Attachment_J.14_Stakeholder_workshop_report.pdf

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FEBRUARY 26, 2018

This publication was produced for review by the United States Agency for International Development. It was prepared by Management Systems International, A Tetra Tech Company.

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Contracted under Order No. AID-391-C-15-00004

Performance Management Support Contract

DISCLAIMER

This report is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents are the sole responsibility of the Management Systems International and do not necessarily reflect the views of USAID or the United States Government.

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CONTENTS

Acknowledgments .............................................................................................................. v

Acronyms ........................................................................................................................... vi

Executive Summary Drivers of Malnutrition and Stunting in Pakistan Mapping of Nutrition Initiatives Lessons Learned from Nutrition Programming Public Sector Support Gaps in Programming and Ways Forward

Introduction Nutrition in Pakistan

Drivers of Malnutrition and Stunting in Pakistan Limited Access to Food Unhygienic Practices and Conditions Limited Awareness of Nutrition Other Drivers of Malnutrition Stunting…………………………………………………………………………………….8

Mapping of Nutrition Initiatives

Lessons Learned from Programming Increasing Focus on Nutrition Strengthening Research Capacity in Nutrition Multi-sectoral Programming Establishing Nutrition Coordination Forums Collaboration of Industry and Regulators Coordination, Networking, and Liaisons

Public Sector Support Stewardship of the Government Provision of Oversight and Monitoring Support Custodianship of Knowledge and Information Base

Gaps in Nutrition Programming Nutrition-Specific Programming Nutrition-Sensitive Programming Systems Strengthening Monitoring, Evaluation, and Learning Other Suggestions

Annexes Annex 1: Draft Concept Note (Abridged) Annex 2: List of Participants Annex 3: Meeting Agenda

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Annex 4: Keynote Address Presentation Annex 5: Mapping of Nutrition Initiatives in Pakistan

List of Tables

Table 1: List of Participants Table 2: Summary of Nutrition Initiatives in Pakistan

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ACKNOWLEDGMENTS

This report represents a joint effort of many people. Dr. Syed M. Ali Shah facilitated the meeting and authored the report. Monitoring and evaluation specialist Amna Khan deserve special recognition for organizing the consultative meeting, assisting with the report, and all the steps in between.

The team would like to thank all the participants in the meeting and USAID/Pakistan for their invaluable input and advice.

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ACRONYMS

AusAID Australian Aid

CIMMYT International Maize and Wheat Improvement Center (Centro Internacional de Mejoramiento de Maíz y Trigo in Spanish)

CSO Civil Society Organization

DFAT Department of Foreign Affairs and Trade

DFID Department for International Development

EU European Union

FAO Food Agriculture Organization

GAIN Global Alliance for Improved Nutrition

HANDS Health and Nutrition Development Society

IFPRI International Food Policy Research Institute

IYCF Infant and Young Child Feeding

KP Khyber Pakhtunkhwa

LHW Lady Health Worker

M&E Monitoring and Evaluation

MDTF Multi-Donor Trust Fund

PARC Pakistan Agricultural Research Council

PDHS Pakistan Demographic Health Survey

PEEP Punjab Enabling Environment Project

PHNP Provincial Health and Nutrition Program

PINS Pakistan Integrated Nutrition Strategy

RMNCH Reproductive, Maternal, Newborn, and Child Health

SBC Social and Behavior Change

SUN Scale Up Nutrition

TRF+ Technical Resource Facility

UN United Nations

UNICEF United Nations Children’s Fund

U.S. United States

WASH Water, Sanitation, and Hygiene

WFP World Food Program

WHO World Health Organization

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EXECUTIVE SUMMARY

The consultative meeting on nutrition gathered stakeholders from the public and private sectors, local universities, civil society, non-governmental organizations, implementing partners, and international donor organizations to learn from their experiences on five key questions:

1. What are the main drivers of malnutrition and stunting in Pakistan?

2. What evidence-based community- and household-level approaches can contribute to addressing childhood stunting and malnutrition in Pakistan?

3. What are the main nutrition initiatives implemented by donors and Pakistani civil society organization (CSO) partners?

4. What federal- and provincial-level public sector support is available to ensure effective, efficient, and sustainable nutrition programming?

5. Where are the gaps in programming and a potential way forward for the United States

Agency for International Development (USAID) in nutrition programming?

Key findings under each question are summarized below.

Drivers of Malnutrition and Stunting in Pakistan

Participants identified the main drivers of malnutrition as: (1) food insecurity and limited understanding of the importance of a diverse diet; (2) poverty as it relates to the ability to purchase a sufficient quantity and diversity of foods; (3) misconceptions, perceptions, and behaviors regarding nutrition, diet, and healthy practices; and (4) gender inequities in access to food. A variety of factors cause stunting, and the importance of individual factors depends on the context. Chronic malnutrition is one of the causes of stunting. Also, stunted mothers are more likely to give birth to stunted children, and limited availability of the mother as a caregiver—for providing appropriate food, health, and care—to the child can increase the likelihood of stunting.

Mapping of Nutrition Initiatives

Based on the limited information provided, the European Union (EU) has focused largely on Balochistan and Sindh; the United Kingdom’s Department for International Development (DFID) on Punjab and Sindh; and Australian Aid (AusAID) on Balochistan and Khyber Pakhtunkhwa (KP). Nutrition International (formerly the Micronutrient Initiative), Engro Industries, the World Food Program (WFP), the World Health Organization (WHO), and the United Nations Children’s Fund (UNICEF) were key partners for nutrition-specific interventions1 at the national, provincial, and district levels with programming on supplementation, food fortification, social and behavior change (SBC), and anemia reduction. WFP, the Pakistan Agricultural Research Council (PARC), the Food and Agriculture Organization (FAO), Nestlé, the Health and Nutrition Development Society (HANDS), and Abbasi Farms were implementing nutrition-sensitive interventions2 at the national, provincial, and district levels with programming on sensitization; promotion of hybrid seeds; economic empowerment; water, sanitation, and hygiene (WASH); and resilient agriculture. The International Food Policy Research Institute (IFPRI), International Maize and Wheat Improvement Center (CIMMYT), FAO, Mott

1 Nutrition-specific interventions refer to those that address immediate and some intermediate causes of malnutrition (e.g., caring for children).

2 Nutrition-sensitive interventions refer to interventions in other sectors that incorporate nutrition objectives (e.g., interventions to support food security or social safety nets).

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MacDonald, PARC, and the Scale Up Nutrition (SUN) movement were key partners in research and development.

Lessons Learned from Nutrition Programming

Key lessons emerging from participants’ experience in nutrition programming in Pakistan include:

• Both public and private sector stakeholders have a renewed sense of the importance of inter-sectoral nutrition approaches and are more responsive to nutrition-centric programming.

• Although some Pakistani research institutions have international reputations for applied research on nutrition, their capacity for adapting knowledge to practical policy and programmatic actions is weak. With the renewed emphasis on public health nutrition, research institutions are struggling to strengthen their technical capacity and find funding for research to support evidence-based design and implementation.

• The SUN movement in 2013 built recognition for nutrition as a stand-alone programming area of vital importance for development and thus established a firm foundation for focused nutrition programming with a high potential for impact.

• Joint training for industries and regulators has contributed to a mutual understanding of roles, expectations, and challenges, which may lead to improved compliance with food safety, input quality, and mandatory food fortification requirements, which may in turn improve compliance and make it easier to attain nutrition objectives.

• Multi-sectoral approaches to nutrition require good planning, appropriate assignment of responsibilities, tight coordination, and an unwavering focus on nutrition.

• Coordination, networking, and liaisons at various levels are essential for successful program implementation.

Public Sector Support

Working with government may be challenging due to limited technical capacity at lower levels, changing priorities and personnel, and bureaucratic barriers. However, to enhance prospects for sustainable results, it is crucial that development partners work to help government define and achieve its objectives. Provincial Planning and Development departments and nutrition cells are natural partners but will likely need technical support in all phases of the project management cycle. Government will likely need assistance to develop and implement monitoring systems, enhance human resources, and fund activities. Donors may also consider supporting, perhaps through public-private partnerships, information storage and retrieval systems.

Gaps in Programming and Ways Forward

In nutrition-specific programming, participants identified the following gaps and ways to plug the gaps.

• Most nutrition programming ignores adolescents. Operational research to understand the factors influencing adolescent malnutrition could aid in designing appropriate nutrition-specific interventions.

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• Nutrition programs do not pay enough attention to maternal nutrition, which includes the pregnancy and lactation periods. Food supplementation and the establishment of women’s support networks can be incorporated in more nutrition interventions.

• Limited capacity to produce multi-nutrient products locally increases costs and risks breaks in supply. Partnering with local (private sector) pharmaceutical manufacturers to build capacity to produce micronutrient premixes locally for food fortification could reduce costs and risks and contribute to improving access to fortified foods.

• There is no standardized SBC strategy for nutrition. Formative assessments to identify key nutrition messages and communication approaches acceptable to the communities could be commissioned.

In nutrition-sensitive programming, participants noted:

• Parochial multi-sectoral programming approaches are not conducive to coordination.

Development partners should engage with provincial Planning and Development departments to steward multi-sectoral initiatives.

• Pakistan’s capacity to produce fortified foods may not be suitable to meeting needs in a reliable manner because manufacturing facilities are geographically dispersed and include many small facilities, making the industry difficult to regulate. Development partners could support large-scale food fortification programming, perhaps in partnership with the private sector.

• Farmers are not growing a diverse range of crops, which may contribute to limited access to a sufficiently diverse diet. Nutrition-sensitive programming in agriculture could support diversification, especially in poor and remote areas, perhaps through interventions to improve the safe and efficient production of dairy products, poultry and eggs, other animal source foods, legumes, and vegetables.

• Overweight and obesity are growing problems among adolescents and youth. Programming could focus on sensitizing boys and girls, especially in urban centers, through outreach and SBC interventions.

• The nutritional status of residents of urban slums is largely unknown. For example, limited data exist on the number of people living in urban slums, the number of women and children, and ethnic composition—which may be related to migration. Research to assess the extent and dimensions of nutrition in urban slums could aid in designing appropriate programs.

Participants noted the following gaps in systems:

• Redundancies in government policies, strategies, and practices contribute to inefficient programming. Development partners could help government review existing systems and mechanisms, assess system capacities, and develop updated reference documents.

• Limited coordination between extension workers (e.g., in agriculture, health, and social welfare) is a missed opportunity to improve nutrition/health outcomes. Donors could support a nutrition coordination mechanism or forum to foster coordinated programming.

• Pakistan’s private sector is not engaged in nutrition interventions. Donors could use their convening power and technical expertise to strengthen linkages between provincial governments and private sector entities.

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Participants also noted gaps in monitoring, evaluation, and learning. Redundant information management systems within the public sector and stand-alone, intervention-focused information systems within the development sector contribute to a lack of consistent, real-time field data that hampers evidence-based decision-making, a deficiency that donor support for developing a multi-sectoral, online information management system for nutrition could address. Participants also noted the lack of context-specific evidence on nutrition and suggested supporting research to gather evidence from the agriculture, poultry, livestock, nutrition, and health paradigms to enable informed decision-making and effective nutrition program designs.

Other suggestions included: (1) investing in building the capacities of public sector human resources for overseeing programs; (2) addressing the affordability aspects of nutrition through livelihood enhancement programs; (3) supporting the design and implementation of structured SBC strategies and approaches; (4) supporting formative research to determine community needs and acceptable programming approaches; (5) engaging private sector organizations as partners; (6) supporting development of a uniform framework for nutrition programming in Pakistan; and (7) establishing an online nutrition logistics supply management system.

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INTRODUCTION

USAID/Pakistan’s draft concept note for future nutrition programming in Pakistan (Annex 1) emphasizes a multi-sectoral approach involving agriculture and health. Specific interventions will likely focus on nutrition-sensitive programming in agriculture and health aimed at addressing the underlying causes of malnutrition, i.e., focused on prevention rather than cure. The overall strategy is to pilot approaches in limited geographic areas; support monitoring and evaluation (M&E) to facilitate learning; and work with local institutions and partners to adapt effective approaches and lessons learned to other geographic areas.

To validate elements of the concept note and refine its programming strategy, USAID/Pakistan convened a meeting of nutrition stakeholders representing public and private sectors, local universities, civil society, non-governmental organizations, implementing partners, and international donors (see the list of participants in Annex 2 and the meeting agenda in Annex 3) for consultation around five questions:

1. What are the main drivers of malnutrition and stunting in Pakistan?

2. What evidence-based community- and household-level approaches can contribute to addressing childhood stunting and malnutrition in Pakistan?

3. What are the main nutrition initiatives implemented by donors and Pakistani CSO partners?

4. What federal- and provincial-level public sector support is available to ensure effective, efficient, and sustainable nutrition programming?

5. Where are the gaps in programming and a potential way forward for USAID in nutrition programming?

This report first briefly presents elements of the draft concept note as they relate to Pakistan’s nutrition situation and drivers of malnutrition. It then summarizes the results of the consultation organized around the five questions on which the discussion focused.

Nutrition in Pakistan

Pakistan has among the highest malnutrition rates in the world. The prevalence of stunting among children under the age of 5 years is 45 percent, and 11 percent are wasted.3

Although diets can vary greatly by region, cereals constitute the main staple food in the Pakistani diet, providing 62 percent of total energy.4 The link between malnutrition and poverty is well recognized, as is the relative poverty of women and children within a household.5 The poor cannot often afford protein-rich and nutritious foods,6 and their diets consist largely of wheat or rice, while those living above the poverty line incorporate dairy products into their diets—the consumption of fruits, vegetables, fish, and meat is, on average, inadequate throughout the country.7

Food consumption (quantity and diversity) is just one of the multiple factors that affect the nutritional status of the population. Other important influences include morbidity, poor coverage of health services, unhygienic environments, contaminated foods and/or water, and socio-economic factors.8 For example, 3 Pakistan Demographic and Health Survey (PDHS) 2012-13, https://dhsprogram.com/pubs/pdf/FR290/FR290.pdf.

4 “Nutrition Country Profiles: Pakistan Summary,” Food and Agriculture Organization (FAO), http://www.fao.org/ag/agn/nutrition/pak_en.stm.

5 Research and Development Solutions, Key Findings of the National Nutrition Survey (2011).

6 Michelle Jimenez and Maryanne Stone-Jimenez, Preventing Moderate Acute Malnutrition (MAM) Through Nutrition-Specific Interventions (CMAM Forum, 2014), 13.

7 Household Integrated Economic Survey, 2008.

8 “Nutrition Country Profiles: Pakistan Summary,” FAO.

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the national rate of exclusive breastfeeding has remained largely static at around 37 to 38 percent in the past 10 years.9 Socio-economic issues such as land acquisition, dispossession, and disempowerment of tenant farmers by influential feudal leaders come across as obstacles to delivering benefits to the poor through social safety net programs.10

Wasting and infant mortality are more serious nutrition-related problems than stunting. A 10 percent rate of wasting has more serious negative impacts than a 45 percent rate of stunting, as the former confers a high risk of mortality. Moreover, addressing the causes of wasting (morbidity and acute undernourishment) and infant mortality would greatly reduce stunting. The poor health and nutritional status of the mother, inappropriate childbearing practices, and little access to quality health services often cause wasting and mortality during the first year of life. Pakistan’s rates of neonatal (within the first month of life) and infant (with the first year of life) mortality are among the highest in the world and do not reflect the status of a middle-income country. The likelihood of stunting has, to a large extent, already been fixed at the time of birth.

DRIVERS OF MALNUTRITION AND STUNTING IN

PAKISTAN

The root causes of malnutrition are consuming an insufficient quantity or variety of food to meet essential nutritional needs, and disease or environmental factors that may inhibit the body’s absorption, retention, or use of nutrients. The drivers of malnutrition are the factors that contribute to these basic causes. Malnutrition, in turn, contributes to stunting, and the mechanisms through which this occurs are the drivers of stunting. Annex 4 contains the slides from the keynote address which summarize the causes and drivers of malnutrition.

The workshop findings presented in this section suggest that economics, cultural factors, awareness, hygiene practices, sanitation, and care may all contribute to malnutrition.

Limited Access to Food

• Pakistan produces enough food to satisfy the energy requirements of its population. However, problems accessing food leave many with insufficient food or food diversity. Availability of and access to all the necessary food groups are also uncertain. Specific issues vary by region.

• Poverty and affordability are major factors affecting access to food, especially among the poor. Limited purchasing power and its consequences for obtaining a sufficient quantity and diversity of food are drivers of undernourishment11 and malnutrition.

• The market system interferes with signals between food producers and consumers.

Therefore, markets may not provide the diversity and quality of foods (e.g., milk, eggs, legumes, vegetables, and fruits) that well-informed consumers would prefer.

9 PDHS, 2012-13.

10 Aga Khan University, PATH, and Health Partners International, Assignment Report: Preventing Undernutrition Through Multi-Sectoral Initiatives in Pakistan – MQSUN Report (DFID, 2015).

11 Undernourishment refers to insufficient intake of energy to compensate for energy expenditures and conserve health.

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Unhygienic Practices and Conditions

• Unhygienic conditions (e.g., open pools of sewage in the streets and animals around drinking water sources) and practices (e.g., open defecation, poor solid waste disposal, unhygienic cooking practices, and poor personal hygiene) in rural and urban communities contaminate the environment and water supply, increase the incidence of diarrhea, and contribute to malnutrition of all members of the family, especially children. Rural populations in Dadu, for example, get water from hand pumps, which nearby animals often pollute. There are environmental clusters of disease. The problems are universal but worse in rural than in urban areas.

• Gray water disposal systems (e.g., drainage systems within the household and in the neighborhood) and inadequate hygiene facilities (e.g., hand-washing areas and girl-friendly toilets at schools) predispose communities to frequent infections, particularly diarrhea and respiratory tract infections, and consequent malnutrition. Children are most at risk.

Limited Awareness of Nutrition

• Lack of education and awareness of the importance of dietary diversity, or of what constitutes a good diet, and appropriate living habits influences malnutrition. This includes a lack of information or awareness of the nutritional value of different foods, high nutrition value foods, and the importance of hygiene and sanitation.

• Breastfeeding practices in Punjab are worse than those in KP, but access to dairy products for older children and women is poorer in KP than in Punjab. In cities, promotion of milk formulas is reducing the number of women using recommended breastfeeding practices. Behavioral studies on maternal, newborn, and child health in Pakistan suggest lower rates of exclusive breastfeeding among women from upper wealth quintiles in urban areas compared to women from lower wealth quintiles.

• Similarly, false perceptions regarding foods suitable for pregnant women (e.g., hot or cold foods) and a belief that eating less during pregnancy reduces the size of the neonate, enabling easy passage through the birth canal at the time of delivery, illustrate the importance of cultural factors that influence behavior and may adversely affect the nutrition of mothers and children.

• Limited reliable information about nutrition and food safety create space for questionable information (propagated through social media especially) regarding food safety. For example, information that consuming poultry causes hormonal imbalances reduced the consumption of chicken. Because chicken was an important and inexpensive source of protein for pregnant women (mostly in rural areas), this information contributed to malnourishment.

Other Drivers of Malnutrition

• Some studies have found little difference in the incidence of diarrhea in children across household wealth levels. In a rural area of Guatemala, children of mothers who were motivated to engage in income generation activities were more underweight than their counterparts in a traditional group, perhaps because working left the women with less time to care for their children. In Pakistan, rural households with more women able to take care of children exhibited better nutrition results for children. Less care for children may contribute to higher malnutrition, lowered immunity, and a predisposition to frequent illnesses in the child.

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• Early marriages of girls during adolescence, and resulting pregnancies before the age of 21, are associated with malnourishment (and stunting) in both the young mother and her children.

Young mothers with poor dietary intake give birth to underweight and malnourished babies, a condition compounded by multiple pregnancies and inadequate birth spacing.

• Women working during pregnancy and during the lactation period (e.g., in agriculture) experience a higher rate of stunting in their children. This is attributable to a lack of sufficient caloric intake to compensate for the activities in the field. Furthermore, children under five years of age are at risk of malnutrition due to the unavailability of a care provider at home. This may imply that getting more help for mothers (e.g., support in care and feeding of the child while the mother is working) may be useful in addressing stunting.

Stunting

Stunting has several causes. A healthy and well-nourished mother is more likely to produce healthy and well-nourished babies. A sick and malnourished pregnant woman is more likely to give birth to a child predisposed to being stunted. These stunted children may also suffer from mental and emotional impairments as a consequence of the same limiting factors. Consequences of general neglect affect the adults and the well-being of families, communities, and nations.

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MAPPING OF NUTRITION INITIATIVES

Participants provided information about their general nutrition-related activities but few gave details about the specific interventions or geographic areas in which they were working.

• Geographically, the primary areas of interest for key donors’ nutrition programming include: (1) the EU in Balochistan and Sindh; (2) DFID in Punjab and Sindh; and (3) AusAID in Balochistan and KP.

• UN agencies such WHO, UNICEF, WFP, and FAO are providing technical assistance and capacity building to federal and provincial governments to strengthen the existing public service delivery systems. They also support other projects in various parts of the country, including Azad Jammu and Kashmir, as part of emergency programs and/or larger national-level programs.

• Nutrition International and Mott MacDonald, both with DFID support, are the key players working in food fortification programming, both at the national level.

• FAO is working on nutrition-sensitive agriculture and resilient agriculture programming at the national level.

• Nutrition International and WFP are supporting nutrition work by the SUN Alliance and the SUN Secretariat, respectively.

• WFP, WHO, Nutrition International, and UNICEF are engaged in nutrition-specific programming focused on acute malnutrition, micronutrient supplementation, anemia reduction, and the prevention of wasting and stunting.

• PARC, WFP, HANDS, Nestlé, and Abbasi Farms are other stakeholders engaged in nutrition-sensitive programming focusing on areas as diverse as promoting hybrid seeds, livelihood programming for economic empowerment, and WASH interventions (focused on clean drinking water, disposal of gray water, waste management, and promoting hygiene).

• UNICEF works with schools to promote health and hygiene practices aimed at overcoming illnesses that lower the immune status of the child (such as diarrhea and respiratory tract infections), confounding factors in malnutrition.

• CIMMYT and Harvest Plus are working on breeding, testing, and disseminating varieties of zinc-enriched wheat.

• IFPRI is working on a food and nutrition security strategy with the government of Punjab.

Annex 5 provides additional detail.

LESSONS LEARNED FROM PROGRAMMING

This section consolidates information from participants’ programming experiences to draw out lessons learned to inform USAID’s program design.

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Increasing Focus on Nutrition

Nutrition was traditionally considered an offshoot of health programming in Pakistan. However, the efforts of programs such as Global Alliance for Improved Nutrition (GAIN) and international movements such as SUN have brought the issues of malnutrition, wasting, and stunting to the forefront, and have succeeded in building recognition for nutrition as a stand-alone programming area of vital importance for development. Both public and private sector stakeholders within Pakistan now recognize the importance of nutrition and are more responsive to nutrition-centric programming.

Strengthening Research Capacity in Nutrition

Research capacity—in particular, operational, applied, and exploratory research capacity—in Pakistan is below international standards. Institutions treat research as a means to publication, which is not necessarily consistent with applied research to generate evidence to inform policy and practice.

Additionally, as nutrition has recently been mainstreamed as a key development issue, researchers and research institutions are struggling to find funding and technical expertise to explore practical issues about how to apply nutrition knowledge to policies and programs.

Multi-sectoral Programming

Multi-sectoral programming in Pakistan had been limited to coordination meetings and occasional information sharing. However, donors and implementers in the country have realized that the parochial approach to multi-sectoral programming may not be effective. They are, therefore, beginning to design programs not only in consultation with and engagement of private sector partners but also in collaboration with other donors and public sector offices and line departments. This approach has evolved to garner better support from the respective sectors, promote participatory governance, encourage ownership, and enhance prospects for sustainability and continuity. Participants emphasized that multi-sectoral nutrition programs may be difficult to coordinate—someone must assume that role—and must remain focused on nutrition.

Establishing Nutrition Coordination Forums

In the past, nutrition programming was a secondary component of mainstream maternal and child health programs in Pakistan as there were no forums available to sensitize key influencers and decision-makers.

Over the past five years, Pakistan has made appreciable strides in the nutrition sector, with the incorporation of the SUN movement in 2013. Since then, under the auspices of the Government of Pakistan, a national task force on early childhood development has been established at the National Planning Commission; national and provincial fortification alliances have been established; and the Civil Society Alliance has been expanded to include 129 CSOs. Additionally, the Academia and Research Network has been strengthened by the participation of 45 universities. The foundations are thus in place for focused nutrition programming with a high potential for impact.

Collaboration of Industry and Regulators

The void between industry and regulators has always antagonized productivity and efforts toward quality control and compliance with standards. However, the recent joint training of industry and regulators has seen a shift toward the mutual understanding of roles, expectations, and challenges, with the private sector realizing that regulations bestow benefits as well as costs.

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Coordination, Networking, and Liaisons

Donor agencies and development partners generally adopted a “top-down” coordination approach to engage public sector offices in the past. However, following the devolution of powers to the provinces, and greater emphasis on results-oriented programming, partners have learned that successful program implementation requires coordination, networking, and liaisons at various levels. Donors and partners should:

• Maintain coordination at the federal and provincial levels, while program implementation and design-related matters should engage the district management or implementation teams.

• Network with key influencers and decision-makers from the public and private sectors to ensure appropriate support, facilitation, and ownership during implementation.

• Maintain liaisons with key technical institutions, including academia, research entities, and knowledge banks to ensure access to technical assistance to ensure a strong information and knowledge base for program design and implementation.

PUBLIC SECTOR SUPPORT

This section summarizes participants’ experiences working with government. It highlights the role government has played, challenges involved with working with government, and participants’ perceptions of the role government should play.

Stewardship of the Government

Government officials at the federal and provincial levels have played a pivotal role in raising awareness of malnutrition, wasting, and stunting by supporting and endorsing the reform efforts of donors, implementing agencies, and other champions of change. National, provincial, and district government offices have facilitated donor-funded nutrition initiatives across the country, with a clear national direction in line with global targets, and a rich patronage to support nutrition initiatives. It is essential to ensure continued engagement, participation, and leadership from the Planning and Development departments (in design) and the provincial nutrition cells (during implementation); to establish and manage partnerships between the public and private sectors; and to engage during the assessment, planning, and design phases of nutrition programming.

Provision of Oversight and Monitoring Support

An essential role of the government at the federal and provincial levels is to provide oversight and support in monitoring program implementation in the field. Public sector officials have provided valuable field monitoring support by visiting program implementation sites wherever possible. However, due to a lack of updated, efficient, online M&E and information management systems; multiple responsibilities;

limited allocations for fuel and logistics; and limited human resource availability, it is not possible for government to monitor all programs. Additionally, the provinces do not have a sanctioned mechanism for coordination across sectors. With several sectors devolved to provinces and others retained at the federal level, coordination between the center and the provinces has also become more complex.

Therefore, essential support requirements for the public sector include advocating for a regular intersectoral coordination meeting at the provincial level, optimized decision support systems that

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include efficient and systems-driven monitoring, increased human resources or outsourcing of services, and availability of resources to undertake field monitoring across programming areas.

Custodianship of Knowledge and Information Base

Reports, data sets, and evidence generated through nutrition programming in Pakistan are already scant, while the lack of knowledge banks and information hubs further compounds the situation for program designers and developers. The government does not have the capacity to undertake a commitment to establish or manage knowledge banks and information hubs, despite its expressed resolve. Such centers for information storage may be supported by donor funding, corporate support, or both, while the public sector may be strengthened through the provision of trained human resources. Once established, these resource centers can support donors, implementing agencies, the corporate sector, media, and CSOs to access information regarding nutrition programming and the overall situation in the country.

GAPS IN NUTRITION PROGRAMMING

This session focused on identifying gaps in nutrition programming in Pakistan and documenting participants’ suggestions for programming to fill gaps.

Nutrition-Specific Programming

Nutrition Interventions for Adolescents (Boys and Girls)

There is a need for adolescent-specific nutrition programming targeted to girls and boys, along with nutrition-specific programming for women of reproductive age, the elderly, disabled, and young men.

Evidence is limited regarding the factors influencing malnutrition among adolescents, and research may be required to determine how best to intervene.

The way forward: Operational research to explore the drivers of malnutrition among adolescents, culminating in nutrition-specific interventions for the adolescents.

Mainstreaming Maternal Nutrition

Maternal nutrition is often overlooked when designing nutrition programs; particularly for supplement-centric programs, maternal supplementation (during pregnancy and lactation) does not get the needed attention. Micronutrient supplementation of iron, folic acid, and calcium have been recognized as important for maternal and child well-being, particularly during pregnancy and lactation, but there are also many other nutrients that are essential for mothers to transfer to their children during pregnancy and through breast milk; this is a safer and more natural manner to improve infant nutrition. However, it must be remembered that women who are malnourished at the time of birth—or during childhood or adolescence—find it difficult to catch up lost nutritional ground and often exhibit stunting.

The way forward: Mainstream maternal nutrition and consider gender relations across all sectors— agriculture, SBC, nutrition/health, and M&E—to ensure that gender is considered in every aspect of programming, from planning to implementation to monitoring. Food supplementation for pregnant and lactating women should be included in nutrition interventions. Activities may include information around a balanced diet and food diversity. This should be accompanied by nutrition education and counseling to improve the nutritional status of women during pregnancy.

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Local Multi-Nutrient Production Capacity

Local production capacity for multi-nutrients is poorly developed. This creates a gap in the availability of affordable, locally produced multi-nutrient products in the market.

The way forward: Stakeholders may be engaged for a focused intervention to develop local products (such as micronutrient premixes to be used in food fortification) that are low-cost and readily available across the country. Partner with local, private sector pharmaceutical manufacturers to begin producing micronutrient premixes for food fortification and supplements aimed at specific groups of the population.

Standardization of SBC in Nutrition

There are no standardized national guidelines for SBC strategies regarding nutrition. Target audiences, key messages, and communication approaches are not standardized.

The way forward: Formative assessments to identify key nutrition messages and communication approaches acceptable to the communities should be commissioned. These messages and evidence-based approaches should be incorporated into national SBC guidelines and adapted for all sensitization and awareness programming.

Nutrition-Sensitive Programming

Multi-Sectoral Programming

Nutrition-sensitive activities are not truly integrated with other thematic areas, e.g., health, food security, WASH, and education. The current parochial approach needs to be replaced with multi-sectoral initiatives. However, nutrition outcomes should remain the primary focus.

The way forward: Engage with the Planning and Development departments at the provincial level to design multi-sectoral initiatives, as they have functional coordination mechanisms in place to mobilize the various sector-specific resources, such as from health, nutrition, education, WASH, social welfare, agriculture, and livestock.

Mass Fortification of Foods

Mass food fortification may have potential in Pakistan, especially for those groups that consume products manufactured by formal industries, such as vegetable oils and fats. Fortification of wheat flour, although potentially difficult because of the geographic dispersion and size—including many small mills—of the milling industry, might be useful to support social programs where fortified flour is distributed to vulnerable families. Although fortification of oils and fats—a less diverse industry—is required by standards in Pakistan, compliance is low. Bottlenecks in fortification are associated with limitations on inputs and production technology, and large and dispersed industries that are difficult to oversee for compliance (e.g., wheat milling). Efforts in this area are ongoing, but much more is needed.

The way forward: Support critical analysis of the role and potential of large-scale food fortification programming and adjust projects as required.

Biofortification

Biofortification increases the nutritional content of foods during the production stage through agronomic practices, selective breeding, or biotechnology. PARC, in collaboration with Harvest Plus and

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CIMMYT, developed and released a zinc-fortified wheat variety in Pakistan during the 2015–2016 season. However, more fortified varieties are needed to reach larger segments of the population and existing fortified varieties need to be disseminated more widely.

The way forward: Support PARC to build the capacity of research institutions to develop biofortified crops (e.g., wheat and rice). Engage provincial line departments for multiplication and dissemination.

Crop Diversity

Programs focused on increasing agricultural production have largely ignored crop diversity because they have focused instead on energy provision (wheat and rice) and cash crops (sugar cane and cotton).

Emphasizing the production of crops that contribute most to household income may be appropriate in areas with well-developed markets but is less so when local markets do not provide the necessary quantity or diversity of foods. In these circumstances, it may be more appropriate for farmers to diversify their production to meet the nutritional needs of their household and community.

The way forward: Collaborate with research institutes and academia to support research that generates evidence on diversified crop production, trade, and consumption. Incorporate an emphasis on diversified local production of nutritious foods in nutrition-sensitive programs that work with farmers, especially in areas such a south Punjab and Balochistan, where agriculture is a marginal enterprise and there is little donor-funded nutrition programming.

Overweight and Obesity in Adolescents and Youth

Nutrition programs in Pakistan have not focused on overweight and obesity. Particularly in adolescents and urban youth (both male and female), obesity is an increasing risk, and statistics are available on its prevalence.

The way forward: Use outreach and SBC to sensitize young boys and girls to the dangers of overweight, obesity, physical inactivity, and risky living habits. Focus interventions in urban centers.

Sensitization activities should focus on balanced diets, healthy foods, and lifestyle modifications.

Universities, colleges, and schools may also be targeted for behavior change. However, research is needed to understand the extent of the problem and potential approaches.

Nutrition in Urban Slums

Although some have speculated that malnutrition and stunting constitute a major nutritional issue among women and children in urban slums, there are no statistics or data available to quantify the extent of the problem. Research to explore the extent of the problem—and its dimensions relative to gender, age, ethnicity, migration, and other factors—could aid in designing appropriate programs.

The way forward: Support research to assess the nutritional status of women and children in urban slums, aimed at collecting credible evidence to quantify the problem and to facilitate program design.

Potential programming might include food supplements, SBC or awareness/sensitization, and economic empowerment and livelihood interventions.

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Systems Strengthening

Redundancies in Policy, Strategy, and Practices

Pakistan has no coordinated community engagement strategy or standard operational guidelines for SBC and community-based programming. Without a clear results framework12—with specific time-sensitive output, outcome, and impact objectives and performance indicators at the provincial level feeding into an overall national framework—nutrition programming priorities and interests of the government in terms of desired change remain undefined. This has led to considerable variation in implementation of awareness and sensitization interventions, duplication of efforts in the field, and wastage of resources for nutritional programming. There is a need to develop a clearly defined direction for nutritional programming in Pakistan and identify the trajectory of change that the federal and provincial governments anticipate. There is a need for continued focus on policy interventions while working with government counterparts at various levels.

The way forward: Support the provincial Planning and Development departments to undertake a robust review of existing systems and mechanisms of the provincial nutrition cells, assess the capacities of the system and its operators, and develop an updated reference document. This should include policy (including the theory of change, the trajectory of change, and the pathways of change), strategy (with a well-defined results logic and indicators), and an implementation plan. Assist government to develop policies where they do not exist and, when they do exist, develop initiatives to increase the capacity of government managers to effectively utilize available resources.

Coordination of Extension Activities

There is a need to leverage the community connections of the various cadres of extension workers (e.g., lady health workers [LHWs], agriculture extension workers, and social welfare teams) to promote nutrition-specific and nutrition-sensitive messages and good practices at the community level. However, there is no coordination mechanism to ensure functional integration and linkages between the outreach program components of the departments of health, agriculture, and social welfare. Coordinated effort of the three departments could enhance impact, e.g., LHWs promoting dietary diversity and agriculture teaching.

The way forward: Support a coordination mechanism at the national and provincial levels to bring the health, agriculture, and social welfare decision-makers together. Focus on eliminating redundancies, promoting coordinated efforts in the field, and facilitating functional integration to enhance prospects for impact. This may require advocacy for initial mobilization.

Private Sector Engagement in Nutritional Programming

There is a need to harness the potential of the private sector to promote nutrition interventions, in particular those that require a manufacturing partner or industry (such as food fortification, micronutrient powders, ready-to-use therapeutic foods, and ready-to-use supplemental foods). Private sector interventions focusing on behavior change, WASH, and nutrition—but lacking innovative or evidence-based approaches—are being implemented as part of corporate social responsibility programs in scattered locations, with no coordination or linkages to development programming or government strategies in the same or parallel locations.

12 Although workshop participants did not discuss this issue, it is important to consider whether results frameworks should be national or province-specific. The former will contribute to a coordinated and common approach to community engagement and SBC. However, regional contexts and differences in the capacities of provincial governments may make provincially specific results frameworks more relevant and effective. A common practice is to develop province-specific results frameworks that feed into a national-level framework.

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The way forward: Support the provincial Planning and Development departments to strengthen their capacities to enable efficient identification, mobilization, and engagement of the private sector—through public-private partnerships—to support, implement, and supplement nutrition-specific and nutrition-sensitive interventions. Furthermore, the private sector may be engaged in collaboration with public sector technical expertise to (1) produce safer fortified products, (2) adopt environmentally friendly practices, and (3) deliver cost-effective alternates to existing expensive products.

Monitoring, Evaluation, and Learning

Information Management Systems

Both public and private nutrition stakeholders are collecting a great deal of data from the field regarding nutrition-specific and nutrition-sensitive interventions.