluding ANC, Obstretric, etc.

Micro-nutrient supplementation integrated toEPI, Mother & Child week


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Programme complementarity - new Screening for malnutrition during immunization

Immunization of all children attending feedingcenters (not just CMAM)

Nutrition counseling in Diarrhea TreatmentCentres (not just treatment)

Provision of water, jerry cans, soap, hygieneeducation to be provided along with CMAM inBHUs

Nutrition, health counseling expanded to includekitchen gardens


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Going forward

PINS Operational PlanThree action areas:1. Actions to prevent and treat acute and chronic

malnutrition2. Interventions that address the underlying causesof malnutrition with a multi-sector approach

3. Interventions that address basic causes -

advocacy, awareness raising, policy and planning,coordination, M&E, financing


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4 key elements: all to be continued and scaled up CMAM including clinical life saving treatment of

complicated cases of severe acute malnutrition

(SC, OTP, SFP) Promoting good nutritional practices (IYCF) and

hygiene practices

Increasing intake of vitamins and minerals(Multi micro-nutrient, Vitamin A ,de-worming)

Food fortification -Wheat with iron and salt withiodine.

PINS Action Area 1 actions to prevent and treatacute and chronic malnutrition


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PINS Action Area 1 activities

IYCF counselling services in health facilities at communitylevel through LHWs, CHWs, including maternal nutrition.Communication for behaviour change, socialmobilization. Mother to mother support groups.

Community outreach, home visits, strengthening referralsystem.

Lifesaving emergency treatment of SAM. Providingtherapeutic and supplementary foods & medicines

Trainingservice providers in CMAM- NIE. Providing multiple vitamins and minerals powder

(sprinkles), iron/folate micro-nutrient supplements to allPLW, de-worming, zinc and ORS supplements, iodized salt

and iron fortified flour consumption


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PINS Action Area 1: Indicators and Targets

Outcome indicators Baselines Targets

1 -Therapeutic feeding (GAM)

(SAM)

13%

3% ( NNS 2001)

9%

2%

2-IYCF( Exclusive breastfeeding) 37%

(PDHS 2006-7)

60%

3- Micro-nutrient supplementation

( Mothers Iron Deficiency Anemia)

45%

( NNS 2001)

35%

4-Micronutrientsfortification

( Iodine Deficiency Disorder)

76%

(NNS 2001)

50%


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For all 3 key elements

P-DOHs already signed MoUs or work plans with WHOand UNICEF on nutrition response plans

WFP has partnership with DoH in mother and child

health WHO, UNICEF and WFP MOUsclarify UN agencyroles WFP , UNICEF & WHO have partnership/field level

cooperation agreements with over 100 national andinternational NGOs

PDMAs, P-DOHs partner with ERWGs Early Recovery Working Groups should transition to

sector working group led by government coordinatingbody

PINS Action Area 1 Partnerships


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PINS Action Area 2 Interventions that address theunderlying causes of malnutrition with a

multi-sector approach

3 key elements to be continued and scaled up

Food - diversification through household education,homestead food production, livelihood support e.g.

food for training, food voucher scheme, micro-credit,etc

WASH- improve access and use of safe drinkingwater and sanitationthrough provision of water

purification tablets, containers, soap and hygieneeducation

Health - increased access and use by most vulnerableto vaccination, PHC, ANC, obstetric and newborn care


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PINS Action Area 2 activities Provide small holder farmers vegetable seeds, fertilizers, tools,

equipment, animals. Support cleaning/repairing fish ponds, providefish feed. Training of trainers/ extension workers, farmers, women,community leaders, animal health workers, producer-marketingmanagers.

Provide meals of High Energy Biscuits to primary school children; take-

home rations of flour and vegetable oil conditional on minimummonthly attendance.

Provision of safe water storage containers to CMAM sites and targetfamilies. Sanitation facilities, hygiene promotion, hygiene kits followup hygiene activities at homes and in community groups.

Training of health staff, increase awareness among mothers andfamilies for improved health practices and disease prevention ofdiarrhea, ARI, malaria and measles. Provide adequate treatmentservices with antibiotics. Strengthen health facilities by provision of

equipment and supplies.


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PINS Action Area 2: Indicators and Targets

Outcome indicators Baselines Targets

1- Food: Proportion of pop. below

minimum level dietary energy

consumption

30%

NNS(2001)

23%

2- WASH: Reduced prevalence of

diarrhea in children < 5

21.8%

(PDHS 06/7)

10%

3- Health: Under five mortality 94/1,000

live births

90/live

births


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For 3 key elementsWFP has partnership with and DOE for school

feeding programme FAO and WFP have partnership with Ministry

of Food, Agriculture and Live stock (MINFAL)WFP and FAO have partnership/field level

cooperation agreements with national andinternational NGOs

UNICEF and WHO have agreement withMinistry of Environment and Local bodies forWASH activities



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1. Advocate for leadership and commitment; give technical

assistance to provincial governments to update/finalisenutrition PC-1 s and provide budget allocations.Establish/support Government led Coordination.

2. Provide support to include nutrition into health careproviders and food security specialists educationalcurriculum, post-graduate training

3. Establish and/or reinforce common nutrition information,monitoring and evaluation system including nutrition

surveillance system in all high risk (of malnutrition) areas.4. Build national capacity to produce medically certifiedRUTF (already producing RUSF & FBF) by providingtechnical assistance to one or two food processingcompanies.

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


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5 PC-1s developed to be updated for PINS, adopted andapproved; advocate for budget allocation.

Create high level National and Provincial NutritionCoordinating Councils

Strengthen DoH Nutrition Units or Cells in Provinces; Advocate for legislation for universal salt iodization, wheat

flour fortification Support the review of LHWs/CMW trainingmaterial/curriculum in line with IYCF priorities, updateintegrated curriculum for health providers, put nutritioninto training and school curriculum

Expand sentinel site surveillance & increase frequencynutrition surveys. Expand Nutrition Informationmanagement system (NIS) to all nutrition interventionsites, agree common process and impact indicators,establish joint monitoring system

Root causes to be addressed by more than PINS!

PINS Action Area 3 activities


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PINS Action Area 3:Indicators and Targets

Indicators Baselines Targets1 Provincial PC1s and budgets

prepared

0 5

2- Nutrition included in medical training

curriculum ( Number of institutions)

0 3

3- Functional Nutrition Surveillance

System(districts)

18 54

4- Certified RUTF produced by local

factory

0 1


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For Leadership and coordination:Planning Commission & MOH, P-DOH; link with otherdepartments such as Education, Agriculture, food, livestocketc. to coordinate and prepare PC1

For Capacity Strengthening:DOHs and MOE will facilitate partnership with private andpublic Institutes (e.g. AKU, Health Services Academy,Institute of Public Health) with financial and technical

support from UN for nation wide capacity strengthening

For Sustainability:

DOH in collaboration with UN will work with private sector

for RUTF and RUSF production ( latter already happening)



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Funding Gap (US$)Action area 18 months 6 months

1. Immediate interventions: 4 elements

107 mill.1.1 CMAM90 mill.

1.2 IYCF10 mill.

1.3 MicrN, supl5 mill.

1.4 Fortif2 mill.

78,600,000 20,000,000

2. Interventions that address the underlying causes

of malnutrition171 mill.

2.1 Food intake + School feed 116 mill.

2.2 WASH 25 mill.

2.3 Health

30 mill.

110,000,000 60,000,000

3. Advocacy, policy, surveillance10 mill.

3.1 leadership and policies4 mill.

3.2 National CB2 mill.

3.3 NIS, Surveil, monitorring4 mill.

8,000,000 3,000,000

Total 196,600,000 83,000,000


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Finalize the Operational Plan through consultativeprocess at national and Provincial levels, bringing inministries and departments

Finalize Joint funding proposals (already in process) Monthly briefings convened by the RC/HC

Monthly technical meeting of the Early RecoveryWorking Groups to transition to sector working

group led by government by 2012

Scale up implementation now!!!

Next steps

pins operational plan final version 2 14 june (1)

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