Khyber Pakhtunkhwa Multi-sectoral Integrated Nutrition Strategy 2014

Page 0 of 77 Khyber Pakhtunkhwa Multi-sectoral Integrated Nutrition Strategy Planning and Development Department Government of Khyber Pakhtunkhwa DECEMBER, 2014 Multi-sectoral Integrated Nutrition Strategy Khyber Pakhtunkhwa December 2014 Planning and Development Department Government of Khyber Pakhtunkhwa Message by Additional Chief Secretary, Planning and Development Department, Khyber Pakhtunkhwa Nutrition is an essential element for human health and sustainable development, yet levels of malnutrition in Khyber Pakhtunkhwa remain unacceptably high. Every second child in the province is stunted (chronically malnourished) while 17 percent children are wasted (acutely malnourished). The status of maternal nutrition and micronutrient deficiencies can be judged from the high level of anemia. Under-nutrition is one of the main causes of death among infants and young children. Those who survive have less learning capacity that reduces their productivity at adulthood, which impacts negatively on the economy. The major findings of the National Nutrition Survey of Pakistan in 2011 clearly indicated the urgent need to address malnutrition through a multi-sectoral integrated approach, which addresses immediate, underlying and basic causes of malnutrition. Realizing the gravity situation, Planning and Development Department, Government of Khyber Pakhtunkhwa took the lead in coordinating the process for development of Provincial Nutrition Policy Guidance Notes and Multisectoral Integrated Nutrition Strategy with the technical support of the nutrition development partners. The Nutrition Policy Guidance Notes for Khyber Pakhtunkhwa were approved by the Steering Committee in September 2013. Following the development of Nutrition Policy Guidance Notes, a multisectoral integrated nutrition strategy was developed through a collaborative process involving the relevant provincial government departments and nutrition development partners in the province. I greatly appreciate the efforts of the members of the technical working group, convener/members of the sectoral working groups and nutrition development partners for their participation and support in the development of the Multisectoral Integrated Nutrition Strategy of Khyber Pakhtunkhwa. I pray that the relevant sectors will continue to work on developing the operational plans for combating the problems of malnutrition in the province in a holistic and synergistic manner, and thus make a critical contribution to the health as well as physical, mental and socio-economic wellbeing of the people of Khyber Pakhtunkhwa. T A B L E O F C O N T E N T S ACRONYMS ......................................................................................................................................... iii EXECUTIVE SUMMARY ...................................................................................................................... iv 1. INTRODUCTION ...................................................................................................................... 1 ToRs for Steering Committee ........................................................................................................... 5 2. Multi-sectoral Nutrition Framework, Relevant Provincial Policies and Strategies .... 6 2.1. Organizational Environment ................................................................................................ 8 2.2. Provincial Health and Nutrition Policy ............................................................................... 8 3. Nutrition Sensitive Strategies for Social Sectors ............................................................10 3.1. Department of Health (DoH) .............................................................................................10 3.1.1. Strategy Outlines & Plan of Actions for DoH, Khyber Pakhtunkhwa .................................... 11 3.1.2. Progress and Achievements ......................................................................................................... 14 3.2. Drinking Water & Sanitation [Local Government and Public Health Engineering Department] .........................................................................................................................16 3.2.1. Strategy Outlines & Plan of Actions for Drinking Water and Sanitation, Local Government and Public Health Engineering Department, Government of Khyber Pakhtunkhwa ........ 18 3.2.2. Progress and Achievements ......................................................................................................... 20 3.3. Nutrition Sensitive Strategy for Agriculture Department ............................................22 3.3.1. Strategy Outlines & Plan of Actions for Agriculture, Livestock and Cooperation Department, Government of Khyber Pakhtunkhwa ............................................................... 24 3.3.2. Progress and Achievements ......................................................................................................... 27 3.4. Nutrition Sensitive Strategy for Food Department .......................................................29 3.4.1. Strategy Outlines & Plan of Actions for Food Department, Government of Khyber Pakhtunkhwa .................................................................................................................................. 31 3.4.2. Progress and Achievements ......................................................................................................... 31 3.5. Elementary & Secondary Education Department .................................................32 3.5.1. Strategy Outlines & Plan of Actions for Elementary & Secondary Education (E&SE) Department, Government of Khyber Pakhtunkhwa ............................................................... 34 3.5.2. Progress and Achievements ......................................................................................................... 36 3.6. Zakat, Ushr, Social Welfare, Special Education and Women empowerment Department ........................................................................................................................37 3.6.1. Strategy Outlines & Plan of Actions for Zakat, Ushr, Social Welfare, Special Education & Women Development (ZUSWSEWD), Government of Khyber Pakhtunkhwa .............................. 39 3.6.2. Progress and Achievements ......................................................................................................... 40 3.7. Industry, Commerce and Technical Education Department .............................41 3.7.1 Strategy Outlines and Plan of Actions for the Department of Industry, Commerce and Technical Education, Government of Khyber Pakhtunkhwa ....................................................41 Page ii 3.7.2 Progress and Achievements ......................................................................................................... 43 4. CROSS CUTTING ISSUES ....................................................................................................44 4.1 Equity and Social Justice ................................................................................................44 4.2 Coordination, Monitoring and Evaluation ...............................................................45 Annexure A ......................................................................................................................................49 Annexure B ......................................................................................................................................50 Annexure C ......................................................................................................................................51 Annexure D ......................................................................................................................................52 Annexure E ......................................................................................................................................58 Annexure F ......................................................................................................................................59 Annexure G ......................................................................................................................................62 Annexure H ......................................................................................................................................63 Annexure I .......................................................................................................................................64 Annexure L ......................................................................................................................................67 Annexure M .....................................................................................................................................68 Page iii ACRONYMS DOH Department of Health EDO (H) Executive District Officer Health E&SE Elementary and Secondary Education FAO Food and Agriculture Organization FATA Federally Administered Tribal Areas GAIN Global Alliance for Improved Nutrition GDP Gross Domestic Product IC&TE Industry, Commerce and Technical Education H&DRA Health and Drug Regulatory Authority IDD Iodine Deficiency Disorders IP Implementing Partners IYCF Infant Young Child Feeding IQ Intelligent Quotient KP Khyber Pakhtunkhwa LG&RD Local Government and Rural Development LHWs Lady Health Workers MDGs Millennium Development Goals MI Micronutrient Initiative MICS Multiple Indicator Cluster Survey MINS Multisectoral Integrated Nutrition Strategy MNCH Maternal Neo-natal and Child Health NNS National Nutrition Survey P&DD Planning and Development Department PC-1 Planning Commission Proforma One PINS Provincial Integrated Nutrition Strategy PSQCA Pakistan Standard Quality Control Authority SC Steering Committee TORs Term of References TWG Technical Working Group UNICEF United Nations Children Emergency Fund VAD Vitamin A Deficiency WFP World Food Programme WHO World Health Organization WTO World Trade Organization ZUSWSEWD Zakat, Ushr, Social Welfare, Special Education and Women Empowerment Page iv EXECUTIVE SUMMARY Malnutrition amongst women and children remains a major public health problem. There is no substantial change in the prevalence of acute malnutrition or in micronutrients deficiencies despite an increase in the per capita income as well as huge spending of public and donors money on different nutrition programmes over the years. The country as a whole and Khyber Pakhtunkhwa and the Federally administered Tribal Areas in particular have alarmingly high prevalence rates of under-nutrition1,2 (wasting, underweight and stunted children) and subclinical micronutrient3, (vitamin A, iron, zinc, iodine) deficiencies which adversely affect an individual’s health, physical and mental performance associated with decreased economic outputs and losses of GDP. A number of interventions including vitamin A supplementation & fortification, salt iodization, wheat flour fortification, iron supplementation, school supplementary feeding programme, nutrition awareness, advocacy seminars and workshops for health promotion were undertaken but they could not yield the desired outcomes due to a variety of reasons including lack of ownership & commitment, limited human resource capacity, limited coverage, short duration of programmes and lack of continuity, donor driven programmes, political interference in designing and implementing programmes, limited budgetary support from the government and lack of interest from stakeholders. Lack of a nutrition policy, non-existence of nutrition set-up at provincial and district levels and lack of coordinated efforts from the Government to integrate vertical nutrition programmes and address the underlying causes of malnutrition can be attributed to failure of these interventions. Keeping in view the dismal nutrition situation of the country, provinces and federating units of Pakistan, a multi-sectoral integrated nutrition strategy (MINS) was envisioned to address the underlying causes of malnutrition through enhanced coordination, communication and collaboration among the social development sectors. In this context, a provincial multi sectoral workshop on nutrition policy guidance notes and strategic planning was held on 29 30 August, 2012 at Peshawar to brainstorm, discuss and suggest appropriate guidelines for developing a multi-sectoral integrated nutrition strategy for Khyber Pakhtunkhwa and Federally Administered Tribal Areas (FATA). A Steering Committee (SC) and Technical Working Group (TWG) were constituted by the Planning and Development Department to lead provincial coordination on multi-sectoral integrated nutrition strategy with inter sectoral planning, coordination, monitoring and sectoral implementation of nutrition sensitive interventions that could address the root causes of malnutrition and honour the political commitments made at the international level in the form of Millennium Development Goals through coordinated efforts of all relevant social sectors. A number of meetings and correspondence with different provincial departments and FATA Secretariat i.e., Health, Agriculture, Food, Elementary and Secondary Education, Local Government, Zakat, Ushr, Social Welfare, Special Education and Women Empowerment and Industry, 1 NNS (2011). National Nutrition Survey, Nutrition Cell, Ministry of Health, Government of Pakistan 2 MICS (2008). Khyber Pakhtunkhwa Multiple Cluster Indicator Cluster Survey, P&D Department 3 Paracha & Jamil (2001). Assessment of Micronutrient Status of children, UNICEF/Govt. of NWFP Page v Commerce and Technical Education were held to formulate, develop and discuss the provincial integrated nutrition sensitive strategy. Political commitment and enthusiasm was demonstrated by the departments in the form of notifying Technical Working Groups by the Departments of Health, Agriculture, Education and Zakat, Ushr, Social Welfare, Special Education and Women Empowerment and Industry, Commerce and Technical Education. The other sectors are working to constitute the TWG and to propel the multi-sectoral integrated nutrition strategy to combat the basic, underlying and immediate causes of malnutrition, improve the nutritional status of the population and to foster socio-economic development of the province and FATA. Efforts are underway to assist the social sectors in developing plan of actions for undertaking nutrition sensitive programmes in each sector within the framework of nutrition policy guidance notes and multi-sectoral integrated nutrition. Improving nutritional status of women and children through multi-sectoral sensitization, mobilization, utilization, coordination, communication, collaboration and facilitation of nutrition services to neglected areas and people is central to this whole exercise. The proposed strategy was reviewed by the professionals and technical experts of the social sector departments and development partners (WFP/ WHO/ FAO/ UNICEF) at Mukshpuri (Nathia Gali) in April, 2013 that helped in fine tuning of the strategy and report. The Mukspuri workshop was followed by the Technical Working Group Workshop of the Planning and Development Department at Islamabad in September 2013 to critically review and make necessary changes in the draft proposal of the Provincial Integrated Nutrition Strategy. In the light of discussions and suggestions, necessary amendments were made in the proposed draft of the provincial integrated nutrition strategy and submitted to individual sectors for final review and approval. Comments and suggestions received from individual sectors are incorporated in this final version of the strategy (April 2014) for final endorsement of the Steering Committee. Page 1 1. INTRODUCTION Nutrition is central to human physical and cognitive development and is a pre-requisite for economic development and prosperity of the country. Investment on nutrition has been recognized as one of the best investments for producing physically strong and mentally smart people whose outputs outweigh the small initial investment made on interventions. Imbalance between body requirements and intake leads to malnutrition which is widely prevalent in South Asian countries. Women and children are more vulnerable to nutritional deficiencies owing to their increased nutrient requirements during growth and development and more often they are the last ones to receive food due to cultural and inequitable intra household food practices. The National Nutrition Survey (NNS) 2010-11 reveals the dismal nutrition situation of the country where both macro and micronutrient deficiencies have been shown to be widely prevalent among women and children. According to the NNS 2010-11, in Khyber Pakhtunkhwa over 40% of the women are either underweight, overweight/obese, anaemic, iodine or zinc deficient while 24% of the children below 5 years of age are underweight; 48% stunted and 17% are wasted4. The direct outcome of high rates of malnutrition in women is seen in the form of long lasting adverse effects reflected by high maternal mortality and morbidity and its perpetuating effects on infant and child growth and development. Malnutrition is also responsible for much of the children’s sufferings with impaired growth, delayed psycho-social development and increased morbidity and mortality. It accounts for 50% of children’s deaths and costs about 3% of yearly GDP in developing countries and results in more than 10% of lifetime earnings potentials in malnourished children5,6. Iodine deficiency alone has been reported to be responsible for a mean intelligent quotient (IQ) loss of 13.5 points in the population residing in severely iodine deficient areas7. The consequences of iodine deficiency in terms of IQ losses, reduction in mental and physical capacity along with other macro and micronutrient deficiencies may cause GDP losses as high as 3% which are certainly greater than the amount required for the processing of iodized salt and prevention of IDD8. Prevention of malnutrition among women and children and their associated morbidity and mortality shall be the first priority of the Government and development partners to reduce their sufferings and provide a congenial environment where they can demonstrate their full potential to improve the quality of life and economic uplift of the country. Pakistan has a maternal mortality rate of 280 per 100,000 which is the highest amongst the South-East Asian countries and a matter of major concern for the allied health professionals9. There are 4 National Nutrition Survey (2010-11), Ministry of Health, Islamabad 5 Khan AA, Bano N, Salma A. Child Malnutrition in South Asia Survey 4(1):129-145, 2011. 6 World Bank Repositioning nutrition as central to development: a strategy for large scale action: The World Bank, Washington DC, 2006 7 Bleichrodt N, Born M. A meta-analysis of research into iodine and its relationship to cognitive development. In: Stanbury JB (ed) The damaged brain of iodine deficiency. Community Corporation, New York, pp.195-200. 8 Manner MG, Sankar R(2004). Micronutrient fortification of foods--rationale, application and impact. Ind J Pediatr 71(11):997-1002. 9 UNICEF (2011). The State of the World’s Children. New York Page 2 many socio-cultural reasons for the high maternal mortality of which poor nutritional status is the most significant one. Khyber Pakhtunkhwa has been confronted by natural and manmade calamities, socio economic, and governance challenges. It is the second most underdeveloped province after Baluchistan with people having limited access and affordability to health care, safe drinking water, basic hygiene and sanitation, education and diversified food. The province has one of the lowest social and economic indicators with inadequate antenatal and postnatal care along with poor breastfeeding and complementary feeding practices. The multiple indicator cluster survey (MICS) 2008 reveals that only 47% of the reproductive women received antenatal care; 13% received postnatal care and 41% of the deliveries were performed by the skilled medical personnel. The MICS 2008 further shows that only 14% of the babies were breastfed within one hour of birth and about 66% within first day of the birth; 45% of the babies were exclusively breast fed during the first six months in combination with poor complementary feeding practices and an estimated infant and child mortality of 76 and 100 /1000 live births. Poor feeding and complementary feeding practices are one of the major reasons of increased childhood morbidity and mortality and it has been estimated that about 300,000 to 400,000 children die each year from diarrhea and acute respiratory infections. The abysmal nutrition situation of women and children of the province calls for revisiting and revitalizing efforts and initiatives that have failed to yield substantial improvements in the nutritional status of the population. Less sensitization of concerned higher authorities to nutritional issues, isolated approach in dealing with the nutritional issues, donor dependent approach, lack of communication, coordination and cooperation between the various branches of one department and amongst different departments have been attributed to the poor performance and achievements. The 18th constitutional amendment passed by the National Assembly of Pakistan has devolved the power and responsibilities from the federation to the provinces. With the enactment of the amendment, KP has been made more autonomous and responsible for delivering health, nutrition, agriculture, education, hygiene-sanitation and other social services in an equitable manner to its population and to pay more attention to those who have been marginalized over the years due to social injustices, mass displacements or financial constraints. The 7th National Finance Commission Award 2009 has further financially strengthened the provinces to receive increased funds from the federation and thus provided them the opportunities to pursue its social programmes in a more vigorous and equitable way to address the nutritional problems of the people and make the province and country prosperous. The rapid urbanization, rising inflation, changes in dietary pattern and a shift from diversified food consumption to energy dense monotonous diets, higher prevalence of nutritional deficiencies, infectious and chronic diseases coupled with increased disabilities and mortality have further necessitated the need to review and formulate new policies, to Page 3 forge multi-sectoral alliances and make the service providers more efficient and responsive to the public needs. Nutritional status is not only an outcome of economic or dietary factors rather multiple socio-economic factors including hygiene-sanitation, education, individual life style, knowledge, behavior, awareness and access to safe food and drinking water have been associated with nutrition outcome. Hence, nutrition has close linkages with other sectors and requires a cross-sectoral approach to deal with chronic and persistent malnutrition. Until recently, nutrition has not been given its due place and is generally considered to be the business of all and responsibility of none which may be reflected from the nutrition budgetary allocation made over the years. Nutrition is not given due importance at the National or provincial levels as evidenced by a lack of nutrition policy or strategy to deal with malnutrition in emergency and non-emergency situations and there is no high level nutrition authority to oversee the nutrition issues at provincial or district levels. This has resulted in poor strategic coordination, halfhearted efforts to reach the most vulnerable and has created a donor dependent nutrition sector which is largely unsustainable. The nutrition programmes and activities both at the federal and provincial levels are being carried out sporadically without any vision, policy, direction and coordination as a result of which parallel nutrition programmes are being run by different sections of the same department as well as other implementing partners and institutions with little success to achieve the international targets set for the country. Weak commitment and ownership of nutrition by the government has resulted in a mushroom growth of non-governmental organizations which have weak infrastructure and technical capacity and thus the end users are not getting the desired benefits from the different nutrition initiatives. The complex nutrition situation of Khyber Pakhtunkhwa has brought the Government and development partners together to deliberate and debate on the issues to find out a viable solution for the preventable nutritional deficiencies that are adversely affecting human health and their potential for economic growth. There was also a common understanding that food availability alone can’t address malnutrition unless it is supported and complemented by a healthy environment, improved health care services, improved knowledge and behaviour, healthy life style, strong institutional support, commitment, ownership, technical capacity and resources. This led to the evolution of “Pakistan Integrated Nutrition Strategy” that envisages linking of all social sectors (agriculture, health, social welfare, public health engineering and education) and having inter-sectoral planning and sectoral implementation with strong coordination, monitoring and evaluation. The provincial integrated nutrition strategy focuses on integrating vertical programmes within each sector into a single entity and establishing inter-sectoral linkages for greater efficiency, sustainability and up-scaling of successful programmes into regular development programmes. The provincial integrated nutrition strategy (PINS) consultative workshop was held to bring all the stakeholders (managers, planners and policy makers of social sectors, development partners, academia and implementing partners) to the discussion table for consensus on Page 4 various dimensions of PINS to facilitate the formulation and development of each sector’s nutrition sensitive strategy to boost its capacity, performance and contribution in enhancing food production, safety, security, improving hygiene-sanitation and promoting the preventive and therapeutic aspects to ultimately reduce the sufferings of the vulnerable population. Provincial Integrated Nutrition Strategy emphasizes the need for constituting high powered Steering Committee (SC) to be chaired by the Additional Chief Secretary and Secretary of each department and representatives of development partners, civil society and others who may technically advice the committee. The key function of SC would be to steer and coordinate cross-sectoral activities to ensure that each sector is complementing the efforts of the other towards attainment of the common goal of reducing malnutrition in women and children of impoverished communities across the province. Besides coordination, the SC shall elicit political support and commitment for necessary resources for each sector to implement the programmes independently under its monitoring with regular and feedback from each sector to make sure that the plans are being implemented timely to achieve the objectives of the programmes. The SC may conduct quarterly meetings to review the progress of programmes, provide necessary support and resolve issues pertaining to their implementation. The Planning and Development Department (P&DD) would be responsible for the overall policy formulation and cross-sectoral coordination in the province. It would serve as a secretariat to SC for facilitating, coordinating and implementing each sector’s policy. The P&DD has notified the Steering Committee along with TORs which highlights the commitments and political will of the department (Annexure-A). Similarly, a technical working group at P&D levels has also been notified along with TORs (Annexure-B). The provincial integrated nutrition strategy also envisages the constitution of Technical Working Group (TWG) within each sector to provide technical support to the sector in formulating plans of action and assist in implementation, monitoring and evaluation. Page 5 ToRs for Steering Committee The purpose of the steering committee is to:  Lead and guide social development departments in strategic planning, coordination, implementation and monitoring across the sectors.  Enhance synchronization and coordination across the sectors for efficient, effective service delivery and outcomes  Strengthen linkages between different departments of Government of Khyber Pakhtunkhwa that are to be involved in dealing with the immediate, underlying and basic causes of malnutrition to reduce and control malnutrition in the population in general and women and children in particular.  Provide technical and financial leadership and support to the sectors for timely completion of the activity  Strengthen monitoring system in each sector to make sure that objectives of interventions are achieved and the targeted population is receiving the benefits  Assess and review progress of interventions in each sector and issues relevant directives to implementers for enhanced qualitative and quantitative outcomes  Build an alliance between the government of Khyber Pakhtunkhwa and development partners to enhance the scope of interventions and increase the number of beneficiaries Page 6 2. Multi-sectoral Nutrition Framework, Relevant Provincial Policies and Strategies Nutritional status of an individual is a result of genetic and socio-economic factors of which dietary habits, health status, education, hygiene-sanitation and lifestyle all play an important role in the final outcome. Focusing only on a single factor and leaving others unattended or working on each factor independently without coordination may not yield any successful results. This could rightly described the current situation for KP and FATA where vertical nutrition programmes mostly funded by the development partners are overriding each other since decades without any significant outcomes in terms of reduction in the prevalence of malnutrition or micronutrient deficiencies. However, the opportunities to improve the nutritional status of the population are enormous if inputs and efforts from all sectors are interlinked and coordinated in a coherent manner. In addition, there is a synergistic relationship between nutrition and the social sector’s performance i.e., good nutrition provides a strong foundation for good health, decreased morbidity and a healthier population with increased quality performance in education and work output which has been proven in a number of studies conducted around the world while poor social sector performance adversely affects the nutritional status of the population. Addressing nutritional problems through short term specific nutrition interventions without attending the underlying and root causes of malnutrition may not be much beneficial and cost effective and in some cases it would be wastage of time and resources. In KP and FATA the nutrition situation has aggravated due to absence of nutrition policy and responsible body to plan, implement and evaluate to identify cost effective and results oriented programmes for up scaling. A higher prevalence of malnutrition, infectious and chronic diseases and their associated mortalities is a reflection of negligence and lack of commitment by the state. The 18th amendment and promulgation of 7th NFC Award is a blessing in disguise that has allowed greater power, authority and resources to be transferred from the federation to the provinces for planning and implementing social sector programmes. This is an opportune time for the province to revisit all its sector policies and strategies and identify the successful programmes for revitalization and scaling up. The time is also ripe for that major UN development partners to evolve a joint strategy of helping the government in its social programs. They are more than willing to extend all possible support to the Government not only for re-formulating the existing policies and strategies but also for possible technical and financial assistance to initiate capacity development and other related nutrition initiatives. It also provides an exceptional opportunity to the Government to pool and invest all the available resources in the development of social sectors and improving nutrition of a marginalized population for a better future of the country. The consultations between the government and development partners from time to time on nutritional issues as well as on millennium development goals (MDGs) has led them to realize that no breakthrough in the reduction of malnutrition as well as in the morbidity and mortality of women and children could be achieved unless a holistic and unified cross sectoral approach is adopted. This gives birth to the evolution of “Pakistan Integrated Nutrition Strategy” (PINS) where emphasis is laid on cross-sectoral planning, coordination Page 7 and sectoral integration of all vertical programmes into a single entity for implementation. It encompasses the notion of complementing each other piecemeal’s efforts towards a comprehensive integrated approach of addressing the basic, underlying and immediate causes of malnutrition to improve the nutritional status of the population. PINS also affirms that improvement in performance of all sectors is crucial for achieving the goal of reducing malnutrition and providing basic social services to disadvantageous population. Effective PINS is fundamentally important for achieving millennium development goals and sustainable growth and development of the underdeveloped province. Revisiting policies and strategies in various sectors is also imperative in the light of emerging challenges due to increased urbanization, nutrition transition and changing dietary habits, production and development of genetically modified food, surging rates of under-nutrition in children under five years; overweight and obesity in the young and adult population, increased prevalence of chronic diseases and resurgence of tuberculosis and malaria, climate changes, WTO and sanitary phyto-sanitary rules that need to be addressed to meet national and international quality standards for import and export of foods as well as to address the problems of malnutrition and diseases. The conceptual framework of malnutrition shown below highlights the immediate, underlying and basic causes of malnutrition and provides sufficient justification for a multi sectoral strategy to deal with multifaceted factors. The immediate, underlying and basic causes of malnutrition need thorough examination in the context of social, cultural, political, economic and institutional capacity for appropriate interventions. Short, medium and long term nutrition strategies would be required to effectively deal with persistent nutritional problems. The strategy for each sector is separately developed and details are given under a separate sector heading. Figure 1: Causes of Malnutrition MALNUTRITION DIETARY INADEQUACY INFECTION & DISEASES FOOD INSECURITY, INAPPROPRIATE FEEDING PRACTICES INADEQUATE MATERNAL & CHILD CARING POOR HYGIENE SANITATION & INADEQUATE HEALTH SERVICES INADEQUATE RESOURCES, LARGE POPULATION CAUSES OF MALNUTRITION OUTCOME IMMEDIATE CAUSES UNDERLYING CAUSES BASIC CAUSES Page 8 2.1. Organizational Environment The earthquake of 2005 followed by flash flood and monsoon rains of 2008 and onwards which caused a massive displacement and heavy devastation to infrastructure, crops, livestock and human losses provided an opportunity to government, non-government organizations and development partners to work together as an emergency relief team to serve the displaced and affected population. Extensive community based nutrition programmes to treat the malnourished women and children were launched in the affected districts which were mainly implemented by national and international non-governmental organizations through the government’s and development partners’ support and this give genesis to the tripartite collaborative alliance. Since then the development partners and international agencies have been pro-active in all social development activities and extending all possible technical, material and financial support to the Government and people of Pakistan for improving the nutritional status of economically disadvantaged population particularly the women and children. The environment is conducive for all national and international agencies who want to contribute to nutrition oriented social development. Almost all the nutrition interventions in the country are being carried out with the support of UN and other development partners because of the Government’s inability to provide the nutrition support to about half of the population who are either food insecure or deficient in one or more than one nutrients. The Government also lacks in the institutional set-up, structure and framework which could cater to the needs of the malnourished population and thus requires public-private partnership to increase coverage and service delivery. The contribution of development partners is crucial for both government and the implementing partners and it is vital for the government, development partners and implementing partners to get united for the sacred cause of treating a vulnerable population i.e., women and children for improving their nutrition wellbeing, reducing their sufferings from preventable nutritional disorders and making them useful and productive citizens. The cross-sectoral provincial nutrition strategy provides a unique opportunity of integrating sectoral nutrition oriented activities through cross-sectoral coordination, planning and sectoral implementation which appears to be more logical, comprehensive, efficient, sustainable, and effective. The passage of 18th amendment, promulgation of 7th National Finance Commission Award and the development partners’ willingness to collaborate and support the Government of Khyber Pakhtunkhwa in its efforts to improve the nutritional status of the underprivileged groups of population are all great opportunities to be availed for the greater interest of the population health and the progress and prosperity of the country 2.2. Provincial Health and Nutrition Policy Currently, there is no provincial health and nutrition policy, however, Khyber Pakhtunkhwa Health Sector Strategy (2010-2017)10 and Comprehensive Development Strategy (2010-17)11 have been developed which demonstrates the government’s commitment to deliver and 10 Khyber Pakhtunkhwa Health Sector Strategy (2010-2017), Govt. of KP 11 Khyber Pakhtunkhwa Comprehensive Development Strategy (2010-17), P&DD, Govt. of KP Page 9 improve health care services both at facility and community levels through an extensive network of about 1616 health facilities and 30,188 medic and paramedic staff12. Both the strategies aim to provide an essential basic health care package at primary, secondary and tertiary health care facilities with a preference for the poor and marginalized population. The priority areas under the strategies include: (i) Improved governance and accountability; (ii) Human resource development; (iii) Improved regulations and quality assurance; (iv) Enhanced coverage and improved access to health care services; (v) Developing and implementing nutrition strategy; (vi) Improved preventive measures; (vii). Disaster risk reduction and management; and (vii) Health insurance and voucher schemes under social protection sector. The strategies also stressed upon the need for multi-sectoral coordination and collaboration under the umbrella of Planning and Development Department to coordinate and provide essential support to the social sectors. The vision of the Government of Khyber Pakhtunkhwa, “Attainment of a secure, just and prosperous society through socio-economic and human resource development, creation of equal opportunities, good governance and optimal utilization of resources in a sustainable manner” is in line with the multi-sectoral integrated nutrition strategy that envisages social development as the key to human and economic development. Though the health department provides health care to about half of the population but its quality is far below normal due to variety of management issues. A recent survey conducted to assess quality care and consumer satisfaction in Khyber Pakhtunkhwa revealed that on a scale of 4, the health facilities and services at primary and secondary levels scored 1.8 and 1.3, respectively13. The Government’s health care delivery system has been confronted with the challenges of equity, efficiency, effectiveness, commitment and justice. However, the private health care providers have taken a major share of the curative services and could be important partners for promoting appropriate feeding and dietary practices and discouraging unhealthy lifestyles both at the facility and community levels. 12 http://www.healthkp.gov.pk/healthstatistics.asp. 13 Khyber Pakhtunkhwa Comprehensive Development Strategy (2010-17), P&DD Govt. of KP Page 10 3. Nutrition Sensitive Strategies for Social Sectors 3.1. Department of Health (DoH) Health department has been considered to be the major caretaker of nutrition due to its strong links with health and diseases. However, it could not achieve proper attention due to less sensitization and projection of the nutritional issues and busy engagements of higher management in other dominating and more threatening health and political issues. A lack of nutrition policy and nutrition set-up at provincial and district levels, lack of ownership and commitment, inadequate technical capacity to undertake nutrition interventions along with poor monitoring and evaluation have been the major challenges toward improving nutritional indicators of the population. Vertical, short term nutrition programmes without any planning and lack of coordination, communication and collaboration between the different units of the health department made the interventions less successful and beneficial for the target population. As a result, prevalence of malnutrition in the population and particularly in women and children remained all time high with increased morbidity and mortality along with failure to honor the international commitments of eradicating and reducing malnutrition. Health sector is an integral component of multi-sectoral integrated nutrition strategy which could play an important role in improving nutrition wellbeing of the people through their facility based health delivery system and outreach activities by mobilizing a force of medic and paramedic staff. Currently, the province of Khyber Pakhtunkhwa has 1616 health facilities and 30,188 medic and paramedic staff which could provide nutrition services along with their normal essential health care responsibilities14. A higher level of advocacy and joint planning is needed to promote integration of nutrition programmes into the health delivery system and concomitant allocation of funds for nutrition activities. A mechanism to energize and re-vitalize the health system is required and PINS may play a pivotal role in coordinating sectoral activities and bringing all the sectors together for collective wisdom, planning and placing nutrition to a central position in the activity of each sector. The provincial nutrition strategy aims to improve population nutrition wellbeing. It focuses on remedial measures for addressing nutritional issues that have not only been adversely affecting the behvioural, cognitive, scholastic, physical performances but have also been increasing morbidity and mortality and impairing socioeconomic development. The role of nutrition in health and socioeconomic development has been well established and recognized. Avoiding and ignoring nutrition issues lead to a vicious cycle of health related problems along with increased sufferings of the families and that perpetuate from one generation to another in terms of health and wealth. The nutrition strategy lays emphasis on interventions that would benefit all in an equitable manner without discriminating gender, ethnic disparities, rural-urban dividends, political affiliation and socio-economic standing. The strategy calls for a pro-poor plan of actions where poorest of the poor may get priority and preference over others in public health 14 http://www.healthkp.gov.pk/healthstatistics.asp Page 11 facilities and for enrollment and treatment in nutrition programmes. The interventions for improving nutritional status of the population shall be culturally acceptable, affordable and sustainable with a large coverage and effectiveness in bringing down the malnutrition rates. Since there is no nutrition policy and nutrition setup at the provincial and district levels, formulation of a nutrition policy and establishment of nutrition set-up in the Department of Health is of paramount importance. The essential components of nutrition strategy within the health sector include the establishment of a nutrition set-up and provision of basic infrastructure i.e., staff, equipment, supplies to undertake nutritional screening and provide nutrition services and counseling to the clients. Preventive, therapeutic and rehabilitative services delivery should be the main focus while research and development should be an integral component of the nutrition strategy. The provincial multi-sectoral nutrition strategy is principally more centered on addressing the underlying causes of malnutrition that require involvement and development of social sectors by complementing each other efforts to ultimately reduce the people’s sufferings from preventable nutritional problems and morbidities. The strategy provides broad guidance for improving nutritional status of women and children and to address the malnutrition issues within the context of multi-sectorality. The provincial nutrition strategy underlines the need to revisit and review all the existing nutrition interventions and to scale up those which have been successful in bringing down the malnutrition rates and prevalence of nutritional deficiencies in women and children. Keeping in view the malnutrition status of women and children, the followings strategic actions are proposed: 3.1.1. Strategy Outlines & Plan of Actions for DoH, Khyber Pakhtunkhwa Target Population: Children < 5 Years, Pregnant & Lactating Women and adolescent girls Strategy Plan of Actions Responsible Department Improving malnutrition in children and women through BCC, CB, surveillance and management (i) Establishing nutrition surveillance, growth monitoring and screening of children and women for assessment of malnutrition including acute malnutrition, vitamin and mineral deficiencies (vitamin A, iron, folate, vitamin B12, zinc, iodine, calcium and vitamin D). (ii) Strengthening nutrition outreach activities and promoting feeding (IYCF) and dietary (diet diversification and healthy eating practices) through IEC, BCC, nutrition education, counseling, health, hygiene-sanitation, clean drinking water and food safety promotion. (iii) Establishing and strengthening of CMAM programme in selected high risk districts. (iv) Introduction of supplementary feeding programme to prevent stunting in children DOH / Development partners Page 12 Strategy Plan of Actions Responsible Department (v) Administering need base vitamin and mineral supplementation and sprinkles to children and women (vi) Administering periodic stool examination of children and women for worm infestation and treating infested children with anti-helminthes. (vii) Strengthening monitoring system for enforcement of vitamin A fortification, salt iodization and all other nutrition interventions. (viii) Advocating for commercialization of iron fortification programme by forging public-private partnership (ix) Encouraging healthy life style practices. (x) Encouraging research for development and production of indigenous ready to use supplementary and therapeutic foods, F-75, F-100 and nutrient dense complementary foods (xi) Coordinating and collaborating with other sectors in their health and nutrition related activities i.e., school health and nutrition programme, health and nutrition awareness campaigns and organizing events on different health, hygiene, sanitation days Promoting nutrition as an essential component of health system and integrating vertical nutrition programmes (i) Establishment of Nutrition set-up at the provincial and district levels (ii) Allocation of budget for Nutrition in the integrated Health and Nutrition PC-1 which may include nutrition positions, HRD, research & development, supplies at provincial, district and facility levels. (iii) Merging of all nutrition programmes and implementation through medic and paramedic, CMWs and LHWs. (iv) Involving private sector health care providers/National and International IPs for implementing nutrition programmes in non catchment areas of government health facilities (v) Building human resource capacity of public and private sectors in nutrition DOH/P&D/ Directorate of Health/ Development partners Human Resource Development i) Developing in-service nutrition training courses for health care providers both in public and private sector ii) Developing short and long duration nutrition courses for new inductees i.e., Nutrition Officers, Nutrition Assistants, LHWs, CMWs, Health, Hygiene and sanitation promoters, Volunteers and outreach workers iii) Inclusion of pertinent information in curricula of relevant cadres of health care providers DOH/ Development partners Page 13 Strategy Plan of Actions Responsible Department Allocating and Enhancing budget for Nutrition i) Recognizing nutrition programme on development agenda and allocating resources for the establishment of nutrition programme in DOH on analogy of EPI and LHWs programmes. ii) Seeking political commitment and support of higher management in the planning & development sections of Health, P&D, Finance and other sectors iii) Eliciting support from donors for nutrition programme, human resource capacity and working jointly to combat the menace of malnutrition DOH/P&D/ Finance/ Donors Revising Pure Food Laws i) In the light of scientific innovation, new research findings and upsurge in the prevalence of nutritional deficiencies and diseases, it is important to revise the Pure Food Laws of 1960 to incorporate food standards and new processed foods. DOH/Developm ent partners Creating enabling environment and synergy between different sectors for promoting nutrition i.e., coordination & alliance building i) Coordinating, communicating, facilitating and collaborating with private sector and relevant Government departments i.e., Department of Industry, Department of Taxation to facilitate procurement of fortificants and RUTF etc with minimum tariff and taxes ii) Encouraging private sector involvement in nutrition product development, food fortification, research and development and assisting them in solving their technical, quality assurance and import export problems iii) Increasing communication, cooperation and collaboration through visits and organizing joint nutrition interventions DOH/ Development partners/ Govt. depts./ private sector Promoting and strengthening nutrition outreach activities (Awareness, nutrition education and counseling, advocacy, BCC) i) Involving, motivating and revitalizing public, private sector health care providers, community volunteers, IPs, school children, media and civil society; ii) Increasing strength of existing LHWs/ CMWs and other paramedic staff to increase outreach coverage DOH/ development partners/ Education/Civil society Improving micronutrient status of children and women i) Establishing nutrition surveillance and screening programmes for assessment of micronutrient vitamin and mineral deficiencies (vitamin A, iron, folate, vitamin B12, zinc, iodine, calcium, vitamin D) ii) Administering need base vitamin and mineral supplementation and sprinkles to children and women DOH/ Development partners/Govt. depts./private sector Page 14 Strategy Plan of Actions Responsible Department iii) Administering periodic stool examination of children and women for worm infestation and treating infested children with anthelminthic medicines iv) Strengthening monitoring system for enforcement vitamin A fortification, salt iodization and all other nutrition interventions v) Advocating for commercialization of iron fortification programme vi) Coordinating and collaborating with other sectors in their health and nutrition related activities i.e., school health and nutrition programme, health and nutrition awareness campaigns and organizing events on different health, hygiene, sanitation days Safety nets programmes (children, pregnant and lactating women) i) Advocating for introducing food supplementation and voucher schemes through donors’ support and allocation of budget in social welfare, Baitul mal, Benazir Support Programme for poor families DOH/Social welfare/Baitul mal /Benazir Support Programme/ Development Partners etc Safety nets programmes (children, pregnant and lactating women) Emergency Preparedness and Response Plan (EPRP) to address emergencies i) Introducing food voucher schemes through donors’ support and allocation of budget in social welfare, Baitulmal, Benazir Support Programme for poor families ii) Capacity building of concerned department staff iii) Ensuring of necessary equipment and supplies to cope with emergencies iv) Promotion of IYCF v) Monitoring of BMS vi) CMAM management vii) Data management Emergency Unit Govt. of Khyber Pakhtunkhwa/ Development Partners These strategies provide broader views on overall improvement in the institutional capacity and service delivery of care providers to address the problem of malnutrition at a grass root level rather than focusing on short term approaches for treating malnutrition. However, the cross-sectoral nutrition strategy including detailed plans of action of nutrition needs to be tailored in the light of budgetary allocation, technical capacity of health care providers, targeted population and coverage. 3.1.2. Progress and Achievements In the context of Provincial Integrated Nutrition Strategy, the Department of Health is ahead of the other provinces and has made a significant progress in conceptualizing the integration and restructuring of different units and sections of the department. The integration would Page 15 not only bring improvement in work performance and financial management but would also bring efficiency, transparency, responsibilities and accountability. In addition, a PC-1 entitled “Integration of Health Services Delivery with Special Focus on EPI, MNCH, LHW and Nutrition Programmes” with an estimated cost of Rs. 17 billion has been approved by the provincial government and submitted to the Planning Commission, Government of Pakistan which is under review . Necessary inputs have been provided to the Department of Health and P&DD in improving the PC-1 in general and nutrition in particular. The approval of PC-1 and its subsequent implementation would help in improving the nutritional status of women and children of the province. The maternal health and wellbeing is crucial for fetal growth and development, neonatal care and averting neonatal and infant morbidity and mortality. The integrated EPI, MNCH, LHW and Nutrition Programmes can be the driving force for improving the health, longevity, physical and psycho-social development and ultimate productivity of the population and allow expenditure on the curative side to be utilized for national development. The Director General (Health) has notified the Technical Advisory Group (TAG) to oversee the planning and implementation of sector specific nutrition sensitive programmes to address acute malnutrition and micronutrient deficiencies in children and pregnant and lactating women (Annexure-C). A presentation on the proposed provincial integrated nutrition strategy was made on April 19, 2013 at Mukshpuri (Nathia Gali) which was presided by the Additional Secretary, Planning and Development Department Khyber Pakhtunkhwa and assisted by the Chief Planning Officers/Focal Persons/ Deputy Director Health and representatives from WFP/FAO/WHO/UNICEF and others. It was followed by P&DD Technical Working Group Workshop held at Islamabad on 25 September, 2013 to further refine the strategy. The technical working group on Health reviewed the proposed provincial integrated nutrition strategy on Health in details and made necessary suggestions in their group presentation which have been incorporated in the report. The Department of Health endorsed the strategy in writing to the Secretary P&DD [Letter# 2-15/ECO/PC/H/Vol 1/2013-14 dated 20-12-2013]. Page 16 3.2. Drinking Water & Sanitation [Local Government and Public Health Engineering Department] Clean drinking water and improved hygiene-sanitation practices are vital for good health and important for preventing water-borne illnesses, malnutrition and their associated deaths. Contaminated water is a common reservoir for bacterial, viral and parasitic vectors and a leading source of gastro-intestinal infections associated with enormous human sufferings, capital losses and impaired individual functions. Untreated waste water and improper disposal of solid wastes remain a continuous risk for environmental pollution increasing human vulnerability to diseases. Diarrhea, dysentery, cholera, malaria and hepatitis A are very common in young children and 88% of children diseases in developing countries are attributed to water-borne diseases15. These diseases cause widespread malnutrition among children due to increased fluid and nutrient losses, low dietary nutrients intake and increased nutrients’ requirement. It has been estimated that in Pakistan over 400,000 children less than five years die each year from diarrhea and acute respiratory tract infections16 and malnutrition accounts for 54% of these deaths17. In addition, malnutrition results in more than 3% of GDP losses18 while poor sanitation alone costs about 1% of GDP in terms of healthcare costs and premature deaths19. Fortunately, all these losses can be averted through improved drinking water and hygiene-sanitation practices. It has been reported that 2.5 million deaths resulting from diarrhea, undernutrition, unsafe water and poor sanitation could be averted every year by improving water and sanitation in the developing countries20. The cost benefit analysis revealed that for every $1 invested on water and sanitation an average of $8 is returned in terms of economic benefits21. Khyber Pakhtunkhwa has been passing through a difficult and turbulent period in its history due to a series of man-made and natural disasters that have been causing mass human displacement, sufferings, agony apart from badly damaging the drinking water supply & sewerage lines, yet the province has made reasonable progress in improving the water supply system and hygiene-sanitation over the years. However, still much work remains to be done to achieve the target of ensuring universal safe drinking water and improved hygiene-sanitation. Current estimates suggest that 74.6% and 56.5% of the population has access to improved drinking water and sanitation in Khyber Pakhtunkhwa22. Conversely, only 45% of the households have accessed to tap water and 30% still depend on dug wells, rivers, canals and streams in Khyber Pakhtunkhwa23. A great disparity in access to safe 15 WHO (2004). Comparative quantification of health risk. World Health Organization, Geneva. 16 http://tribune.com.pk/story/131565/one-child-dies-every-minute-in-pakistan-report/ 17 Pelletier DL, Frongillo EA, Schroeder DG, Habicht JP (1995). The effects of malnutrition on child mortality in developing countries. Bull WHO 73:443-48. 18 World Bank (2006). Repositioning nutrition as central to development: a strategy for large scale action: The World Bank, Washington DC. 19 http://www.wsp.org/sites/wsp.org/files/publications/WSP-ESI-Kenya-brochure.pdf. WSP (2011) Economic impacts of poor sanitation in Africa. Water and Sanitation Program, Kenya. 20 WaterAid (2012). Saving lives: sanitation and water for all would save 2.5 million lives. WaterAid, New York. 21 WHO (2006). Economic and health effects of increasing coverage of low cost water and sanitation interventions. World Health Organization, Geneva. 22 P&D (2009). NWFP Multiple Indicator Cluster Survey 2008. Planning and Development Department, Government of Khyber Pakhtunkhwa, Pakistan. 23 PSLSMS (2011). Pakistan Social and Living Standards Measurement Survey (2010-11). Pakistan Bureau of Statistics, Govt. of Pakistan, Islamabad. http://tribune.com.pk/story/131565/one-child-dies-every-minute-in-pakistan-report/ http://www.wsp.org/sites/wsp.org/files/publications/WSP-ESI-Kenya-brochure.pdf Page 17 drinking water and basic sanitation exists between urban and rural areas, the proportion of urban inhabitants having access to tap water was about six-fold higher than the rural inhabitants. The quality of drinking water in those areas was characterized as poor since the samples were contaminated with E. coli, Enterobacter, Salmonella and Clostridium due to unchecked mixing of waste water and solid wastes with drinking water10. Similarly, 62% of the households in Khyber Pakhtunkhwa have access to flush toilet facilities and only 39% of the latrines are considered sanitary, the rural-urban disparities in having access to these facilities are enormously high9,24. The poor sewerage and drainage systems of Khyber Pakhtunkhwa have become a source of contamination for drinking water and consequent water borne illnesses, the situation described by the Government as: “There is no village or towns in Khyber Pakhtunkhwa that can be considered as free from exposure to human excreta. Hence, poor sanitation is a serious public health risk for the entire population of Khyber Pakhtunkhwa”25. The targets 9 & 10 of the Millennium Development Goal 7 that envisage halving the proportion of population who don’t have sustainable access to safe drinking water and basic sanitation call for immediate interventions to improve the drinking water supply, hygiene and sanitation practices, reduce morbidity, mortality and to improve the quality of people life and enhance their contributions in the socioeconomic development and prosperity of both the province and country. The Government of Khyber Pakhtunkhwa and development partners have been crusading for decades to reduce and control malnutrition which is widely prevalent among women and children of the province. Despite improvements in the economic growth of the country, very little progress has been made in reducing malnutrition and the prevalence rates of malnutrition have remained steady since independence. Malnutrition being a silent syndrome of the under-privileged classes of the society fails to attract the attention of those at the whelm of affairs and thus its adverse effects have been perpetuating from one generation to another leading to impaired social development, unrest and anarchy. Failure to address the underlying causes of malnutrition including vital areas of unclean drinking water and poor hygiene and sanitation have resulted in the resurgence of many infectious and non-infectious diseases with the losses in term of human sufferings and socio-economic development going beyond human imagination. The National Drinking Water Policy26 provides a comprehensive framework and guidance to the provinces and district governments for devising appropriate strategies and plans for improving public accessibility to safe drinking water in an affordable, sustainable and equitable manner; to prevent water-borne illnesses and its associated morbidity and mortality. The policy recognizes the right of every citizen to safe drinking water and the state’s responsibility to ensure supply and access of safe drinking water to all citizens. The Policy further emphasizes that coverage of safe drinking water supply will be increased to 24 Jabeen S, Mahmood Q, Tariq S, Nawab B, Ealhi N (2011). Health impact caused by poor water and sanitation in district Abbottabad. J Ayub Med College Abbottabad 23(1):47-50. 25 P&D (2010). Khyber Pakhtunkhwa Comprehensive Development Strategy (2010-17). Planning & Development Department, Khyber Pakhtunkhwa 26 http://www.environment.gov.pk/act-rules/D NATIONAL DRINKING WATER POLICY.pdf Page 18 93% by the year 2015 and the number of water filtration and treatment plants will also be increased which appear to be a quite challenging task to achieve under the existing system and resources. Under the Local Government Ordinance 200127, power has been devolved to the cities, towns and Tehsils Municipal administrations to devise their own strategies and plans of action. Lack of proper strategies in the drinking water and sanitation sector, the un-planned expansion of housing schemes and depletion of natural reserves and resources due to over population have been negatively affecting the development of effective water and sanitation schemes in the province. Post devolution provides a unique opportunity to the Government of Khyber Pakhtunkhwa to develop its own road map that ensures safe drinking water supply and improved sanitation in an equitable manner that could help in the reduction of morbidity and mortality of young children and would eventually lead to a healthy and economically prosperous society. The aim of the present effort of proposing a safe drinking water and sanitation strategy is in line with the Government of Khyber Pakhtunkhwa and Development Partners efforts to facilitate the supply of drinking water and sanitation which is safe and harmless to human consumption and does not serve as a reservoir for bacterial and parasitic growth responsible for water borne illnesses, malnutrition, morbidity and mortality. The strategy outlines the broader areas of interventions in drinking water and sanitation for brainstorming and developing plan of actions in close coordination with the Department of Planning and Development to ensure support and guidance of the Steering Committee for approval of the sector’s programme within the framework of Multi-sectoral Integrated Nutrition Strategy. 3.2.1. Strategy Outlines & Plan of Actions for Drinking Water and Sanitation, Local Government and Public Health Engineering Department, Government of Khyber Pakhtunkhwa Strategy Plan of Actions Responsible Department Improving Nutrition through Ensuring safe drinking water & reducing risk of water borne diseases Replacement of old rusted perforated pipes on emergency basis. Essential step towards ensuring supply of clean and safe drinking water and preventing water-borne diseases and malnutrition. Replacement of tap water pipes from waste water streams and open surface drains. Water pipes passing through the waste water courses/ channels/ streams are frequently perforated and waste water contaminates the drinking water resulting in epidemics. Local Government and Rural Development Department (LG&RDD), Public Health Engineering Department (PHED) & Donors for coordinating and organizing the programme. The Technical Working Group (TWG) of LG&RD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. 27 CPSD (2001). The North West Frontier Province, the Local Government Ordinance 2001. Controller Printing & Stationary Department, NWFP Page 19 Strategy Plan of Actions Responsible Department Improving drinking water supply to public places, schools and homes Clean and safe drinking water is essential for good health and has been recognized as a basic human right. Pakistan is a signatory to the resolution passed by the UN general Assembly for providing clean, safe drinking water to all. Water treatment with potassium permanganate, disinfectants and installation of filtration plants has been suggested. LG&RDD, PHED & Donors for coordinating and organizing the programme. The TWG of LG&RDD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. Ensuring safe and clean drinking water supply to public by new installations Ensuring clean drinking water to the public through installation of tube wells, water filtration plants and increasing network water supply schemes in rural and urban areas are fundamentally important. LG&RDD, PHED & Donors for coordinating and organizing the programme. The TWG of LG&RDD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. Increasing public awareness about clean drinking water & hygiene sanitation Advocacy seminars/workshops for public about the use of clean, safe drinking water, and promoting hygiene sanitation practices at household and community levels as well as creating awareness through print and electronic medias. LG&RDD, PHED & Donors for coordinating and organizing the programme. The TWG of LG&RDD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. Improving sanitation in public places, schools and homes & construction of garbage collection points Poor hygiene-sanitation is one of the strong determinants of malnutrition and diseases. Improving hygiene-sanitation in public-places, schools and homes is crucial for reducing malnutrition and diseases. Disposal of household and public places’ garbage to safe places & cleaning of open surface drains & water streams. Quick removal of garbage is important for decreasing and preventing the incidence of diseases and malnutrition. Increasing the number of garbage collection points and their quick disposal to avert hygiene-sanitation related issues and ensure food safety LG&RDD, PHED & Donors for coordinating and organizing the programme. The TWG of LG&RDD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. Enhancing capacity of sanitary inspectors/hygiene promoters/ cleaners Human resource development of the staff involved in administering and maintaining hygiene-sanitation activities is essential for success of the programme. LG&RDD, PHED & Donors for coordinating and organizing the programme. The TWG of LG&RDD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. Page 20 Strategy Plan of Actions Responsible Department Provision of water borne & hygiene sanitation related disease surveillance system Disease surveillance system helps in the early detection and identification of diseases and provides necessary information for remedial measures. LG&RDD, PHED & Donors for coordinating and organizing the programme. The TWG of LG&RDD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. Improving sanitation and reducing risk of diseases by discouraging open defecation Encouraging households for construction of latrines and discouraging children from open defecation LG&RDD, PHED & Donors for coordinating and organizing the programme. The TWG of LG&RDD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. Elicit political commitment & ownership Political commitment in the form of recognizing nutrition as central to human development, increased budget allocation and extending support to the department by adopting department’s initiatives LG&RDD, PHED & Donors for coordinating and organizing the programme. The TWG of LG&RDD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. Strengthening monitoring system For programme implementation and improving the efficiency of staff to achieve outputs in a stipulated time, strong monitoring is vital. LG&RDD, PHED & Donors for coordinating and organizing the programme. The TWG of LG&RDD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. Strengthening coordination, communication, collaboration and harmonization between different sectors and stakeholders Fostering collaboration with different sectors and stakeholders for sharing resources, laboratory facilities, expertise and complementing each other efforts. LG&RDD, PHED & Donors for coordinating and organizing the programme. The TWG of LG&RDD/PHED may brainstorm, assess, plan and recommend the proposal for implementation. 3.2.2. Progress and Achievements The Department of Drinking Water and Sanitation has allocated a good chunk of the budget in Annual Development Programme, 2012-2013 for mass awareness, behavioural change communication, health and hygiene promotion besides working on a number of water supply schemes to provide safe and clean drinking water to the public and to ensure optimal hygiene and sanitation. These schemes includes replacement of old rusted pipes, gravity flow water supply schemes, repair and extension of water supply schemes, rehabilitation of Page 21 existing old water supply schemes, sanitation/sewerage and drainage schemes. The representatives from the Drinking Water & Sanitation Department participated in the recently held workshop (April 19-20, 2013 at Mukshpuri) on endorsement of policy guidance notes and deliberations and critical review on the proposed provincial integrated nutrition strategy. The technical working group of the Drinking Water and Sanitation gave their suggestions on the strategy which have been incorporated in the report. Page 22 3.3. Nutrition Sensitive Strategy for Agriculture Department Khyber Pakhtunkhwa (KP) with an estimated population of over 20 million is the second most underdeveloped province after Baluchistan. Agriculture is the mainstay of the provincial economy on which over 60% of the population livelihood depends; 94% of the farmers have less than 12.5 acres of land and 44% of the rural population lives below the poverty line28. Twenty three out of the 24 districts of the province have been classified as food insecure by the World Food Programme29. Agriculture growth rate stands around 2% which is far below to meet the growing demand of the population. Agriculture growth and its contribution to growth domestic product (GDP) have been declining over the years which have becoming a serious concern to agriculture professionals and policy makers. The growth rate of 6.5 in 2004-2005 to 1.2 in 2010-201130 reflects the devastating agriculture situation that needs concerted efforts to get out of this pathetic situation. Population of the province has been growing rapidly; the increased population has put enormous stress on the existing resources leading to shortage of land and water reserves, environmental hazards and deteriorating nutrition and health status of the population (Figure 2-3). On top of this, weather and climate changes have been adversely affecting the production of major and minor crops enhancing the risk of food insecurity. Livestock sector which contributes over 50% to the agriculture’s GDP is under exploited for value added products that has tremendous potential to grow and contribute to the national economy. Political instability, conflicts, displacement and migration of people put further pressure on the province and discourage local and foreign investors to invest in agribusinesses. Production of major crops, fruits, vegetables, livestock and dairy is much lower than many countries around the world. Figure 2. Water Availability Per Capita Over the Years 28 www.khyberpakhtunkhwa.gov.pk/agriculture/agri/ag 29 SDPI/SDC/WFP. Food insecurity in Pakistan (2009). 30 Economic Survey (2010-11), Planning Commission, Islamabad Page 23 Figure 3. Comparison of Average Yield of Wheat by Different Countries Lower food production and higher food demands due to population explosion results in escalation of food prices and food becomes beyond the purchasing power of the poor segment of the population increasing food insecurity and malnutrition. Revitalization of agriculture system and investment in agriculture sector are critically important for improving agriculture production, nutritional status of the population, raising national economic growth and alleviating poverty. Improvement in the nutritional status of rural population would boost agriculture productivity and income through farmers’ enhanced physical capacity, decreased incidence of illnesses and absentees from work. The 18th constitutional amendment which empowers provinces to develop its own policy and strategies for sector’s development provides a unique opportunity to agriculture to develop its own roadmap that could lead to enhance food productivity, food security and eradicate hunger and malnutrition in the province. Agriculture and rural development are crucial for bringing improvement in health and nutrition indicators of people and that requires political commitment, coordination and interventions that are technically sound, economical viable, culturally acceptable and environmentally non-degrading. To improve agriculture production and food security, agriculture policies need to be tailored to meet the large and small farmers’ needs, public and private sectors’ aspirations and consumer demand. Placing nutrition at the center of agriculture strategy appears to be the most viable option for improving food security and nutrition wellbeing of the population. Improving production of nutritious foods or increased investment in agriculture sector that could enhance the small farmers’ capacity to buy quality inputs and facilitate their produce access to markets would be the right steps towards food self-sufficiency and improving nutritional status of the population. The proposed nutrition sensitive strategy for agriculture sector is aimed at improving nutrition wellbeing through improved agriculture practices and where nutrition occupies a central place. Improving nutrition of marginalized population through kitchen gardening, raising livestock, beekeeping and increasing households nutrition awareness by strengthening agriculture extension services and empowering households and communities for self-reliance and controlling the factors that affects their wellbeing is the main principle behind the nutrition-sensitive agriculture strategy. Page 24 3.3.1. Strategy Outlines & Plan of Actions for Agriculture, Livestock and Cooperation Department, Government of Khyber Pakhtunkhwa Strategy Plan of Actions Responsible Department Improving Nutrition through Improving food security, nutrition and income through home/kitchen gardening Selection of one district as a pilot (Model District) district, mapping and selection of smallholder farmers and distribution of vegetable-fruit seeds and plants free of cost to the farmers with the technical assistance from Farm Services Centre. Developing PC-1 including HRD, BCC, supplies in partnership with donors. Agriculture Department/ Donors/ communities Enhancing food security, nutrition and income through livestock raising Selection of one district as a pilot (Model District) district, mapping and selection of smallholder farmers and distribution of chicken, goat, cattle free or on credit with the technical assistance from the Farm Services Centre. Developing PC-1 including HRD, BCC, supplies in partnership with farmers, private sector and donors. Agriculture Department/Donors/ communities/academia/ private sector/IPs/donors/ communities Improving food security, nutrition and income through beekeeping Selection of one district as a pilot (Model District) district, mapping and selection of smallholder farmers and distribution of beehives and queens free or on credit through community based organizations with the technical assistance from the Farm Services Centre. Developing PC-1 including HRD, BCC, supplies in partnership with farmers, private sector and donors. Agriculture Department/private sector/donors/ communities Improving food security, nutrition and income through promoting farm fisheries Promoting research, outreach activities and developing model fish farms in the technically feasible areas. Encouraging farmers and investors to invest in the development of fisheries and related facilities for marketing fish in and out of the district to improve nutrition and income of the marginalized population. Agriculture Department/private sector/donors/ communities Page 25 Strategy Plan of Actions Responsible Department Strengthening outreach activities (awareness, nutrition education, counseling, advocacy, BCCS) Reaching households particularly women for behvioural changes toward improved household dietary practices in general and women and children in particular and promoting healthy lifestyle. Recruitment of female nutrition workers for outreach activities to improve dietary practices and nutrition screening for early identification and treatment of malnourished women and children in rural communities will be required. Agriculture Department through their extension services and outreach programs/Donors/ communities/ Promoting and facilitating milk and meat industry Potential exist for investors to invest in dairy and meat value addition and researchers to undertake research in enhancing milk and meat production Agriculture Dept./ Private Sector Strengthening monitoring and accountability Establishing strong monitoring and accountability by applying principals of good governance Agriculture Dept./Donors Making attitudinal change towards responsibility and work (from casual to responsible) Performance based promotions and rewards for hard worker, honest officials will create conducive environment for work Agriculture Dept. Facilitating reduction in prices of agricultural inputs through administrative and regulatory measures Through mutual consultations and regulatory measures, prices of agricultural inputs may be kept under control. Improving monitoring, changes in agriculture policy to make it farmer’s friendly policy, improvement in marketing system, provision of subsidy etc. Agriculture Department/public private sectors/farmers Ensuring timely availability of certified quality seeds, fertilizers pesticides, insecticides, weedicides, equipment, irrigation water, technical services, credit and marketing facilities to farmers Proactive Government role has been envisaged in regulating and facilitating supply of agricultural inputs to farmers by making appropriate agriculture policy, necessary legislations and plan of actions to enhance agriculture production, food security and nutritional status of the population. Agriculture Department shall take a leading role in coordinating and communicating with public and private sectors and farmer associations to achieve the objectives. Agriculture Department/public private sectors/farmers Enhancing household food availability, accessibility, through Promoting enhanced agricultural production through improved inputs delivery services and creating job Agriculture Dept/Private Sector/Donor Page 26 Strategy Plan of Actions Responsible Department demand creation opportunities for population as well as promoting rural development activities Improving household food distribution & food diversification in households Increasing nutrition awareness and counseling of women for balanced dietary practices and improving intra-household food distribution as per need and requirement of individuals Agriculture Dept./Donors Enhancing household food storage capacity for rainy days i.e., extreme cold weather for hilly areas, natural calamities etc Establishing microcredit schemes for marginalized population as well as provision of Silos for small landholders or economically disadvantaged farmers. Agriculture Dept./ Banks/ Donors Promoting research and development and strengthening research system Increasing investment in R&D: Essential for producing new high yielding disease resistant, nutrient rich crops, vegetables, fruits, livestock through new innovation and technologies development. Enhancing human resource capacity, laboratory facilities, changing staff recruitment eligibility criteria and promotion criteria, monitoring and accountability. Establishing and strengthening linkages between academia, research, extension, farmers, industry and other stakeholders. Establishment of Nutrition Research Unit at agricultural research system. A well equipped Nutrition Research Unit with adequate human resource and sophisticated analytical laboratory is essential for development of indigenous ready to use supplementary and therapeutic foods and has the capacity to analyze foods for essential nutrients and toxic compounds to ensure food safety and to meet international food quality standards. Agriculture Dept./ Private Sector/ Donors Promoting organic farming Organic farming and compost making shall be encouraged to maintain biodiversity, minimize and decreased the role of insecticides, pesticides and other practices that cause loss of biodiversity and enhance human vulnerability to toxic and unhealthy foods. Agriculture Department/ Donors Strengthening HRD, changing staff recruitment eligibility criteria and promotion criteria, monitoring Agriculture Dept./Donors Page 27 Strategy Plan of Actions Responsible Department Extension System and accountability. Establishing and strengthening linkages between academia, research, extension, farmers, industry and other stakeholders. Enhancing capacity of all pillars of agriculture system Trainings, short and long term courses and establishing liaison with academia, private sector and institutions. Extension and outreach workers shall be involved in nutrition awareness campaigns to promote healthy eating practices and lifestyle. Agriculture Dept/ Donors/ Private Sector Encouraging application of improved technology for Agriculture Extending credit facility for purchase of agriculture machinery and exemption of tariff on import of machinery. Agriculture Depart/Banks/Donors Efficient Management of Agriculture Inputs Efficient use of land and water resources as well as judicious use of agriculture inputs Agriculture Depart/Farmers/ Communities/ Donors Creating supportive and enabling institutional and policy environments Supporting farmers at all levels starting from agricultural inputs to marketing of agriculture produce and export Agriculture Dept./ Private Sector Promoting nutrition sensitive programmes through farm field schools and village based community organizations Farm field schools and village based organization platforms could be used for disseminating nutrition awareness as well as for motivating farmers to get involved in nutrition sensitive programmes. Agriculture Department/ Communities/ Donors Strengthening public private partnership Forging alliance for enhancing agriculture production, supply chains, value added and export of agriculture produce Agriculture Dept/private sector 3.3.2. Progress and Achievements In response to submission of the nutrition sensitive strategy, the department took keen interest in the integrated nutrition strategy. The Secretary Agriculture, Livestock and Cooperative Department convened a meeting of Director Generals Agricultural Research, Agriculture Extension, Livestock & Dairy Development Research, Livestock & Dairy Development Extension, Director Fisheries and Chief Planning Officer for brainstorming on the proposed strategy and taking appropriate decisions. A detailed presentation on the proposed Integrated Nutrition Strategy for Agriculture was given by the Consultant. The minutes of the meeting and decisions taken by the department have been attached as Annexure-D. The Technical Working Group (TWG) for Agriculture Sector was constituted and Page 28 Director General Agricultural Research was nominated as a Focal Person for the TWG and all the sector specific nutrition sensitive activities (Annexure-E). The Focal Person, Director General Agricultural Research convened the meeting of the TWG in February, 2013 which includes Director Generals and Director Fisheries for further deliberation on the subject. It was decided that a comprehensive nutrition sensitive PC-1 representing all the respective agricultural, livestock and fisheries systems would be developed for further submission and funding. The minutes of the meeting have been attached as Annexure-F. The representatives from the Agriculture Department participated in the recent workshop held at Mukshpuri on 19-20 April, 2013. The Technical Working Group comprising representatives from Agriculture Department and FAO further deliberated on the proposed nutrition sensitive agriculture strategy and gave their suggestions which are incorporated in the report. The strategy was again critically evaluated by the TWG of the Agriculture department at the P&DD TWG workshop held at Islamabad on 25 September, 2013, the suggestions put forward by the TWG have been included in the report. Page 29 3.4. Nutrition Sensitive Strategy for Food Department Food is a basic necessity which provides essential nutrients to the human body for growth and development and performing optimal functions. Despite an increase in food grains production and utilization over the years31, (Figure 2), about 870 million people around the world are undernourished and millions of children die every year from malnutrition and preventable diseases32. In Pakistan, although the per capita income has increased over the recent years yet level of food insecurity, malnutrition, infectious and non-infectious diseases is almost static. The food and nutrition situation in Khyber Pakhtunkhwa is not very much different from rest of the country rather the province is lagging behind in many health, nutrition and socio-economic indicators due to the deteriorating law and order situation, mass human displacements, lack of industrialization and technological base and increasing unemployment and poverty. Figure 4: World Cereals Production and Utilization over the Years Khyber Pakhtunkhwa has an agricultural based economy, wheat, maize, rice, sugarcane and tobacco are the major crops grown in the province. It produces 1.3 million tonnes of wheat which is about 1/3rd of its total requirements and the rest is marketed from Punjab33,34. Almost all the districts of Khyber Pakhtunkhwa are food insecure35, food prices in the province fluctuate and are relatively higher than the other provinces. The province has been plagued by the continuous stress of food availability and affordability increasing the population’s vulnerability to food insecurity and malnutrition. A good amount of wheat and other food grains is smuggled to Afghanistan which contributes significantly to local food shortages, rise in food prices and aggravates the food and nutrition state of the people. A combination of factors including inadequate food grains supply and limited purchasing power of people largely determines the quality and quantity of food consumed which in turn influences the health and nutritional status of the population. Food thus becomes one of the most important determinants of health, social wellbeing and economic development of the country. 31 FAO (2013). World Food Situation. 32 FAO (2012). The State of Food Insecurity in the World. 33 Daily Times, 21 March, 2013. Meeting wheat procurement target for 2013. 34 Economic Survey of Pakistan(2012-2013), Ministry of Finance, Government of Pakistan 35 WFP (2009). Food Insecurity in Pakistan, World Food Programme, Islamabad Page 30 Food Department, Government of Khyber Pakhtunkhwa provides wheat to flour millers on subsidized rates to regulate and control wheat flour prices in the province which has helped the poor population to some extent, however, the key aspect of ensuring food safety and food fortification has largely been overlooked. Food safety is one of the most important pillars of food security vital for ensuring that the food supplied and consumed by the population is safe and free from adulterants, toxic substances and pathogens. Food borne illnesses resulting from foods that are contaminated with harmful bacteria, microorganisms and adulterants are widely prevalent in developing countries which not only cause enormous health problems but also lead to capital and human losses with increased sufferings of the families. Though there are a number of federal and provincial departments such as Pakistan Standard and Quality Control Authority (PSQCA), Health and Drug Regulatory Authority (H&DRA), Executive District Officer Health (EDOH), Veterinary and Agriculture Department to look into food safety issues but all are working independently without any synchronization and thus the outcome of efforts is not palpable. Food fortification is another key area of complementing dietary nutrients intake and preventing nutritional deficiencies as none of the foods are complete in providing all the essential nutrients and meeting the recommended daily nutrients requirement of the body particularly during the years of growth and development, pregnancy and lactation stages of life. A number of fortification programmes such as salt iodization to prevent iodine deficiency disorder (IDD), vitamin A fortification of ghee and oil to prevent vitamin A deficiency (VAD), fortification of milk and dairy products with vitamin A and D to prevent vitamin A and D deficiencies (VA&DD) have been in place, yet the nutrients deficiencies are still significantly prevalent in the general population. Failure to prevent nutrient deficiencies through fortification implies that insufficient quantitative and qualitative practices are in place and therefore suggest stringent monitoring to implement the food fortification regulations. Besides, collaborative efforts between the Government of Pakistan, development partners (Global Alliance for Improved Nutrition (GAIN) and Micronutrient Initiative (MI) and private sector had been made in the past to fortify wheat flour with iron and B-complex vitamins. A number of flour mills were selected from federal, provincial and federating units of Pakistan to whom wheat-fortificants mixers and premix were supplied to process fortified wheat flour but it could not be commercialized due to a paucity of funds and lack of political commitment. Wheat flour fortification project needs to be revitalized to reduce and control anaemia and other micronutrient deficiencies in the population and particularly in women children which have been adversely affecting their pregnancy outcomes and increasing morbidity and mortality. Anaemia alone has been responsible for contributing to 18% of the maternal mortality36. Keeping in view the importance of food-based nutrition interventions to combat micronutrient deficiencies in the population, a nutrition sensitive strategy has been proposed to improve the nutritional status of the population. 36 Bhutta et al. (2012). Is it time to replace iron folate supplements in pregnancy with multiple micronutrients? Page 31 3.4.1. Strategy Outlines & Plan of Actions for Food Department, Government of Khyber Pakhtunkhwa Strategy Plan of Actions Responsible Department Improving Nutrition through: Developing an efficient and equitable system of food grain procurement , distribution and storage Khyber Pakhtunkhwa is a food deficit province requiring efficient and equitable system for wheat and other food grains procurement and distribution to combat food insecurity and malnutrition. Building grain storage facilities in remote far-flung hilly mountainous areas to ensure round the year availability of cereals and other food commodities. Food Department Construction of food grain godowns at district, tehsil, community and household levels particularly in far flung mountainous areas In order to maintain food availability and to prevent incidence of malnutrition especially during cold winter season and to meet emergency situations, construction of godowns at district, tehsil, community and household levels is essential. Food Department & Donors for coordinating and organizing the programme. TWG of Food department may brainstorm, plan and recommend the proposal for implementation. As per food department Ref [Letter# SOF (Food Dept.) 1-70/14—Attached as Annex-M] below proposed strategies and plan of actions highlighted in yellow, are under the domain of Health Department and therefore need to be taken out from the Food department responsibilities. The activities thus have been taken out in the final version from food. 3.4.2. Progress and Achievements A representative from Food Department has attended the Mukshpuri workshop of 19-20 April, 2013 and also attended the previous workshops held at Peshawar and Islamabad on policy guidance notes and integrated nutrition strategy. The representative expressed his inability to review and submit comments on the proposed strategy due to his extremely busy schedule in the day-day wheat procurement and distribution activities which are extremely demanding. However, the representative assured all possible help to move forward the proposed integrated nutrition strategy of Food department towards a successful end. The strategy was critically evaluated by the representative of the Food Department at the P&DD TWG Workshop held at Islamabad on 25 September, 2013 and the suggestions made at the workshop have been incorporated in the report. Page 32 3.5. Elementary & Secondary Education Department Education plays an important role in human capacity building and development with the acquisition of knowledge, skills, technical knowhow, confers social and economic status and empowers people to differentiate between right and wrong, good and bad. Its transforms the country from a labour intensive economy to a knowledge-based economy where individuals are involved in more sophisticated innovations and value added product developments that help in increasing productivity, exports and economic growth of the country. Education promotes a healthy environment that enables people to make wise choices and select quality food, housing, adopt measures that ensure proper hygiene and sanitation within and outside their homes and allows them to attain good health and prosperous life. A synergistic relationship has been established between education, health and socio-economic development; countries with higher literacy rates and technical education have far less health and nutritional problems, higher longevity and better socio economic status than those with low literacy rates and who are technologically less advanced. Good education creates awareness about healthy practices and helps in preventing illnesses, malnutrition and mortality. Lack of literacy and education give a birth to demographic surge, social unrest and uprising, poor law and order that make the people insecure, depressed and miserable. Education thus is a source of respect, decorum and sophistication and gives a decent and respectable position in the comity of nations. Education is one of the most important pillars of social development influencing human behavior, attitude and approach towards different aspects of life. It changes people vision and perceptions for leading a better quality of life. It facilitates food selection, access to and use of clean drinking water, better healthcare facilities, family size and education, as well as employment choices. Maternal education seems to be a key factor in determining the pendulum swing towards good living and has a strong influence on the nutritional status of women, children and subsequent generations. Strong links have been found between mother’s education and nutritional status of children, the rate of child mortality was found higher among un-educated mothers as compared to mothers with basic education37. Investment on education has been recognized as one of the best investments and countries who have invested in education have surpassed other countries in the field of socio economic development. It is well documented that educated individuals earn higher wages and occupies prestigious positions than others and each year of an additional schooling increases their earning between 11 and 13%38. Southeast Asian countries, Japan, Taiwan, Hong Kong, Korea, Indonesia, Malaysia, Singapore and Thailand, China and India who have invested in education have shown remarkable progress in technology development and increase in economic growth. In China, the per capita income has gone up from $350 in 1990 to $4,940 in 201139,40. Pakistan is currently spending 2.4% of GDP on education which is lower than many South Asian and African countries40. Investment in education with good governance is essential for economic development and mitigation of inequity issues. It 37 Abuya et al. (2012). Effect of mother’s education on child’s nutritional status in the slums of Nairobi. BMC Pediatrics 12:80. 38 Uusitalo R (1999). Essays in Economics of Education. http://www.oecd.org/eco/labour/37576324.pdf. Accessed Jan 2013. 39 http://www.economywatch.com/world economy/china/income.html 40 http://data.worldbank.org/indicator/SE.XPD.TOTL.GD.ZS http://www.oecd.org/eco/labour/37576324.pdf http://www.economywatch.com/world economy/china/income.html http://data.worldbank.org/indicator/SE.XPD.TOTL.GD.ZS Page 33 needs to be tackled on war footings to achieve the goals of universal primary education and quality education. Khyber Pakhtunkhwa covers an area of 74,521 sq. km and has been confronted with social, economic and law and order challenges. It has been ranked the second least developed province after Balochistan with a population of 26.62 million and an annual growth rate of 2.8%41. The adult literacy (15-24 years) in women of Khyber Pakhtunkhwa has been estimated at 45% as compared to 81% in males while the proportion of primary school aged children (5-9 years) admitted in schools is only 43%42. Female literacy rate in the province stands below 30% implying that only 3 out of 10 mothers are educated, capable of understanding proper feeding practices, importance of child vaccination and family planning, significance of hygiene and sanitation in the health of their children, consequences of the food choices they make and may play a contributory role in the household affairs and livelihood5. The adult female literacy rate of Pakistan is much lower than the developing countries average adult literacy rate of 79%43. Gender and urban-rural disparities in terms of literacy rates and enrollment of children exist, literacy rates and enrolment of boys in primary schools as well as in urban areas are predominantly higher than those of girls in rural areas of Pakistan in general and in Khyber Pakhtunkhwa in particular. There is a wide gap in adult literacy rates as well as in primary, secondary and tertiary education levels between the rich and poor households. These gaps need to be narrowed down and the disadvantaged children have to be brought into the mainstream of development by providing them with equal opportunities to achieve the target of universal primary education by the year 2015. Equitable public spending in education, health and other social sectors are crucial for improving the quality of life, socio-economic development and alleviating poverty. Under the 18th constitutional amendment, the provinces have been empowered to plan, manage and implement their own education policies and strategies. The National Finance Commission Award 2010 has given a boost to the provinces by increasing their financial shares and economic positions. Along similar lines, the Government of Khyber Pakhtunkhwa has expressed its commitment to increase equitable public spending on all social sectors which could facilitate access of the disadvantaged and poor people to education, health, agriculture and basic sanitation and safe drinking water44. The Department of Elementary and Secondary School Education cognizant of the existing education system has been adopting a proactive approach by increasing children’s enrolment in schools and taking all necessary steps to make the primary education universal. The development partners (DFID, AusAid, USAID, CIDA, GIZ, Netherland, EU) in Khyber Pakhtunkhwa have been playing a key supportive and developmental role in improving access to primary education, increasing primary school enrolment, improving quality of education, capacity building of teachers, 41 UNESCO (2012). Education policy analysis report of Khyber Pakhtunkhwa. United Nations Educational Scientific and Cultural Organization, Paris. 42 P&D (2008). Khyber Pakhtunkhwa Multiple Indicator Cluster Survey. Planning & Development Department, Peshawar 43 UNESCO (2009). Overcoming Inequality: Why Governance matter. United Nations Educational Scientific and Cultural Organization, Paris. 44 P&D (2010). Khyber Pakhtunkhwa Comprehensive Development Strategy (2010-17). Planning and Development Department, Government of Khyber Pakhtunkhwa, Peshawar. Page 34 repairing of school buildings and expanding school amenities i.e., water supply, electricity and construction of latrines etc. The National Education Policy 2009 provides a comprehensive framework for addressing the issues of: (i) achieving universal primary education; (ii) improving basic facilities in primary schools; and (iii) improving the quality of education and number of schools45. The policy has been endorsed by all the provinces and the federating units of Pakistan, all of whom are engaged in formulating strategies in scaling up primary education, however, implementation of the policy requires political commitment, resources, coordination, cooperation and collaboration between the Government, donors and private sector. In light of the National Education Policy, a nutrition sensitive strategy for elementary and secondary education has been proposed to improve nutrition wellbeing of the school going children which is a prerequisite for good health, physical and mental growth and development, scholastic performance and physical activity. These children in turn can play a vital role in influencing family perception and behaviour towards healthy eating practices, improved hygiene and sanitation and a healthy lifestyle to reduce and control infectious and non infectious diseases. The strategy covers a wide range of interventions which can be reviewed for their feasibility, planning and implementation by the Technical Working Group and other officials of the Department of Elementary and Secondary Education. The main essence of the strategy is to integrate vertical nutrition programmes within and between the social sectors to improve efficiency, effectiveness and outcomes while ensuring a holistic approach of inter-sectoral thinking, planning, collaboration and sectoral implementation of the programmes. Since the department of Elementary and Secondary Education alone does not have the requisite resources to implement and execute all the nutrition sensitive interventions, the support from other sectors is crucial to achieve the desired outcomes. 3.5.1. Strategy Outlines & Plan of Actions for Elementary & Secondary Education (E&SE) Department, Government of Khyber Pakhtunkhwa Strategy Plan of Actions Responsible Department Improving Nutrition through: Introduction of school health and nutrition assessment programme Selection of urban and rural schools in one or more nutritionally impoverished districts of Khyber Pakhtunkhwa for implementing the proposal in light of the recommendations put forward by the Technical Working Group of the Department of E&SE. Depts. of E&SE, Health, Human Nutrition (University) & Donors for coordinating, organizing and arranging MOs/ Nutrition Officers for the programme. TWG of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. Changes in school curricula to make It nutrition An Introduction to health, nutrition and sports concepts shall be included in the curricula to highlight their Depts. of E&SE, Health, University Text Book Board and Human Nutrition (University) 45 National Education Policy (2009). Ministry of Education, Government of Pakistan, Islamabad. Page 35 Strategy Plan of Actions Responsible Department sensitive importance in the prevention of malnutrition, communicable and non communicable and diseases. and Donors. School milk/food/fortifie d food & vitamin supplement programme for malnourished children especially middle/high school girls (adolescents) Screening of children in urban and rural schools in one or more nutritionally impoverished districts of Khyber Pakhtunkhwa for the identification of malnourished children. Treatment of malnourished children with supplementary feeding programme in all or selected schools of food and nutrition insecure districts on the recommendations of MOs/Nutrition Officer/ Principal (School Committee). Depts. of E&SE, Health, Human Nutrition (University) & Donors for coordinating and organizing the programme. TWG of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. Establishing and strengthening of basic health, hygiene sanitation and nutrition oriented programmes Ensuring safe and clean drinking water, repairing of latrines with safe disposal of excreta, water and soap for hands washing to meet the minimum basic standards of hygiene, provision of electricity and studies jute/rug sheets or desk and chair. Introduction to proper hand washing techniques and use of hand sanitizers. Depts. of E&SE, Public Health Engineering, PESCO & Donors for coordinating and organizing the programme. TWG of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. Nutrition advocacy, behvioural modification and awareness Special short and long term nutrition education courses for teachers and students’ capacity building who may act as guides in the selection of foods and groceries for the family and community. Depts. of E&SE, Human Nutrition (University) and Donors for coordinating and organizing the programme. The Technical Working Group of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. Strengthening monitoring and evaluation Periodical visits to a selected district and schools shall be made to gauge the success and impediments in implementation of the programme. Qualitative and quantitative output indicators shall be set to measure the efficiency and effectiveness of the programme. Depts. of E&SE and Donors for coordinating and organizing the programme. The Technical Working Group of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. Promoting exercise and sport in schools Establishing play grounds for outdoor games and a gymnasium for indoor sports, fitness and exercises along with necessary sports’ equipment. Depts. of E&SE and Donors for coordinating and organizing the programme. TWG of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. Page 36 Strategy Plan of Actions Responsible Department Regulating schools’ canteen and vendors for nutritious and safe foods Instructions to schools for ensuring availability of milk, fruits and good quality/standard snacks and discourage sale of candies, toffees and junk foods to the students. Depts. of E&SE for issuing directives to schools. TWG of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. Organizing debates/seminars & workshops on Nutrition & Health Creating awareness and advocacy through debates/ seminars and workshops. Depts. of E&SE and donors for coordinating and organizing programmes. TWG of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. Enhancing budget allocation for promoting academic activities The budget needs to be increased to enhance basic facilities in rural schools i.e., building, electricity, clean drinking water, desk and chair etc Depts. of E&SE/P&D/Donors. Capacity building of Parent Teacher Council Capacity building and revitalizing the services of PTC as an outreach counselor for adopting a healthy lifestyle Depts. of E&SE/P&D/Donors for coordinating and organizing programmes. TWG of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. Revising teachers’ eligibility and promotion criteria Revision of teachers’ qualifications and experiences in the light of country’s needs and requirements and bringing them at par with international standards Depts. of E&SE/P&D/Donors for coordinating and organizing programmes. TWG of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. Improving governance in education Good governance is the key to quality education, to shun disparities and inequities in children enrolment and facilitate scaling up education to achieve the target of universal primary education. Depts. of E&SE/P&D/Donors for coordinating and organizing programmes. TWG of the Dept. of E&SE may brainstorm, plan and recommend the proposal for implementation. 3.5.2. Progress and Achievements The Elementary & Secondary Education Department (E&SED) has made progress by attending workshops and notifying the Technical Working Group for the department (Annexure-G). The Technical Working Group for E&SED at Mukshpuri workshop reviewed the proposed integrated nutrition strategy and the suggestions made at the workshop have been included in the report. Page 37 3.6. Zakat, Ushr, Social Welfare, Special Education and Women empowerment Department Khyber Pakhtunkhwa is a strategically important province blessed with abundance of resources, favourable climate, weather and human resource to produce a variety of fruits, vegetables and crops that could have made the province self-sufficient in agriculture and free of malnutrition and poverty. The province however, unfortunately lags behind in many of health and nutrition indicators and is afflicted with poverty that ranges between 35 to 46% and has a comparatively lower economic growth than the national average46. The natural catastrophes including the earthquake of 2005, flash floods of 2010 and 2011 and deteriorating law and order situation of the province have resulted in large scale human displacements, destructions, badly affected the people livelihood, businesses and crippled the economy of the province. These events have inflicted enormous economic hardships on the people and incurred an additional financial burden on the Government to restore the damaged infrastructure, rehabilitate the communities and initiate food assistance, cash transfer and agricultural support programs for the affected population. Women deserve special attention in the social safety net and social protection programmes because of their increased vulnerability to malnutrition, morbidity and mortality. Pregnancy and lactation impose additional nutritional stress on the women and make them more susceptible to nutritional deficiencies. Women are the last ones in the family to be served with food and health care services in less developed countries due to ignorance about their body needs, lack of resources, inadequate health care facilities, inbuilt spirit of love and sacrifice for others and culture norms. In addition, women are mostly overburdened with field, office and domestic work besides looking after the husband and children with lack of empowerment and say in family decisions. Women though deserve the most but receive the least due to a variety of factors. Women health is immensely important for the prenatal and post-natal growth and development of infants and poor maternal health has been recognized as one of the strongest predictors of adverse pregnancy outcomes and poor child growth and development that subsequently impede their psychomotor and cognitive development. Poor performance in early preschool childhood initiates a vicious cycle of poor start in child school performance in subsequent classes, lack of interest in school activities and inclination for participation in antisocial activities leading to absentees and attrition from schools. The health of women plays an important role not only influencing their own performance but it also affects the nutritional, behvioural, psychological, cognitive, scholastic and physical performance of their children. Thus, the effects of maternal ill health and compromised nutritional status perpetuate from one generation to another. The Government of Khyber Pakhtunkhwa is conscious of hardships faced by the people due to rising living costs, unemployment and poverty and has committed itself to boost economic growth through exploitation of untapped natural resources and value added products. The Government has increased its provincial annual development programmes budget from 39 billion in 2009-2010 to 69 billion for the year 2010-11 which is a 46 P&D (2011). Economic Growth Strategy. Planning and Development Department, Government of Khyber Pakhtunkhwa, Peshawar. Page 38 manifestation of political commitment to reduce unemployment and wipe out poverty from the province1. The Government has further reiterated its pledge in scaling up the development programmes to all the districts of the province to protect human rights, provide equal opportunities to all without discrimination and alleviate poverty47. The Department of Zakat, Ushr, Social Welfare, Special Education and Women Empowerment, Government of Khyber Pakhtunkhwa has been implementing a number of social protection and safety net programmes to help the poor, disabled and distressed population. Bacha Khan Khapal Rozgar Scheme, Pakhtunkhwa Hunermand Rozgar Scheme, Pakhtunkhwa Morusi Hunermand Scheme are the social protection schemes initiated for the children, youth and elderly population from the poor families to provide them financial assistance. However, these programmes are downstream initiatives with limited coverage, life and effectiveness. Benazir Income Support Programme (BISP) is the country largest safety net programme providing financial assistance to more than five million low income families in the form of monthly cash transfer of Rs. 1000/. The BISP is a federally administered safety net programme being implemented vertically with other safety net programmes and the lack of coordination amongst the parallel safety net programmes is often questioned. The amount of Rs. 1000/- per month is also considered to be insufficient for catering to even a single person’s basic needs. The BISP programme is also a downstream initiative and does not address the root causes of poverty and the underlying causes of malnutrition which are essential for poverty alleviation. The BISP though provides financial assistance and job opportunities to the public, yet its transparency, efficiency, effectiveness and outcomes have been criticized. Monitoring and evaluation reports may reveal the real outcomes of the programme. Safety net programmes are essential to provide relief and support to the poor and marginalized population to rehabilitate and restore them to perform their routine duties and bring them into mainstream of socio-economic development. Though a number of safety net and social protection programmes including cash transfer (Benazir Income Support & Zakat disbursement schemes, Guzara allowance, Educational stipends, Health care, Eid grants and Marriage grants etc), food assistance programmes, agriculture support (free seeds and fertilizers), education support (free books, waivers of tuition fees & stipends for children and youths), free shelters for homeless women and children, free vocational and technical education, free medical treatment and healthcare, child support programme and child protection centres to protect children from violence and exploitation have been in place in Khyber Pakhtunkhwa to help poor individuals and families, yet the level of poverty has been increasing over the recent years48. It has been estimated that 75% of the population are surviving merely on a monthly income of Rs. 4000/- which by all means is inadequate to meet the basic needs of the people. These safety net and social protection programmes have achieved limited success in alleviating poverty, improving the living standards of the people and reducing the prevalence of malnutrition, morbidity and 47 P&D (2010). Khyber Pakhtunkhwa Comprehensive Development Strategy. Planning and Development Department, Government of Khyber Pakhtunkhwa, Peshawar. 48 Saleem M (2010). Rising trends of poverty and violence in Pakistan. J Mgt Sci 1(2):27-43. Page 39 mortality because of fragmentation, isolation and lack of communication, cooperation, coordination and collaboration between the institutions which are carrying out these programmes. Improving governance, equity, integration of different vertical safety net programmes within and between the sectors, stringent monitoring and evaluation along with increased budgetary allocation for safety net and social protection programmes is the only way to tackle the problems of poverty and other related issues like health, nutrition and hygiene-sanitation. Keeping in view the importance of social protection as a means for socio-economic development and need to bring in the socially and economically deprived segments of the population into active participation in the national development activities, a nutrition sensitive strategy is proposed for brainstorming and developing plan of actions in annual development programmes. 3.6.1. Strategy Outlines & Plan of Actions for Zakat, Ushr, Social Welfare, Special Education & Women Development (ZUSWSEWD), Government of Khyber Pakhtunkhwa Strategy Plan of Actions Responsible Department Improving Nutrition through: Initiating health and nutritional assessment programmes in welfare centres Initiation of health and nutritional assessment programmes in selected vocational, special education, industrial training centres and other welfare homes working under the administrative control of the department of ZUSWSEWD. Depts. Of ZUSWSEWD, Health, Human Nutrition (University) & Donors for coordinating, organizing and arranging MOs/ Nutrition Officers for the programme. The MOs and Nutrition officers may either be requisitioned or hired for the said purposes. TWG of the Dept. of ZUSWSEWD may brainstorm, plan and recommend the proposal for implementation. Placing nutritional assessment as an essential component of registration/enrollme nt in all welfare programmes Giving due place to nutrition in all welfare programmes implemented by the dept. of ZUSWSEWD, nutritional assessment of subjects under discussion shall be made mandatory with the provision of proper documentation and record keeping in all districts. Depts. Of ZUSWSEWD, Human Nutrition (University) & Donors for coordinating, organizing and arranging the programme. TWG of the Dept. of ZUSWSEWD may brainstorm, plan and recommend the proposal for implementation. Initiating safety-nets (food-based) welfare schemes for marginalized population Food based programmes such as food vouchers for receiving free food commodities (wheat flour, oil, sugar, milk, fruits, eggs, vegetables, oil etc) from Utility Stores for marginalized families, children and pregnant & lactating women. Depts. of ZUSWSEWD & Donors for coordinating, organizing and arranging the programme. TWG of the Dept. of ZUSWSEWD may brainstorm, plan and recommend the proposal for implementation. Capacity building of social mobilizers/ Development of nutrition education courses for capacity Depts. of ZUSWSEWD, Human Nutrition (University) & Donors for Page 40 Strategy Plan of Actions Responsible Department outreach workers and caretakers involved in nutritional assessment building of social mobilizers, outreach workers, caretakers as well as the enrolled women and children in nutrition coordinating, organizing the programme. Nutrition interventions for improving nutritional status of enrolled women and children Appropriate dietary plans including dairy, meat, fruit, vegetables, cereals along with vitamin supplements shall be developed for the enrolled population. Milk or any other food could be selected for nutrition intervention. Depts. of ZUSWSEWD, Human Nutrition (University) & Donors for coordinating, organizing and arranging the programme. TWG of the Dept. of ZUSWSEWD may brainstorm, plan and recommend the proposal for implementation. Promoting child protection and encouraging children for schooling to reduce malnutrition Understanding & visualizing the problems of un-supervised, orphans, neglected and socially rejected children and providing them support for schooling through the department and charity organizations Depts. of ZUSWSEWD & Donors for coordinating, organizing and arranging the programme. TWG of the Dept. of ZUSWSEWD may brainstorm, plan and recommend the proposal for implementation. Encouraging children for technical & professional education and trainings for poverty alleviation and reducing malnutrition Increasing the number of vocational and technical schools at Tehsil levels for youth and offering short and long courses to produce skilled and technically sound workers for the country and abroad. Depts. of ZUSWSEWD & Donors for coordinating, organizing and arranging the programme. TWG of the Dept. of ZUSWSEWD may brainstorm, plan and recommend the proposal for implementation. Promoting and strengthening equitable social delivery system for poverty alleviation and reducing malnutrition Developing transparent, efficient and effective welfare schemes with measurable outcomes to build the people and donors’ trust for sustainability and scalability of the programmes for reducing poverty and malnutrition from the province Depts. of ZUSWSEWD & Donors for coordinating, organizing and arranging the programme. TWG of the Dept. of ZUSWSEWD may brainstorm, plan and recommend the proposal for implementation. 3.6.2. Progress and Achievements The Department of Zakat, Ushr, Social Welfare, Special Education and Women Development (ZUSWSEWD) has positively welcomed the initiative of provincial integrated nutrition strategy. A number of meetings with the officials were held to deliberate upon the development of nutrition sensitive strategy for the department. The Technical Working Group of the department was notified (Annexure-H). Representative from the Department attended the Mukshpuri and Islamabad workshops where the proposed strategy was critically reviewed. Suggestions made by the TWG during the workshops have been incorporated in the report. Page 41 3.7. Industry, Commerce and Technical Education Department The Industry, Commerce and Technical Education Department (IC&TED) may facilitate the procurement of food grade elemental compounds that are needed for fortification of foods as well as plays a role in disseminating nutrition awareness in public through organizing seminars and workshops in technical and vocational institutions and industries. The strategy has been developed in consultation with the Industry, Commerce and Technical Education Department and outlined as under: 3.7.1 Strategy Outlines and Plan of Actions for the Department of Industry, Commerce and Technical Education, Government of Khyber Pakhtunkhwa Strategy Plan of Actions Responsible Department Improving Nutrition through: Facilitating relevant sectors of Khyber Pakhtunkhwa in import of food grade nutrients for fortification of foods Will assist all the relevant departments on request. Dept of IC&TE in coordination and collaboration with relevant sectors and development partners. TWG of the Dept. may brainstorm, plan and recommend the proposal for implementation Facilitating relevant sectors of Khyber Pakhtunkhwa in ensuring food safety laws and enhancing food quality to improve health and nutrition of the people Will assist all the relevant departments on request. Dept of IC&TE in coordination and collaboration with relevant sectors and development partners. TWG of the Dept. may brainstorm, plan and recommend the proposal for implementation. Introduction of health and nutrition assessment programmes in technical and vocational institutions and industries Selection of urban and rural technical institutions in one or more nutritionally impoverished districts of Khyber Pakhtunkhwa for implementing the proposal in light of the recommendations put forward by the Technical Working Group of the Department of IC&TE. Dept of IC&TE in coordination and collaboration with relevant sectors and development partners. TWG of the Dept. may brainstorm, plan and recommend the proposal for implementation. Initiating basic health, hygiene sanitation and nutrition oriented awareness programmes Ensuring safe and clean drinking water, repairing of latrines with safe disposal of excreta, water and soap for hands washing to meet the minimum basic standards of hygiene. Introduction to proper hand washing techniques and use of hand sanitizers. Dept of IC&TE in coordination and collaboration with relevant sectors and development partners. TWG of the Dept. may brainstorm, plan and recommend the proposal for implementation. Nutrition advocacy, behavioural Special short and long term nutrition education courses for Dept of IC&TE in coordination and Page 42 Strategy Plan of Actions Responsible Department modification and awareness teachers and students’ capacity building who may act as guides in the selection of foods and groceries for the family and community. collaboration with relevant sectors and development partners. TWG of the Dept. may brainstorm, plan and recommend the proposal for implementation. Strengthening monitoring and evaluation Periodical visits to a selected district and institutions will be made to gauge the success and impediments in implementation of the programme. Qualitative and quantitative output indicators shall be set to measure the efficiency and effectiveness of the programme. Dept of IC&TE in coordination and collaboration with relevant sectors and development partners. TWG of the Dept. may brainstorm, plan and recommend the proposal for implementation. Promoting exercise and sports in educational institutions and industries Establishing play grounds for outdoor games and a gymnasium for indoor sports, fitness and exercises along with necessary sports’ equipment. Dept of IC&TE in coordination and collaboration with relevant sectors and development partners. TWG of the Dept. may brainstorm, plan and recommend the proposal for implementation. Regulating technical institutions and industries canteens and Vendors for nutritious and safe foods Instructions to technical institutions and industries for ensuring availability of fortified food/supplementary food/ milk, fruits and good quality/standard snacks and discourage sale of candies, toffees and junk foods to the students. Dept of IC&TE in coordination and collaboration with relevant sectors and development partners. TWG of the Dept. may brainstorm, plan and recommend the proposal for implementation. Organizing debates/seminars & workshops on nutrition & health in technical institutions and industries Creating awareness and advocacy through debates/seminars and workshops. Dept of IC&TE in coordination and collaboration with relevant sectors and development partners. TWG of the Dept. may brainstorm, plan and recommend the proposal for implementation. Enhancing budget allocation for promoting nutrition programmes in the department The budget needs to be increased to enhance basic facilities in technical institutions i.e., building, electricity, clean drinking water, desk and chair etc Dept of IC&TE in coordination and collaboration with relevant sectors and development partners. TWG of the Dept. may brainstorm, plan and recommend the proposal for implementation. Improving Good governance is the key to Dept. of IC&TE for issuing Page 43 Strategy Plan of Actions Responsible Department governance in technical institutions and industries quality education, to shun disparities and inequities in students’ enrolment and universal education. . directives to all technical institutions as well as industries. The Technical Working Group of the Dept. may brainstorm, plan and recommend the proposal for implementation 3.7.2 Progress and Achievements The participation of the higher officials (Special Secretary and Deputy Secretary) in the endorsement workshop held at Islamabad on 25 September, 2013 and their willingness to support the provincial integrated nutrition strategy by notifying Technical Working Group of the Industry department demonstrates their political will and commitment. Page 44 4. CROSS CUTTING ISSUES 4.1 Equity and Social Justice The provincial integrated nutrition strategy is based on an equitable use of social, economic, political resources and opportunities for improving nutritional wellbeing of the population irrespective of gender, race, creed, color, social and financial status. The strategy lays more emphasis on food and nutritionally insecure, poverty stricken districts, more attention and importance is given to the neglected poorest of the poor and more focus on the most vulnerable groups of population, <1000 days of age children, pregnant-lactating women and adolescent girls in all social development programmes. A greater urban-rural disparity exists in the availability of health facilities and qualified professionals, elementary and secondary schools and enrollment of children, safe and clean drinking water supply, hygiene and sanitation, jobs opportunities and basic infrastructure. Similarly, gender disparities in availability and utilization of health facilities, schooling and dietary practices are also widely prevalent owing to resource limitation, ignorance, culture and social norms, and lack of women empowerment to decide independently. The Khyber Pakhtunkhwa province is passing through a difficult stage in its history as it has been confronted with challenges of extremely fragile law and order situation, large scale human displacements with increased psychological, economic and social deprivations, sufferings and distress coupled with energy crisis, poor governance and debilitated institutional performance, low technological, industrial and revenue base, food insecurity with poor health and nutrition indicators and crippled economy. A lot of potential exists in the form of a physically strong youth workforce, untapped resources, enhanced funding inflow from the National Finance Commission Award and transfer of more autonomy to the province under the 18th constitutional amendment for initiating social development programmes in collaboration with development partners. It is an opportune time for the province to mobilize and utilize the resources in a judicious manner by devising ways and means for initiating nutrition sensitive sector specific technically sound, economically viable and culturally acceptable programmes with an integrated approach of inter-sectoral coordination, communication and collaboration. Lack of resources, ownership, commitment and effective monitoring and evaluation are the major impediments towards achieving the national and internationals targets set in education, health and other social development sectors. Investment in social sectors will promote socio-economic development by enhancing human physical and cognitive capacity with increased productivity, reducing diseases, medical costs and poverty. Improving nutrition has been recognized as a prerequisite for improved quality of life, physical outputs, economic productivity and sustainable poverty reduction. The importance of health, education and improved hygiene–sanitation has been well recognized by all segments of the population and are calling on the Government to enhance budgetary allocations in health, education, water and sanitation and other areas of social development, however, in the backdrop of population explosion and in the existing political system it would take a while to mitigate inequity and injustice and put in place an equitable social system so as to allow economically disadvantaged population both male and female to have priority access or at least equal access to the Government run social sector Page 45 programmes or where the Government may plan and implement safety net programmes for the marginalized population. Promoting child nutrition, girls’ education and women access to health facilities for quality antenatal, postnatal health care, nutrition interventions and safe drinking water, hygiene and sanitation are the areas which need greater attention from the Government and development partners. In general, women are more vulnerable to inequities due to their low levels of literacy, insecurity in remote areas, limited income opportunities, large numbers of children and heavy home management burdens that restrict their participation in developmental activities. Promoting an equitable social system is the key to socio-economic development, improved quality of life and to reduce social problems that have been incurring huge human and financial losses to the country. For Pakistan, to achieve its Millennium Development Goals, improve nutrition and health care it has to adhere to the concept of equity and provide preventive and curative services especially to the marginalized population. 4.2 Coordination, Monitoring and Evaluation No organization alone can deliver its services effectively to meet the basic social needs of marginalized population, achieve the desired goals of reducing malnutrition and to improve the health, nutrition, education, water and sanitation indicators of the country due to disintegrated approaches, limited technical capacity and resources, time constraints, large scattered geographical areas and difficult terrain. Effective communication and coordination among the sectors are vital in complementing efforts and combining the wisdom, knowledge and resources for planning and implementing nutrition sensitive programs in each sector to address the problem of malnutrition more efficiently and effectively. Coordination is the process of synchronization and integration of vertical initiatives and activities within and between sectors to ensure efficient and effective use of resources in pursuit of desired outcomes. Intra and inter-sector cooperation, communication and coordination are needed to tackle the widespread nutrition problems on war footings and reduce the alarmingly high rates of morbidity and mortality in women and children. Coordination requires simultaneous initiation of interventions across different relevant social sectors with strong mutual support, trust and sharing knowledge, skills and resources for joint planning and effective monitoring. Weak Coordination within and across the sectors and lack of good governance, accountability and transparency adversely affects the performance and work outputs of individuals and are some of the factors for poor health and nutrition indicators, unavailability of clean and safe drinking water and inadequate hygiene and sanitation. Establishment of a Provincial Integrated Nutrition Strategy Liaison and Coordination Cell (PINSLCC), constituting of Steering Committee and Technical working Group at Planning and Development Department is a right step towards integrating and coordinating nutrition sensitive programmes by bringing alignment and harmonization among the sectors for addressing malnutrition problems efficiently and effectively. The PINSLCC shall be responsible for overseeing the progress of each sector and provide necessary inputs during the planning, implementation and evaluation phases of the programme. Figure 5 describes the existing structure of social sector departments showing linkages between the different social sector departments. Each department works independently and there is no communication and coordination between the different departments. Each department is unaware of the other’s programs, most of them are engaged in donor driven programmes with multifaceted problems of duplication, inefficiency, ineffectiveness, lack of Page 46 ownership, limited coverage and duration and un-sustainability. There is no central depository for record keeping and program documentation which could be used for guidance and planning new interventions. Figure 5. Existing Structure of Social Sectors Departments ZAKAT, USHR, SOCIAL WELFARE AND WOMEN EMPOWERMENT DEPARTMENT AGRICULTURE DEPARTMENT DRINKING WATER & SANITATION/LOCAL GOVERNMENT DEPARTMENT SANITATION EDUCATION DEPARTMENT PLANNING AND DEVELOPMENT DEPARTMENT HEALTH DEPARTMENT Page 47 Figure 6 shows the proposed coordination framework of Multi-sectoral Integrated Nutrition Strategy where Planning and Development Department has been given a central role of coordination to improve communication and networking between the sectors, facilitate and support all the relevant social sectors in developing and implementing nutrition sensitive programs for improving nutritional status of women and children and to reduce their morbidity and mortality associated with malnutrition. The framework envisages/is based on the principles of collective wisdom, mutual sharing of knowledge and skills, building trust and confidence, team work, equity and judicial use of resources for targeted outcomes. Figure 6. Proposed Coordination Structure in Provincial Multi-sectoral Integrated Nutrition Strategy ZAKAT, USHR, SOCIAL WELFARE AND WOMEN EMPOWERMENT DEPARTMENT AGRICULTURE DEPARTMENT LOCAL GOVERNMENT DEPARTMENTW ATER AND SANITATION PLANNING & DEVELOPMENT DEPARTMENT EDUCATION DEPARTMENT HEALTH DEPARTMENT Page 48 4.3 Nutrition Information System Documentation and information on nutrition related programmes in the province has been one of the challenges since there is no central depository office at the Government level to maintain and keep a record of information on various nutrition programmes being run by the Government and implementing partners. Lack of coordination, communication and sharing of information between the social sectors as well as development partners make it difficult for researchers, planners, policy makers, programme managers for tracking progress on various interventions. Due to nominal budget allocation from the federal and provincial Governments for nutrition, most of the programmes are implemented with the financial, technical and material support of development partners by different organizations and by and large no documentation sharing procedure exists. The Nutrition Information System (NIS) was developed in 2010 for the purpose of tracking community management of acute malnutrition programme performance by the implementing partners who facilitate data transfer with some oversight by UNICEF. There is a dire need of a nutrition surveillance and management information system at the provincial level to monitor and record the nutrition situation and types of nutrition interventions being carried by different organizations. Page 49 Annexure A Page 50 Annexure B Page 51 Annexure C Page 52 Annexure D Minutes of the meeting held on 20-12-2012 on multisectoral integrated nutrition strategy, Agriculture, Livestock and Cooperation Department, Government of Khyber Pakhtunkhwa A meeting was held 0n 20.12.2012 under the Chairmanship of Secretary Agriculture livestock & Cooperation Department. The List of participants is attached. After welcoming remarks, the Chair asked Dr. Parvez Iqbal Paracha Professor & Consultant Multi-sectoral Integrated Nutrition Strategy to brief the forum about the strategy. The consultant presented the draft strategy and informed that nutrition is primary key for socioeconomic development. He informed the forum that in Pakistan malnutrition is increasing day by day and both children and women are badly suffering. The Micronutrients deficiencies in Khyber Pakhtunkhwa are serious, which reduces the immune system leaving the body more susceptible to infection and causing many other diseases like anemia etc. He further added that the basic question arises that how to move forward within the existing system to improve nutritional & health status. He also informed that malnutrition is outcome of multiple factors which requires coordinated efforts from multiple sectors to combat malnutrition. Health Sector alone can’t fight against all the social determinants of malnutrition. For sustainability, efficiency, scalability and effectiveness all vertical nutrition programmes need integration and coordination with a strong political support and commitment. The consultant also presented the strategy outlines and plan of action for Agriculture Sector regarding enhancement of food security and nutritional improvement of the population The Chair highlighted the various interventions and efforts of this Department to improve the food security situation in Khyber Pakhtunkhwa. The Chief Planning Officer highlighted the objectives of important ongoing projects. The concerned Head of Attach Departments (HADs) also shared their viewpoint pertaining to subject matter. After detail discussion the Chair agreed with the following proposal to the extent mentioned against each: Strategy Plan of Actions Responsible Department Improving Nutrition through: Home/Kitchen Gardening Selection of one district as a pilot (Model District) district, mapping and selection of smallholder farmers and distribution of vegetable-fruit seeds and plants free of cost to the farmers with the technical assistance from Farm Services Centre. Developing PC-1 including HRD, BCC, supplies in partnership with donors. The Agriculture Department support the proposal and would provide the technical support through Model Farm Services Centers. Donor would be search by the consultant for activities under home/ kitchen gardening by Multi-Sectoral Integrated Nutrition Strategy. Livestock Raising Selection of one district as a pilot (Model District) district, mapping and selection of smallholder farmers and distribution of chicken, goat, cattle free or on credit with Agriculture Department would provide the technical support through Farm Services Centers and concept paper. The consultant MSINS should Page 53 Strategy Plan of Actions Responsible Department the technical assistance from the Farm Services Centre. Developing PC-1 including HRD, BCC, supplies in partnership with donors. search donor for livestock raising activities Beekeeping Selection of one district as a pilot (Model District) district, mapping and selection of smallholder farmers and distribution of beehives and queens free or on credit through community based organizations with the technical assistance from the Farm Services Centre. Developing PC-1 including HRD, BCC, supplies in partnership with donors. Agriculture Department would provide the technical support through Farm Services Centers and concept paper. The consultant MSINS should search donor for beekeeping. Strengthening Outreach Activities (Awareness, nutrition education, counseling, advocacy, BCCS) Reaching households particularly women for behvioural changes toward improved household dietary practices in general and women and children in particular and promoting healthy lifestyle. The consultant should arrange trainings/workshops at village level. Recruitment of Female Nutrition Workers Enhancing nutrition awareness in women to improve dietary practices and nutrition screening for early identification & treatment of malnourished women and children in rural communities The services of already available experts with Director General Agriculture Research and Livestock &DD Research would be utilized. Value Addition Products and Appropriate Storage and Marketing Enabling environment by facilitating credit facilities, tax exemption on equipment, facilitating exports & encouraging private sector for investment in value addition of agriculture produce i.e., fruits, vegetables, dairy, livestock, cereals, legumes etc. Establishing and finding appropriate markets for the products (on-farm-retail-outlets, grocery stores) The Agriculture Department is already making efforts for value addition of fruits vegetable and livestock under ongoing projects. Improving Livelihood Credit schemes/soft loans to smallholder farmers/jobless youths/households/women through communities based organizations for small businesses i.e., (handicrafts, tailoring, carpentry, dairy, poultry, and livestock) and agricultural inputs. Cooperative Banks in Khyber Pakhtunkhwa is already functioning for provision of credit. Page 54 Strategy Plan of Actions Responsible Department Safety nets/Social Protection Building a transparent and well managed system of safety nets for marginalized population. Poorest of the poor or malnourished households/ senior citizens/disabled/handicapped/oth ers unable to participate in the developmental activities i.e. food stamps/voucher schemes/WIC support programmes Not covered by the mandate of Agriculture Department Promoting milk/meat production Potential exist for investors to invest in dairy and meat value addition and researchers The Department supports the idea. Strengthening monitoring and accountability Establishing strong monitoring and accountability by applying principals of good governance The Department has already evolved its own mechanism for monitoring of activities. Attitudinal change towards responsibility and work (from casual to responsible) Performance based promotions and rewards for hard worker, honest officials will create conducive environment for work Agreed Reduction in Agricultural Inputs Prices Through regulatory measures, improving monitoring, changes in agriculture policy to make it farmer’s friendly policy, improvement in marketing system, provision of subsidy Agriculture Department has recently approved the ten year Agriculture policy/action plan 2012 which would hopefully address the problems of the farming communities. Ensuring timely availability of certified quality seeds, fertilizers pesticides, insecticides, weedicides, equipment, irrigation water, technical services, credit and marketing facilities to farmers Proactive Government role has been envisaged in regulating and facilitating supply of agricultural inputs to farmers by making appropriate agriculture policy, necessary legislations and plan of actions to enhance agriculture production, food security and nutritional status of the population. Agriculture Department shall take a leading role in coordinating and communicating with public and private sectors and farmer associations to achieve the objectives. The subject matter has been covered under Agriculture policy 2102 Enhancing household food availability, accessibility, through Promoting enhanced agricultural production through improved inputs delivery services and Agriculture Department is making efforts with in its available resources to boost Page 55 Strategy Plan of Actions Responsible Department demand creation creating job opportunities for population as well as promoting rural development activities the agriculture production through dissemination of latest technologies. Enhancing household food storage capacity for rainy days i.e., extreme cold weather for hilly areas, natural calamities and others Establishing micro credit schemes for marginalized population Department suggest steel silos for storage of grains in rainy season etc. Improving household food distribution Increasing nutrition awareness of women through outreach activities The services of already available experts with Director General Agriculture Research and Livestock &DD Research would be utilized. Encouraging food diversification in households Increasing nutrition awareness and livelihood opportunities for households The services of already available experts with Director General Agriculture Research and Livestock &DD Research would be utilized. Promoting Research and Development Increasing investment in R&D: Essential for producing new high yielding disease resistant, nutrient rich crops, vegetables, fruits, livestock through new innovation and technologies development Agreed Strengthening Research System HRD, strengthening laboratory facilities, Changing staff recruitment eligibility criteria and promotion criteria, monitoring and accountability. Establishing and strengthening linkages between academia, research, extension, farmers, industry and other stakeholders. Linkages between various stakeholders and capacity building of Research System are agreed. At present Department does not feel any change in existing Eligibility as well as promotion criteria. Strengthening Extension System HRD, changing staff recruitment eligibility criteria and promotion criteria, monitoring and accountability. Establishing and strengthening linkages between academia, research, extension, farmers, industry and other stakeholders. Linkages between various stakeholders and capacity building of Extension are agreed. At present Department does not feel any change in existing Eligibility as well as promotion criteria. Enhancing capacity of Trainings, short and long term Agreed Page 56 Strategy Plan of Actions Responsible Department all pillars of agriculture system courses and establishing liaison with academia, private sector and institutions Enhancing Investment in Agriculture Creating supportive environment for investment Not covered by the mandate of Agriculture Department Promoting Rural Development Agribusiness and capacity development of rural population to enhance household income for diversified balanced diets Agreed Re-orienting Agriculture Services Strengthening monitoring, accountability, performance based appointment, promotions and delegation of powers and responsibility against personal liking and disliking Already discussed and decided Forging alliance between government/ private sector/ implementing partners Increasing communication, cooperation and collaboration through visits and organizing joint nutrition interventions Not covered by the mandate of Agriculture Department Enhancing budgetary allocation for Agriculture i) Seeking political commitment and support of higher management in the planning & Development sections of Agriculture, P&D, Finance and other sectors ii) Eliciting support from donors for nutrition sensitive programmes, human resource capacity and working jointly to combat the menace of malnutrition Enhancement of budgetary allocation for Agriculture sector and donors support for food security would be welcomed Developing an efficient and equitable system of food procurement , storage and distribution Building grain storage facilities in remote far-flung hilly mountainous areas to ensure round the year availability of cereals and other food commodities Not covered by the mandate of Agriculture Department Plugging gap between the resource potential and food production Enhancing food production through exploiting available productivity potential Agreed Conserving agro- Conservation of agro-ecosystem, species and genetic diversity for Not covered by the mandate of Page 57 Strategy Plan of Actions Responsible Department biodiversity enhancing food security. Agriculture Department Establishing and Strengthening Provincial Seed Certification Registration and Analysis Laboratory Regulating seeds import and ensuring good quality certified seeds for increased production and food security. The subject matter has been covered under Agriculture policy 2102 Encouraging Application of Improved Technology for Agriculture Extending credit facility for purchase of agriculture machinery and exemption of tariff on import of machinery. The subject matter has been covered under Agriculture policy 2102 Efficient Management of Agriculture Inputs Efficient use of land and water resources as well as judicious use of agriculture inputs Agreed Creating supportive and enabling institutional and policy environments Supporting farmers at all levels starting from agricultural inputs to marketing of agriculture produce and export The subject matter has been covered under Agriculture policy 2102 Village based community organizations Empowering communities to plan and implement nutrition sensitive activities The subject matter has been covered under Different ADP Projects Strengthening public private partnership Forging alliance for enhancing agriculture production, supply chains, value added and export of agriculture produce Agreed Increase Household Income Generation Essential for reducing poverty and food insecurity. Income generation of households can be increased by promoting homestead activities, agri-businesses etc Agreed In addition to above the following decisions were also arrived at: i) The Director General Agriculture Research System will be the focal person for Multi Sectoral Integrated Nutrition Strategy ii) A technical working group headed by the Secretary Agriculture should be constituted to help the department in technical matters related to nutrition sensitive programmes and assist the Steering Committee and Technical Working Group in Planning & Development department in implementation of “Multi-Sectoral Nutrition Programmes in Khyber Pakhtunkhwa”. The meeting ended with vote of thanks to the Chair. Page 58 Annexure E Page 59 Annexure F Page 60 Page 61 Page 62 Annexure G Page 63 Annexure H Page 64 Annexure I Page 65 Annexure J Page 66 Annexure K Page 67 Annexure L Page 68 Annexure M Page 69