May 2010 Edited Version

DIR & SWAT – NWFP RAPID ASSESSMENT REPORT

FOOD SECURITY & LIVELIHOODS WATER, SANITATION & HYGIENE NUTRITION

MARCH 2010

EXECUTIVE SUMMARY Kabal and Khwazakhela in Swat) and in IDP settlements (Munda and Samarbagh in Lower Dir). These are linked to broad asset depletion at the time of the conflict and poor to minimal recovery to‐date, depending on the BACKGROUND area. Markets have substantially recovered, with pre‐ crisis trade flows of major commodities restored and From mid‐2008, in response to the militancy surge in systems of credit and procurement largely intact. its north‐western region, the Government of Pakistan Market activity remains dampened however by low scaled up its security forces offensive across the demand from buyers (who are still constrained by Federally Administered Tribal Area (FATA) and in income) and lack of cash for reinvestment in Malakand Division of North West Frontier Province businesses, in particular among small rural traders. In (NWFP). The insecurity triggered by the conflict led to addition 78% of food commodity dealers report being the largest population movement recorded in the affected by ongoing free food distributions. Market country since the partition of India in 1947 with over activity overall is fuelling recovery by supporting 2.7 million civilians from NWFP and FATA officially employment and the movement of food commodities, displaced at the height of the conflict. cash crop and labour into and out of the area. The rapid market assessment was conducted in winter This rapid assessment sought to evaluate Nutrition, when activity generally slows. It is likely that the arrival Water, Sanitation & Hygiene (WaSH) and Food‐ of summer and the harvest of the Rabi winter wheat Security & Livelihoods (FSL) needs across key conflict‐ crop will provide fresh cash infusion into the local affected areas of three adjoining districts of Malakand economy and reinvigorate systems. Division – Swat, Lower Dir and Upper Dir – nearly one year after the end of security forces operations in the Until then, livelihoods recovery is likely to be poor zone. unless significant support continues to be extended by humanitarian actors. Findings suggest that the The areas assessed were either directly affected by restoration of lost, looted or liquidated livelihoods operations, served as transit and host areas in 2009 or assets has been slow, with 18% of lost assets are currently serving as transit and host areas for recovered to‐date. The most rapid recovery is Bajauri IDPs in the wake of ongoing security forces observed in the return areas of Matta, Kabal and operations in FATA. Khwazakhela (Swat) with 22‐26% of lost holdings recovered. Recovery has failed in the return area of Maidan (L Dir) with just 3% of lost assets recovered to‐ METHODOLOGY date. Losses of assets in Maidan were roughly double those suffered in other assessed regions. The delayed 91 villages and settlements across 19 Union Councils in recovery is attributed to an acute depletion in Swat, Dir Lower and Dir Upper were assessed from 1st th household income sources combined with the relative to 14 February 2010. Seventeen enumerators isolation, poverty and continuing insecurity of some organized into sector‐specific teams carried out field areas. Female livelihoods in tailoring and data collection, led by team leaders and sectoral processing/sale of animal products have also been lost, managers. with 71% of communities now lacking opportunities for female livelihoods compared to 36% pre‐crisis. A mix of primary and secondary information sources Income portfolios have become more diverse out of and methods was used. Secondary sources included necessity, with remittances, various forms of income meetings at Province/District/UC and community level support (zakat, aid) and asset sales figuring with PaRRSA, DCO/ACO, EDOs, UN Agencies, ICRC and prominently. An estimated 35% of households rely on local and international NGOs. Primary sources and remittances, either national or foreign. Most of the methods included Key Informant Interviews, Focus new credit being sourced today by households is used Group Discussions (FGD), Household Interviews, to cover food and health‐related needs rather than Observation, Water Quality testing, MUAC screening asset restoration. and rapid Market Assessment. The bulk of sampling methods were non‐random as significant constraints Local social networks and food distributions have to primary data collection were faced on the field. supported the food security of the most vulnerable populations in recent months with gifts, sharing and FINDINGS borrowing of food contributing 32% of all sourced food. While overall dietary diversity was found to be Food security and livelihoods (FSL): Overall significant adequate, a small minority of the population (12%) livelihoods‐related needs were observed across return areas (Lal Quilal and Adenzai in Lower Dir; Matta,

across IDP, returnee and stayee1 groups is especially magic and poor awareness of and access to existing vulnerable to food insecurity by their reliance on therapeutic nutrition programs. precarious food sources and unsustainable and damaging coping strategies. Knowledge and attitudes of medical and paramedical staff generally were found lacking in nutrition. Gaps Overall the analysis of findings reveals IDPs and were observed with regard to staff knowledge on returnees to be the most highly vulnerable groups. breastfeeding practice, maternal nutrition and proper Outstanding gaps and needs in FSL include: 1/ identification and referral of malnutrition cases. Cost restoration of farm and off‐farm livelihoods and food of injectable medications in therapeutic nutrition security of vulnerable stayee and returnee households, programs in Swat and Lower Dir is serving as a 2/ recovery of female livelihoods, 3/ enhancement of deterrent to treatment and a reason for default among income generating activities among IDP households, 4/ poor households. rehabilitation of vital community infrastructure, and 5/ revitalization of small businesses. Outstanding gaps in Nutrition concern 1/ the capacity of District‐level therapeutic nutrition programs to WASH: Water, sanitation and hygiene related needs provide adequate treatment according to accepted were identified, and these were generally greatest in standards, 2/ the capacity of local medical and rural areas of Lower Dir. The major problem was paramedical staff to support communities, pass health recognised as a lack of dry season water with 41% of and nutrition messages and refer cases, and 3/ the water sources providing insufficient yields during that knowledge base at community level. period. There were also some water quality issues, but bacteriological contamination was usually in the low or Rapid MUAC screening among surveyed host and medium range despite 53% of water points being displaced populations in Lower Dir show malnutrition unprotected. prevalence currently below emergency threshold (0.4% SAM and 3.2% GAM). Open defecation was widely practiced and 38% of visited communities had very low latrine coverage. Most vulnerable zones: Lower Dir district and Hand washing was widely practiced, but only 14% of specifically the areas affected by conflict in 2009 people washed their hands with soap after defecation. (Maidan, Adenzai) and those currently serving as host Latrine facilities were also limited in schools and health and transit areas to Bajauri IDPs (Samarbagh, Munda) structures with 16% of visited schools %and 25 of have the greatest needs, are experiencing the slowest visited Basic Health Units having non‐functioning or recovery and tend to be most underserved among the non‐existent latrines. assessed zones.

Although a high incidence of scabies was noted, emergency WASH needs were not observed during the assessment. However at the time of the assessment the emergency needs were considered dormant as key informants described them as being likely to recur. During the previous year there had been seasonal cholera outbreaks and water scarcity as well as major IDP influxes.

Nutrition: Community knowledge and practices around infant feeding are suboptimal on breastfeeding, use of breast milk supplements and introduction of complementary foods. Knowledge of nutrition, especially the nutritional needs of infants, young children and pregnant and lactating women, is low. Cultural practices around meal order and food restrictions will tend to exacerbate the nutritional vulnerability of these groups. The high levels of psychosocial stress reported among displaced and stayee populations is likely to further negatively affect maternal milk production and breastfeeding practice. There is a widespread belief in malnutrition as black

1 Stayee: population left “stranded” within the areas of conflict

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RECOMMENDATIONS The WASH recommendations involve a dual approach to address the ongoing and the emergency needs of The findings in FSL suggest an approach the area. It is recommended to rehabilitate and addressing the need for broad economic improve small scale rural water projects, to mobilise recovery in the affected areas coupled with communities to implement household latrines and to the provision of targeted support to very improve both water and sanitation facilities in vulnerable populations. Recommended institutional structures. All this should be underpinned activities involve cash‐based support for asset with hygiene promotion. Emergency needs should be restoration including restocking as addressed through the pre‐positioning of key material, appropriate, cash‐for‐work schemes, capacity building of local actors and the development revitalization of small business through cash of an emergency response plan in collaboration with grants and support to female livelihoods such local authorities and local partners. as tailoring and embroidery. To enable emergency alert and response among The needs identified in Nutrition suggest an approach vulnerable stayee, returnee and displaced organized around i) enhanced CMAM implementation populations, including across newly accessible through capacity building at primary, secondary and zones in FATA, it is recommended to carry out district level, ii) nutrition and health education surveillance of the underlying food security promotion at community level, and iii) nutritional situation on a series of pre‐identified surveillance of identified vulnerable populations and indicators on regular or ad hoc basis. This zones. A baseline nutrition survey to launch should be done following the upcoming Rabi surveillance activities is needed to pinpoint areas and harvest and according to new population populations at higher nutritional risk. movements likely to occur across host, transit and return zones.

iv TABLE OF CONTENTS

Executive Summary ...... ii List of Abbreviations ...... vi List of Figures ...... vii List of Tables ...... viii A. Introduction ...... 9 A.1. Background ...... 9 A.2. Objective ...... 9 A.3. Map of the surveyed area ...... 10 B. Methodology ...... 11 B.1. Study team and sites ...... 11 B.2. Sampling approach ...... 12 B.3. Methods and tools ...... 13 B.4. Constraints ...... 16 C. Findings ...... 17 C.1. Findings Food Security & Livelihoods (FSL) ...... 17 C.2. Findings Water Sanitation & Hygiene (WaSH) ...... 35 C.3. Findings Nutrition ...... 45 D. Conclusion ...... 55 D.1. General Perspectives ...... 55 D.2. Food Security & Livelihoods ...... 55 D.3. WaSH ...... 56 D.4. Nutrition ...... 57 E. Recommendations ...... 59 E.1. Type of interventions proposed ...... 59 E.2. Priority geographic areas ...... 63 E.3. Target groups ...... 63 ANNEX 1 ...... 64 ANNEX 2: Survey Instruments used for the assessment ...... 74

LIST OF ABBREVIATIONS

Acronym Definition BHU Basic health unit CLTS Community Led Total Sanitation CMAM Community‐Based Management of Acute Malnutrition CSI Coping Strategies Index DCO District Coordination Officer DHQ District Headquarters Hospital EDO Executive District Officer EPI Extended Program of Immunization FATA Federally Administered Tribal Areas FGD Focus Group Discussion FSL Food security and livelihoods GAM Global Acute Malnutrition HDDS Household Diet Diversity Score HH Household ICRC International Committee of the Red Cross IDP Internally Displaced Person IEC Information, Education, Communication LHS Lady Health Supervisor LHV Lady Health Visitor LHW Lady Health Worker MT Medical Technician MUAC Mid Upper Arm Circumference NGO Non ‐governmental organization NWFP North West Frontier Province OCHA Office for the Coordination of Humanitarian Affairs OTP Outpatient Therapeutic Program PaRRSA Provincial Reconstruction, Rehabilitation and Settlement Authority, NWFP PDMA Provincial Disaster Management Authority PHED Public Health Engineering Department PLW Pregnant and lactating women PHRP Pakistan Humanitarian Response Plan PRCS Pakistan Red Crescent Society RHC Rural Health Centre RWSSP Rural Water Supply and Sanitation Program SAM Severe Acute Malnutrition SFP Supplementary Feeding Program SRSP Sarhad Rural Support Program TBA Traditional Birth Attendant TMA Town Municipal Administration UC Union Council WASH Water, Sanitation and Hygiene WFP World Food Programme WHO World Health Organisation

LIST OF FIGURES

Figure 1: Methodology MUAC screening ...... 14 Figure 2: Profile of Focus Group Discussions (FGD) ...... 14 Figure 3: Profile of Medical & Paramedical Staff interviewed ...... 15 Figure 4: Community profile by settlement status ...... 17 Figure 5: Household composition ...... 18 Figure 6: Supply chain of food commodities at crisis time and currently ...... 20 Figure 7: Constraints faced by traders for increasing turnover ...... 22 Figure 8: Sources of food ...... 23 Figure 9: Sources of food by settlement status ...... 24 :Figure 10 Household Dietary Diversity Score (HDDS) ...... 25 :Figure 11 Share of households having micronutrient‐rich diets...... 25 :Figure 12 Changes in income sources ...... 26 :Figure 13 Extent main source of income was affected ...... 27 :Figure 14 Natural asset loss & recovery ...... 28 :Figure 15 Physical and financial asset loss & recovery ...... 29 :Figure 16 Availability and access to credit ...... 30 :Figure 17 Uses of new loan ...... 30 :Figure 18 Strategies employed in the last 7 days to manage food shortage ...... 31 :Figure 19 Coping Strategies Index (CSI) ...... 31 :Figure 20 Sources of female livelihoods ...... 32 :Figure 21 Constraints to resuming livelihood activity (male) ...... 33 :Figure 22 Community priorities ...... 34 :Figure 23 Current water sources by percent of usage ...... 35 :Figure 24 Dry season water sources by percent of usage ...... 36 :Figure 25 Number and percent of morbidity cases by district, WHO source ...... 37 :Figure 26 Type, number and percent of water schemes visited ...... 38 :Figure 27 Levels of bacteriological contamination per water scheme visited ...... 39 :Figure 28 Location, type and number of 'medium and highly contaminated' water sources ...... 39 :Figure 29 Water sources yield 'Dry Season' ...... 40 :Figure 30 Water systems management responsibilities ...... 41 :Figure 31 Latrine coverage: percent of visited sites with percent of coverage ...... 42 :Figure 32 Washing frequency per week in adults and percent of villages with washing frequency per week ...... 42 :Figure 33 Water supply in schools ...... 43 :Figure 34 Latrine coverage in schools ...... 43 :Figure 35 Water supply in BHUs ...... 44 :Figure 36 Latrine coverage in BHUs ...... 44 :Figure 37 Knowledge, attitudes & practices towards malnutrition among community and med/paramed staff ...... 47 :Figure 38 Attitudes towards meal order among medical and paramedical staff ...... 48 :Figure 39 Prevalence of infant feeding practices ...... 49 :Figure 40 Medical and paramedical staff knowledge and attitudes on infant feeding practices ...... 50 :Figure 41 Frequency of psychosocial stress indicators ...... 51 :Figure 42 Psychosocial Stress Index by settlement group ...... 51 :Figure 43 Referral of psychological cases ...... 52 :Figure 44 Facility Level Health Hierarchy ...... 73 :Figure 45 Provincial Level Health Hierarchy ...... 73

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LIST OF TABLES

Table 1: Population figures across survey zone by district and Union Council ...... 10 Table 2: Assessment locations ...... 12 Table 3: District and Tehsil‐level Health Facilities visited ...... 15 Table 4: Assessment zone classification ...... 17 Table 5: Seasonal calendar of activities ...... 19 Table 6: Changes in access to trader credit ...... 20 Table 7: Impact of food aid on wholesale and retail commodity dealers...... 22 Table 8: Profile of household diets by diversity tercile ...... 24 Table 9: Estimated share of households receiving remittances* ...... 26 :Table 10 Asset recovery as a % of lost or damaged assets ...... 27 :Table 11 Percent decline in credit access by source ...... 29 :Table 12 Services available by Health Facility (tertiary & secondary care level) ...... 46 :Table 13 Summary of rapid screening results...... 53 :Table 14 Results of the rapid screening displayed by geographic units ...... 54 :Table 15 Results of the rapid screening displayed by residence status ...... 54 :Table 16 Results of the rapid screening displayed by gender ...... 54 :Table 17 Consolidated vulnerability ranking of settlement groups by FSL indicators ...... 56 :Table 18 Field data collection detail ...... 64 :Table 19 Number of trader interviews by business type ...... 64 :Table 20 Asset losses by zone and asset type...... 65 :Table 21 Asset recovery by zone and asset type* ...... 65 :Table 22 Baseline price trend for staple commodities, February 2010 ...... 67 :Table 23 WASH morbidity data (source WHO) ...... 68 :Table 24 Therapeutic Nutrition Program parameters ...... 69 :Table 25 Physical condition of tertiary and seconday care health facilities ...... 69 :Table 27 Location of the OTP sites, CMAM program of Lower Dir ...... 70 :Table 26 Type and number of health facilities present in Swat, L‐Dir and U‐Dir ...... 70 :Table 28 Extract of the data provided by the CMAM program, February/March 2010, Lower Dir district...... 71 :Table 29 Health Designations ...... 72

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A. INTRODUCTION

A.1. BACKGROUND

Since mid‐2008, in response to the militancy surge in its north‐western region, the Government of Pakistan scaled up its security offensive across the Federally Administered Tribal Area (FATA) and in Malakand Division of North West Frontier Province (NWFP). The insecurity triggered by the conflict led to the largest population movement recorded in the country since the partition of India in 19472 with over 2.73 million civilians from NWFP and FATA officially displaced at the height of the conflict.

Some districts of former Malakand Division of NWFP (Swat, Lower‐Dir, Upper‐Dir and Buner) have been seriously affected by both the new local restrictive rules and the armed conflict opposing the Pakistan security forces and militant groups.

Local militant groups have been active in Lower‐Dir and Swat districts since the early 1990s when soviet‐jihadist Pakistani groups’ agenda started to shift from Afghanistan to local issues, calling for the implementation of Shari’a (Islamic law) in the region. The first serious confrontation between Pakistan security forces and militant groups in Malakand Division happened by the end of 2007, when the security forces were deployed in Swat District to oust the local militant group from the region. Several hundred of thousand civilians were displaced by the fighting. Despite the Pakistan security forces victory, militants slowly re‐entered Swat over the subsequent months.

After 2009 flawed “Shari’a‐for‐peace” truce signed by the Pakistani Government and Malakand Division militants and, moreover, the latter’s expansion in Buner District, the Pakistan security forces launched a full scale military operation with the objective of eliminating the militant stronghold in the Malakand division. The operation started in Lower‐Dir and Buner in April 2009, and was over on June 14. Over 1.2 million civilians have been displaced by the Malakand Division battle, being hosted for several months within secure areas of Swat, Lower‐Dir and parts of Upper‐Dir as well as outside the area in Charsadda, Mardan, Peshawar and elsewhere. In addition significant portions of the affected population were left “stranded” inside the areas of operation due to the imposition of strict curfew, unwillingness to abandon homes and assets as well as cultural restrictions in moving women, children and elders.

As of March 22, 2010, about 80%4 of registered internally displaced persons (IDP) from Malakand Division have returned to their area of origin.

A.2. OBJECTIVE

The objectives of the rapid assessment were to:

Assess Nutrition, Water Sanitation & Hygiene (WaSH) and Food Security & Livelihoods (FSL) needs across key conflict‐affected areas of Malakand Division NWFP and on this basis, Make appropriate recommendations for the development of an integrated humanitarian strategy for an identified intervention in the zone.

2 'Pakistan: Millions of IDPs and Returnees Face Continuing Crisis' [pdf], IDMC // NRC – 2/12/2009 3 PHRP 2010 4 PDMA/PaRSSA

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A.3. MAP OF THE SURVEYED AREA

The assessment covered 3 adjoining districts of Malakand Division: Swat, Lower Dir and Upper Dir. The districts are located in the far northern and western part of NWFP and border Afghanistan, FATA, Chitral, Kohistan, Shangla, Buner and Malakand PA. Areas were assessed that were either directly affected by the operations (Lal Qila in Dir Lower; Matta, Kabal and Khwazakhela in Swat) or served as transit and host areas in 2009 (Adenzai in Dir Lower and Warai in Dir Upper). Munda and Samarbagh in Dir Lower were also assessed for their current strategic importance as hosting and transit zones for Bajauri IDPs ein th wake of ongoing security forces operations in Bajaur Agency which have forced the migration of thousands of Bajauris across the border into Dir Lower in recent months.

Of the districts covered, Swat is the most populous at 1.84 million people followed by Dir Lower at 673,000 and Dir Upper at 553,000. Note that this assessment largely focused on populations in Dir Lower (60% of total assessed populations) with smaller accents on Swat (30%) and Dir Upper (10%). Reported findings for each district refer only to the zones covered in the assessment, and not the district as a whole. Refer to table below for population figures by District and Union Council.

Table 1: Population figures across survey zone by district and Union Council District Union Council District Tehsil UC population population surveyed

1 Dewlai 24,372 Kabal 2 Koza Banda 24,667 3 Arkot 28,525 Swat 1,842,398 Matta 4 Chupriyal 30,814 5 Gowalarai 26,881 Khwazakhela 6 Kotanai 21,788 7 Asbanr 36,049 8 Khanpur 36,241 Adenzai 9 Kotigram 39,655 10 Ouch 11 Beshigram 26,207 Dir 673,314 Lal qila 12 Lal qila 22,246 Lower 13 Zaimdara 23,777 14 Mian Kalay 19,502 Munda 15 Munda 21,840 16 Sadbar Kalai 34,584 Samarbagh 17 Samarbagh 31,344

Dir 18 Darora 22,957 552,957 Warai Upper 19 Wari 23,348 TOTAL 3,068,669 494,797

Source: OCHA

See map below which indicates the 6 broad zones covered in this assessment. Jandool refers to a district sub‐division which includes Munda and Samarbagh Tehsils in L‐Dir, and Maidan refers to a sub‐division which includes Lal Qila Tehsil also in L‐Dir.

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UPPER-DIR SWAT

Warai Matta

Maidan Khwazakhela Jandool Kabal LOWER-DIR Adenzai

B. METHODOLOGY

B.1. STUDY TEAM AND SITES

23 national and 3 international staff supported field‐level data collection over a 15 day period. 3 managers (WaSH, Nutrition & FSL) led secondary data review, primary data collection and data analysis; and an Assessment Team Manager supported by a Liaison Officer coordinated logistics, security and contacts with authorities. 17 enumerators organized into 5 sector‐specific teams carried out field data collection, led by 5 team leaders:

1 WaSH team (4 enumerators) 1 Nutrition team (5 enumerators) 1 MUAC screening team (10 enumerators)5 1 Market team (2 enumerators) 1 FGD team (6 enumerators)

Teams were trained over 2 days prior to fieldwork. 91 villages and settlements across 19 Union Councils in Swat, Dir Lower and Dir Upper districts were assessed from 1‐14 February 2010:

5 The MUAC team was subcontracted locally for 3 days and not included in the formal count of enumerators

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Table 2: Assessment locations District Tehsil Union Council Villages / Settlements 1 Dewlai Coloney, Dewlai, Fazal Abad, Nusrat Kalli Kabal 2 Koza Banda Ghand Khat, Khan Abad, Kuza Bandai, Shaheen Mohalla, Sigram 3 Arkot Ronyal Swat Matta 4 Chupriyal Chupriyal, Gharai, Matta Bazar, Sayd Abad, Shahtoot Kas, Shokhdara 5 Gowalarai Awarai, Gowalarai, Lil Band, Roringar, Wainay Khwazakhela 6 Kotanai Asala, Chalyar, Kotanai, Manpitai 7 Asbanr Abi Shah, Asbanr, Dehran, Kashmir 8 Khanpur Khanpur Miana, Varghar Adenzai 9 Kotigram Bar Kalay, Kotigram Bala, Kuz Kotigram 10 Ouch Ouch 11 Beshigram Awarai, Bagh Maidan, Beshigram, Gumbatbanda, Kandu Machla Lower Dir Lal qila 12 Lal qila Bandagai, Chamgay, Dehro Chalgazay, Kumber, Lal qila 13 Zaimdara Asghar, Dapur, Gohar Khat, Karin, Patao, Swara Walrai, Zamdara 14 Mian Kalay Anagorai Mena, Arif Kaley, Badalzoi, Dak Mian Kalay, Drabusha, Mian Kalay, Takora Munda 15 Munda Bazrak, Godar, Jan Muhhammade, Khaista Derai, Munda, Musa Abad, Tajik Abad 16 Sadbar Kalai Jabo, Jabo camp, Pro Kale, Sadbar Kaley, Sadbar Shah, Satwar Ghundi, Tangai Samarbagh 17 Samarbagh Ali Sheer, Chamartali, Damtal, Gul Dehri, Kamangar, Rahim Abad, Samarbagh, Samarbagh camp, Tatar 18 Darora Darora, Landy Shah Payeen Upper Dir Warai 19 Wari Bando, Kakad, Manai, Tangai, Warai

B.2. SAMPLING APPROACH

Population lists based on the 1998 census (carrying 2009 estimated population figures) were obtained from OCHA for use as a sampling frame.6 Both probability and non‐probability sampling approaches were used:

8 Tehsils selected as the broad sample population: Kabal, Matta, Khwazakhela, Adenzai, Lalqila, Munda, Samarbagh, Warai. Of the 57 Union Councils (UC) contained therein, 11 removed from the list due to security concerns.7 UCs in Kabal, Matta, Khwazakhela, Adenzai and Lalqila selected from this reduced list using Probability Proportional to Size Sampling UCs in Munda, Samarbagh and Warai selected using Purposive Sampling to ensure coverage of IDP host areas Villages selected on a Simple Random basis for community‐level data collection wherever possible8 but excluding sites in Munda, Samarbagh and Warai where IDP settlements/host areas were purposively selected. 4 or more sites per UC visited in almost all cases. FGD groups assembled without assistance from local authorities to reduce bias HH food security interviews administered randomly to 3 or more female FGD participants per site Mid‐Upper Arm Circumference (MUAC) screening sites purposively selected in Munda, Samarbagh and Sadbar Kalai UCs to ensure coverage of IDP settlements/host areas (15 in total).

6 Administrative boundaries have been frequently redrawn since 1998 and available maps did not necessarily reflect either the 1998 or the current administrative breakdown. 7 UC’s Bar Abakhel Kabal, Koz Abakhel Kabal, Qalagay, Shah Dehrai, Tall in Kabal; UC’s Jano/Chamtalai, Miandam in K.Khela; UC’s Darmai, Sakhra, Beha in Matta; UC Gal Maidan in Lal Quila. 8 Random selection of sites for FGD and WaSH teams (Note: in Adenzai and Lal Qila, selection made prior to arrival on the field using village lists; in Kabal, Matta and K.Khela, selection made upon arrival in the field due to the absence of updated village lists). Purposive selection of sites for BHU med/ paramedical staff interviews. Purposive selection of sites for MUAC screenings.

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B.3. METHODS AND TOOLS

1/ Secondary sources including meetings at Province/District/UC and community level with PaRRSA, DCO/ACO, EDOs, UN Agencies, ICRC, NGOs

2/ Primary sources using Key Informant Interviews, Focus Group Discussions (FGD), Household Interviews, Observation, Water Quality testing, MUAC screening and rapid Market Assessment

Several sector‐specific tools were used to support these methods:

Community level FGD guides9 Household questionnaire Food Security Market assessment form WaSH technical observation form WaSH key informant guide Nutrition key informant question guides10 MUAC screening forms

Most tools were administered across 4 or more villages in each of the 19 UCs in order to triangulate results. In particular female FGDs were always held in parallel with male FGDs at the same sites. WaSH teams also largely visited the same sites as the FGD teams.

Market teams selected sites according to the location of important markets, and Nutrition teams according to the location of Basic Health Units (BHU), medical/paramedical staff and district‐level health institutions.11 MUAC screenings were carried out at 15 IDP hosting/settlement sites across Munda, Sadbar Kalai and Samarbagh UCs from 10 ‐12 February 2010. All children between 6 months and 5 years of age in each site were measured. The anthropometric measurements were done as follows:

9 1male guide covering overall livelihoods; 1 female guide covering female livelihoods, WaSH and Nutrition 10 1 medical & paramedical staff guide; 1 district‐level health institutions guide 11 These sites were not counted towards the 19 UCs covered by the assessment as no community‐level data was collected; they appear in gray in Table 17

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Figure 1: Methodology MUAC screening

46 focus group discussions – 32 male and 14 female – were held. FGD were organized into four types: general cross‐ sections of the village population (23), livelihood groups such as artisans, small farmers or casual labourers (9), social groups such as youth (2), and settlement groups such as IDPs or hosts (16). This allowed for greater insight into the specific needs and concerns of groups of interest. 51 household interviews covering household food security (diet diversity, meal frequency and consumption‐related coping strategies) were conducted alongside female FGDs with randomly selected group participants. On average 3‐4 interviews were administered at each site.

Focus Group Discussion Types

Traders, 3% Small farmers , General cross section 6% Youth, 6% Casual laborers

Artisans, 6% Hosts

General cross IDPs (Bajawar) section, 44% IDPs (Bajawar), Artisans 9% Small farmers

Hosts, 13% Youth Casual Traders laborers, 13%

Figure 2: Profile of Focus Group Discussions (FGD) 79 trader interviews were conducted across 12 market sites. Price and availability data was also gathered at each site for basic food & fuel commodities and daily wage rates. Trader interviews covered the following range of businesses: general stores (18), vegetable and meat/poultry dealers (13), skilled trades such as barber, carpenter, hblacksmit or welder (20), manufacturers such as concrete block, stone crush or marble (9), agricultural goods dealers (6),

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transporters (6), fuel stations (2) and hotels/restaurants (6). See Table 19 in Annex 1 for a detailed profile of traders interviewed.

127 medical and paramedical staff interviews were conducted across 18 UCs. Staff were found present in the BHU of each assessed Union Council; where absent from the BHU, efforts were made to find them in the community. Medical staff interviewed includes doctors, nurses, medical technicians (MT), immunization program (EPI) techs and nutrition assistants (total 40). In addition Lady Health Workers (LHW), Lady Health Visitors (LHV), Lady Health Supervisors (LHS) and Traditional Birth Attendants (TBA) were interviewed (total 64): approximately 1 of each type in every UC visited. Finally, influential individuals such as religious leaders (molvi) and hakeem (traditional healer) who serve as resource persons with regard to health and nutrition practices in communities were also included in this assessment (total 23). See Figure 3 below.

8 District and Tehsil‐level health facilities were visited, including 5 Rural Health Centres (RHC), 1 Tehsil Headquarters Hospital (THQ) and 2 District Headquarters Hospitals (DHQ) which include Community‐Based Treatment of Malnutrition (CMAM) stabilization centers. See Table below.

Table 3: District and Tehsil‐level Health Facilities visited District UC Facility Chuprial RHC Chuprial Swat Dewlai RHC Dewlai Saidu Sharif DHQ Saidu Sharif Lal Qila RHC‐Lal Qila Munda RHC Munda L‐Dir Samar Bagh THQ Samarbagh Taimargara DHQ Timergara U‐Dir Wari RHC Warai

Type of Medical & Paramedical Staff Interviewed

Other*, 3% LHS, 6% LHW

Hakeem, 6% Religious leader

Medical Technician LHW, 27% LHV, 8% EPI Tech

Doctor, 8% TBA Religious leader, Doctor TBA, 9% EPI 12% Tech, LHV 9% Hakeem Medical Technician, LHS 11% Other* * Nurse, Nutrition Assistant, Homeopath

Figure 3: Profile of Medical & Paramedical Staff interviewed See Table 18 in Annex 1 for a table of survey instruments and number of observations per site. See Annex 2 for the survey instruments.

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B.4. CONSTRAINTS

Significant constraints were faced on the field. Sources of bias were minimized wherever possible but the bulk of sampling methods were non‐random. As such the overall results should be considered representative only for the UCs visited and not necessarily representative of the situation in the most remote and isolated villages of those UCs.

Security constraints prevented access to 11 conflict‐affected UCs. Time constraints prevented remote regions of Upper Dir or Upper Swat to be included in the sampled population. Lack of updated population lists reflecting the newest administrative breakdown hampered the village selection effort Time constraints prevented access to the most remote villages in the selected UCs, although efforts were made to reach far‐flung villages whenever possible. Bajauri IDPs living in host communities were exceedingly difficult to locate due to a recent political pressure encouraging their movement to camps. As a result they remain “in hiding” in the communities where they are present. In Beshigram, Lal Qila and Zaimdara UCs, collection of community‐level data was incomplete due to security restrictions for female enumerators preventing their access.12 Livelihood‐related findings from community‐level FGD could not be cross‐checked with observation and in many places were based on recall. Asset losses and damages will tend to be overreported by community members. Administration of the household questionnaire could not be done on a proper sample size and thus its results should be considered only as support to broader qualitative findings.

12 Data on female livelihoods, household food security, water & sanitation and nutrition was not collected.

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C. FINDINGS

Six broad zones were visited across the 3 districts of Swat, Lower Dir and Upper Dir: 1) Matta/Kabal, 2) Khwazakhela, 3) Maidan, 4) Adenzai, 5) Jandool and 6) Warai, indicated in the Table below.

Table 4: Assessment zone classification District Tehsil Union Council Zone designation Matta, Kabal Dewlai, Koza Banda, Arkot, Chupriyal, Gowalarai Matta, Kabal Swat Khwazakhela Kotanai K.Khela Lalqila Beshigram, Lal qila, Zaimdara Maidan Lower Dir Adenzai Asbanr, Khanpur, Kotigram, Ouch Adenzai Munda, Samarbagh Mian Kalay, Munda, Sadbar Kalai, Samarbagh Jandool Upper Dir Warai Darora, Warai Warai Communities were classified according to their settlement status in order to distinguish differences: Host, IDP, Returnee or Stayee13. Zones tend to be shared by different groups, with returnees and stayees concentrated in direct conflict‐affected areas (Maidan, Adenzai, Matta, Kabal and K. Khela); IDPs concentrated in Jandool (from Bajaur Agency); and hosts clustered in Jandool and Warai.14 Note that Jandool residents are currently serving as hosts to off‐ camp Bajauri IDPs, whereas Warai residents served as hosts to Swati IDPs during the 2009 operations. See Figure below.

Community profile by settlement status 100%

80% Host 60% IDP 40% Returnee

20% Stayee

0% L Dir/ Maidan L Dir/ Adenzai Swat/ Matta, Swat/ K.Khela L Dir/ Jandool U Dir/ Warai Kabal

Figure 4: Community profile by settlement status

C.1. FINDINGS FOOD SECURITY & LIVELIHOODS (FSL)

The Food Security and Livelihoods findings draw from 4 sets of data: 1) focus group discussions, male; 2) focus group discussions, female; 3) trader interviews; and 4) household questionnaire. In addition key informants and observation were used to triangulate sources of information whenever possible.

C.1.1. HOUSEHOLD PROFILE Across the assessed zones, the average household size stands at 9.3, including 5.2 children and 4.1 adults (see Figure below). The number of dependants per household averages 7.9 (including infants, children, women and elders); the dependency ratio15 is 4.9.

13 Stayee: population left “stranded” within the areas of conflict 14 Stayee communities in Asbanr UC (Adenzai, L‐Dir) also served as hosts to Swati IDPs. 15 Dependants to adult males

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Household composition

Infants <1 Infants <1 year year, 0.5, 5% Children 1‐4 years, 1.3, Children 1‐4 years 14% Children 5‐17 years Adults 18 or above, 4.1, Adults 18 or above 44%

Children 5‐17 years, 3.5, 37%

Figure 5: Household composition 76% of households are reportedly headed by adult males, 4% by males less than 18 years of age, and 20% by women. Note that the 20% share of women‐headed households self‐identified as such, and includes households where men have migrated for jobs and are absent from their homes.

C.1.2. LIVELIHOOD SYSTEMS16 Swat District lies towards the north of NWFP having high mountain ranges, steep valleys and plains of fertile land. The total population is 1.84 million people with 200,000 farm families. The District is inhabited by small scale farmers with average land holding below one hectare per family.

The major cereal cropsn grow are maize, wheat and paddy followed by Kharif, Rabi and other vegetables, oilseed and pulses as minor crops.17 The favorable climatic conditions and availability of wide range of agro‐ecological pockets permits the production of different kinds of fruits and vegetables. The major fruits grown are apples, peaches, persimmon followed by citrus, plums, apricots, pears and nuts while major vegetables are onion and tomatoes followed by potato, okra, turnip, cabbage, radish and cauliflower. The total area under fruits is 12,830 hectares with a production of 138,836 tons whereas the total area under vegetable (excluding onion and potato) stands at 8507 hectares with a production of 96,708 tons respectively. 60% of the Provincial production of major fruits and vegetables is produced in the district.

Fruits and vegetables are a significant source of cash income derived mainly from apples, peaches, persimmon, onion and tomato, majority of which is marketed in down country markets with the main markets in Lahore, Rawalpindi and Peshawar. Labour engaged in agriculture is 56%.

Until recent events tourism was a cornerstone of the Swati economy and employed a significant share of the population in service industries including as hotels and restaurant workers, transporters, weavers, handicraft artisans, retailers and others. The region is also a significant exporter of labour in winter season in‐country and towards the Gulf States. Other sectors include manufacturing and mining.

Upper and Lower Dir Districts lie adjacent to Swat having a combined population of 1.23 million people, a more rugged and less hospitable terrain and an agriculture and remittance‐based economy. Wheat, maize and paddy are the major cereals. Production of cash crops such as rabi mustard, onion, barley, pulses, tobacco, potato and kharif and rabi fruits and vegetables including citrus occurs on a smaller scale than in Swat and is limited to the valley areas where irrigation water is available. The region is more isolated and exports significant labour seasonal towards Sindh, Baluchistan and Punjab and on longer term basis to the Gulf States.

16 Majority of the text drawn from Agriculture Department SWAT “Brief and Damages of Allied Components”, 2010 17 Kharif crop is the summer or monsoon crop with autumn harvest, and Rabi crop the winter crop with spring harvest

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Livestock play an important role in the local economies of both regions, supporting household nutrition by providing often the only source of high quality food in the local diet as well as generating supplemental income and serving as a savings bank. Most households have 4‐5 goats and sheep, poultry and a dairy cow.

Subsistence activities involving cereal crop and livestock production are year‐round, as the Rabi season wheat crop is immediately followed with Kharif‐season maize. Livestock are set out to graze from May to August and stall fed from November to February from fodder grasses cut in the fall. Seasonal labour migration of males takes place from November to February. See calendar of activities below.

Table 5: Seasonal calendar of activities Activity Jan Feb Mar Apr May June Jul Aug Sept Oct Nov Dec 1 Wheat production Planting Harvest 2 Maize production Planting Harvest 3 Rice production Beginning late August 4 Orchard pruning (peach, apple, plum, apricot) 5 Peach production 6 Apple production 7 Citrus production 8 Availability of agricultural credit 9 Pasture grazing 10 Grass cutting for fodder 11 Livestock stall feeding 12 Firewood collection Peak season 13 Collection of non‐timber forest products 14 Dry season – low water availability 15 Peak cholera season 16 Seasonal labour migration

Note that seasonal activities, timing and duration of rains, and seasonal incidence of disease vary widely across the zone by location and altitude. The timings represented here reflect the primary data collected from communities during this assessment largely in lower plain areas. Other sources indicate a small monsoon season in the summer months (accentuated in northern mountainous zones) and cropping calendars adjusted for water availability and temperature differences.

C.1.3. MARKETS 79 traders across 5 different classes (Artisans, Manufacturers, Retailers, Service providers and Wholesalers) and 20 types of businesses were interviewed using a structured questionnaire, representing a broad range of businesses operating in rural and urban areas in the assessed zones. Gem stone mining, wool weaving and handicraft shops all linked to eth Swat tourism industry are sectors whose representatives were included in the assessment as key informants. See Table 19 in Annex 1 for a detailed profile of traders interviewed.

Overall markets across the assessed zones are observed to be functional, dynamic and vibrant, with significant recovery achieved since the operations in 2009. Market dynamism in turn is helping to fuel recovery across other sectors. All major commodities are now available on local markets and all trade flows restored from the crisis period, as illustrated in the mapping of food commodity supply chain carried out using information collected in the course of this assessment (see Figure below). New actors have entered the market: notably humanitarian agencies distributing food aid, in direct competition with local food dealers who supply the same items.

Similarly, trade flows and credit availability for the export of fruit and vegetable cash crops from the region to wholesale markets in Mingora, Peshawar, Batkhela and Punjab are completely or nearly completely restored.

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Figure 6: Supply chain of food commodities at crisis time and currently

Some types of business continue to face challenges as supplier sources of credit has contracted somewhat, transport and fuel prices have increased, and low demand from consumers is limiting sales and turnover. These points are developed in the sections below.

SUPPLIER CREDIT: In normal times a majority of traders (64%) relies on credit from suppliers for purchasing inputs – largely wholesalers, retailers, manufacturers (concrete block and marble factories) and artisans (blacksmiths, carpenters). Following the crisis, findings indicate that:

76% of traders previously accessing supplier credit continue to access credit, while 24% tdo no Overall credit access does not differ significantly between rural and urban traders, but Regular sources of supplier credit have dried up for rural traders, who now purchase on credit “occasionally” rather than “most or all of the time”.18

Regularity of access to credit sources is likely linked to both demand issues e.g. traders are not moving as much stock due to lagging business demand, as well as supply issues e.g. suppliers are hesitant to extend credit. See Table below for a summary table of changes in credit access.

Table 6: Changes in access to trader credit Percent traders Rural Urban Total

Accessing credit previously* 61% 68% 64% Accessing credit now** 53% 48% 51% Accessing credit now*** 80% 71% 76% * Occasionally, most of the time or all of the time

18 4% of rural traders currently buy on credit on a regular basis, compared with 31% prior to the crisis.

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** Among all traders *** Among traders who accessed credit previously

BUYER CREDIT Just as suppliers routinely lend to local traders, traders also routinely lend to their customers. This established custom is a vital safety net for vulnerable members of the community who are not always able to pay up front. Borrowing from shopkeepers and traders to cover basic necessities is one of the most prevalent coping strategies in the assessed region (see dC.1.7 an C.1.8).

Globally 80% of rural traders and 70% of urban traders report extending less credit to their buyers compared to last year. This finding concerns the vast majority (90%) of wholesalers and retailers who supply items of first necessity. Traders report that due to the depletion in buyers’ income sources they are hesitant to continue lending when individuals are not credit worthy.

PRICES AND BUSINESS VOLUME Shortages of basic commodities at the national level – sugar, fuel and natural gas to name a few – has placed significant upward pressure on prices and led to inflation. 100% of interviewed traders report significantly higher inputs prices associated with inflated fuel and transport costs.

Higher prices combined with low consumer demand in the affected areas have affected recovery for all types of traders. A majority of traders report higher business volume compared with one year ago. Geographically, higher sales across all types of traders are reported mostly in areas where business was shut down in 2009 due to operations 58% of manufacturers who export their product out of the region (stone crush, concrete block) as well as 57% retailers, 50% wholesalers and 70% service providers (transporters, restaurant owners) report higher business volume than one year ago. Sales volume for artisans is mixed: 45% report higher sales,% 45 lower sales, and 9% no change compared to one year ago. 65% of rural traders and 45% of urban traders report increased business. Artisans and retailers do not expect to have the capacity to meet additional demand in the near future, but manufacturers, wholesalers and service providers do

Refer to Table 22 in Annex 1 for a price table of basic commodities and wage labour rates. Price trends were not able to be obtained.

IMPACT OF FOOD AID ON TRADERS The World Food Programme (WFP) has been carrying out general food distributions in the affected areas of Buner, Swat and Lower Dir since 2009. WFP rations contain sugar, tea, wheat, rice, oil and pulses. Eligible households must be formally registered with the government to receive assistance. The International Committee of the Red Cross (ICRC) and its partner organization the Pakistan Red Crescent Society (PRCS) do not rely on the government registration process to determine eligibility and have been distributing food on a need basis to 90,000 households across the affected areas, including Swati stayees and returnees (60,000 HH) and L‐Dir dcamp‐base IDPs and hosts (23,000 HH). In addition ICRC has supported returnee/stayee communities in L‐Dir with seed protection rations in Rabi 2009 alongside agricultural inputs. World Food Programme is transitioning from general distributions to food‐for‐work, food‐for‐ training, school feeding and other livelihoods‐oriented programs in March 2010.

78% of food commodity dealers19 report being significantly affected by ongoing free food distributions. Reported impacts include fewer buyers and lower sales of wheat, rice and ghee. Among food dealers, low consumer demand is reported to be one the major constraints currently faced for improving their business. Food aid is partially responsible for the lower demand in basic food items.

19 Wholesale and retail general stores present in towns and villages that deal in rice, gurr, wheat flour, tea, sugar, ghee, pulses and fertilizers (among other essential items).

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Table 7: Impact of food aid on wholesale and retail commodity dealers Have food distributions had an Rural dealers Urban dealers Total impact on your business? None or N/A 25% 17% 22% Yes 75% 83% 78%

LABOUR MARKET Local economic activity slows in winter. Skilled and unskilled labour from Swat and Dir tends to migrate in the winter months to Punjab and Sindh (Karachi) for jobs in construction, factories and sugarcane harvesting; Baluchistan (Quetta) for coal mining; and Mardan and Charsadda for sugarcane harvesting and gurr20 production. Workers return in summer for labour opportunities in agriculture and other sectors. A significant portion of the male population also migrates abroad to Gulf countries for years at a time. Dir households export significantly more labour than Swat due to the lower development of the region. Share of households exporting labour and relying on remittances is estimated at roughly 35% (see Table 9).

Labour markets therefore tend to contract in the wintertime, both in terms of labour supply and labour demand. At the time of the assessment, demand for labour from contractors, manufacturers and other types of businesses was reported to be lower than in normal times but recovering. Supply of labour is higher than demand. Daily wage rates hover around 200‐300 PKR for unskilled labour and 400‐550 PKR for skilled labour21.

CONSTRAINTS FACED BY TRADERS Main constraints reported faced by traders are:

High transport and fuel costs (55%) Lack of cash (36%) Lack of demand from buyer (32%)

Wholesalers and retailers are primarily affected by high transport and fuel costs, lack of demand and checkpost delays. Artisans are constrained by lack of cash, irregular electric supply and lack of credit. Service providers are mainly impacted by lack of demand, checkpost delays and high input & labour costs. See Figure below.

Constraints faced by traders for increasing turnover 53% High transport and fuel costs 56% 40% Lack of cash 33% 33% Lack of demand fr buyer 31% 17% Shortage electric supply 11% 7% Checkpost delays 11% 10% Urban High input and labor costs 7% 3% Rural Lack of credit fr supplier 7% 7% Black market sales/smuggling 0% 3% Insecurity 2% 0% Poor road condition 2%

0% 10% 20% 30% 40% 50% 60% Percent traders Figure 7: Constraints faced by traders for increasing turnover

20 Unrefined whole sugar 21 Mason, carpenter, welder, electrician, etc.

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The Swati tourism industry has been especially affected by recent events and is one of the sectors facing the hardest recovery. Traditionally the industry draws tourists from Punjab, NWFP and Sindh provinces followed by foreign visitors. Hotels located in Upper Swat (Kalam, Behrain, Madyan) and in the surroundings of Mingora city (Marghuzar, Fizaghat) were closed during the operations while hotels of Upper Swat remain closed to this day. A large proportion of Swati handicraft shops have shut down.22 Hotel and restaurant owners, artisans and retailers of handicrafts and gem stones, weavers, transporters and other actors depend on renewed confidence on the part of tourists that the area is secure in order to recover their livelihood. While specific sectors such as the Islampur weaving industry has effectively diversified its customer base and is selling to dealers outside of the local area (Karachi, Islamabad), many actors are still struggling to regain a foothold.

Barbers and CD shop owners deserve special mention as their business was targeted during the militancy period and a major portion of their business assets lost. Lack of cash remains the primary constraint to capital reinvestment.

C.1.4. FOOD SOURCES AND DIETARY DIVERSITY

FOOD SOURCES More than half of all food is sourced from the market, with significant shares also contributed by food aid (16%) and social networks (borrowing & gifts, 16%). In areas where aid is distributed (ICRC and WFP) most sugar, tea, wheat, oil, rice and pulses is sourced from the aid. Milk,y green leaf vegetables, maize and eggs tend to be sourced from own production when available. See Figure below.

Sources of food Exchange labor for food, 3% Own production, Other*, 1% Purchase 6% Food aid Gift, 8% Borrow Gift Borrow, 8% Own production Food aid, Exchange labor for food 16% Other*

Purchase, 58%

*gathering, exchanging items for food and local government sources

Figure 8: Sources of food IDP households followed closely by returnees are most dependent on precarious food sources such as borrowing, gifts and official food aid. Today these sources collectively support a large portion (61% and 55%, respectively) of these groups’ food needs, but are unlikely to be sustainable in the mid‐ to long term.

Compared to other groups, returnee and stayee populations are most reliant on gifts and borrowing to meet their current food needs (34% and 22%, respectively), reflecting the importance and resilience of local community‐based social networks. In contrast, host communities are able to source the large majority (85%) of their food from the market and so remain less vulnerable to food insecurity. See Figure below for sources of food by settlement status.

22 According to one local informant, only 5% of Mingora‐based handicraft retailers remain open.

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Sources of food by settlement status 100% 2% 2% 2% 2% 2% 5% 2% 15% 9% 9% 80% 11% Exchange 19% 59% 11% Own production 60% 7% 21% Gift 40% 85% 55% Borrow 20% 42% 38% Food Aid 0% Purchase IDPs Returnee Stayee Host

Figure 9: Sources of food by settlement status

DIETARY DIVERSITY Household dietary diversity was assessed on the basis of 12 different food groups:

1. Cereals 7. Oil/ Butter/ Ghee 2. Potatoes 8. Vegetables 3. Fish 9. Fruit 4. Meat/organ meats 10. Sugar/ sugar products 5. Eggs 11. Milk/milk products 6. Pulses/ Lentils / Beans/ Nuts 12. Condiments Women were asked what food items were consumed by members of their household in the previous 24 hours. A score of 1 was assigned to the food group if one or more items from that group had been consumed; and 0 if it had not. The resulting Household Dietary Diversity Score (HDDS) ranges up to a maximum of 12 points. Higher scores reflect greater diversity in the diet, and also tend to correlate with better quality diet and higher economic status.

HDDS in the assessed zone varied between 4 and 10, with a mean 6.9 food groups consumed by households. Given that sugar and tea were found to be universally consumed across all zones and population groups, a diet with an HDDS of 6 or more can be considered adequate for supplying all necessary macronutrients (cereal or starch, pulse, oil and vegetable).

See Table below for a profile of household diets by dietary diversity tercile ine th assessed zones.23

Table 8: Profile of household diets by diversity tercile Lowest diversity (4‐5 groups) Medium diversity (6‐8 groups) Highest diversity (9‐10 groups) 1 Cereals (wheat, rice) Cereals (wheat, rice) Cereals (wheat, rice) 2 Vegetables (green leafy & other) Vegetables (green leafy & other) Vegetables (green leafy & other) 3 Oil or ghee Oil or ghee Oil or ghee 4 Sugar Sugar Sugar 5 Condiments Condiments Condiments 6 Pulses, lentils, nuts and beans Pulses, lentils, nuts and beans 7 Milk and milk products Milk and milk products 8 Potato 9 Meat 10 Other fruits With households currently achieving an average HDDS of 6.9, diets can be considered on average adequate for macronutrient content. This finding is largely attributable to:

23 Food groups consumed by >50% of households

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Food distributions undertaken by aid agencies in areas of return in recent months that have supported basic food security for vulnerable stayees, returnees and IDPs and have in all probability served to prevent a large scale food crisis, and Food sharing that occurs through local social networks.

Stayee and host groups were found to enjoy marginally more diverse diets than IDPs and returnees (HDDS=7.3 vs. 6.3, respectively), reflecting their comparatively more secure food and economic situation. See Figure below.

HH Dietary Diversity Score (HDDS) 7.5 7.2 7.3 7.0 6.5 6.3 6.3 6.0 5.5 Returnee IDPs Stayee Host

Figure 10: Household Dietary Diversity Score (HDDS) In order to examine the micronutrient profile of diets, Cereals, Vegetables and Fruit were divided into subgroups reflecting micronutrient content24. Diets were assessed according to the presence of iron and vitamin A‐rich foods.

Globally diets were found to be rich in vitamin A due to the near‐universal consumption of milk and milk products; but poor in iron due to the very low consumption of iron‐rich foods.25 This finding holds true across all settlement groups, with some marginal differences correlated to the overall dietary diversity of each group (see Figure below).

Share of HHs having micronutrient‐rich diet 100% 100% 88% 82% 80% 63% Vitamin A rich diet 60% Iron rich diet 36% 40% 25% 20% 13% 13%

0% Returnee IDPs Host Stayee

Figure 11: Share of households having micronutrient‐rich diets

C.1.5. INCOME SOURCES Major pre‐crisis income sources are Agriculture, Remittances and Unskilled Labour followed by Trader income, Skilled Labour and other sources such as livestock and transporter income. Following the crisis:

The relative contribution of income from major sources declined across all zones due to displacement, disruption of economic activities and loss of assets26. Declines were most drastic for Agriculture (from 14% to 6% share of global income) followed by unskilled labour and trader income.

24 Cereals were split into 1/wheat, 2/rice, and 3/ maize; Vegetables were split into 1/dark green leafy vegetables, 2/vitamin A‐rich vegetables, and 3/other vegetables; Fruit was split into 1/vitamin A‐rich fruit and 2/ other fruit. 25 Sources of vitamin A: dark green leafy vegetables, vitamin A‐rich vegetables (carrots, squash, pumpkin), vitamin A‐rich fruits (apricot, mango, papaya, black persimmon), eggs, and milk/milk products. Sources of iron: Fish and Meat/organ meats. 26 With the exception of U‐Dir/Warai, where income sources have remained stable

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Remittances remain the notable exception as a stable and increasingly vital income source, rising from 7% to 9% of total income. It is currently the most important of household income sources. Income portfolios became more diversified, with 2 new sources of income emerging: Income Support (zakat, aid, etc.) and Asset Sales (livestock, jewelry, rifle, etc.). Income support is currently the 4th most important source of income across all zones, and the second in Maidan and Jandool.

Table 9: Estimated share of households receiving remittances*

Foreign National remittance remittance

1 L‐Dir/ Maidan 46 50 2 U‐Dir/ Warai 44 44 3 Swat/ K.Khela 38 25 4 Swat/ Matta,Kabal 34 28 5 L‐Dir/ Adenzai 31 38 6 L‐Dir/ Jandool 22 44 Grand Total 34 39 *as reported in male FGD National remittances provide a critical source of income in the winter months, when men migrate to Sindh, Punjab and Baluchistan for work in coal mines, factories, construction and sugarcane harvest. An estimated 39% of households rely on national remittances as a seasonal source of income, with a slightly larger share coming from Dir relative to Swat.

Foreign remittances are nearly as important and are supplied by family members working in the Gulf who stay away for years at a time. An estimated 34% of households rely on foreign remittances. See Table 9.

See Figure below for a comparison of income sources.

Income sources before crisis Income sources after crisis Agriculture

U Dir/ Warai Agriculture U Dir/ Warai Remittances

L Dir/ Jandool Remittances L Dir/ Jandool Unskilled labor L Dir/ Adenzai Unskilled L Dir/ Adenzai labor Trader Swat/ K.Khela Trader Swat/ K.Khela Income Skilled labor Swat/ support Swat/ Matta,Kabal Matta,Kabal Sale assets L Dir/ Maidan Other L Dir/ Maidan Other

0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%

Figure 12: Changes in income sources Main income sources in stayee and return areas (Maidan, Matta, Kabal and Khwazakhela) were acutely affected – on average 75‐83%. This can be attributed to the direct impacts of the conflict (displacement, damage to assets & infrastructure, curfew and security restrictions, etc.). Main income sources in host areas (Jandool, Adenzai) were less severely but still significantly affected – on average 43‐50%. Bajauri IDPs in the Jandool area report their main income source badly or completely affected. See Figure below.

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Extent main source of income affected

L Dir/ Maidan

Swat/ Matta, Kabal

Swat/ K.Khela Completely Badly L Dir/ Adenzai Moderately L Dir/ Jandool Not at all U Dir/ Warai

0% 20% 40% 60% 80% 100%

Figure 13: Extent main source of income was affected

C.1.6. ASSETS Significant asset loss was suffered in areas of return in Swat and L‐Dir and among Bajauri IDPs. Livestock assets were lost as people slaughtered or sold livestock on low rates as they fled their villages during the operations or left animals behind. Seed stocks were lost or consumed upon return. Personal financial assets such as jewelry and guns were sold to pay for transport and cover subsistence needs. In some communities, forest and agricultural land was damaged from shelling or set ablaze to remove cover for militants. Homes and businesses were looted during villagers’ absence. In host and transit areas, the presence of IDPs stretched and eroded residents’ resources and placed pressure on natural assets such as forests and water sources. Global asset loss was reported at 28% (see Table below).

Table 10: Asset recovery as a % of lost or damaged assets Zone Asset loss Asset recovery 1 L‐Dir/ Maidan 56% 3% 2 Swat/ Matta,Kabal 42% 26% 3 L‐Dir/ Adenzai 26% 21% 4 Swat/ K.Khela 19% 22% 5 L‐Dir/ Jandool 18% 18% 6 U‐Dir/ Warai 5% 79% All zones 28% 18%

Asset recovery has been slow across almost all zones,27 with 18% of lost assets recovered to‐date. Among the conflict‐ affected areas, the most rapid recovery is observed in the return areas of Matta, Kabal and Khwazakhela (Swat) with 22‐26% of lost holdings recovered. This can be attributed to the significant deployment of humanitarian assistance in this area and the level of development of the region prior to the crisis. Host and transit areas of Adenzai and Jandool (L‐ Dir) have recovered assets at a similar rate (18‐21%).

The poorest recovery is noted in the return area of Maidan (L‐Dir) where just 3% of lost assets have been recovered. Losses of assets in Maidan were roughly double those suffered in other assessed regions.28 Nearly all livestock was slaughtered or sold across the major livestock classes (oxen, cow, sheep/goat and poultry) and none has been reported restocked to‐date. Seed stocks, agricultural tools, animal shelter and handicraft assets have been partially recovered as a result of aid distributions in Maidan region. Nevertheless, net asset levels remain well below pre‐crisis holdings, in particular for poultry, small and large ruminants, fodder, community infrastructure and personal financial assets.

The failed recovery in Maidan is associated with the acuteness of the depletion suffered, which has hindered any significant reinvestment in productive activities, as well as the relative poverty and isolation of the region.

27 With the exception of Warai (U‐Dir) where low levels of damage/decapitalization facilitated rapid recovery 28 68% of livestock and 55% of other assets were lost in Maidan, compared with 30% and 28% losses across all zones, respectively.

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NATURAL ASSETS Livelihoods in the affected areas draw from the natural resource base such as land, water and forest resources:

Fruit and vegetable production is a vital source of employment and cash income and underpins the regional economy. Forests serve as water catchment areas that control erosion and regulate water availability. Fuelwood and non‐timber forest products such as mushrooms and aromatic & medicinal plants also support local livelihoods. Hives for honey production are traditionally kept inside homes in the hill areas to supplement income and diets.

Forests and agricultural land were damaged in the operations by shelling and eth destruction of forested areas thought to be providing cover for militants29 and continue to be damaged in ongoing security operations in IDP places of origin. Fruit orchards (apple, peach, persimmon, etc.) in Swat and other types of agricultural land in Swat and Dir could not be maintained as a result of population displacements and imposition of strict curfew. Honey bee colonies were lost during the displacement from villages. Mean estimated damage to natural assets is 35%, with 5% total asset level now recovered (see Figure below).

Natural asset loss & recovery

Hives 56 0

Other agric land 48 13 After losses

Forests 67 0 Recovered

Fruit orchard 71 6

0 20406080100

% holdings fr pre‐crisis level Figure 14: Natural asset loss & recovery

PHYSICAL AND FINANCIAL ASSETS Similarly, physical and financial assets were lost or damaged most acutely in areas of return. Community infrastructure such as schools, BHUs, water supply schemes and irrigation networks were affected by shelling. Schools in particular were targeted by militants and damaged or destroyed on a large scale. Household assets such as livestock, tools, trader stocks, handicraft assets and jewellery were lost, looted or liquidated. Seed stocks were consumed. Regarding the overall recovery of physical and financial assets:

Shops and small businesses have made the most significant recovery (17% of prior level) by relying on traditional sources of credit to recapitalize stocksd an related assets (see section 3.1.7). Agricultural tools have been partially restored (13% of prior level) due to widespread aid delivery in certain areas Poultry, sheep and goats remain seriously undercapitalized with minimal restocking to‐date Mean estimated loss of physical and financial assets is 28% with 5% of total assets recovered (see Figure below).

29 Forest cover was particularly affected in Maidan region.

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Physical and financial asset recovery Livestock asset recovery

Agric tools 76 13 Animal fodder/ 54 4 grasses Irrigation 85 3 networks Animal shelter 88 5 Other comm 82 3 infrastructure Donkey/mule 88 4 Shops/ small 64 17 After businesses Buffalo 79 3 After losses losses Handicraft assets 80 3 Recov Oxen 74 3 Recov ered ered Cash, jewlery, 80 1 other HH assets Cow 68 3

Fuelwood 73 3 Sheep/goat 64 3

Seed stocks 35 4 Poultry 46 5

0 20406080100 0 20406080100 % holdings from pre‐crisis levels % holdings from pre‐crisis level

Figure 15: Physical and financial asset loss & recovery See dTable 20 an Table 21 in Annex 1 for a detailed table of asset losses and recovery by type and zone.

C.1.7. DEBT There are 2 main sources of credit in the assessed zones:

Non‐institutional sources: 80‐90% of total Banks: 10‐20% of total

Traditional sources of credit are largely informal and include relatives, friends, moneylenders, local traders and seed & pesticide dealers who sell on credit. These sources are available to small farmers and other individuals. Banks such as ZTBL extend credit to large farmers ahead of the growing season for the purchase of agricultural inputs and are paid back at harvest time.

All sources of credit were found to be less accessible following the crisis. Informal sources have remained most steady with declines of one‐fifth to one‐third of previous level, while dealer and bank credit has contracted by nearly two‐ thirds. One‐fifth of communities report no source of credit after the crisis – these are largely IDP communities, both camp and off‐camp. See Table below.

Table 11: Percent decline in credit access by source Source Percent decline Family and friends 19% Moneylenders and shopkeepers 36% Buyers/wholesalers and banks 61%

The findings reflect the impact of the crisis on traditional lending networks which are stretched thin. Shopkeepers, dealers and institutions are increasingly reluctant to extend credit as sources of income in affected communities have dried up, and relatives outside of the affected areas are less able to support family over the long term as scarce resources become increasingly burdened. See Figure below.

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Availability of and access to credit

100% 100% 88% 81% 80% 56% 56% 60% Before crisis

40% After crisis 22% 19% 20% 0% 0% family, friends & moneylenders & wholesalers & no source of community shopkeepers banks credit Percent FGD reporting access to credit source Figure 16: Availability and access to credit Uses of the new debt taken on by households were assessed to determine whether it was being used to rebuild livelihoods or to meet daily expenses. Findings suggest that:

Most expenditure of new loans is being directed to subsistence needs such as food and health care, rather than livelihood recovery. Livelihoods ranks as the 3rd priority behind food and health care. 50% of assessed communities report using some share of the loan for livelihoods recovery such as repair or replacement of assets. Greater indebtedness combined with low levels of livelihood recovery is likely to increase the vulnerability of affected households in the mid‐ to longer term

See Figure below for a breakdown of uses for newly acquired debt by % of communities reporting such use.

Uses of new loan Shelter 3% Cultural event 3% Transport 13% Education 25% Livelihoods 50% Health care 97% Food 100%

0% 20% 40% 60% 80% 100%

Figure 17: Uses of new loan

C.1.8. COPING STRATEGIES Household coping strategies are a reflection of household food sources, income sources and expenditure in relation to the scope and magnitude of a shock or strained situation. Strategies are weighted according to the severity and unsustainability of the behavior to determine overall vulnerability of the household. 5 coping strategies related to dfoo shortage were assessed by settlement group (returnee, stayee, IDP and host) and analyzed in terms of:

Percent of households employing each strategy Ranking of mean scores weighted by severity of strategy

The most common strategies employed by a majority of households involve dietary change (reliance on less preferred and less expensive foods, 78%) and increasing short‐term food access (borrowing food or relying on gifts from friends

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and relatives, 57%). More damaging rationing strategies are employed by a smaller but still significant share of the population (limiting portion size, 29%; reducing the number of meals, 16%; and restricting consumption by adults, 12%). See Figure below.

Strategies employed to manage food shortage

Rely on less preferred and less expensive foods 78% Borrow food or rely on help from a friend or 57% relative

Limit portion size at mealtimes 29%

Reduce number of meals eaten in a day 16% Restrict consumption by adults in order for small 12% children to eat

0% 20% 40% 60% 80% % Households

Figure 18: Strategies employed in the last 7 days to manage food shortage A Coping Strategies Index (CSI) score was compiled for each household based on the number of days in the past week each strategy was employed and the severity of that particular strategy.30 Higher scores indicate greater incidence and severity of strategies and therefore greater vulnerability. Groups were then ranked by CSI score to compare their relative vulnerability. Data suggests:

Bajauri IDPs are the most vulnerable group followed by returnee, host and stayee groups. IDP households have a mean CSI 2‐2.5 times that of returnees, hosts and stayees and are 2 to 3 times more likely to rely on damaging coping strategies. 12% of all assessed households report employing damaging coping strategies in the last 7 days

See Figure below for a vulnerability ranking of settlement groups by CSI score.

Coping Strategies Index 25 30%

25% 25% 20 % HHs resorting to damaging coping strategies* 20%

score 15

15% CSI

10 13% % 9% 10%

Mean 8% 5 5%

0 0% IDPs Returnee Host Stayee

*restricting consumption by adults in order for small children to eat

Figure 19: Coping Strategies Index (CSI) The findings suggest that a significant minority of households, in particular those resorting to more acute rationing strategies (12%), are currently facing a very precarious food security situation and can be considered extremely

30 Frequency scores varied from 0 to 7 according to the number of days the strategy was used. Weights were assigned based on severity as recommended by CARE USA’s Coping Strategies Index Field Methods Manual. Rely on less preferred food, limit portions at mealtime & reduce meals had a weight of 1; borrow food had a weight of 2; and restrict adult consumption had a weight of 3. Maximum CSI score = 56 points.

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vulnerable. Qualitative data suggests these households are characterized by high dependency ratios (6‐7:1) and irregular sources of income (casual labour, gifts). Many are female or disable‐headed.

C.1.9. FEMALE LIVELIHOODS Prior to the crisis, women report being engaged in livelihood activities in 64% of assessed communities.31 Traditional female livelihoods are home‐based and derive from (in order of importance):

Tailoring32 Livestock, in particular the processing and sale of milk products such as curd, ghee and yoghurt and sale of eggs33 Embroidery and handicrafts34

Female livelihoods are most diversified in Swat, where handicraft and milk & ghee production are important, reflecting the relative wealth, development and cultural openness of the area. Livelihoods in Dir are less diversified and largely limited to tailoring.

The militant period confined women to their homes and deprived them of mobility and their source of livelihood. Some women reported carrying out activities covertly out of economic necessity. Today the loss of livestock, tailoring and handicraft assets combined with residual fear and depression has prevented women in the majority of assessed communities from resuming their activities.

71% of communities now lack opportunities for female livelihoods compared to 36% pre‐crisis. Tailoring activities have been partially recovered while milk & ghee production and handicrafts are at a standstill. See Figure below.

Sources of female livelihood*

Tailoring 64% 29%

Milk, ghee sales 43% 0% Before crisis Handicraft 21% 0% After crisis

Poultry, egg sales 14% 7%

No livelihood 36% 71%

0% 20% 40% 60% 80% * Percent FGD where livelihood source was reported available Figure 20: Sources of female livelihoods

C.1.10. LOCALLY EXPRESSED CONCERNS AND PRIORITIES The three main constraints cited in male FGD for resuming livelihood activities are:

Lack of cash (84%) Lack of employment opportunities (59%) Security concerns (28%)

31 Swati women report greater opportunity for female livelihoods due to fewer cultural restrictions. 32 Swat and Lower Dir 33 Swat and Lower Dir 34 Swat only

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Lack of cash is cited relative to small farmers and traders for the purpose of replacing assets and purchasing inputs. Lack of employment is cited relative to landless classes who are dependent on local casual labour opportunities for income.

Security concerns are cited in the zones of Adenzai (L‐Dir), Matta, Kabal & K.Khela (Swat) and by IDPs in Jandool (L‐Dir) where people are still worried about the law and order situation35 and PAF checkposts and curfews continue to restrict mobility and economic activity. See Figure below for a full listing of constraints as cited by male FGD participants.

Constraints faced for resuming livelihood activity (male)

Lack of cash 84% Lack of employment opportunities 59% Security concerns 28% Loss of productive assets e.g. livestock, tools 16% Physical access to markets disrupted 13% Buyers or lenders not extending credit 13% Damage to natural assets e.g. orchards, land 9% Damage to productive infrastructure e.g. irrigation … 6% Lack of agric inputs 3% GOP restrictions on crop cultivation 3% Death/disability of wage earner 3%

0% 20% 40% 60% 80% 100% Percent FGDs Figure 21: Constraints to resuming livelihood activity (male) Major constraints to livelihoods mentioned by women are in agreement with those cited by men. Women accorded a higher level of importance to the loss of productive assets (cited by 56% female FGD vs. 16% male FGD).

The three main community priorities cited in male FGD are:

Access to cash (94%) Other types of livelihoods recovery besides cash e.g. asset restoration, access to agric inputs & support to income generation (57%) Food security (56%)

Infrastructure rehabilitation, health and security were cited as lower priorities.

The three main priorities cited in female FGDs are:

Support to income generation, in particular tailoring and embroidery (in‐kind provision of sewing machines, establishment of vocational centres, etc.) (71%) Access to cash, for animal restocking (57%) Water supply (57%)

Other priorities include security, food, female health services and education. See Figure above.

35 Including in IDP places of origin

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Community Priorities (male) Community priorities (female)

Access to cash 94% Support to IGA 71%

Other livelihoods 57% Access to cash 57% recovery*

Food security 56% Water supply 57%

Infrastructure 34% Security 29% rehab

Health 13% Food security 29%

Security 9% Female health services 21%

Education 3% Female education 21%

0% 50% 100% 0% 20% 40% 60% 80%

* besides cash e.g. asset restoration, access to agric Percent FGDs inputs, support to IGA

Figure 22: Community priorities

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C.2. FINDINGS WATER SANITATION & HYGIENE (WASH)

The compiled results present a variety of information and trends from the assessment area. The following analysis is presented in four sections: WASH‐related practice, water supply, sanitation/hygiene and WASH in institutional structures. The core data comes from the 14 Focus Group discussions and WASH observation forms that were carried out in 52 different sites, but it is also supported by information from the WASH key informant interviews, the BHU visits carried out by the nutrition team as well as some secondary data (that is referenced accordingly). Where possible the analysis has been divided into the 6 sub‐classified zones, namely: Maidan, Jandool and Adenzai in Lower Dir; Matta/Kabal and Khwazakhela in Swat; and Warai in Upper Dir.

C.2.1. WASH RELATED PRACTICE Information on WASH related practice was drawn mainly from the female Focus Group Discussions (FGDs). Female based information was considered more relevant as women are responsible for water collection and domestic hygiene.

WATER SOURCES The main water sources used outside of the dry season are:

Piped water: this can refer to large scale networks involving groundwater pumping, tanks and distribution systems, or it could refer to gravity flow systems. Bowsers/Tanks: which referred to private household tanks or a tank shared between several households that were filled by small scale gravity flow or by an electrical pump placed in a well or a depression at a spring outlet. Unprotected well/springs. Protected well /springs. Protected hand pumps.

When the preferred water supply option is not available, the users are obliged to find alternative sources. The tendency for alternative sources (either as a second source, or during the dry season) is to rely more on smaller scale often private water sources where the point of water collection is adjacent to the source (namely springs, wells and tubewells). In key informant interviews privately owned wells and the water points used by mosques were often cited as perennial water sources that served as commonly used public water points during the dry season. Figure 23 and Figure 24 below analyse the different water sources used by the local population at different times.

Protected hand pumps 7.1% 35.7%

Protected well/spring 7.1% 14.3%

Unprotected well/springs 14.3% 21.4% 1st Source 2nd Source Bowsers/Tanks 21.4% 14.3%

Piped water 50.0% 14.3%

0% 20% 40% 60% 80% 100%

Figure 23: Current water sources by percent of usage

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N/A 64.3%

Canal/River 7.1%

Protected hand pumps 7.1%

Protected well/spring 21.4% 1st Source

Unprotected well/springs 50.0% 2nd Source

Bowsers/Tanks 14.3%

Piped water 21.4% 7.1%

0% 20% 40% 60% 80% 100%

Figure 24: Dry season water sources by percent of usage It was somewhat surprising to note that protected hand pumps do not serve as a 1st choice dry water source, but that dugwells and tubewells do. This raised questions about the quality of borehole construction, whether they had been drilled deep enough and whether pumping tests had been carried out.

WATER QUANTITY In terms of water supply the 1st choice source provided sufficient quantities of water in 57% of cases and the alternative source in 50% of cases; and overall there were 5 of 14 villages that declared insufficient water from both their first and second choice sources. The daily demand for water was comparatively high averaging 314 liters per household considerably higher than Sphere emergency standards and in line with what is delivered in pipeline serviced habitats. The average daily supply estimated by the focus groups was 238 liters per household, and although one focus group claimed just 30 liters of water was required per family per day, this result was an outlier as the next lowest figure of daily water availability was 150 liters per household. In terms of water supply from the 1st choice dry season source 50% of the sources provided insufficient water, as did 100% of the alternative dry season sources. This meant that 50% of the focus groups had insufficient dry season water availability, while the other 50% were reliant on a single source that could potentially have technical problems to inhibit its functioning and result in downtime. In addition to the FGD data, during the key informant interviews 11 of 12 informants said there was insufficient domestic water and 10 of 12 said there was insufficient water for agricultural and pastoral purposes.

WATER COLLECTION, STORAGE AND TREATMENT Water is collected and stored in containers made of either plastic or metal (jerry cans, pitchers, buckets). The containers were always covered, but one of the fourteen focus groups stated their collection vessels were dirty. The time needed to collect water was maximum one hour, and for 79% it was less than 30 minutes. One focus group had access to treated water (disinfected by chlorination), but the rest (93%) consumed water untreated by any method (filtration, chlorination, Sodis, boiling).

WATER POINT MANAGEMENT The water point management structure also varied across the different focus groups. The local authority (Public Health Engineering Department or PHED) managed 36% of water supply schemes and 36% were community managed by a local committee made up of influential male figures from the village. One water point was privately owned and managed by the land owner, while two water points were natural sources without ownership or management. One final source was listed as being managed by a local NGO, although it later appeared that in this case the distinction between rehabilitation (done by the NGO) and management (by the community) was not fully explained by the focus group facilitator. The topic of paying for water was a sensitive issue and only nine of fourteen focus groups chose to answer it. Of these nine 67% did not pay for water while 33% did pay for water. For those who paid monthly quotas varied from 60 rupees/month to 100 rupees/month. Needing to pay a quota did serve as a barrier to access at some piped systems, but the more significant access barrier concerned privately owned wells where the owner would only authorize certain individuals to extract water.

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WATER RELATED DISEASE Data only exists in a district wide compiled format as part of WHO weekly reports. It is consequently hard to break down the data by zones or Union Councils. Furthermore the assessment data collection methods did not allow for accurate estimation of disease incidence as this should be done through morbidity surveys rather than focus group discussions and observation. Analysis of the WHO weekly report data compiled from district health structures (including BHUs) showed that the common water related diseases were watery diarrhea, bloody diarrhea and scabies. The caseload was much higher in Swat than in Lower Dir, but this is epartly du to Swat being more populated; being better resourced in terms of medical facilities and supplies; and the Swat health structures being more accessible by the local population. To provide a more relative comparison between Swat and Lower Dir it was chosen to look at water related disease as a percentage of overall consultations. This is done in Figure 25 below and summarized in Table 23, Annex 1 using WHO compiled data from week 6 that coincided with the timing of the assessment (data was not available for Upper Dir).

1600 9.0% 1400 8.1% 1400 8.0%

1200 7.0% 6.0% 1000 Total Acute Diarrhea 5.0% 800 5.0% 800 % Acute Diarrhea Total Bloody 4.0% 2.9% %Bloody Diarrhea 600 500 Diarrhea 3.0% 2.1% % Scabies 400 Total Scabies 260 2.0% 130 0.9% 0.5% 200 1.0% 32 0 0.0% Swat(27733 Lower Dir(6194 Swat(27733 Lower Dir(6194 people) people) people) people)

Figure 25: Number and percent of morbidity cases by district, WHO source The water related disease data showed that acute diarrhea was more prevalent in Lower Dir than in Swat. Conversely Scabies was nearly five times more prevalent in Swat and bloody diarrhea nearly twice as prevalent. Overall, the water related disease prevalence as a ratio of total consultations is greater in Lower Dir than Swat, but the caseload remains higher in Swat. MSF who are present in Lower Dir describe endemic cholera in the region with peaks between May and October, this included an outbreak in 2009 with 2300 cases.

SANITATION AND HYGIENE PRACTICES First choice defecation practice in the majority of cases was to use latrines. In total 64% of males and 71% of females defecated in latrines. Conversely this meant that 36% of males and 29% of females habitually practiced open defecation. Furthermore the latrine users often cited open defecation as an alternative option. In the case of women this would always be carried out nearby their domestic shelter and required removing the excrement to solid waste pits or compost heaps, whereas for men this generally involved defecation in fields and no subsequent excrement removal. Focus group participants could not always answer precise questions about latrine coverage and availability within their village, but in 10 of 14 cases (71%) the participants said there was insufficient latrine coverage in their community, while the remaining 29% were unable to respond, meaning that none of the fourteen focus groups were able to say they had sufficient latrines in their community. After defecating, hand washing was fully and uniformly observed, however only 14% used soap and the rest used only water. When asked about hygiene practice within the community, the key informants frequently cited a problem being the lack of hygiene knowledge amongst the population, and 10 of 12 key informants recommended carrying out hygiene promotion through awareness raising and community education.

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C.2.2. WATER SUPPLY Two major kinds of water supply systems were identified:

Water points: could be hand‐dug wells (dugwells), boreholes (tubewells) and springs. Water supply schemes (piped water): could vary considerably in scale from small schemes ”gravity flow distribution systems” to a bigger civil schemes “ motorized pumping distribution systems”

TYPE OF SCHEME VISITED In total 52 different water schemes were visited in Swat, Lower Dir and Upper Dir. Overall it shows that the majority of schemes were springs (30/52 or 58%) followed by Dugwells (23%) and tubewells (19%).

25 80% 72% 21 70% 66% 20 60%

15 50% 45% Springs % springs 40% 35% 34% Dugwell % Dugwell 10 9 30% 7 7 Tubewell 24% % Tubewell 20% 20% 5 4 2 10% 1 1 4% 0 0% 0 0% Swat Lower Dir Upper Dir Swat Lower Dir Upper Dir

Figure 26: Type, number and percent of water schemes visited Figure 26 show that Lower and Upper Dir are more reliant upon springs that constitute 72% and 66% of their water sources respectively. These numbers show that there is more opportunity to work on spring protection and rehabilitation rather than wells.

LEVEL OF CONTAMINATION PER SCHEME Observational data showed that 53% of water sources were unprotected and 47% were protected. However of these unprotected sources, the vast majority, 89%, were springs. Figure 27 show that the bacteriological contamination of water sources was not alarming. Of the 51 water points where analysis took place, 30 sources (59%) showed zero contamination and 13 sources (25%) showed low risk contamination of less than 10 coliforms/100ml. Of the remaining 8 water sources, 6 (12%) showed medium risk contamination between 11 and 50 coliforms/100ml and 2 (4%) showed high risk contamination above 50 coliforms/100ml.

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100% 90% 90% 80% 70% 0 coliforms/100 ml 60% 54% 50% 1 ‐ 10 coliforms/100 ml 50% 40% 36% 11 ‐ 50 coliforms/100 ml 30% 26% 20% 51 ‐ 100 coliforms/100 ml 20% 10% 10% 10% 4% 0% Springs Dugwell Tubewell

Figure 27: Levels of bacteriological contamination per water scheme visited Detailed analysis of the medium and Highly contaminated water sources show that the location of contaminated water points was principally in Lower Dir with 6 of the 8 water points (75%) suggesting that water quality needs were greater in Lower Dir than in Swat. These were split between Jandool (3), Maidan ),(2 Adenzai (1). The remaining two sites were in Matta in Swat. Of the eight water points seven were springs, one was a dugwell; seven of the water points were community managed, one was managed by the public health engineering department; and seven were linked to distribution networks while one served as an “at source” public water collection point. The number of users of the contaminated water points varied from less than 100 up to 6000, showing that both large and small scale systems could suffer water quality problems.

6 5 5 4 3 2 Springs 2 1 Dugwell 1 0 Swat Lower Dir

Figure 28: Location, type and number of 'medium and highly contaminated' water sources The indication from Figure 28 show that activities relating to improved water quality would be best located in Lower Dir targeting community managed springs. However it is also recognized that water quality is not a widespread concern as only two of 51 water points were highly contaminated and a total of 15 “unprotected water points” showed zero bacteriological contamination.

WATER QUANTITY At most sites visited the population and the key informants anecdotally informed the assessment team that the major problem concerning water supply was a lack of water in the dry season (a period identified by 87% of communities as a 3 – 5 month period from June – August that sometimes included May or September). This applied equally to irrigation water as to domestic water. Figure 29 showed that out of 51 water points 21 (41%) gave reduced yields (or zero yields) of water during the dry season. Proportionally these were evenly split between the three districts of Swat (42%), Lower Dir (48%) and Upper Dir (66%); but when broken down by zone the highest number of water points with low dry season yields were in Matta (15), Jandool (11), Maidan (10) and Adenzai (8). When categorized in terms of type of water point the majority of water points with low yield in the dry season were springs (62%), followed by dugwells (24%) and finally tubewells (14%).

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100% 90% 34% 80% 8% 70% 68% 62% 60% Zero Yield Proper Yield 50% 33% 33% Low Yield Low Yield 40% 59% Proper Yield Zero Yield 30% 20% 37% 31% 33% 10% 7% 0% 5% Swat Lower Dir Upper Dir

Figure 29: Water sources yield 'Dry Season' The major reasons leading to water yield reductions were principally:

Diminished groundwater recharge. Higher electricity demands during the hot months (to run refrigerators and fans) results in voltage drops that make it impossible to power electrical pumping equipment (even with a regulator installed), or alternatively load shedding takes place and the daily pumping schedules are significantly reduced. Breakdowns in the system that would not be immediately repaired.

Water point yields can be improved by:

Deepening dugwells, Digging out springs Integrating storage tanks into distribution systems

WATER POINT MANAGEMENT The water systems can be classified mainly in to:

PHED systems: which are fully built and managed by the PHED engineers Community systems: 50% were community constructed and funded, others had been built and handed over to the community by government associated bodies/individuals such as the PHED, TMA ,and Nazim” while some had been built with money from humanitarian or development initiatives “RWSSP or SRSP”. In three cases local politicians had supposedly paid for water scheme construction in order to curry favor and gain votes from specific communities.

Concerning community managed projects individual household had often “accessorized” water schemes with the connection of small electrical pumps and PE pipes placed either in depression springs, spring boxes, wells or reservoir tanks. These were locally purchased and privately owned pumps that delivered water to household tanks. This was widely practiced and it was not unusual to see up to 10 private connections attached to of a common reservoir tank. This technique reflects how some households develop and fund their own strategies to improve domestic water access. While this demonstrates good initiative, it also shows how an individual rather than community approach to water supply has often evolved.

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The different bodies responsible for managing the visited water points and water schemes were:

Community Public Health Engineering Department (PHED) Basic Health Unit staff (BHU)

Figure 30, below, showed that most of the water points (67%) were managed by the local user community while 31% were managed by the PHED and one single water point was the responsibility of the BHU as it existed within the confines of the BHU perimeter wall. However it was noticeable that the majority of PHED managed projects (53%) were in Swat. This reflected the locally held belief that government had generally allocated more resources towards Swat than towards Lower and Upper Dir.

100% 4% 2% 90% 20% 80% 53% 70% 31% 60% Community BHU Staff 50% 100% PHED PHED 40% 76% BHU Staff 30% Community 67% 47% 20% 10% 0% Swat Lower Dir Upper Dir

Figure 30: Water systems management responsibilities

C.2.3. SANITATION AND HYGIENE Observation showed that towns and villages were relatively clean. Some solid waste could be seen strewn on the streets and in open irrigation channels, but this would be low risk organic matter such as plastic bags, plastic containers and metal tins. Other solid waste such as ash and food waste was collected at household level and deposited in communal collection points. From there it would compost and then be taken to the fields. This system seemed well established and well adhered to; furthermore it was purely voluntary and involved no financial input.

Latrine coverage was the main indicator used for gauging sanitation levels. The locally accepted latrines were pour‐ flush models with waste flowing into either open or sealed septic tanks. Figure 31 below shows the latrine coverage per 45 of the 52 visited sites (at seven of the 52 sites it was not possible to retrieve accurate estimations of latrine coverage). When people did not have access to latrines they would practice open defecation. Men would defecate in open areas while women would sometimes defecate in open areas, but more often would do so in the confines of the courtyard of their home and would then remove the excrement as nightsoil by shoveling it over the wall or by taking it in a bucket or plastic bag to the communal solid waste collection points.

Latrine coverage varied from 8% to 100%, but coverage tended towards the very high or very low, with fewer villages falling into the mid‐range category. A total of 38% of villages had less than 20% coverage, 26% of villages had more than 80% coverage and 36% fell einto th wider category of 20% – 80% coverage. The proportionally high number of villages with less than 20% coverage suggests there is opportunity for latrine building. Villages with poor latrine coverage tended to be smaller and more isolated. The average population of the 17 low coverage villages was 420 families, and 14 of the villages were located in the hills rather than in the more densely populated valley communities. Latrine coverage was a more concerning issue in Lower Dir where 13 of the 17 low coverage villages were located. When analyzed by zone the needs appeared most acute in Jandool where 55% of the villages had low latrine coverage, followed by Maidan (44%) and Adenzai (38%).

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100%

25% 81‐100% 33% 0‐20 % coverage 80% coverage 50% 7% 61‐80% 26% 21‐40% 4% 38% 60% coverage coverage 20% 18% 41‐60% 41‐60% 7% 40% coverage 11% coverage 61‐80% 13% 21‐40% 7% coverage 46% 50% 18% 20% coverage 27% 0‐20% 0% coverage Swat Lower Dir Upper Dir

Figure 31: Latrine coverage: percent of visited sites with percent of coverage Washing frequency in adults was investigated and is presented below. Washing frequency in children was also examined, and although it was noted that washing occurred slightly less frequently in children than in adults, there were no major differences in the adult/children washing tendencies between the six different zones. Soap was found to be widely available and widely used, this contrasted with the FGD information that found soap to be used infrequently.

Figure 32 show that low weekly washing frequency seemed less of a problem in Swat where in 11 of 13 villages people washed 5 times per week. Conversely in Lower Dir 10 of 24 villages washed only once per week and 5 of 24 villages only twice per week (there were equally concerning numbers in Upper Dir, but these were based on a much smaller sample size). The problem was most acute in Maidan where 6 of 8 villages washed once per week, followed by Warai (1 of 2), Jandool (3 of 9) and Adenzai (1 of 7). However it must also be considered that at the time of the assessment it was bitterly cold, and due to fuel costs in heating water, some individuals may have been inclined to wash less often during the winter months.

100% 90% 17% 80% 3% 50% 70% 17% 31% 1 time 5 times 38% 60% 2 times 84% 4 times 50% 21% 3 times 40% 3 times 4 times 30% 2 times 50% 5 times 20% 42% 1 time 18% 10% 8% 10% 8% 3% 0% Swat Lower Dir Upper Dir

Figure 32: Washing frequency per week in adults and percent of villages with washing frequency per week

C.2.4. WASH IN INSTITUTIONAL STRUCTURES Two kinds of institutional structures were visited; schools and health structures. The schools included boy’s schools, girl’s schools at primary and secondary school level; meanwhile the health structures principally covered primary health care in Basic Health Units (BHUs) which were the standard medical facilities in the area and they carried outt ou ‐ patient treatment; but information was also obtained from secondary and tertiary health care structures such as District Headquarters Hospitals (DHQ), Tehsil Headquarter Hospitals (THQ) and Rural Health Centres (RHC). Schools and BHUs were evaluated on whether they had a water supply, how many functional latrines they possessed and whether the staff provided hygiene promotion messages.

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Figure 33 show that 28% of visited schools did not have water supply, and this ratio remained fairly consistent over the different districts. Water supply could be a well within the compound or a tap linked to a distribution network. Secondary data from the Executive District Officer in Lower Dir suggested ttha 341 primary schools and 77 secondary schools in the entire district lacked water supply. Similar information was not available in Swat. A lack of water availability also impacted upon the utilization of latrines as water was needed to operate pour flush toilets.

100% 90% 18% 33% 80% 34% 70% Insufficient 60% water 28% Sufficient water 50% supply supply 40% 82% Insufficient 77% 30% 66% Sufficient water supply water 72% 20% supply 10% 0% Swat Lower Dir Upper Dir

Figure 33: Water supply in schools When considering standards of 50 pupils per latrine, almost all schools were underserved in toilet facilities. Figure 34 below show that latrines were not present in 16% of schools, and in the 24% of schools there was only one latrine; solitary latrines were reserved for use by staff rather than pupils. This meant that in 40% of schools students did not have any access to latrines. It was also frequently observed that latrines were badly used and the obscured area behind the latrines was often used as a defecation area by children. In terms of passing hygiene promotion messages 30 of 46 schools did do this, and the messages were passed by teachers during class, but schools Clacked IE materials to support their efforts to provide hygiene education.

8% No latrine 5% 16% 1 latrine 5% 5% 2 latrines 3 latrines 24% 4 latrines 6 latrines 37% proper coverage

Figure 34: Latrine coverage in schools Figure 35, below, show that 28% of BHUs lacked water supply, and this situation was slightly worse in Swat than in Lower Dir. Many of the BHUs had been constructed with a raised reservoir tank and water distribution but this was often in disrepair and not used, meaning that even if there was a water point, the water had to be carried to latrines, hand washing stations and consulting rooms in a bucket. This constraint dramatically reduced water availability and utilization within the BHU, which in turn risked impacting upon environmental hygiene and cleanliness of the structure. Figure 36 show that 25% of BHUs had no latrines at all, but it is not possible to derive further accurate analysis on other aspects concerning BHU latrines as due to an oversight in the data collection process five BHUs were listed as having latrines without specifying exactly how many.

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100% 90% 23% 80% 40% 70% 28% 60% Sufficient water 50% 100% Insufficient supply water supply 40% 77% Insufficient water 30% 60% Sufficient water supply supply 72% 20% 10% 0% Swat Lower Upper Dir Dir

Figure 35: Water supply in BHUs

No latrine 21% 25% 1 latrine

2 latrines 8% 4% 3 latrines

17% 4 latrines 25% proper coverage

Figure 36: Latrine coverage in BHUs The BHUs lacked solid waste management facilities. Incinerators were non‐existent and medical waste was either disposed in a pit or over the exterior wall. Most of the BHUs (72%) also carried out hygiene promotion. This was often done by the Lady Health Workers (LHWs) providing messages to other women. In previous years the LHW system had been more comprehensive, but following security related events of 2009 several LHWs had ceased in performing their duties. As was seen with the school teachers, the LHWs were also lacking IEC materials.

At secondary care level the water supply and latrine coverage of the majority of RHCs and the Samarbagh THQ was observed to be poor in particular concerning:

Water supply – quality was reported poor and quantity insufficient at 50% facilities Latrines – access was observed poor in 50% cases; cleanliness was poor in 75% cases and number was often insufficient. At tertiary care level the identified needs focussed around stabilisation centres located in the therapeutic nutrition programs at DHQ level. The needs of the Saidu Sharif (Swat) stabilization centre were observed to be largely covered. Several gaps were observed with regard to the Timergara (L‐Dir) stabilization centre, in particular with regard to an absence of drinking water facilities and an absence of latrines and handwashing stations. Furthermore caretakers have to source drinking water outside of the facility for patients. These conditions risk compromising patient recovery rates as the facility is unable to adhere to basic hygiene standards.

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C.3. FINDINGS NUTRITION

The Nutrition assessment was structured to gather information and fill key information gaps regarding knowledge, attitudes and practices of communities, medical and paramedical staff at local level and key persons at secondary and tertiary level on nutrition, infant feeding and psychosocial condition. This methodology was chosen after discussions with actors on the ground confirmed that 1) important risk factors for nutrition linked to WaSH and FSL exist, 2) currently there is no nutrition emergency in the zone, and 3) the presence of gaps in health facility capacity is impeding the delivery of high quality services, particularly in the area of nutrition.

A rapid MUAC screening was carried out among vulnerable host and IDP populations in Lower Dir in order to confirm the validity of our initial assumption and to complement the data gathered on community and health staff knowledge and practices.

The Nutrition findings presented below therefore draw from 4 sets of data:

Secondary and tertiary level Institutions key informants: In charge Rural Health Centre, District Headquarters Hospital stabilization center, children ward, gyne ward, EDO Health, Deputy EDO, National Program Coordinator, etc. Basic Health Unit medical & paramedical staff: Medical Officer, Medical Technician, EPI Tech, Nurse, Lady Health Visitor, Lady Health Worker, Lady Health Supervisor, Traditional Birth Attendant, Hakeem (traditional healer), Religious Leader Community, through Female Focus Groups MUAC screening results: 15 sites in Munda, Sadbar Kalai and Samarbagh UCs (Lower Dir)

Secondary data is also used to help fill in gaps and provide a fuller picture.

The analysis is structured in the following order: 1) Secondary and tertiary care health structures, followed by medical & paramedical staff and community knowledge and practices on 2) Nutrition, 3) Infant feeding, and 4) Psychosocial condition, followed by 5) MUAC screening results.

C.3.1. SECONDARY AND TERTIARY CARE HEALTH STRUCTURES The tertiary care District Headquarters Hospital (DHQ), one in each District, provides a full range of medical services including maternity, obstetrics/gynecological, pediatric, internal and external medicine and therapeutic nutrition programs. 1 Tehsil Headquarters Hospitals (THQ) in Lower Dir and 6 Rural Health Centres (RHC) across the 3 districts (3 in Swat, 2 in L‐Dir and 1 in U‐Dir36) provide a more limited range of services as secondary care institutions. RHCs are 25‐ bed hospitals that normally count 3 doctors (2 male, 1 female), 1‐2 nurses, 9‐12 medical technicians (MT), 2 EPI technicians and 3 LHVs on staff. Refer to the Table below for information on services fand staf in the institutions covered in this assessment.

36 The RHC in Upper Dir was not able to be visited

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Table 12: Services available by Health Facility (tertiary & secondary care level) Number staff Other Internal External Therapeutic Medical (LHV, MT, Facility Maternity OB‐GYN Pediatric Medicine Medicine Nutrition Doctors Nurses EPI, etc.) 1 DHQ Saidu Sharif √ √ √ √ √ √ 132 45 1000 2 DHQ Timergara √ √ √ √ √ √ 32 40 415 3 RHC Chuprial √ ‐ √ ‐ √ ‐ 3 0 8 4 RHC Dewlai √ ‐ √ ‐ √ ‐ 2 0 17 5 RHC Lal Qila ‐ ‐ √ √ √ ‐ 3 0 20 6 RHC Munda √ ‐ ‐ √ √ ‐ 6 3 46 7 RHC Warai √ ‐ ‐ √ √ ‐ 5 5 35 8 THQ Samarbagh √ ‐ ‐ √ ‐ ‐ 6 8 64 14 Basic Health Units (BHUs) across the districts (4 in Swat, 7 in L‐Dir and 3 in U‐Dir) provide primary care and referrals to the population and are present at the Union Council level.

Refer to Table 26 ‐ dTable 29 an Figure 44‐45 in Annex 1 for additional background information on the assessed health institutions and CMAM programs.

Secondary level institutions such as THQs and RHCs refer diagnosed cases of malnutrition to DHQ level. Upon referral, caretaker advice is given concerning balanced diets. Buildings were observed to be generally structurally sound and water and sanitation gaps have been identified in section C.2.4. (refer to Table 25 in Annex 1 for observations on physical infrastructure and water access by facility). In terms of human resources at secondary level health facilities, the staff unanimously expressed need and interest in integrating a nutrition centre (SFP, OTP or SC) at their facility level. Data on referral rates from Rural Health Centres and comparable facilities was not able to be obtained, limiting any further analysis.

At tertiary level stabilization centres located in the therapeutic nutrition programs at DHQ level treat cases of moderate malnutrition and acute malnutrition with and without complications. The programs follow the 2008 CMAM protocol and are partially supported by UNICEF. Refer to Table 24 in Annex 1 for basic data on the various admission, treatment and discharge parameters at the stabilization centres. In line with the WASH findings in section C.2.4 the Saidu Sharif (Swat) stabilization centre was seen to be in good condition and well equipped, but the Timergara (L‐Dir) stabilization centre lacked a storeroom and had no antibiotics available.

In addition, it is noteworthy that in‐patient treatment in the stabilization centres in both L‐Dir and Swat is not free of charge: the cost of injectable medication is the responsibility of the patient who must source it outside of the facility. Given the poverty of most patient households, the cost of treatment is a serious concern and was reported to act as a deterrent to poor families and a reason for default.

Staff knowledge on the various parameters of the program they are implementing (protocols, admission and discharge criteria, type of follow‐up provided, etc) was observed to be incomplete and patchy.

C.3.2. NUTRITION KNOWLEDGE

GENERAL KNOWLEDGE Knowledge and attitudes of local level medical and paramedical staff and community members around nutrition was observed to derive largely from traditional beliefs. Malnutrition (marasmus) is often talked about as sorey or a ‘shadow’ befalling the child as a result of black magic or spirit possession.37 Local religious and spiritual leaders or traditional healers known as ‘hakeem’ are often turned to for guidance. Magico‐religious therapies are often applied or the child is simply kept at home. A large proportion of local‐level staff was found to share community members’ beliefs about the nature of malnutrition ande th ways in which to approach it.

37 This belief is also documented in Mull, DS. Traditional perceptions of marasmus in Pakistan. Soc Sci Med 1991: 32(2): 175‐91.

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79% of community consider malnutrition to come from black magic 23% of religious leaders, hakeem and traditional birth attendants report the same belief, as do 2% of medical and Lady Health Worker staff 43% of community consult religious and spiritual leaders or hakeem for guidance with a malnourished child, while 57% bring the child to a doctor or hospital 58% of medical and paramedical staff will recommend bringing a malnourished child to a doctor or hospital, and the remainder to religious leaders and hakeem or taking no action. This is due to belief in malnutrition as black magic, not knowing what malnutrition is or considering malnutrition to be normal body development.

See Figures below which show the breakdown in knowledge, attitudes and practices towards malnutrition among medical and paramedical staff and community.

'Malnutrition' is understood to mean… When a child is malnourished, it is best to… LHV LHV Don't know Don't know TBA TBA LHS LHS A curse or magic Send to religious LHW LHW or spiritual leader Send to hakeem Medical staff Normal body Medical staff Religious… development Community Send back home Hakeem A disease Hakeem Send to doctor or Community Religious leader hospital

0% 50% 100% 0% 20% 40% 60% 80% 100%

Figure 37: Knowledge, attitudes & practices towards malnutrition among community and med/paramed staff

Nutrition is also poorly understood. Among medical and paramedical staff:

39% know nutrition applies to all types of food and drink while 61% do not know or believe it concerns only food. Religious leaders, TBA and LHW are especially ill informed. 52% know that a balanced diet contains cereals, oils, high quality protein sources, vegetables and fruits while 48% do not know or fail to include fruits and vegetables in the definition of balanced diet. Meanwhile, 80% routinely advocate the benefits of a balanced diet to mothers.

KNOWLEDGE AND ATTITUDES ON NEEDS OF WOMEN AND CHILDREN Nutritional needs during pregnancy and lactation are heightened, with maternal diet an important determinant of pregnancy outcomes. Traditional beliefs regarding food restriction of pregnant and lactating women are influential and will contribute to the low birth weights and high rates of anaemia documented among this population. Social norms around meal order also influence nutrition of women and children, as the highest quality food is often given to and consumed first by men. Traditionally men will take food first while children and women follow.

Attitudes of medical and paramedical staff towards diets of pregnant and lactating women and proper meal order in the home will impact the nutrition of vulnerable persons through the type of guidance that is offered.

Among medical and paramedical staff:

83% know that pregnant and lactating women require more food than normal, while 17% believe the same amount of food is required, only restricted foods should be allowed or do not know. Religious leaders, TBAs and BHU‐based medical staff are especially ill informed. 42% consider that all members of the household should take food together while 23% think males should eat first. Another 18% believe females should take food first while 17% think children should be dfe first. Religious

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leaders, TBAs and LHWs believe most strongly in the convention of separate meal‐taking in the household and males getting first priority. See Figure below showing attitudes towards meal order.

Meal order LHV Males should take first Hakeem Medical staff Females should take first LHS Children should Religious leader take first TBA Everyone should LHW take food together 0% 50% 100%

Figure 38: Attitudes towards meal order among medical and paramedical staff

ACCESS TO SERVICES A small share of assessed communities is aware of or has been able to access various health and nutrition services.

50% report being aware of existing Nutrition programs, but only 15% of programs mentioned concern the publicly‐supported hospitals in Saidu Sharif and Timergara, and the rest are private clinics. Difficulties mentioned in gaining access to programs concern the high cost of transport. 57% have been visited by an outreach worker for vaccination purposes, most commonly polio 29% report accessing a health & hygiene session delivered by an LHW

The findings suggest that the global level of awareness of and access to health and nutrition services in assessed communities is relatively poor.

C.3.3. INFANT FEEDING Exclusive breastfeeding is defined as "an infant's consumption of human milk with no supplementation of any type (no water, no juice, no nonhuman milk, and no foods) except for vitamins, minerals, and medications." International guidelines recommend that all infants be breastfed exclusively for the first six months of life. Breastfeeding may continue with the addition of appropriate foods, for two years or more.

COMMUNITY PRACTICES Practices regarding infant feeding were assessed for their importance in determining infant and child nutritional status. Findings in the assessed communities are:

Colostrum is routinely discarded in favor of supplements such as ghee, green tea, honey and ghutti (sugar water) which are given prior to or at the start of breastfeeding. Breastfeeding is most commonly started with the first hour of birth A broad share of the population reports practicing exclusive breastfeeding, but there is confusion over the meaning of exclusive breastfeeding and only 14% actually practices exclusive breastfeeding (to the exclusion of all other types of liquids and foods). Use of breast milk supplements such as cow milk, goat milk and Lactogen is extremely common. Complementary foods are introduced to the infant at 6 months of age in roughly half of assessed communities, and at 4 months of age in the remainder Mothers‐in‐law have significant influence in the household regarding the types of infant feeding and care practices employed by women

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The results suggest that there is a need for education of all women on optimal infant feeding practices. See Figure below for a breakdown of infant feeding practices by share of FGD reporting the practice.

Infant feeding practices

Supplement given at birth e.g. ghuttee, honey, green tea 79%

Breastmilk supplement given during feeding e.g. cow's milk 79%

Start breastfeeding within first hour of birth 71%

Complementary foods introduced at 6 mo. of age 57%

Complementary foods introduced at 4 mo. of age 43%

Exclusive breastfeeding practiced 14%

0% 20% 40% 60% 80% 100% % FGD

Figure 39: Prevalence of infant feeding practices

MEDICAL AND PARAMEDICAL STAFF KNOWLEDGE Medical and paramedical staff knowledge and attitudes on infant feeding were found to largely mirror community practices but with a higher general level of awareness.

The data suggests a high level of knowledge and awareness with regard to:

The nature of exclusive breastfeeding (82%) Proper timing for initiation of breastfeeding (94%) Inappropriateness of giving supplements such as ghuttee, honey or green tea at birth (82%)

A moderate level of awareness was found with regard to:

Proper timing for introduction of complementary foods [6 months] (76%)

A poor level of knowledge and awareness was found with regard to:

Importance of exclusive breastfeeding up to but not beyond 6 months of age (51%)

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Knowledge and attitudes around infant feeding

Start breastfeeding within first hour of birth 94%

Breastfeed up to 2 years of age 94%

Give breastmilk rather than supplements after birth 82%

Exclusive breastfeeding means no supplements 82%

Introduce complementary foods at 6 mo of age 76%

Exclusively breastfeed up to 6 mo. of age* 51%

Give ghuttee immediately after birth 13%

0% 20% 40% 60% 80% 100% % medical & paramedical staff *among those who understand the meaning of exclusive breastfeeding

Figure 40: Medical and paramedical staff knowledge and attitudes on infant feeding practices The issue of breast milk supplements (milk and other) is especially salient. Among BHU medical staff and Lady Health Workers, Visitors and Supervisors, 89% know and understand exclusive breastfeeding and 78% support the importance of exclusive breastfeeding up to 6 months of age. Still, a significant minority of medical staff recommend eth use of breast milk supplements to mothers, a finding which is concerning and requires more investigation.38 Overall the data suggests that significant training and capacity‐building of local‐level medical and paramedical staff on best practices for infant and young child feeding is needed.

C.3.4. PSYCHOSOCIAL CONDITION Posttraumatic stress disorder (PTSD) is a severe anxiety disorder that can develop after exposure to any event which results in psychological trauma. Diagnostic symptoms include re‐experiencing the original trauma(s) through flashbacks or nightmares; avoidance of stimuli associated with the trauma; and increased arousal, such as difficulty falling or staying asleep, anger, and hypervigilance. Formal diagnostic criteria require that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning. As an effect of psychological trauma, PTSD is less frequent and more enduring than the more commonly seen acute stress response, whose symptoms last for a maximum of 4 weeks and occur within 4 weeks of the event.

There are clear established links between maternal stress, breast milk volume, low birthweight and infant nutritional status.39 For this reason it was thought important to consider psychosocial aspects of maternal health to the extent possible in this assessment.

COMMUNITY Rough indicators of psychosocial stress at community level were included in order to provide broad guidance on the possible level and scale of stress and trauma in assessed communities. Questions were included in the female FGD as to whether participants were observing certain behaviour in themselves or people near to them since the onset of the crisis. Most commonly reported stress indicators (across half or more of all female FGDs) are:

Nightmares Flashbacks Unusual fear and anxiety

38 This share could not be determined as a significant number of respondents reported they recommend breast milk supplements even while correctly understanding and recommending exclusive breastfeeding to 6 months. It is possible that some of these cases concern mothers who are unable to breastfeed, but the finding requires further probing. 39 See: Chatterton et al, 2000. Relation of Plasma Oxytocin and Prolactin Concentrations to Milk Production in Mothers of Preterm Infants: Influence of Stress. The Journal of Clinical Endocrinology & Metabolism Vol. 85, No. 10 3661‐3668. See also: Lau et al, 2007. Ethnic/racial diversity, maternal stress, lactation and very low birthweight infants. Journal of Perinatology 27, 399–408.

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Other commonly noted stress indicators are hopelessness and despair, anger and increased violence in the home. See Figure below for the frequency of the various psychosocial stress indicators across FGDs.

Psychosocial stress indicators

Have nightmares 64% Have flashbacks 50% Experience unusual fear and anxiety 50% Have feelings of hopelessness and despair 43% Get angry 43% Experience domestic violence 43% Often cry 36% Find any changed behavior in children 29% Find any changed behavior in husbands, brothers, adult sons 29% Have suicidal or violent thoughts 7%

0% 20% 40% 60% 80% % FGD Figure 41: Frequency of psychosocial stress indicators Data suggests certain groups are more severely affected from stress than others. Simple frequency scores for each indicator (0 or 1) were summed to produce a psychosocial stress index which varies between 0 and 10. Higher scores mean a greater number of behaviours are noted in that community and suggest higher levels of stress were/are being experienced.

Scores varied between 0 and 9. Stayee groups, followed by IDPs and returnees, scored highest on the index suggesting they are most affected from stress/trauma. Host groups report no stress of any kind. See Figure below.

Psychosocial Stress Index 7.0 80% 80%

6.0 6.4 67% % female FGD reporting flashbacks 60% 5.0 5.0 50% FGD

4.0 score 4.0 40% 3.0 Mean 2.0 Percent 20% 1.0 0.0 ‐ 0% 0% Stayee IDP Returnee Host

Figure 42: Psychosocial Stress Index by settlement group The most acute psychosocial impact is noted in Swat conflict‐affected zones and among currently displaced populations in Jandool, Lower Dir (mean score=7.6).40 Meanwhile Adenzai (L‐Dir), Warai (U‐Dir) communities and host populations in Jandool scored much lower on the scale (mean score=0.3).

40 Note Maidan (L‐Dir) could not be assessed as female FGD were not conducted in the region due to security constraints

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MEDICAL AND PARAMEDICAL STAFF KNOWLEDGE A majority (81%) of medical and paramedical staff is aware that stress decreases milk production, including 97% of medical staff. A minority (37%) of medical & paramedical staff interviewed reported observing one or more of the following stress indicators that can be related to PTSD, acute stress response or depression:

Increased aggression, anger Sleeplessness Anxiety Debilitating fear (generally and from contact w PAF, militants) Flashbacks (triggers: sounds of helicopter, vehicles, weapon use) Repeated nightmares Social detachment, withdrawal Depression, repeated crying

28% report not knowing how to recognize trauma cases or describe unrelated cases; and 35% report observing no cases of trauma. A majority of staff (71%) report that they refer cases to a doctor or hospital when they encounter persons with psychological problems, while a minority (17%) refers them to a spiritual or religious leader. See Figure below.

In case of psychological problem, the person is referred to:

LHV Don’t know LHS

LHW Left at home in same condition

Medical staff Hakeem TBA Spiritual or religious leader Hakeem Hospital or doctor Religious leader

0% 20% 40% 60% 80% 100% % informants

Figure 43: Referral of psychological cases Results at medical and paramedical level concerning psychosocial stress suggest that there is a basic level of awareness but that overall, staff is not adequately trained on identifying and referring cases.

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C.3.5. RAPID NUTRITION ASSESSMENT

RISK FACTORS Based on discussions with a large number of key informants and our broad analysis of the context, a number of key risk factors for malnutrition in the assessed zones are tentatively identified. These include: Poor infant and young child feeding practices Maternal psychosocial stress in populations directly affected by conflict Latrine coverage Hygiene practices Water related diseases linked to water availability in the dry season (see C.2.1 and )Figure 25 Displacement and settlement status Dependence on damaging coping strategies linked to food rationing

Given that household interviews on a representative sample size were not conducted nor was background information on MUAC screenees collected, it was not possible to directly investigate a range of other variables linked to socioeconomic and demographic status of households that may also impact nutritional status. These include income sources and level, dependency ratios and type of household head e.g. female‐headed.

Risk factors linked to water availability and food are expected to vary in the coming months as the dry season approaches (reducing water availability) and the Rabi harvest comes in (increasing food and incomes) with expected impacts on prevalence rates. In addition population movements linked to changes in the security environment are also expected to impact nutritional status in these populations.

A full nutrition survey linked to FSL and WaSH indicators would help elucidate the relevance and importance of each proposed risk factor relative to malnutrition as well as shed light on its seasonal component.

MUAC SCREENING RESULTS 1117 children from 6 to 59 months old were measured by the nutrition team in 15 sites across IDP host areas41 of 3 Union Councils in Jandool, Lower Dir district. The analysis shows the following prevalence:

Table 13: Summary of rapid screening results Moderate Acute Malnutrition 2.8% Severe Acute Malnutrition 0.4% Global Acute Malnutrition 3.2% The prevalence of acute malnutrition observed in this sample is low, at 0.4% of SAM and 3.2% of GAM (Global Acute Malnutrition). These results have to be taken cautiously due to the limitation of the nutrition rapid assessment methodology itself: the sample cannot be considered as representative of the overall population, dan the measurement procedure will not give a thorough evaluation of the nutrition status of the sample (i.e., it is possible that a child is acutely malnourished according to his Weight for Height index, and have a MUAC>=125mm). Nevertheless, these results are considered as an indicator and as such reveal that the overall nutrition status of the surveyed population is satisfactory.

The results of the screening are reported in the tables below, by geographical units, per residence status, and per gender:

41 The sites were purposively selected based on the presence of IDPs, as described in the Methods section

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Table 14: Results of the rapid screening displayed by geographic units Moderate acute Severe Acute Location Number of Malnutrition Malnutrition children (MAM) (SAM) screened Union Council Village or settlement N % N % Bazrak 32 1 3.1% 1 3.1% Godar 50 2 4.0% 0 0.0% Munda Jan Muhammade 56 2 3.6% 0 0.0% Munda 81 2 2.5% 0 0.0% Musa Abad 78 0 0.0% 1 1.3% Jabo 15 0 0.0% 0 0.0% Pro Kale 68 2 2.9% 0 0.0% Sadbar Kaley Sadbar Shah 142 4 2.8% 0 0.0% Sawar Ghundi 73 4 5.5% 1 1.4% Ali Sheer 50 1 2.0% 0 0.0% Chamartalai 72 0 0.0% 0 0.0% Samar Bagh Damtal 76 3 3.9% 0 0.0% Tatar Lour 51 1 2.0% 0 0.0% Samar Bagh Camp 273 9 3.3% 2 0.7% Total 1117 31 2.8% 5 0.4%

Table 15: Results of the rapid screening displayed by residence status Number Moderate Acute Severe Acute of Malnutrition Malnutrition Residence status children N % N % screened IDP 373 10 2.7% 2 0.5% Host 734 21 2.9% 3 0.4% Refugee (Afghan) 10 0 0.0% 0 0.0% Total 1117 31 2.8% 5 0.4%

Table 16: Results of the rapid screening displayed by gender Number Moderate Acute Severe Acute of Malnutrition Malnutrition Gender children N % N % screened Female 517 20 3.9% 4 0.8% Male 600 11 1.8% 1 0.2% Total 1117 31 2.8% 5 0.4%

The number of acutely malnourished individuals is too small to allow a statistical differential analysis of the situation per geographical situation, residence status or gender: even though some factors seem to have an impact on nutrition status (i.e., girls seem to be more affected than boys), the difference observed is not significant.

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D. CONCLUSION

D.1. GENERAL PERSPECTIVES

With over 2.742 million civilians from NWFP and FATA being officially displaced at the height of the conflict, the humanitarian situation in North West Pakistan has deteriorated significantly since 2008. Between 15 and 20%43 of those registered IDPs were or are being accommodated in camps; the rest hosted by local communities or staying in unofficial IDP settlements and rented accommodation while depending on humanitarian aid or host communities’ support. Returnee, stayee and currently displaced populations will continue to depend on humanitarian assistance for a significant period of time as a result of losing assets and livelihoods, having few to no agricultural outputs and lacking access to basic services. Stayees who were stranded or trapped inside conflict zones, and returnees/other displaced persons whose assets were looted and livelihoods largely destroyed in the conflict, are the most affected groups.

In recent months, the Pakistan security forces have built upon the operations it achieved in Swat and South Waziristan to expend its fight against militants in other parts of FATA (Bajaur, Orakzai and Kurram in 2009 and early 2010). However, recent indiscriminate attacks in the country, small scale security operations in Swat, Lower‐Dir, Kohistan and ongoing security forces operations in Kohat, Hangu ...etc FATA Agencies tend to confirm that the militancy in North West Pakistan is far from being contained. It is therefore widely expected to have security forces operations to go on for some time in the region, focusing on disrupting the militancy leadership as well as decreasing their ability to launch attacks in the country.

The expected ongoing low‐intensity conflict and extension of security forces operations in other parts of FATA Agencies, NWFP Districts and even in neighbouring Baluchistan will continue to affect livelihoods, infrastructure, leading to further small scale and cyclic population displacements. At the same time, a process of return in areas severely affected by previous security forces operations will continue which will imply a massive amount of reconstruction and development work to prevent any kind of unrest or general instability.

Besides limiting access to conflict affected populations, a foreseen unstable and unpredictable security environment will continue to challenge effective and well‐timed humanitarian response.

D.2. FOOD SECURITY & LIVELIHOODS

Overall significant livelihoods‐related needs were observed across return areas and in IDP settlements. These are linked to broad asset depletion at the time of the conflict and poor to minimal recovery to‐date, depending on the area. Markets have substantially recovered, with pre‐crisis trade flows of major commodities restored and systems of credit and procurement largely intact. The major constraint on market activity related to the disruption suffered in 2009 is lower demand from buyers (who are still constrained by income) and lack of cash for reinvestment in businesses, in particular for small rural traders. Market activity overall is fueling recovery by supporting employment and the movement of food commodities, cash crop and labour into and out of the area. The rapid market assessment was conducted in winter when activity generally slows. It is likely that the arrival of summer and the harvest of the Rabi winter wheat crop will eprovid fresh cash infusion into the local economy and reinvigorate systems.

Until then, livelihoods recovery is likely to be poor unless significant support is extended by humanitarian actors. Findings suggest that the restoration of lost, looted or liquidated livelihoods assets such as livestock and livestock fodder, agricultural and handicraft tools, agricultural land, irrigation networks and other small scale community infrastructure has been delayed across all areas but most notably in Maidan (L‐Dir). The delay can be attributed to an acute depletion in household income sources combined with the relative isolation, poverty and continuing insecurity of some areas. Female livelihoods in tailoring and processing/sale of animal products have also been lost. Income portfolios have become more diverse out of necessity, with remittances, various forms of income support (zakat, aid) and asset sales becoming more prominent. Most of the new credit being sourced today by households is used to cover food and health‐related needs rather than asset restoration.

Local social networks and food distributions have supported the food security of the most vulnerable populations in these recent months with gifts, sharing and borrowing of food. While overall dietary diversity was found to be

42 UN PHRP 2010 43 CAR, PaRRSA

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adequate, a small minority of the population (12%) across IDP, returnee and stayee groups was found to be especially vulnerable to food insecurity by their reliance on precarious food sources and unsustainable and damaging coping strategies.

Overall the analysis of consolidated findings reveals IDPs and Returnees to be the most highly vulnerable groups. Refer to the vulnerability ranking in the Table below where higher scores indicate greater vulnerability.

Table 17: Consolidated vulnerability ranking of settlement groups by FSL indicators

Dependence Vitamin VULNERABILITY Iron rich Income Asset Asset Total on precarious HDDS A rich CSI RANKING diet affected loss recovery Score food sources diet

1 IDP 4 2 3 2 3 4 4 3 25 2 Returnee 3 2 3 4 2 3 3 2 22 3 Stayee 2 1 1 3 2 2 2 1 14 4 Host 1 1 2 1 1 1 1 1 9

Outstanding gaps and needs include:

Restoration of farm and off‐farm livelihoods and food security of vulnerable stayee and returnee households Recovery of female livelihoods Enhancement of income generating activities among IDP households Rehabilitation of vital community infrastructure Revitalization of small businesses

Locally expressed priorities by men, women and youth are in line with the needs cited above and concern access to cash and employment, asset restoration and support to income generation. It is noteworthy that cash is preferred over in‐kind provision of assets – largely for the purpose of animal restocking and purchasing agric inputs. Meanwhile in‐ kind restoration of female livelihood assets such as sewing machines and handicraft tools is preferred. Restoration of education and health services and water supply schemes is also a major community priority.

D.3. WASH

There are WASH related needs in the assessment area, but these were not identified as acute needs associated with humanitarian emergencies. During the period of the assessment people were observed to have access to water, and even when they claimed not to have sufficient quantities, the per capita amount was still above Sphere standards of 15 litres/person/day. Some water supply infrastructure is in poor condition and several schemes are no longer working or suffer frequent interruptions; but populations have found ways to access or exploit alternative sources (often smaller scale private sources). Many of these coping strategies for facilitating water supply haven bee organised on an individual household basis such as household wells and private electric pumps and piping in common water reservoirs. ACF must be conscious of how some water supply methods have evolved on a more individual rather than community level. Consequently any targeting must ensure identification of populations who are asking for and willing to manage community based interventions, furthermore additional mobilization time will be necessary to fully communicate the ACF community based approach to stakeholders.

Some water quality problems were identified through water testing, but bacteriological contamination was mostly zero or low risk. Open defecation was practiced but this was more prevalent in rural villages where defecation control was less critical. Villages appeared visibly clean and solid waste was well managed, and although various hygiene promotion initiatives did exist, amongst certain portions of the population hygiene knowledge and practice were lacking.

Water related disease was present, and although detailed statistics could not be obtained, the incidence as a proportion of total consultations was not alarming and MSF who were present in the zone suggested that the diarrhea rates were habitual amongst the catchment population, but that scabies rates were unusually high. WASH infrastructure in BHUs and schools was often absent, insufficient or in a state of disrepair.

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The more emergency related WASH needs were identified as a lack of water availability during the dry season, recurrent IDP influxes and cholera outbreaks. Due to the timing of the assessment, these needs were all dormant during the field‐based data collection period, but they were widely identified by stakeholders at all levels. Mitigating or preventing vulnerability associated with these hazards should be the core of any WASH related activities. The dry season occurs during in the May to August period, cholera outbreaks most commonly occur in the August to October period, and at the time of the assessment many of the IDPs had left the area, households were no longer hosting IDPs, several camps had closed and the remaining ones were already supported by established actors.

With all the identified needs there is opportunity for ACF to contribute within the WASH sector, but interventions need to be correctly targeted, coordinated and agreed upon by all stakeholders to ensure that any activities (especially more costly hardware) will be providing significant improvement to the existing situation, will not overlap will other projects, will be sustained and will be accepted by the target community. ACF also needs to clearly define its mandate within the local context. Although some urban water infrastructure is nearing the end of its useful life, rehabilitating it constitute development oriented work and would generally be considered outside of the ACF approach as it surpasses “community based interventions” involving large scale civil engineering, long term projects and Ministerial partnership.

More pertinent projects for ACF would be the improvement of existing water infrastructure to protect contaminated water points and to augment dry season yields. There may also be the possibility of linking irrigation schemes to water supply projects. Furthermore water scarce areas could be identified and new water points constructed there. Sanitation could be improved with latrine implementation programs and the existing hygiene promotion initiatives based in schools and BHUs can be reinforced and augmented. Emergency preparedness and response activities can be coordinated with local actors and will help brace the area for the anticipated IDP influxes and cholera outbreaks.

D.4. NUTRITION

Overall the findings from the nutrition assessment confirm the initial hypothesis that while malnutrition prevalence rates among vulnerable host and displaced populations are currently below emergency threshold (0.4% SAM and 3.2% GAM), significant risk factors are present with regard to:

Poor infant and young child feeding practices Maternal psychosocial stress in populations directly affected by conflict Latrine coverage Hygiene practices Water related diseases linked to water availability in the dry season Displacement and settlement status Dependence on damaging coping strategies linked to food rationing

Knowledge and practices of communities around breastfeeding, widespread use of supplements at birth and broad reliance on breast milk supplements was found to be concerning. Knowledge in the community of nutrition, especially the nutritional needs of infants, young children and pregnant and lactating women, was found to be low. Cultural practices around meal order and food restrictions will exacerbate the nutritional vulnerability of these groups. The high levels of psychosocial stress reported among displaced and stayee populations is likely to further negatively affect maternal milk production and breastfeeding practice. There is a widespread belief in malnutrition as black magic and poor awareness of and access to existing therapeutic nutrition programs.

Knowledge and attitudes of medical and paramedical staff vary but generally were found lacking. Significant gaps in capacity were observed with regard to staff knowledge on breastfeeding practice, maternal nutrition and proper identification and referral of malnutrition cases. The Lower Dir DHQ stabilization centre and a majority of RHCs suffer from inadequate water supply and sanitation facilities affecting the hygienic environment and proper delivery of care. It is also noteworthy that patient responsibility for the cost of injectable medications in therapeutic nutrition programs in Swat and Lower Dir is reported to be serving as a deterrent to treatment and a reason for default among poor households.

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Overall important gaps exist in the capacity of District‐level therapeutic nutrition programs to provide adequate treatment according to accepted standards; in the capacity of local medical and paramedical staff to satisfactorily support communities, pass health and nutrition messages and refer cases; and in the knowledge base at population level.

Factors such as immunization, vitamin A distribution and deworming program coverage were not able to be looked into in this assessment due to time and resource limitations, but are likely to be important in pinpointing areas and populations at higher nutritional risk. In addition contextual factors such as water availability, harvests and population movements will continue to affect risk. Secondary level health facility staff expressed notable interest in integrating nutrition programs at their level to have the capacity to respond to these types of risks.

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E. RECOMMENDATIONS

The section is divided into 3 parts: Type of interventions proposed, Priority geographic areas and Target groups. The proposed interventions are presented sectorally followed by a section on opportunities for integration.

E.1. TYPE OF INTERVENTIONS PROPOSED

It is recommended to adopt a low key approach that will allow ACF to address some of the ongoing problems of the area while bringing in surveillance data to improve the understanding and analysis of the evolving context. However should any humanitarian emergency occur, activities can be rapidly scaled up to respond to the increased and immediate needs.

FSL, WaSH and Nutrition activities are recommended to be integrated across zones and target the same beneficiary populations wherever possible in order to maximize impact and optimize resources as well as reduce risk exposure of staff. Interventions will focus on surveillance, building emergency preparedness and response capacity, and response to current identified needs.

E.1.1. FOOD SECURITY & LIVELIHOODS Based on the needs analysis undertaken here, the priorities for recovery expressed by the communities themselves and the anticipated evolution of the context in future months, it is recommended that ACF and other humanitarian actors focus on a 3‐pronged approach in FSL. The approach addresses the need for broad economic recovery in the affected areas and the provision of targeted support to very vulnerable populations. In addition surveillance of the underlying food security situation is recommended following the upcoming Rabi harvest across the zones of intervention and in current IDP hosting areas. The proposed activities have a 12 month timeframe but may require revision as new information becomes available regarding the food security situation in the intervention zone and movements of displaced populations to and from Bajaur.

To accelerate livelihoods and asset recovery across the affected areas and support vulnerable groups, the recommended activities are:

Cash‐based support for asset restoration, inputs purchase and restocking according to local priority among asset‐poor small farmers in the form of vouchers or cash grants. Regarding restocking methodologies, weekly melas or fairs are routinely organized and carried out at district and local level with livestock dealers coming from Sindh and Punjab. Opportunities for establishing a voucher program for small farmers in conjunction with livestock dealers who already visit the area can be investigated. Restocking programs should be closely coordinated with the Livestock and Dairy Development arm of the district Agriculture Department. An integrated livestock intervention should also consider the provision of high quality fodder and technical support and adopt appropriate quarantine protocols wherever possible. Cash‐for‐work schemes that aim to:

- Support the rapid development of income generation among IDP households accounting for their highly mobile and impermanent status, and among vulnerable landless households residing in return areas - Rehabilitate vital damaged community infrastructures including irrigation networks, water supply schemes, schools and other locally‐identified priority projects - Support latrine construction in underserved areas as appropriate and in conjunction with the WASH department Revitalize small businesses and microenterprise in rural areas through targeted cash grants focusing on existing small business owners and microentrepreneurs whose activity or assets were damaged in recent events and whose recovery is primarily constrained by lack of capital or credit. Support to restart female livelihoods (tailoring, embroidery) in areas where these activities previously existed, with the provision of in‐kind assets and technical training for restart of activities among vulnerable IDP, returnee and stayee households including sewing machines and handicraft tools. Care should be taken to ensure that a viable market for tailoring and embroidery products exists in the local area and that there is acceptance from community leaders. Partnership with exisiting female CBOs and other local organizations should be considered as a criteria for site selection in order to promote the program’s acceptance.

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Restocking of goats among vulnerable stayee and returnee households whose livestock assets were lost, in particular landless and female‐headed. This could be done in conjunction with the first named activity (cash grants or vouchers for restocking purpose) with a different targeting mechanism.

To enable emergency alert and response to a degrading food security situation in particular with regard to vulnerable IDP groups as well as stayee and returnee populations across newly accessible conflict‐affected zones, it is recommended to:

Carry out regular integrated surveillance activities on a series of pre‐identified and agreed upon indicators and to establish an official mechanism for the dissemination of results via OCHA or local coordination bodies44

E.1.2. WASH A dual approach is proposed to address both the ongoing and emergency needs of the area. For the activities addressing the ongoing problems of the area it is recommended to focus on small scale projects in rural communities. This will avoid crossover with government managed projects in urban areas, will bring greater impact in a smaller community, will provide an easier operating environment with fewer stakeholders and will permit greater opportunity for ACF to work on community mobilization and participation. This approach is also relevant in terms of needs as water quality was shown to be worse in community managed schemes and latrine coverage was worse in smaller and more isolated villages, while water quantity problems occurred across all scale of infrastructure (in low density population and high density population areas). Conversely the emergency preparedness and response activities should cover urban areas as well as rural areas. This reflects that an IDP or cholera crises can occur anywhere in the area and that ACF should have the operational capacity to respond. The emergency needs should be prioritised over the “ongoing” needs, but in the absence of immediate emergencies the initial focus of activities should be on the pre‐positioning of emergency response material as well as on the implementation of regular WASH activities whose completion will facilitate acceptance of ACF amongst the local population.

The recommended activities are:

Water point mapping carried out during the dry season to properly observe and identify the most water scarce areas. Setting up of groundwater level monitoring (piezometers in boreholes) to establish the aquifer recharge rate and to build an evidence base to examine local claims that groundwater reserves are depleting and the water table is dropping. This can also be complemented by rain gauges that can help establish how much water is lost to surface run‐off and how much goes into the water table. Improvement of water quality by:

- Properly protecting contaminated springs with a spring catchment and where relevant a spring box - Extending water inlet pipes in mountain streams uphill to the groundwater source of the stream - Constructing concrete aprons around dugwells Improvement of water quantity by:

- Deepening dugwells - Excavating existing springs - Implementation of new boreholes - Capturing of unexploited mountain springs and creating gravity flow systems - Construction/improvement of storage tanks as part of distribution systems - Integrating/replacing small scale water pumping equipment in established water schemes to improve distribution networks and supply previously unserved households - Potentially linking water supply infrastructure with irrigation channels if the supply surpasses the quantity required for domestic needs - Pilot projects involving solar pumping equipment at water points located at a lower altitude than the user community (solar panels are locally available) - Pilot project to develop a kareze (horizontal shaft in mountainside to allow groundwater to flow out)

44 in partnership with other humanitarian actors operational in the area where possible

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Improvement of sanitation facilities by:

- Household latrine implementation involving community participation through a CLTS methodology (while being aware that CLTS will be limited in villages where digging is challenging due to the geological context – in these cases subsidisation or remuneration can be considered) Improvement of hygiene knowledged an practice by:

- Reinforcing school based hygiene education by providing training and IEC materials to teachers - Reinforcing the Lady Health Workers based out of the BHUs with booster training and IEC materials (while remaining vigilant of local sensitivities about working directly with women and empowering them to spread messages to the female population) - Cholera prevention campaigns targeting riverside and urban populations during the cholera “window” - Awareness raising on scabies and how to prevent it - Regular hygiene promotion by ACF agents targeting female groups and using IEC materials developed by Unicef Improvement of WASH infrastructure in BHUs and schools

- Provision/rehabilitation/improvement of water points within the compound (dugwell or piped delivery) - Provision of sufficient latrines according to minimum standards (50 individuals per latrine) - Rehabilitation of broken internal water distribution systems in BHUs - Emptying of septic tanks (where necessary and feasible) – otherwise digging of new septic tanks - Ensuring sufficient distance between wells and latrines - Implementing medical waste management systems in BHUs (pits or incinerators) Emergency preparedness

- Improving of water availability in areas where unofficial IDP camps have previously existed - Pre‐positioning of emergency equipment (bladders, tapstands, plastic latrine slabs) - Identification of local businessmen with water tankers capable of supplying sites by water trucking - Elaboration of a district emergency response plan in collaboration with other actors Emergency response (during IDP or cholera emergencies)

- Immediate emergency water supply through distribution of point of use products or through water trucking - Immediate provision of sanitation facilities through construction of emergency latrines and solid waste pits - Hygiene promotion focussed on the immediate morbidity risks - Identification and implementation of more sustainable methods to replace the “immediate” WASH interventions

Furthermore it is not recommended that ACF involve itself in PHED projects, which tend to be of a larger scale, for the following reasons:

- The PHED has been operating water supply systems for many years and has excellent working knowledge of the schemes to carry out their own repairs - The PHED projects should be funded by government subsidies and user quota payments. If this is unable to cover the repair costs then such a scheme is not adapted to the means of the local area. - Substituting for the duties of the PHED in terms of water scheme repairs may reduce people’s expectations from the PHED and risks making the PHED less accountable to its beneficiaries. - PHED projects tend to rely on electricity from the power company in order to provide power to the pumps. This means that any repairs would automatically involve three stakeholders (local community, PHED and electric company) and ACF would find it very hard to dtry an mediate between these different parties

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E.1.3. NUTRITION Based on the analysis that was undertaken and our understanding of relevant dynamic contextual factors, the identified needs in nutrition suggest an approach organized around i) enhanced CMAM implementation through capacity building at primary, secondary and district level, ii) nutrition and health education promotion at community level, and iii) nutritional surveillance of identified vulnerable populations and zones. A baseline nutrition survey to launch surveillance activities is needed to pinpoint areas and populations at higher nutritional risk.

The recommended activities are:

CMAM implementation through capacity building: Treatment activities could be a way to gain acceptance by communities, authorities and donors, and be prepositioned in case of emergency (in the areas of operation or other ones). The health system is in place and well organized but in need of capacity building. ACF is recommended to: Partner with a local organization already positioned on the ground and knowledgeable about the health sector in order to maximize the use of resources and permit rapid scale‐up Provide technical and organizational training at facility and district level and equipment, rehabilitation and cash support in the host facilities The expected outcome is that the program could be run by the medical staff and local authorities after ACF withdraws. If no major difficulty is met (staff turnover, shortage of drugs/RUTF, lack of access to the field, poor acceptance of the program by communities, etc.), the program should require a timeframe of 12‐18 months, ideally. It is premature to identify the location of this program, but it could be beneficial in every context due to its capacity building nature. Integrated education activities: Nutrition and health promotion could be incorporated into other education activities (WaSH) by ACF agents and reinforce existing initiatives in hygiene promotion and nutrition education currently provided by schools and the Lady Health Worker program. This would serve to both improve community knowledge and practice as well as build the capacity of local health staff. Baseline nutrition survey and surveillance activities: The nutrition situation is expected to vary in the coming months due to seasonal and contextual factors: harvest season (expected positive impact of food availability and security at household level), dry season (expected negative impact on water availability and quality), end of the WFP General Food Distribution (expected negative impact), return of the IDP population in their place of origin. Depending on the security and political context, new areas might become accessible, and movement of population may occur again, leading to the creation of new camps. It is recommended to establish a baseline through a comprehensive nutrition survey in intervention areas. Surveillance could be done through ad hoc nutrition assessments or integrated through ongoing field activities.

E.1.4. OPPORTUNITIES FOR INTEGRATED INTERVENTIONS There is the opportunity to integrate some of the proposed activities in Wash, FSL and Nutrition.

Regular hygiene promotion activities targeting females can also feature nutrition messages, and Lady Health Workers at BHUs can be educated to pass on both hygiene and nutrition messages. Assessing technical feasibility of improving water supply to fields and water flow in irrigation channels (FSL and WaSH). Linking water supply systems with irrigation channels as appropriate and coordinating work between WaSH and FSL departments. Implementing latrine pit digging through cash for work, if it is not possible to do so through free community participation because the task of digging in hard ground is too demanding. Targeting and monitoring of this activity would involve both WASH and FSL departments. Regular or ad hoc integrated surveillance of identified vulnerable zones and populations as appropriate

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E.2. PRIORITY GEOGRAPHIC AREAS

Return, transit and host areas in Lower Dir district have been substantially affected. The higher poverty and relative isolation of the region combined with fewer actors to‐date has significantly delayed recovery in parts of the district, in particular those that were directly conflict‐affected. Thus it is recommended that ACF and other humanitarian actors focus interventions on the following priority areas of Lower Dir:

L‐Dir, Maidan L‐Dir, Adenzai L‐Dir, Jandool

E.3. TARGET GROUPS

Returnee, stayee and displaced populations are found to be significantly vulnerable groups in terms of income and asset depletion and slow rate of livelihoods recovery. Off‐camp Bajauri IDP populations hosted in the Munda and Samarbagh region are a highly vulnerable and until now largely neglected group.

Small farmers and landless and wage labourers have experienced the poorest recovery to‐date among the livelihoods classes. In addition, small traders located in the rural areas require assistance to reinvest in their business. Their recovery is vital in terms of supporting local economic activity. Special attention is recommended to groups such as barbers and artists who were targeted and persecuted during the militant period.

Households with high dependency ratios (6‐7:1), irregular or no sources of income (casual labour, gifts) and resorting to acute and damaging rationing strategies make up the poorest, most vulnerable and most affected class. Female, youth and disable‐headed households are disproportionately represented.

FSL interventions should focus on small farmers, landless & wage labourers, and small traders in return and stayee areas, as well as internally displaced populations. Special attention should be brought to the most vulnerable segments of the population such as female or disable‐headed households and households with high dependency ratios and unreliable sources of income. Wherever possible Nutrition and FSL programs should collaborate in targeting beneficiaries, so that households with children discharged from therapeutic nutrition programs benefit from livelihood support activities.

WASH interventions should mainly target rural areas, which were considered underserved compared with urban areas. This proviso still remains coherent with the target groups identified above. However WASH emergencies may occur anywhere (urban, semi urban or rural contexts), and any related intervention should retain the capacity to carry out life saving activities in all three contexts.

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ANNEX 1

Table 18: Field data collection detail

Male Female HHFood Market WASH Nut Med Nut MUAC District Tehsil UC FGD FGD Sec KI obs Paramed Facilities screening Kabal Dewlai 2 1 3 7 4 11 1 Kabal Koza Banda 2 1 3 6 4 9 Matta Arkot 11 Swat Matta Chupriyal 2 1 3 11 4 2 Matta Gowalarai 2 1 3 6 4 10 Khwazakhela Kotanai 2 1 3 4 10 Adenzai Asbanr 2 1 6 6 3 4 Adenzai Khanpur 2 1 4 1 7 Adenzai Kotigram 4 1 Adenzai Ouch 11 Lal qila Beshigram 2 3 5 Dir Lower Lal qila Lal qila 2 1 7 3 3 2 Lal qila Zaimdara 2 4 4 Munda Mian Kalay 3 1 4 3 2 Munda Munda 3 9 1 5 Samarbagh Sadbar Kalai 2 2 8 1 1 5 Samarbagh Samarbagh 3 2 7 7 4 9 1 5 Warai Darora 2 1 6 Dir Upper Warai Wari 2 2 6 7 2 14 1 Adenzai Chakdara 5 Dir Lower Timergara Timergara 9 5 Khwazakhela Khwazakhela 9 Swat Saidu Sharif Saidu Sharif 7 TOTAL 32 14 51 80 52 127 20 15

Table 19: Number of trader interviews by business type

Type of Trader Type of Business Rural Urban Grand Total Artisan Blacksmith 2 1 3 Cap maker/handicraft 1 1 Carpenter 4 3 7 Artisan Total 7 4 11 Manufacturer Concrete block plant 4 1 5 Marble plant 1 1 Stone crush plant 1 1 Manufacturer Total 5 2 7 Retailer Agricultural goods 1 2 3 Agricultural tools 1 1 2 Bakery shop 1 1 Fuel station 2 2 General store 7 4 11 Meat/poultry 1 1 2 Plant nursery 1 1 Vegetable dealer 7 3 10 Retailer Total 19 13 32

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Service provider Barber 4 1 5 Hotel & restaurant 2 4 6 Transporter 5 1 6 Veterinarian 1 1 Welding shop 1 1 Service provider Total 13 6 19 Wholesaler General store 5 2 7 Livestock dealer 1 1 Meat/poultry 1 1 Vegetable dealer 1 1 Wholesaler Total 5 5 10 Grand Total 49 30 79

Table 20: Asset losses by zone and asset type

MEAN L‐Dir/ L‐Dir/ Swat/Mat Swat/ L‐Dir/ U‐Dir/ ACROSS ASSET LOSSES Maidan Adenzai ta,Kabal K.Khela Jandool Warai ZONES Forests 68 0 56 20 20 0 27 Fruit orchard 10 0 60 40 33 0 24 Other agric land 90 53 68 20 31 10 45 Hives 97 67 48 50 0 0 44 Shops/ small businesses 68 33 68 0 31 13 36 Irrigation networks 32 0 30 10 14 5 15 Other comm infrastructure 38 0 43 10 17 0 18 Fishery ponds 0 0 0 NA 0 0 0 Seed stocks 100 67 81 60 40 45 65 Fuelwood 55 27 40 10 33 0 27 Agric tools 50 27 36 0 29 0 24 Cash, jewellery, other HH assets 57 23 40 0 3 0 20 Handicraft assets 28 40 40 10 0 0 20 Animal fodder/ grasses 88 53 59 25 40 10 46 Animal shelter 38 0 20 0 14 0 12 Poultry 100 55 58 50 28 33 54 Sheep/goat 90 45 43 10 21 5 36 Cow 87 30 46 10 18 0 32 Oxen 77 33 23 20 0 0 26 Buffalo 33 25 43 10 18 0 21 Donkey/mule 20 0 15 20 17 0 12 Horse 0 0 17 20 0 0 6 MEAN ACROSS ASSETS 56 26 42 19 18 5 28

Table 21: Asset recovery by zone and asset type*

MEAN L‐Dir/ L‐Dir/ Swat/Mat Swat/ L‐Dir/ U‐Dir/ ACROSS ASSET RECOVERY Maidan Adenzai ta,Kabal K.Khela Jandool Warai ZONES Forests 0 NA 0 0 0 NA 0 Fruit orchard 0 NA 6 20 0 NA 6 Other agric land 0 0 16 20 27 10 12 Hives 0 0 0 0 NA NA 0

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Shops/ small businesses 0 20 29 NA 17 20 17 Irrigation networks 0 NA 15 0 0 0 3 Other comm infrastructure 0 NA 10 0 0 NA 3 Fishery ponds NA NA NA NA NA NA Seed stocks 17 0 10 0 0 0 4 Fuelwood 0 0 9 0 7 NA 3 Agric tools 3 20 27 NA 0 NA 13 Cash, jewelery, other HH assets 0 0 6 NA 0 NA 1 Handicraft assets 5 0 5 0 NA NA 3 Animal fodder/ grasses 0 10 5 0 7 0 4 Animal shelter 5 NA 10 NA 0 NA 5 Poultry 0 0 13 20 0 0 5 Sheep/goat 0 0 19 0 0 0 3 Cow 0 10 10 0 0 NA 4 Oxen 0 10 10 0 NA NA 5 Buffalo 0 7 10 0 0 NA 3 Donkey/mule 0 NA 13 10 0 NA 6 Horse NA NA 8 0 NA NA 4 MEAN ACROSS ASSETS 2 5 11 4 3 4 5

* As a percent of total pre‐crisis holdings

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Table 22: Baseline price trend for staple commodities, February 2010

Type Item Description Source Availability Unit Price/unit Notes Wheat Plain, fine, super flour Local mill Bathkhela, regional markets, Punjab High 20 kg 560‐620 Available in 50% of area markets. Local mill (Gowalarai, Madyan, Samarbagh), Maize Regular flour Low 50 kg 900‐1200 Low production in 2009, most regional market consumed locally. Sela Regional markets (Batkhela), Punjab High 40 kg 65‐80 Rice Swati Local producer (Chuprial, Begamai) High 50 kg 48‐60 Katcha Timergara High 40 kg 32‐40 Gram Local, regional market, Punjab High kg 45‐60 Moong Provincial market High kg 50‐70 Pulse Mash Regional market High kg 120‐150 Red bean Regional market Normal ‐ High kg 70‐80 GCP Regional market High 5 kg 510‐520 Mujahid Banaspati Regional market High 5 kg 500‐620 Food Ghee commodities Sharma Regional market High 5 kg 540‐620 Sher or Taj Banaspati Regional market High 5 kg 500‐550 Cooking oil Kisan, Mujahid, Sharma Local, Regional and Provincial markets High 5 Liter 610‐680 Sugar (refined) Regional and Provincial markets Low kg 70 Sugar Gurr Import Low kg 60‐70 Available in 30% of markets Tea Kenya Regional market High kg 350‐400 Potato Cartinol, Raja, Diezeel Punjab Normal ‐ High kg 15‐20 Tomato Sindhi Sindh Normal ‐ High kg 15‐20 Onion Pulkari, Sindhi Sindh Normal ‐ High kg 25‐30 Cost of chicks and feed has risen 2‐6 Chicken broiler Punjab Normal ‐ High 2 kg 200‐260 x since 2008 Buffalo beef Provincial market, Punjab Normal ‐ High kg 150‐160 Local cash crop in Kuza Bandai, Walnut Local Local Low kg 100 Kabal and elsewhere Fuel Diesel Provincial market High Liter 74.5‐74.8 Other staple Urea Regional market Normal‐High 50 kg 840‐970 commodities Fertilizer DAP Regional market High 50 kg 2500‐2550 Available in 50‐80% markets Super Phosphate Regional market High 50 kg 600‐730

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Askari Nizampur (NWFP) Normal 50 kg 260‐300 Cement Bestway Taxila Punjab High 50 kg 260‐265 Unskilled Local Normal day 200‐300 Concrete block, marble, stone crush Labor Labor Skilled Local Normal day 400‐550 Carpentry, masonry, welding Buffalo ‐ Faisalabad (transport cost 1 unit is 5,000) ‐ Unit 60‐90,000 Jersey ‐ Unit 65‐70,000 Business is poor and sales are low Freizen ‐ Unit 65‐70,000 due to lack of demand from buyers Cow Sahiwal ‐ Punjab (transport cost 1 unit is 7,000) Unit 50‐60,000 Fodder problem noted by dealers Cross Sindhi ‐ Unit 45‐50,000 Achai ‐ Unit 30‐35,000 Livestock Punjabi ‐ Unit 10‐18,000 Local production sold in local livestock fairs on weekly basis Watanai ‐ Local and regional market Unit 4‐8,000 Goat Sindhi ‐ Unit 10‐15,000 Sellers’ markets are local and in Sahiwal ‐ Unit 10‐18,000 Punjab Kochai (Kabulai) ‐ Unit 10‐15,000 Sheep Local and regional market Watanai ‐ Unit 5‐8,000

Table 23: WASH morbidity data (source WHO)

Consultations WHO compiled morbidity data Total Bloody Total Consultations Total Acute Diarrhea % Acute Diarrhea % Bloody Diarrhea Total Scabies % Scabies (approximate figures) Diarrhea

Swat 27733 1400 5.0% 260 0.9% 800 2.9%

Lower Dir 6194 500 8.1% 130 2.1% 32 0.5%

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Table 24: Therapeutic Nutrition Program parameters

General Admission During treatment Discharge Other 6 mo ‐ 5 Daily Food Avg Protoco <6 mo yrs of Medic Discharge Follo Program Staff Program Facility admis supple length Cost of treatment l of age age and ation criteria w‐up support training needs sions ment treatmt PLW 2008 MUAC, MUAC, Amoxi F75, Patient responsible for MUAC, weight 1 DHQ Saidu Sharif < 10 1 wk OTP UNICEF CMAM medications CMAM oedema oedema cillin F100 cost of injectable meds gain (%) 2008 MUAC, MUAC, Amoxi F75, Patient responsible for MUAC, weight 2 DHQ Timergara < 10 1 wk OTP UNICEF CMAM multiple CMAM oedema oedema cillin F100 cost of injectable meds gain (%)

Table 25: Physical condition of tertiary and seconday care health facilities Waitin Anthropometric General Presentation Latrines Water Supply Stock Register g Materials Rooms

Numb Cleanl Water Water Stockro Stockca Measuri Weighin Consultation Waiting Facility Building condition er iness Access quality quantity om rds ng board g scale s record room 1 DHQ Saidu Sharif Structure like new. Wards need whitewash. ‐ ‐ ‐ Clean Sufficient Present Present Present Present Register used ‐ 2 DHQ Timergara ‐ <10 Poor Good Clean Insufficient Present Present Present Present Register used ‐ 3 RHC Chuprial New construction. 4 Clean Good Poor Sufficient Present Present ‐ ‐ Register used Present 4 RHC Dewlai Building partially damaged in operations 9 Poor Poor Poor ? Present ‐ ‐ Present Register used ‐ 5 RHC Lal Qila Repair and whitewash needed 4 Poor Good Clean Insufficient Present Present ‐ Present Register used ‐ 6 RHC Munda structure is good 3 Poor Poor Poor Insufficient Present Present ‐ ‐ Register used ‐ 7 RHC Warai Repair and whitewash needed 13 Poor Poor Clean Insufficient Present Present ‐ Present Register used ‐ 8 THQ Samarbagh structure is good 25 Poor Poor Poor Sufficient Present Present ‐ ‐ Register used Present

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Table 26: Type and number of health facilities present in Swat, L‐Dir and U‐Dir

Swat district: • International actors present regarding health • 82 health facilities in total • 3 RHC (Rural Health Centre) • 1 DHQ (District Hospital) • 4 BHU (Basic Health Unit) • 132 medical doctors, 45 nurses and 1000 others • 1 Stabilization centre • 35 OTP centres • 35 SFP centres

Lower Dir: • International actors present regarding health • 51 health facilities in total • 2 RHC • 1 THQ (Tehsil hospital) • 1 DHQ • 7 BHU • 32 medical doctors, 40 nurses and 415 others • 1 Stabilization centre • 44 OTP centres • 44 SFP centres

Upper Dir: • No international actor is present regarding health • No CMAM program • 1 RHC • 5 MD, 5 nurses, 35 others

Table 27: Location of the OTP sites, CMAM program of Lower Dir

District Tehsil Union Council Health structure Lower Dir Mian kalay Mian kalay BHU Arif Kalay Lower Dir Adenzai Asbanr BHU Asbanr Lower Dir Lal qila Beshigram BHU Bishigram Lower Dir Adenzai Chakdara BHU Chakdara Lower Dir Samarbagh Samarbagh BHU Damtal Lower Dir Samarbagh Drangal BHU Drangal Lower Dir BHU Gall Maidan Lower Dir Adenzai Khadakzai BHU Khadagzai Lower Dir Adenzai Khanpur BHU Khanpur Lower Dir Balambat Lajbook BHU Lagbuk Lower Dir Samarbagh Mayar BHU Mayar Lower Dir Adenzai Ouch BHU Osakai Lower Dir Adenzai Ouch BHU Ouch

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Lower Dir Temergara Bagh Dushkhel BHU Pingal Lower Dir BHU Ramora Lower Dir Samarbagh Sadbar kalai BHU Sadbar Kalay Lower Dir BHU Shagai Lower Dir BHU Siya Wargahar Lower Dir BHU Tawda China Lower Dir Adenzai Asbanr BHU Utala Lower Dir Lal qila Zaimdara BHU Zaimdara Lower Dir Lal qila Beshigram CD Bagh Lower Dir Khal Khal CD Khal Lower Dir Adenzai Kotigram CD Kotigram Lower Dir Adenzai Asbanr CD Sha Alam Baba Lower Dir Adenzai Khadakzai MCH Badwan Lower Dir Adenzai Khanpur MCH Kityari Lower Dir Samarbagh Miskini MCH Maskiney Lower Dir Lal qila Lal qila RHC Gulabad Lower Dir Lal qila Lal qila RHC Lal Qila

Table 28: Extract of the data provided by the CMAM program, February/March 2010, Lower Dir district

MUAC >=115 and MUAC<115mm N <125mm n % n % Week 5 (Feb. 2010) 6227 140 2.2% 731 11.7% Week 6 (Feb. 2010) 2860 86 3.0% 303 10.6% Week 7 (Feb. 2010) 2429 73 3.0% 260 10.7% Week 8 (Feb. 2010) 2943 57 1.9% 371 12.6% Week 9 (March 2010) 2562 41 1.6% 273 10.7% Total 17021 397 2.3% 1938 11.4%

Remarks on Table 28: • We are presenting here the statistics of the program that concern acute malnutrition for children only. • MUAC measurement only is considered, and the thresholds used are different from the ones used during the assessment. • The statistics presented do not differentiate between new cases and already screened/admitted cases. Therefore, it is possible and probable that the same individuals are reported several times in several distributions. • The system of reference to the screening point is not documented

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Table 29: Health Designations

9 EDO Health: every district has one Executive District Officer Health. This person is responsible for all the health related activities in that specific district, and is key in decision making. Now after the recent emergency it is compulsory to get an NOC from EDO (H) to work in an area.

9 Deputy EDO Health: This person is second in command to EDO health he/she is also responsible for making major decisions about health in the region. In most of the cases he is the person dealing with NGO’s and INGO’s. He usually is the focal person for the emergency duties and activities. 9 National Program Coordinator: This person is responsible for Lady Health Workers, polio program, and TB control program. This person is not a key in decision‐making about health except Polio, TB, and Lady Health Worker Program. 9 Medical Officer: The Medical Officer is present at the Basic Health Unit level and provides the Primary Health care services for the community. In general every 20,000 to 30,000 has one BHU. 9 Medical Technician: The Medical Technician can be at different levels but the one working in community at BHU level were interviewed to know about the Nutrition status in general. 9 Lady Health Visitor: The LHV or Lady Health Visitor provides the Maternal and Child healthcare services. She also provides the reproductive health of her clients. 9 Lady Health Supervisor: The LHS or Lady Health Supervisor supervises 10 Lady Health Workers and monitors their work. She also monitors the quality of services by both Lady Health Visitor and Lady Health Workers. 9 TBA: Traditional birth attendants are those who manage the delivery and labor services at community level. She also provides a limited amount of other reproductive healthcare.

March 2010 ACF Pakistan ‐ Dir & Swat ‐ NWFP Rapid Assessment Report Page 72 of 99 Medical Superdinant of DHQ, THQ

Medical Officer Deptuy EDO Incharge of Basic Health Unit Medical Incharge of Rural health centers

EDO Health Admin issues of Depty Director Health Assistant EDO (one per district ) Health facilities

Director Health services Lady health worker Program Depty Director MIS Coordinator

National Program EPI coordinator Depty Director National Coordinator Director General Health Program (Polio etc) (NWFP) TB control Director Public Health program Depty Director Publich Coordinator Health services (nutrition Program)

Depty Director Admin Director Admin and Logistics

Figure 44: Provincial Level Health Hierarchy

Figure 45: Facility Level Health Hierarchy

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ANNEX 2: SURVEY INSTRUMENTS USED FOR THE ASSESSMENT

CONTENTS

1. Male Focus Group Discussion Guide ...... 75

2. Female Focus Group Discussion Guide...... 79

3. Household Food Security Questionnaire ...... 84

4. Market Trader Questionnaire...... 85

5. Nutrition Insitutions Staff Questionnaire ...... 88

6. Nutrition Medical & Paramedical Staff Questionnaire...... 90

7. Water and Sanitation Observation Checklist ...... 93

8. Water and Sanitation Key Informant Interview Guide ...... 97

9. Water Quality Daily Report Sheet ...... 99

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MALE FOCUS GROUP DISCUSSION GUIDE NWFP PAKISTAN RAPID NEEDS ASSESSMENT MALE FOCUS GROUP GUIDE FEBRUARY 2010

______GI GENERAL INFORMATION SP5 Specify other

GI1 Community identification number If 3 is not selected then jump to SP7

GI2 Date of survey (dd /mm / yy) SP6 What is the place of origin of IDP households present at this site? GI3 Time of survey (hh / mm) District/Agency GI4 Interviewer Name Tehsil GI5 Interviewer Gender Union Council Village/Mahalla GI6 District Date they left GI7 Te hs il /Taluk a

SP7 What percent of families are GI8 Union Council registered as IDPs at this site? SP8 How many families are currently GI9 Village / Deh re ce iving humanitar ian ass istance ? SP9 Of these families, how many are

BI BACKGROUND INFORMATION registered?

BI1 Number of Focus Group participants : SP10 Overall how satisfied are you with

t he ass istance you have re ce ived until now? Se le ct only one

BI2 Identify the main type of persons present in the Focus Not satisfied Satisfied Very well satisfied Group Discussion Select only one 1. WFP or other UN agency O O O 1. General cross section / Mixed O 2. NGOs (local or international) O O O 2. Elders / Village leaders O 3. Live lihood gr oup O

SP11 If not satisfied,

BI3 Specify type of livelihood: explain.

4. Social group O

BI4 Specify type (women, youth, disabled…): SP12 Of families who have received the cash card, has anyone f ace d any problem w ithdr aw ing t he mone y?

1. Yes O BI5 The site is accessible by: (select all that are relevant) 2. No O A 4*4 B Car

C Truck D By foot BI6 Specify SP13 If yes, specify the problem. X Other. other

SP14 Specify the value of the cash card PK R SP SITE POPULATION SP15 What percentage of people (18+) residing at this site does not have their NIC (National Identification Cards)? SP1 What is the number of households at the 1. Males site? 2. Females SP2

SP3 The majority of people VP VULNERABLE POPULATION at this site belong to which tribe(s)? Vulnerability is determined by a household or community’s exposure to hazard and ability to survive and recover from crisis. SP4 What is the per ce nt of the population that can be Vulnerability may be based on gender, age, wealth, tribe, religion, des cr ibed as ……? Total should be 100 ethnicity, social status, displacement status, geographic location, 1. Stayee/remained behind type of livelihood activity or political affiliation. 2. Returnee Most often the poorest and most marginal groups before a crisis will also be the groups most affected by a crisis. Vulnerability is defined 3. Internally displaced from other location differently according to local context and culture. Your job is to guide the FGD s o that par ticipants themsel ves define 4. Host t he cr ite r ia for vulner ability and ide nt if y vulner able & most affe cte d groups in their community. Do not suggest answers. 96. Other

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Vulnerability is determined by a household or community’s 2 Very vulnerable exposure to hazard and ability to survive and recover from crisis. Vulnerability may be based on gender, age, wealth, tribe, religion, ethnicity, social status, displacement status, geographic location, type of livelihood activity or political affiliation. 3 Vulnerable Most often the poorest and most marginal groups before a cr is is will also be the groups most affected by a crisis. Vulnerability is defined differently according to local context and culture.

Your job is to guide the FGD so that participants t hemsel ves define the criteria for vulnerability and identify vulnerable & most affected groups in their community. Do not suggest answers. 4 Less vulnerable Mos t af fe cte d populat ions 1=Women, children, elderly, disabled 2=Stranded populations VP1 What type of population 3=Barbers, artisans, musicians was most affected by the 4=Landowners crisis? 5=Small farmers, tenant farmers 6=Nomadic herders 7=Traders and shopkeepers Rank 3 main groups only 8=Landless and wage laborers LA LIVELIHOOD / AGRICULTURE 9=Other 98=Don’t know Main sources of income - =N A/Blank 1=Farming/Landowner 1. 1st gr oup 2=Income support (Zakat/Aid etc) LA1 Identify the 3=Fishing 2. 2nd group main sources of 4=Livestock poultry income for this 5=Remittances 6=Tourism rd community? 3. 3 group 7=Gvt/Pvt services 8=Handicrafts, artisanry VP2 Specify other Rank 3 main 9=Gem/stones sour ces only 10=Sharecropping VP3 Specify other 11=Shopkeeper/Trader IF THERE IS ONLY 12=Skilled Wage labor ONE SOURC E 13=Unskilled Wage labor WRITE ONLY ONCE 96=Other VP4 Explain the reason why/how these groups were affected. - =N A Be fore the cr is is After the cr is is

st 1 source 2nd source rd 3 source LA2 Specify other

LA3 How badly has your main source of income (as mentioned VP5 Vulner ability Rank ing above) been affected by the crisis? Identify the major population groups in the community. Rank them by Select one only vulnerability. Estimate the share of households in the community in each group. TOTAL SHOULD BE 100% 1. Not at all (0%) O M ain s our ces of income Main sources of food 2. Moderately (0<50%) O 1=Farming/Landowner A-Own Production 2=Income support (Zakat/Aid etc) B-Hunting, Fishing 3. Badly (50 to 95) O 3=Fishing C-Gathering 4. Completely (96-100%) 4=Livestock poultry D-Borrow O 5=Remittances E-Purchase 5. Don’t know O 6=Tourism F-Exchange labor for food 7=Other services G-Exchange items for food

8=Handicrafts, artisanry H-Gift (food) from family 9=Gem/stones I-Food aid (NGOs etc) For questions LA4 and LA5, ask only of Focus Groups with 10=Sharecropping J-Local Government participants whose livelihoods include livestock, or groups that are 11=Shopkeeper/Trader K-Other CROSS-SECTION or ELDERS/AUTHORITIES. 12=Skilled Wage labor -=N A 13=Unskilled Wage labor 96=Other - =N A LA4 What share of animals DIED or were lost Group Main sources of Vulnerabilit % as a result of the cr is is? N (Community food & income y Pop (Tick one per row) identifies) (use codes above) None None half than Less Half More than Half All know Don’t NA

1 Ex tr emely 1. Cows O O O O O O O vulnerable 2. Buffalo O O O O O O O 3. Donkey/mules O O O O O O O 4. Horses O O O O O O O 5. Oxen O O O O O O O 6. Poultry O O O O O O O

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1. Buffalo O O O O O O O 13. Fuelwood O O O O O O O 2. Donkey/mules O O O O O O O 14. Animal fodder/grasses O O O O O O O 3. Horses O O O O O O O 15. Animal shelter O O O O O O O 4. Oxen O O O O O O O 16. Other O O O O O O O 5. Poultry O O O O O O O 17. Other O O O O O O O 6. Sheep/goats O O O O O O O LA7X Specify other:

LA1 What major share of the following assets were LA3 Do you foresee a shortage of irrigation water? looted, damaged, lost or destroyed as a result of 1. Yes O the cr is is? (Tick one per row) 2. No None None half Less than Half More than Half All know Don’t NA O

1. Fruit orchards O O O O O O O LA4 If yes , des cribe how you plan to face this problem . 2. Other agricultural land O O O O O O O 3. Agr ic ul tur al tools O O O O O O O 4. Seed stocks O O O O O O O

5. Irrigation networks (small scale) O O O O O O O

6. Other community O O O O O O O infrastructure 7. Forests O O O O O O O

8. Fishery ponds O O O O O O O 9. Hives for honey M ain sources of loan production O O O O O O O 1=Family, friends or community 10. Shops and small LA5 What are the 2=Moneylender/Shopkeeper businesses O O O O O O O sources of loan for 3=Buyer/Wholesaler this community? 4=Landlord 11. Traditional handicraft 5=Bank assets O O O O O O O Rank 3 main sour ces 96=Other 12. Cash, jewelry, other HH only - =N A items e.g. sewing mach O O O O O O O Before the crisis After the crisis 13. Fuelwood O O O O O O O 1st source 14. Animal fodder/grasses O O O O O O O 2nd source 15. Animal shelter O O O O O O O rd 3 source 16. Other O O O O O O O LA6 Specify other 17. Other O O O O O O O M ain uses of new loan LA6X Specify other: LA7 What are 1=Food pe ople us ing the ir 2=Health care new loan for? 3=Education 4=Transport LA2 To what extent has 5=Livelihoods (assets and input purchase/repair) the community or families Rank 3 main 6=Rebuild house been able to recover these e xpe nditures only 96=Other assets? - =N A (Tick one per row) 1st expenditure Not at all or all Not at minimally very half than Less Half More than Half All know Don’t NA 2nd expenditure 1. Fruit orchards O O O O O O O 3rd expenditure 2. Other agricultural land O O O O O O O LA12X Spe cify other

3. Agric ul tural tools O O O O O O O Main constraints on livelihoods 4. Seed stocks O O O O O O O 1=Security concerns LA8 What are the 2=GOP restrictions on crop cultivation 5. Irrigation networks (small 3=Death/ disability of wage earner/ working member scale) O O O O O O O major constraints 4=Damage to natural assets e.g. orchards, land 6. Other community you face for 5=Damage to productive infrastructure e.g. irrigation i nfr as tr uc ture O O O O O O O res uming your networks, markets, roads, bridges livelihood activity? 6=Loss of productive assets e.g. livestock, tools 7. Forests O O O O O O O 7=Lack of cash 8=Lack of employment opportunities 8. Fishery ponds Rank 3 main O O O O O O O constraints only 9=Physical access to markets is disrupted 9. Hives for honey 10=Buyers or lenders are not extending credit production O O O O O O O 96=Other - =N A 10. Shops and small st b us i ness es O O O O O O O 1 constraint 2nd constraint 11. Traditional handicraft O O O O O O O assets 3rd constraint 12. Cash, jewelry, other HH items e.g. sewing mach O O O O O O O LA13X Spe cify other

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M ain pr ior ities 1=Access to cash 2=Water supply LA1 If 1, specify 3=Food Security security concerns WU2 What are your priority 4=Health needs for rehabilitation in 5= infrastructure rehabilitation order to get back to normal? 6=Access to inputs for Kharif 2010 7=Livestock 8=Support to income generating Rank 3 main priorities only LA2 What percent of the activities households de pend on 9=Access to fuelwood 10=Restoration of looted assets income from the 11=Other following? - =N A

(Tick one per row) None Less than half Half More than Half All Don’t know NA 1st priority 1. Household member working 2nd priority abroad O O O O O O O 3rd priority 2. Household member working in O O O O O O O down country WU2X Specify other 3. Child working or employed O O O O O O O

WU WRAP-UP

Main concerns WU1 What are your main 1=IDP registration issues concerns regarding rapid 2=Insecurity and fair re cover y of your 3=Loss of social cohesion community? 4=Children & youth concerns 5=Meeting daily expenses 6=Damages to community infrastructure Rank 3 main concerns 7=Livelihood recovery only 8=Other - =N A 1st concern 2nd c onc er n 3rd c onc er n WU1X Specify other

De s cr ibe your concerns about the prese nt se curity s ituation and the impact on your life .

Describe the specific concerns & needs of youth (15-24 yrs) after the cr is is .

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FEMALE FOCUS GROUP DISCUSSION GUIDE NWFP PAKISTAN RAPID NEEDS ASSESSMENT FEMALE FOCUS GROUP GUIDE 1 FEBRUARY 2010

______GI GENERAL INFORMATION VP1 1st group

GI1 Community identification number VP2 2nd group

GI2 Date of survey (dd /mm / yy) VP3 3rd group

GI3 Time of surve y (hh / mm) VPX Specify other GI4 Interviewer Name VP4 Explain the reason why/how these groups were affected. GI5 Interviewer Gender

GI6 Dis trict

GI7 Tehsil /Taluka

GI8 Union Council

GI9 Village / Deh

BI BACKGROUND INFORMATION

BI1 Identify the main type of persons present in the Focus VP5 Vulnerability Ranking Group Discussion Select only one Identify the major population groups in the community. Rank them by vulnerability. Estimate the share of households in the community in each 1. General cross section group. TOTAL SHOULD BE 100% O Main sources of income Main sources of food 2. Se ttlement group O 1=Farming/Landowner A-Own Production 2=Income support (Zakat/Aid etc) B-Hunting, Fishing BI2 Specify type (stayee, returnee, IDP or host 3=Fishing C-Gathering families…) 4=Livestock poultry D-Borrow 3. Live lihood gr oup 5=Remittances E-Purchase O 6=Tourism F-Exchange labor for food BI3 Specify type (small farmer, herder, 7=Other services G-Exchange items for food landless, artisan, teacher, dancer…) 8=Handicrafts, artisanry H-Gift (food) from family 9=Gem/stones I-Food aid (NGOs etc)

10=Sharecropping J-Local Government BI4 Number of Focus Group participants: 11=Shopkeeper/Trader K-Other

12=Skilled Wage labor -=N A BI5 The site is accessible by: 13=Unskilled Wage labor (select all that are relevant. Use your observation.) 96=Other - =N A A 4*4 B Car Main sources of C Truck D By foot Group Vulnerabilit % food & income N (community BI6 Specify y Pop (use the codes X Other. identifies) other above)

VP VULNERABLE POPULATION 1 Ex tr emely vulnerable

Vulnerability is determined by a household or community’s e xposure to haz ar d and abilit y to sur vive and re cover fr om cr is is . Vulnerability may be based on gender, age, wealth, tribe, religion, ethnicity, social status, displacement status, geographic location, type of livelihood activity or political affiliation. 2 Very Most often the poorest and most marginal groups before a cris is vulnerable will also be the groups most affected by a crisis. Vulnerability is defined differently according to local context and culture.

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9=Other unimproved sources 98=Don’t know WS WATER AND SANITATION - =N A/Blank

WATER

Dr ink ing water s our ce st 1=Canals/ponds/rivers 1 source 2=Protected well/spring nd WS1 3=Unprotected well/spring 2 source 4=Protected hand pump From where do 1=Sufficient rd you get 5=Unprotected hand pump 2=Not sufficient 3 source 6=Piped water supply dr ink ing w ater 7=Bowser/Tanker - =NA/Blank now? 8=Other Improved sources WS10 Do you think there will be enough water to meet your 9=Other unimproved sources nee d in the coming ye ar ? 98=Don’t know 1. Yes - =N A/Blank O 1st source 2. No O 2nd source 3. Don’t know O 3rd source WS11 If no, what is your plan to WS2 How long does it take to collect water from the major source face this and how long do you have to walk to collect it? problem? 1. Time to collect water (in minutes)

2. Distance covered to collect water(km) SANITATION AND HYGIENE

WS12 Where do people defecate? WS3 Estimate how much water is needed everyday and how Male Fem ale much is available? (Select all those apply) (Put s ame value if wate r available is more than re quire d) A Latrines (Communal) 1. Water required (in liters) B Latrines (Household) C Near to shelter (excrement

2. Water available (in liters) removed) D Near to shelter (excrement left) WS4 What major water treatment practices Select at most E Open field (away from shelter) are present at this site? Two X Other A Disinfection WS13 Specify other B Boiling C Filter and stand D Solar If A or B or both are not selected then jump to WS16

Y None WS14 If defecation takes place at latrines, how Available Functional Select at most WS5 How is water stored at the site? many are there? Two 1. Male A Decantered storage 2. Female B Closed storage 3. Combined (for both sexes) C Open storage

D Dirty vessels WS15 Are these latrines sufficient to satisfy the needs of all the people at the site? (Select one only) WS6 Who owns or manages the water 1=Own points you use? 2=M anage 4. Yes O 5. No A Community O B Local authority WS16 Are water and soap being used to wash hands before C Landowner eating? (Select one only) D Other 1. Yes, water and soap O WS7 Specify other 2. Only water O 3. Neither water nor soap O WS8 How much do you pay for water?

Specify the unit WS17 Are water and soap being used to wash hands after Drinking water source defecation? (Select one only) WS9 1=Canals/ponds/rivers From where 2=Protected well/spring 1=Sufficient 1. Yes, water and soap O do you get 3=Unprotected well/spring 2=Not sufficient drinking water 4=Protected hand pump 2. Only water O 5=Unprotected hand pump - =NA/Blank outside of the 6=Piped water supply 3. Neither water nor soap O r ainy se as on? 7=Bowser/Tanker 8=Other Improved sources

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LA LIVELIHOOD / AGRI CULTURE 7. Sheep/goats O O O O O O O

Main constraints on livelihoods LA1 Identify the M ain s our ces of income 1=Security concerns main sources of 1=Milk 2=GOP restrictions on crop cultivation FEMALE livelihood LA13 What are the 2=Curd major constraints 3=Death/ disability of wage earner/ working in this community. 3=Ghee member 4=Sewing of clothes your community 4=Damage to natural assets e.g. orchards, land Rank 3 main 5=Handicrafts faces for resuming 5=Damage to productive infrastructure e.g. sources only 96=Other your livelihood irrigation networks, markets, roads, bridges - =N A IF THERE IS ONLY activity? 6=Loss of productive assets e.g. livestock, tools 7=Lack of cash ONE SOURC E Be fore the cr is is Af ter the cr is is 8=Lack of employment opportunities WRITE ONLY ONC E Rank 3 main constraints only 9=Physical access to markets is disrupted 1st source 10=Buyers or lenders are not extending credit 96=Other nd 2 source - =N A 3rd source 1st constraint LA1X Specify other 2nd constraint 3rd constraint LA2 Explain the IM PACT of the cr is is on fem ale live lihoods . LA13X Specify other LA14 If 1, specify security concerns

WU WRAP-UP

Describe the specific concerns & needs of girls after the crisis.

LA3 What type of SUPPORT is needed to recover or improve female livelihoods here

WU1 What are your Main concerns main concerns 1=IDP registration issues 2=Insecurity regarding rapid and 3=Loss of social cohesion fair re covery of your 4=Children & youth concerns community? 5=Meeting daily expenses LA4 What share of 6=Damages to community infrastructure animals DIED or were lost Rank 3 main 7=Livelihood recovery as a result of the crisis? concerns only 8=Other (Tick one per row) - =N A 1st concern None None half Less than Half More than Half All know Don’t NA 2nd source 1. Cows O O O O O O O 3rd source 2. Buffalo O O O O O O O WU2 Specify other 3. Donkey/mules O O O O O O O 4. Horses O O O O O O O M ain pr ior ities WU3 What are your 5. Oxen 1=Access to cash O O O O O O O priorities concerning 2=Water supply 6. Poultry O O O O O O O rehabilitation in 3=Food Security 4= infrastructure rehabilitation 7. Sheep/goats order to get back to O O O O O O O normal? 6=Access to inputs for Kharif 2010 7=Support to income generating activities 8=Access to fuelwood Rank 3 main 9=Restoration of looted assets pr ior ities only LA5 To what extent have 10=Other - =N A families been able to st restock? 1 priority (Tick one per row) 2nd priority rd Not at all or all Not at minimally very half Less than Half More thanHalf All know Don’t NA 3 priority 1. Cows O O O O O O O WU4 Specify other

2. Buffalo O O O O O O O 3. Donkey/mules O O O O O O O 4. Horses O O O O O O O 5. Oxen O O O O O O O 6. Poultry O O O O O O O

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NUTRITION Did you or do give any a. yes O supplement to the child 12 b. No O during or before starting a. It’s a Curse/Magic O breastfeeding? c. don’t know O What is meant by 1 b. It’s a disease. O Malnutrition? c. It’s Normal body development. O 12.x If "a" then specify d. Don’t know. O a. Within first hour of birth O When did you start breast b. After 24 hours of birth O 13 a. Take him/ her to Hakeem O feeding your child? c. After one week of birth O What should be done b. Take him/her to Doctor/hospital O d. After one month of birth O 2 with a malnourished child? c. Take him/her to Religious leaders O d. Don’t know. OWhen did you start a. 4 month O 14 providing supplementary b. 6 month O food to your child? c. 1 year O a. Take him/ her to Hakeem O d. Don’t know O b. Take him/her to Doctor/hospital O Who do you consult for 3 c. Take him/her to Religious leaders O w your Health problems? d. Don’t know. Oa. yesO Did you exclusively b. No O 15 breastfeed your child? c. don’t know O a. LHW O Do you know of or b. Health Promoter O a. yes O participated in any Did you provide any breast 4 Health and Hygiene c. Vaccinator O milk supplement to your b. No O 16 session provided by d. No/ Don’t know O child? E.g. Lactogen, c. don’t know O health staff? Cows/Goat milk

Who makes the a. Father of Patient O 16.x If "a" then specify decision in the b. Mother of Patient O a. yes O 5 household when a Did you give any c. Other O b. No O patient needs a supplement to the child 17 consultation? d. Don’t know O Just after birth and/or c. don’t know O During Breast feeding? 5.x If "c" then specify 17.x If "a" then specify Have you met an a. Yes O a. Within first hour of birth O 6 outreach worker and/or b. NO O When did you start breast b. After 24 hours of birth O know Him/Her? 18 c. Don’t remember O feeding your child? c. After one week of birth O 6.x If "a" then specify d. After one month of birth O

Do you know of any a. No O When did you start a. 4 month O 7 program for treating b. Don’t know O 19 providing supplementary b. 6 month O malnutrition? c. Yes O food to your child? c. 1 year O d. Don’t know O 7.x If "a" then go to question (9) 7.x.x If "c" then specify Are your children fully a. Yes O 20 a. Distance O vaccinated? b. No O What are some of the b. Don’t have money to get there O c. don’t know O difficulties you face in 8 accessing that c. Don’t know the address O program? MICRONUTRIENTS a. Hakeem/ Tradition healers O a. Yes O What is usually done with a malnourished b. Hospital O b. No O 9 child when no program c. Religious Leaders O 20a Do you use iodized salt? c. Don’t know O is there? d. Don’t know O

For Pregnant and Lactating Ladies who were Displaced during the Crisis: a. yes O a. Yes O Did you exclusively Did your children receive 10 b. No O 20b b. No O breastfeed your child? Vit-A drops? c. don’t know O c. Don’t know O

Did you provide any a. yes O breast milk b. No O 11 supplement? E.g. c. don’t know O Lactogen, cow/goat milk.

11.x If "a" then specify

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PSYCHOSOCIAL Since the crisis, do you find that you or people around you often: (tick all Comments and observations (Vit‐A drops, iodized salt, that apply) violence in the home, trauma in children, etc.): No/ No Yes comme nt/NA 21 Have nightmares? OO 22 Have flashbacks? OO Experience domestic 23 O O violence? 24 Get angry? OO Have feelings of 25 hopelessness and O O despair?

26 Often cry? OO

Experience unusual fear 27 O O and anxiety?

Have suicide or violent 28 O O thoughts?

Find any change of behavior in the men 29 O O (husbands, brothers, sons)?

Find any change of behavior in the children, 30 including fear, low O O energy or increased aggression?

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HOUSEHOLD FOOD SECURITY QUESTIONNAIRE NWFP PAKISTAN RAPID NEEDS ASSESSMENT FEMALE HOUSEHOLD INTERVIEW GUIDE (FOOD SECURITY) FEBRUARY 2010

BI BACKGROUND INFORM ATION BI21 Who is the head of household? (select one only)

BI1 Community Identification number 1. Male ≥ 18 years O

BI2 HH identification number 2. Female ≥18 years O BI3 Date of survey (dd /mm / yy) 3. Male < 18 years O BI4 Time of surve y (hh / mm) 4. Female < 18 years O BI5 Inter view er Name BI6 Dis tr ict BI22 How m any people are ……? Male Fem ale 1. Infants <1 year BI7 Tehs il /Taluk a 2. Children 1 - 4 years BI8 Union Council 3. Children 5 - 17 years BI9 Village / Deh Better- 4. Adults 18 or above Poorest Middle BI20 Status of the family off select one only) 5. Currently employed or working? O O O

FOOD S ECURITY FS1 What foods were eaten in the household in the last 24 hours? 1=yes, 0=no FS2 What was the main source of the food? Score Main food Food items (0 or 1) source Food sources

1. Wheat products (naan, roti) 1-Own Production 2-Hunting, Fishing 2. Rice 3-Gathering 3. Maize (makai roti) 4-Borrow 4. Potatoes 5-Purchase 6-Exchange labor for food 5. Fish 7-Exchange items for food 6. Meat/organ meats 8-Gift (food) from family 9-Food aid (NGOs etc) 7. Eggs 10-Local Gover nment 8. Pulses/ Lentils / Beans/Nuts (daal, channa, muttur, lobya) 96-Other -=NA 9. Oil/ Butter/ Ghee 10.Dark green leafy vegetables (saag) 11. Vitamin A rich vegetables (carrots, squash, pumpkin) 12. Other vegetables (tomato, onion, eggplant) 13. Vitamin A rich fruits, fresh or dried (apricot, mango, peach,

papaya, black persimmon) 14. Other fruits, fresh or dried (citrus, apple, banana, guave) 15. Sugar/ sugar products 16. Mi lk /mi lk pr oduc ts (c ur d, rai ta) 17. Condiments (achar, chutney, tea) FS3 Specify other food source

1. Rely on less preferred and less expensive FS4 How m any me als did members of your family eat yesterday, not including foods between meals? foods? 2. Borrow food, or rely on help from a friend or

1. Children (1-4 years) relative? 2. Children (5-17 years) 3. Limit portion size at mealtimes? 4. Restrict consumption by adults in order for 3. Adults (18+ years) small children to eat? FS5 In the past 7 days, if there have been No. days times when you did not have enough food or out of the 5. Reduce number of meals eaten in a day? enough money to buy food, how often has past seven your household had to: (0 -7)

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MARKET TRADER QUESTIONNAIRE

NWFP PAKISTAN RAPID NEEDS ASSESSMENT MARKET ASSESSMENT GUIDE FEBRUARY 2010

Conduct Individual Interviews Cross‐check with observation and multiple sources Types of informants: Food traders, Agricultural goods Traders, Fuel Stations, Tourism businesses (restaurant, guest house), Transporters, Handicrafts Traders, Service Providers (e.g. barbers), Hirers of Casual Labor

1 Type of Trader Wholesaler O Retailer O

O Other:

2 Type of business General store O Cereals O Vegetables O Meat/Poultry O Fuel Station O

O Other:

3 Do you purchase on credit from Yes, all the time or most of the your suppliers? O Before the time crisis O Occasionally No O

Yes, all the time or most of the O After the time crisis Occasionally O No O

4 Are you extending more or less More O credit to your buyers compared to Less O last year? No change O

5 How are the transport costs Normal O compared to last year? High O Higher O Don't know O 6 What is the usual period of Winter O highest volume for the goods you Spring O sell? Summer O Autumn O No Change O

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7 What is your current level of sale Lower O compared to last year? Higher O No change O

8 Do you have more or less More O suppliers you have compared to Less O last year? No change O

9 More O Do you have more or less buyers Less O compared to last year? No change O

10 Do you have the capacity to Yes O increase your supply if the No O demand increases? Don't know O

11 No impact O What has been the impact of food Fewer buyers O distributions on your business? O Other:

12 What are the main constraints/ Lack of credit from supplier O problems you face to increase Lack of demand from buyer O your turnover? High transport costs O

O Other:

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Fill one price table per location District Tehsil U/R Union Council Location

Source of Item Availability of Market (producer, regional market, Item (high, Price Item Description of item Unit Cost/unit Price/unit provincial market, food aid normal, low, Data beneficiaries, other) not available) Food and Wheat cash Maize crops Rice Pulse Ghee Oil Sugar Potato Tomato Onion Chicken Beef

Other Diesel staple fuel commodit ies

Labor Casual Daily labor Other

Observations on the market (size, accessibility, diversity of items sold, main commodities sold, main constraints faced by traders...)

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NUTRITION INSTITUTIONS STAFF QUESTIONNAIRE

NWFP PAKISTAN RAPID NEEDS ASSESSMENT NUTRITION INSTITUTIONS GUIDE FEBRUARY 2010

S.No. No Questions Replies 1 2 Nutrition If there is a Nutrition Program available at the Hospital

a. Less then 10 O How many patients are b. 10 to 20 O 2.02 taken in the program Do you know a. Yes O c. More then 20 O 1.01 every day? Malnutrition? b. NO O d. Don’t know. O c. Don’t know O What protocol is used for a. WHO protocol? O 2.03 treatment of Severe b. None O Malnutrition c. Don’t know O a. Yes O Maternity Services 1.02 b. No O a. MUAC O available What is the Criteria for c. Don’t know O b. Weight for Height O 2.04 Admission of Under 6 months of age? c. Visibilly wasted O d. Don’t know O a. Yes O Obstetrics/Gynecology b. No O a. MUAC O 1.03 What is the criteria for services c. Don’t know O b. Weight for Height O 2.05 Admission for 6 months to 5 years, and PLW? c. Visibily wasted O d. Don’t know O

a. Yes O What is the Criteria for a. MUAC O 1.04 Pediatric services b. No O 2.06 Discharge for Children b. Weight gain (%) O c. Don’t know O and PLW c. Don’t know O

a. Amoxicillin O What Drugs are provided b. Deworming tablets O 2.07 during malnutrition a. Yes O c. Iron tablets O Therapeutic Nutrition treatment? 1.05 b. No O d. Don’t know O services c. Don’t know O a. Unimax O What food supplements b. Plumpynuts O 2.08 are provided for c. Plumpydoze treatment of Malnutrition O a. Yes O d. Other O Internal Medicine 1.06 b. No O services c. Don’t know O a. If yes then specify O What food is prohibited 2.09 b. Don’t know O during treatment? c. Nothing is prohibited O

External Medicine a. Yes O a. 1 week O 1.07 What is the avg length of Services b. NO O 2.1 b. one month O treatment? c. Don’t know O c. Don’t know O

a. Yes, if yes then a. Yes O Is there any followup specify……… O 1.08 Other services 2.11 mechanism for treated b. No O b. No O children? c. Don’t know O c. Don’t know O

Do you recive the a. Yes, If yes then Number: medicine and Food specify______O 1.09 Medical doctors 2.12 supplements from b. No O another organization? c. Don’t know O

Number: a. yes O Is treatment free of cost b. No, If No then 2.13 1.1 Nurses for everyone? specify______O c. Don’t know O

a. Yes, If yes, then specify______O Is all the staff trained in Number: 2.14 b. No O Nutrition Program c. Don’t know O 1.11 Nursing Assistant

a. Yes, If yes then Specify Is there any need for the needs______O 2.15 Number: Nutrition Program? b. No O c. Don’t know O 1.12 Others

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3 If there is NO nutrition program available

a. Admitted at O hospital b. Advice given for O What is done with Balanced diet 3.01 Diagnosed cases of c. Sent home O Malnutrition ? without any advice d. Sent to any other place, Please O specify_____

a. No advice is given O b. Advice given What advice is given to regarding use of 3.02 O Caretaker? Medicine c. Advice regarding O Balanced diet

a. less then 10 O How many cases you b. 10 to 20 O 3.03 had diagnosed till c. more then 20 now? O d. Don’t remember O

a. Yes O Do you think there is a b. No O 3.04 need of a Nutrition c. Don’t know center (SFP,OTP or SC) O

a. Yes O Are you intrested in b. No O 3.05 Integrating Nutrition center in you hospital? c. Don’t know O

Overview of the Centers, Observation: Give a quick description and evaluation of what you see in the structure 4 Structure, walls, roof Are all consultation General Presentation: doors and Register: recoreded in a registers? windows? Is this book used? 4.06

4.01

Waiting Rooms, Waiting waiting rooms condition? lines for consultati on? 4.07 Latrines: How many, are they clean, accessible? 4.02

is water clean, in Water Supply: sufficient quantity 4.03

Is there any specific Stock: room for the stock? Or stock cards?

4.04

Are there a Anthropometric Measuring Board? Material: Weighing scales? Etc 4.05

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NUTRITION MEDICAL & PARAMEDICAL STAFF QUESTIONNAIRE

NWFP PAKISTAN RAPID NEEDS ASSESSMENT NUTRITION MEDICAL AND PARAMEDICAL STAFF GUIDE FEBRUARY 2010 MISSION PAKISTAN

GI GENERAL INFORMATION NU NUTRITION

GI1 Community identification NU1 What is your understanding of nutrition? Select only one GI2 Date of survey (dd /mm / yy) 1. Food that we eat only O GI3 Time of survey (hh / mm) 2. Food that we drink only O 3. Food that we drink and eat O GI4 Interviewer Name 4. Don’t know O GI5 Interviewer Ge nde r NU2 What is your understanding of malnutrition? GI6 District Select only one 1. A curse/magic O GI7 Tehsil /Taluka 2. A disease O GI8 Union Council 3. Normal body development O 4. Don’t know GI9 Village / Deh O

NU3 What should be done with a malnourished child? BI BACKGROUND INFORMATION Select only one BI1 Identify the type of persons present in the Key Informant 1. Send the child back to his/her home O Interview. Select only one 1. Lady Health Worker (LHW) O 2. Send him/her to the hospital O 3. Send him/her to religious or spiritual 2. Lady Health Visitor (LHV) O leader O 3. Lady Health Supervisor (LHS) O 4. Don’t know O 4. Traditional Birth Attendant (TBA) O 5. Midwife O NU4 Do you know of any program for treating malnutrition? Select only one 6. Medical staff O 1. Yes O BI2 Specify type of Medical Staff (doctor, nurse, Medical Technician…) 2. No O 7. Religious and spiritual leader O 3. Don’t know/don’t remember O BI3 Specify type of religious leader (Molvi, Imam…) NU5 Have you ever advocated for a balanced diet? 8. Hakeem or other traditional healer O Select only one 9. Other O 1. Yes O BI4 Specify other 2. No O 3. Don’t know/don’t remember O NU5x. If “2” then got to answer NU7

NU6 What is meant by a balanced diet? Select only one 1. Diet rich in meat, poultry, eggs, pulses and oil O 2. Diet rich in wheat, rice, cereals and sugar O 3. Diet that includes vegetables, fruits, meat, wheat, rice and oil O 4. Don’t know O

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NU1 How much diet do pregnant or breastfeeding women BF BREASTFEEDING require for health? Select only one Inquire about the knowledge of and recommendations 1. The same amount of food as normal O ma de by medi cal and pa ramedi cal staff regar ding br ea stfeeding practice 2. More food than normal O 3. Restricted foods BF1 What is Exclusive Breastfeeding? Select only one 4. Don’t know/don’t remember O 1. Only breastfeeding O NU7x. If “3” then specify 2. Breastfeeding with milk supplements O 3. Breastfeeding with other supplements O NU2 What do you consider should be the practice of meal 4. Don’t know intake in the home? Se le c t only one O 1. Males should take it first O BF2 When should breastfeeding be started? Select only 2. Females should take it first O one 3. Children should take it first O 1. Within the first hour of birth O 4. Everyone should take food together O 2. 24 hours after birth O

3. One week after birth O NU3 Have you observed cases of Goiter? 1. Yes 4. One month after birth O 2. No 5. Don’t know O 3. Cannot recognize it BF3 For how long should the child be exclusively breastfed? NU4 If Yes, how many cases a month? Select only one 1. 4 months O NU5 Can you identify cases of Anemia? 2. 6 months O 1. Yes 3. 1 year O 2. No 4. Don’t know O 3. Don’t know NU6 If yes, specify the signs/symptoms. BF4 When should supplementary foods be added to the child’s diet eg. Banana, cereals, kichri? Select only one 1. 4 months O NU7 If yes, how many cases of Anemia do you receive per day? 2. 6 months O 1. Less than 10 per day O 3. 1 year O 2. 10 to 20 per day O 4. Don’t know O 3. More than 20 per day O BF5 Until what age should the child be breastfed? Select only one NU8 Have you seen any cases of Night Blindness? 1. Up to 6 months O 1. Yes 2. Up to 1 year O 2. No 3. Up to 2 years O 3. Don’t know/don’t remember 4. Don’t know O NU9 If yes, specify the number. BF6 Do you recommend that breast milk supplements be given to children? e.g. Lactogen, cow or goat milk. Select only one 1. Yes O 2. No O 3. Don’t know O

BF7 What do you recommend be given to the child after his/her birth? Select only one 1. Gutte (sugar water) O 2. Honey O 3. Breast milk O 4. Water 5. Other O BF8 Specify other

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IM IMMUNIZATION PS PSYCHO‐SOCIAL CONDITION IM1 Are you familiar with child vaccination programs e.g. EPI? Select only one PS1 Does stress decrease the amount of milk production? Select only one 1. Yes O 1. Yes 2. No O O 3. Don’t know O 2. No O 3. Don’t know O IM2 Name some of the diseases for which children are normally PS2 Are you familiar with any psychological disorders? vaccinated. Tick all that apply 1. Yes O 1. Polio 2. No O 2. Hepatitis B 3. Don’t know 3. Diptheria O 4. Tetanus PS3 If yes, specify: 5. Measles PS4 Have you seen any cases of psychological trauma in this area? Select 6. Other, specify: only one 7. Don’t know 1. Yes O

IM3 Do you consider it necessary that children be vaccinated? Select 2. No O only one 3. Don’t know O 1. Yes O PS5 If yes, describe: 2. No O 3. Don’tknow O

IM4 If yes, name some of the benefits of vaccination. Tick all that apply 1. To keep a child healthy 2. To prevent disease 3. To increase the we i ght of the child 4. Other IM5 Specify other IM6 Are your children fully vaccinated? Se le c t only one 1. Yes O 2. No O PS6 When a person has a psychological problem, where are they MOST 3. Don’t know O OFTEN referred? IM7 If no, what is the reason? Select all that apply 1. Hospital or doctor O 1. I am against it. 2. Hakeem O 2. It is not available 3. Spiritual and religious leader O 3. Other IM8 Specify other 4. Left at home in same condition O 5. Don’t know O

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WATER AND SANITATION OBSERVATION CHECKLIST

N° WATER AND SANITATION OBSERVATION AND INFORMATION FORM FOR VILLAGES date: ...... (Note: Most of this information will come from observation/inspection but some will need to be complemented by information from key informants – but this document will also serve to collate all key information on individual villages)

Village name: District: Province: Valley:

x: y: Altitude:

No. Houses: No. families: No. people: (before displacement)

No. Houses: No. families: No. people: (now)

Village leader:

1 Ge ne ral de tails

Terrain (mountain, topography, etc.)

Ground cover (grassy, rocky, barren, etc.)

Presence of surface water (lakes, rivers etc.)

Geographic location (on hill, in valley, spread out etc.)

Overall c leanliness

2 Wate r Resources

Type Volume Is access Is the Dry season Nb of Who Year Who Quality or Technical details Options for per hour free for source wat er family manages constr built it quant ity improvement of all prot ected availability users it . problems wat er point

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1.1 If there is a piped water supply:

Describe the key features

What is the condition of the system

How long is the system

Technical details of pipes

How many water points

How many users

Is there a high risk of contamination

Who manages the system

Are repairs needed

What is preventing repairs being made

2 Water quantity:

Problems for village in normal years:

General:

Seasonal (months):

Same question for this year:

Dry season duration: which year worst: recurrence:

Coping mechanism during dry periods:

Main problem for drink, domestic, agricultural, cattle?

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1 Water quality:

Do any water points have colour/smell/turbidity/PH etc :

Give results of any bacteriological testing:

Are any household water treatment techniques used (give details):

What are the recent diarrhoea cases in children:

2 Water management and storage:

Daily quantity / nb people:

Daily quantity / nb people during dry season:

Transport container type:

Storage type: cover?

Fetching type: who does: frequency: access time:

3 Water and health:

Regular use of soap: - - - - - soap available in village: price (250g):

If not, closest place to buy: price:

Washing frequency adults: children: babies:

4 Excreta:

Nb latrine posts in village / houses nb:

What materials are latrines made of:

Are any latrines close to water sources:

If open defecation happens where does it take place:

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1 Institutional Structures

Is there a health structure (specify health center, health post etc) : ......

If yes: How many patients per day: Is there water a water supply (if yes define) : How many latrines are there (describe materials and condition)? Are there hand washing facilities? Is there an incinerator? How is solid waste managed? What is the overall cleanliness?

How many schools are there in the village : ......

If schools exist : Give details of students (number of students, age range, gender etc)? Is there a water supply (if yes define)? How many latrines are there (describe materials and condition)? Are there hand washing facilities? Do the teachers pass hygiene promotion information?

2 NGO plans:

Period Who What When Past

Now

Future

3 Propositions for projects:

Food, water quantity, water quality, sheltering, medical, sanitation, cattle, irrigation, sanitary products, latrines

Propositions from villagers: 1) ...... 2)...... 3)...... (in order of importance)

Poorest villages in area: ......

Richest villages in area: ......

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WATER AND SANITATION KEY INFORMANT INTERVIEW GUIDE

Semi Structured Interview Guide

Name of Individual interviewed:______Role/Position: ______Date: ______

Village: ______Union Council: ______Tehsil: ______District: ______

Population Specifics:

1. What is the total population of the region/districts/ main towns, villages (serviced per health facility) pre-emergency?

2. Number of residents (local population); number of displaced; number of returnees. How have these numbers changed since 6 months ago?

General:

1. What have been Ministry of Water interventions and government response up to now and what are their short terms and long term plans for the future?

2. What WASH-related capacities are present in the population (health workers, engineers, construction, etc)?

Water Supply:

1. Water resource information (annual precipitation, local geology, groundwater levels, surface flow etc.)?

2. What water supply systems are available; what types of problems exist and what kind of improvements can be made?

3. Who owns or manages the water systems and describe any problems concerning the operation and maintenance?

4. How has population movement changed the water demands on the area?

5. Do people have enough water for drinking, household use, agriculture, livestock?

6. What do people do if they do not have enough water (coping mechanisms)?

7. Does everyone have equal access to water? If not, Why?

8. What are the anticipated problems over the next 6 months concerning water supply?

Water Quality

1. What is the quality of the water that is consumed?

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2. Does water purification/treatment take place at source and/or at household level?

3. Do people have the knowledge, interest or means to treat water at household level?

4. How can household water treatment be encouraged?

Hygiene and Sanitation

1. What is the coverage, acceptability and use of latrines?

2. If open defecation is a problem how can people be encouraged to use latrines?

3. How solid waste is managed at household and village levels?

4. Concerning sanitation where are the most vulnerable areas, who are the most vulnerable groups and how can the sanitation situation be improved?

5. What are cultural/traditional beliefs concerning water collection, hygiene and sanitation practices. Do any of these practices present hygiene risks? How can these poor practices be improved?

6. Discuss diarrhoea rate in children (talk about prevalence, trends, peaks, causes and concerns)?

7. Is there presence of other water related disease, if yes which ones and discuss prevalence, trends, peaks, causes and concerns)?

Final Questions

1. How do they describe the situation and how do they think that it will evolve?

2. What do they feel are the priority needs of the affected population in terms of water and sanitation?

3. What do they feel are the most appropriate and feasible interventions?

Other important information from this interview:

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WATER QUALITY DAILY REPORT SHEET

Daily Report Sheet

District ______Tehsil ______

Union Council ______Village ______

Water Source ______Date ____/ ___/______/

Water Quality Analyst ______

Colour Odour Turbidity Conductivity PH Free Thermotolerant Coliforms (TTC) Chlorine Time (NTU) (µS/cm) Vol. No. of TTC per (mg/L) filtered Colonies 100 ml DPD No 1 (ml)

Result:

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