Assessment on Internally Displaced Persons (Idp) Status in Khyber Pakhtunkhwa and Federally Administered Tribal Areas

ASSESSMENT ON INTERNALLY DISPLACED PERSONS (IDP) STATUS IN KHYBER PAKHTUNKHWA AND FEDERALLY ADMINISTERED TRIBAL AREAS

Nutrition Cluster

Submitted to UNOCHA

KP Nutrition Cluster Aien Khan 1. INTRODUCTION

1.1 Background

The current existing displacement of caseload is estimated about one million IDPs (159,609 families; 957,654 individuals – 54 per cent men/46 per cent women),1who fled between 2008 to 2013 due to insecurity related to armed non-state entities, security operations and sectarian violence in various Agencies of FATA. Almost four cent of this population is living in the three IDP camps, including 4,682 IDP families in Jalozai (KP), 1,157 families in Togh Sarai (KP)and 732 in New Durrani (FATA) IDP camps. The remaining 96 per cent are residing in host communities, mostly in the adjoining districts in KP and safer areas in FATA. So far 517,133 Children displaced and over 1 million in IDPs in KP and FATA. As of may 20 2014, 824 registered families returned to Tirah Valley, Khyber Agency in the on-going Phase II of Tirah IDPs return, which started on 7 May 2014.2

1.2 The rational for theIDP Assessment This assessment was planned in response to OCHA request to carry outIDP assessment by the respective clusters on the Internally Displaced persons (IDP) within Khyber Pakhtunkhwa (KP) and Federally Administered tribal areas (FATA).The main objective of the assessment is to identify and estimate the humanitarian needs of the IDPs community and prepare response based on the facts in the targeted areas. Thus, theassessment wasdesignedbased on UNHCR IDP official figure that was shared to the clusters during the technical working group meeting. This assessment was believed to fill the lack of updated information on IDP status and provide basis for IDP humanitarian response planning in areas of Nutrition and other sectors through: Promote a shared vision of needs and priorities; Establish the priority needs from an integrated perspective and use resources more efficiently; Obtain a more comprehensive picture of needs for better guide donor funding; Allow clusters to analyze and decide on the most appropriate strategies to support IDPs; Serve as a foundation for planning for IDP response; and Reduce duplication of effort and promote inter-cluster learning.

Therefore, the nutrition cluster decided to coordinate with implementing partners (IPs) in order to conduct the assessment in their own operational area using simple random sampling. Almost all who are renting the house are living within the host community. In terms of place origin, the IDPs came from different parts of the province. The highest origin was reported from Alihera for Kurram agency followed by Tirah, slaarzai for other districts. This assessment was conducted in DI Khan, Hangu, Nowshera, Khot,Kurram, Nowshera, Peshawar,Tank of KP districts, Bajour, Mohmand, Kurram agencies of FATA and three camps Jalozai in Nowshera, Togh Sarai in Hangu, New Durrani in Kurram camps in KP and FATA.

1UNHCRIDP statistics as of 30 April 2014 2 Situation Report Complex Emergency in KP and FATA Monthly Sitrep # 29

1.3 Objectives of the Study The cluster developed tool and harmonize it to come up simple tool for IDP assessment. The assessment specifically will look into;

 The prevalence of malnutrition among children aged 6-59 months in the IDP households.  Determine of measles coverage and illness among children in the IDP population  Assess the Infant and young child feeding practice among the IDP population

2. METHODOLOGY 2.1 Sample size calculation

Simple random sampling was used as indicated on Table1. The sample size for nutrition cluster was derived using the formula:

t2(p×q) 푁 = D ⌈ ⌉ The parameters are tabulated as follows: 푑2

Table 1: Parameters used in calculation of sample size calculation IDP assessment

Parameter Definition value N Sample size: 1.962(0.5 × 0.5) 푁 = ⌈ ⌉ t2(p × q) 0.052 푁 = 2 ⌈ ⌉ 푑2 =384.16 rounded up to 384 t Error risk. t=1.96 at 95% confidence interval p Expected prevalence Used 50% corresponding to p=0.5 as proportion q 1-p Thus q=1-0.5=0.5 d Degree of accuracy (5% for each survey) and given as 0.05 proportion

D Design effect 1 because we are using random sampling

Simple random sampling is always used for small populations that contain more than 1000 sampling units (or households). The assessment team was requested to prepare the list of IDP households up on arrival in each selected village for purpose of sampling.

Table 2. IDP sampling by district with in KP/FATA

S/ District Total Total under Total Total OCHA IDPs OCHA Sample Actual N population five @ 12.1% IDPs Returnees Sample Returnees Sample 3 1 Peshawar 2,020,463 244476 71469 382 384 2 DI Khan 705,403 85354 25331 378 384 3 Kohat 554,750 67125 21670 377 384 4 Tank 360,539 43625 11684 372 384 5 Nowshera 671,328 81231 9304 369 384 6 Hangu 373,520 45196 1205 291 384 7 Kurram 649,287 78564 9770 10263 370 370 384 8 Khyber 973,330 117773 2082 6187 324 362 384 9 SWA 574,270 69487 ??? 1900 320 384 10 Bajaur 1124141 136021 ??? 559 228 384 11 Mohmand 627,120 75882 ??? 186 126 384 8,634,151 1044732

3 Sample was taken at confidence interval (CI) of 95%, desired precision of 5% if the prevalence of malnutrition is 50% 3

Since in most contexts the number of basic sampling units (BSU) is large, simple random sampling procedure was conducted by numbering each basic sampling unit i.e IDP households and then choosing the desired number IDPs households randomly using the random number table as presented on Figure 2Error! Reference source not found.. Assessment was then be taken based on these IDP households only. For instance we have 71469 IDP households in Peshawar and our total sample is 382 (OCHA sample). Therefore, in order to select 386 IDP households randomly in Peshawar the team usedrandom table generated from ENA software as follow.

Figure 1: ENA Random Number Generator

2.2 Sampling procedure

Option 1:Using simple random sampling methodology.

 In order to select the specific IDPs Households from village after listing that is 386 IDP households from the total IDP list in each district, the following optionwas given to the team

o Number each of the 71469 IDPs of Peshawar from 1 to 71469. o Enter 1 in the box named Range from and 71469 in the box named To (Figure 1Error! Reference source not found.). o Enter the number of IDPs you need for your sample (386) in the box named Numbers. o Click on the Generate Table button. o A word file will open displaying the 386numbers selected randomly (Figure 2).

Figure 2: List of random IDP numbers in a Word document generated by ENA software

2.3.Data Analysis, Management and Process 2.3.1Data quality management and clearance One day a partner meeting was organized by nutrition cluster and the pretest of the questioner was carried out with partners. The review and daily editing of the questionnaires was carried out on daily basis by the district supervisors in order to identify errors, omissions and inconsistencies. This quality checking was not done daily after data collection and feedbacks wasnot given before the next data collection measure as a result the anthropometric data quality was affected. That means the consistency of data wasn’t assessed by plausibility check on digit preference in height and weight measurements, overall sex ratio, and standard deviation for weight for height. Therefore, the analysis of this report was based on the MUAC finding.

2.3.2Data Analysis SPSS version 16 was used for data cleaning, outliers checking and analysis of contextual or non-anthropometric data analysis. Moreover, anthropometry Data entry and analysis was done using ENA for SMART software.

2.3.3 Ethical Considerations Clearance for the assessment was collected from the respective mandated offices and verbal consents were obtained from each assessment participants. The participants were briefed about the objectives and importance of the assessment before the commencement of interviews and all interviews was conducted in areas where the privacy of the study participants was maintained.

3. RESULT

3.1 Resident status of the IDP household According the findings 4,576 IDP households were visited both within the host community of eight districts and three camps. The mean household size was 7.27 +3.75 standard deviation. A total of 3549 children were visited in the assessment and 52.2% of them were male. The majority of the IDPs in the host community of Hangu, Kohat, Nowshera, Peshawar and Tank are living within rented houses whereas the IDPs in the camps reported they have been living within the camp. The situation in Bajour, Mohmand and Kurram is different where the majority IDPs live in their own house.

Figure 3: percentage of IDPs by types of resident Housing conditiong of IDPs

40.0 33.3 35.1 35.0 31.6 30.0 25.0 25.0 18.9 15.4 14.9 20.0 12.8 14.114.6 14.6 13.6 11.8 12.1 13.0 15.0 9.4 11.2 9.1 6.5 7.66.0 6.9 7.6 9.2 8.8 10.6 10.0 4.3 4.4 4.1 7.4 5.0 6.2 0.0

Rented house Living with relatives Owner of the house In IDP camp Linear (Living with relatives)

Out of the total 4574 households, 41.1% are living in rented house while 24.3% and 25.9% of them were living in IDP camps and own house respectively.

Figure 4: Resident status of in the overall respondents

Resident status of IDPs households

24.30% 41.10%

25.90% 8.70%

Rented house Living with relatives Owner of the house In IDP Camp

3.2 The number of children per household Except in Hangu and Togh Sarai camp in Hangu where more than 75 of the households reported they haveonly1 to 2 children, the rest of the IDPs households in the other districts reported they have more than 3 to 4 more children. Figure 5: Number of children per household

The number of children in Household 120%

100% 1% 1% 1% 1% 3% 10% 9% 2%1% 8% 12% 7% 3% 4% 12% 11% 18% 6% 12% 80% 7% 15% 13% 15% 15% 24% 27% 24% 22% 24% 60% 50% 16% 23% 26% 28% 35% 29% 86% 31% 28% 40% 30% 78% 25% 27% 30% 43% 20% 40% 29% 32% 32% 25% 26% 26% 27% 21% 18% 0%

1 to 2 3 to 4 5 to 6 7 to 8 9 to 10 more than 10

3.4 IDP Household Income source

Casual labor and skilled labor are accounting for 50 %of the income source for IDPs population

Figure 6: The source of income for households

Source of income%

Other 12.5 Family support 5.7 Petty trading 1.3 Salaried work 9.1 Skilled Labour 16.7 Casual labour 42.2 Sale of Food Aid 1.7 Sale of Natural Resources 2.8 Sale of livestock and animals 3.2 Sale of crops 4.3 No income 0.4 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0

3.5 Frequency of meal in 24 hours.

The majority of the households consumed three times except in Tank where 73.3 of the households consumed food twice a day.

Figure 7: Meal frequency in 24 hours recall Meal frequncy in 24 hurs 120.0 100.0 100.0 84.6 79.5 82.5 71.7 75.8 73.3 80.0 64.6 66.4 53.4 60.0 50.5 48.248.2 46.4 43.4 40.0 25.7 26.7 17.4 16.3 19.7 20.0 10.9 10.0 12.6 9.7 20.3 13.3 3.1 3.2 5.4 3.7 4.3 4.9 4.5 0.0 0.0

2 times 3 times 4 times

3.6 Assistances received

52.8 % of the IDP households mainly from host community didn’t receive any form of assistance in the past three months. Most households who reported they received FGD for the last three month, they have also confirmed they received supplementary food in addition.

Table 3 Type of assistance by District District None GFD Supplementary Seeds Cash Total food and tools assitance Kurram Camp 100 0 0 0 370 Bajour 96.8 2.6 1.0 0.8 0.3 386 DI Khan 49.7 19.7 28.9 1.3 0.3 380 Hangu 76.8 10.9 8.0 2.1 2.1 375 Hangu Camp 3.6 90.3 5.9 0.0 0.3 390 Jalozai IDPs Camp 21.2 61.0 1.0 0.0 16.8 387 Khot 60.8 21.9 14.1 2.7 0.5 375 Kurram 55.5 36.1 5.7 1.6 1.1 366 Mohmand 1 89.8 1.2 3.7 3.0 2.2 403 Nowshera 48.9 40.8 7.9 1.3 1.1 380 Peshawar 55.1 30.8 9.2 1.8 3.1 390 Tank 76.2 17.9 0.3 0.5 5.1 374 Total 2420 1645 327 58 126 4576

3.7 Donation of Infant feeding supplies

Out of the total households, 83.3% of the total households reported there was no donation of infant feeding supplies

Table 4: Types of infant feeding donation District No Bottles Dry Infant Liquid Teats Dont Others distribution % milk formula milk % know % % % % % % Kurram Camp 100 0 0 0 0 0 0 0 370

Bajour 94.6 0.8 2.8 0 0.3 0.5 0.5 0.5 386 DI Khan 81.1 0.3 0 0 0.3 0.3 2.4 15.8 380 Hangu 83.5 0 2.1 6.4 0.5 0 3.5 4 375 Hangu Camp 21.3 0 39.7 18.5 5.4 0 2.8 12.3 390 Jalozai IDPs 98.7 0.5 0.3 0 0 0 0.52 0 387 Camp Khot 84.5 0.27 1.3 2.1 0 0 2.9 8.8 375 Kurram 93.7 1.09 0 2.2 0.55 0 1.6 0.82 366 Mohmand 1 78.7 2.7 5.5 2.2 1.2 0.0 5.7 4.0 403 Nowshera 88.7 0.5 0 0 0.5 0.0 1.8 8.4 380 Peshawar 81.5 0 3.8 1.0 0.5 0 1.0 12.1 390 Tank 84.0 0 0.53 0 0 0 14.7 0.8 374 Total 3767 24 219 125 36 3 143 259 4576

3.8 Shock faced

The price of food commodities is reported as the primary challenge for IDP households followed by insecurity.

Figure 8: Shocked faced by IDP households Others, 525, 12% weeds or Pest, 27, 1% None, 105, 2% Delay of rains, 34, 1% Insecurity, 784, 17% Social event, 115, 3% IDP living with HH, late91 food, 2% distribution, 192, 4%

Human sickness, 490, 11%

Floods, 41, 1% Livestock disease, 154, 3% Food too expensive, Lack of free access, 1770, 39% 192, 4%

3.2 Infant and young child feeding practice 3.2.1 Ever breast feeding

The ever breastfeeding coverage is higher as expected for all the districts and camps.

Table 5: Ever breast feeding Districts No Yes % Kurram Camp 0 265 100.0 265 Bajour 0 234 100.0 234 DI Khan 0 262 100.0 262 Hangu 0 282 100.0 282 Hangu Camp 2 253 99.2 255 Jalozai IDPs Camp 2 176 98.9 178 Kohat 3 252 98.8 255 Kurram 0 246 100.0 246 Mohmand 1 12 246 95.3 258 Nowshera 1 243 99.6 244 Peshawar 2 291 99.3 293 Tank 0 366 100.0 366 22 3116 3138

3.2.2 Initiation of breastfeeding More than half (56.7%) of the mothers initiated breastfeeding within one hour as per the recommendation.

Table 6: Initiation of breastfeeding among mothers of children under two years Districts Immediately % In first % After first % Total under in 1 hr day day two children Kurram Camp 223 84.2 42 15.8 0 0.0 265 Bajour 78 33.6 111 47.8 43 18.5 232 DI Khan 143 54.6 75 28.6 44 16.8 262 Hangu 83 29.4 111 39.4 88 31.2 282 Hangu Camp 58 22.7 98 38.4 99 38.8 255 Jalozai IDPs Camp 153 86.0 17 9.6 8 4.5 178 Kohat 101 39.6 62 24.3 92 36.1 255 Kurram 168 68.3 55 22.4 23 9.3 246 Mohmand 1 100 38.8 63 24.4 95 36.8 258 Nowshera 148 60.7 45 18.4 51 20.9 244 Peshawar 177 60.4 48 16.4 68 23.2 293 Tank 346 94.5 14 3.8 6 1.6 366 1778 56.7 741.0 23.6 617.0 19.7 3136

3.2.3 Colostrum feeding The colostrum feeding was reported highest in Hangu(68.6%) and Jalozai(62.9%)camps whereas New Durrani camp in Kurram shows the lowest of all surveyed areas.

Table 7: Colostrum feeding District No % yes % Total under Two Kurram Camp 157 59.2 108 40.8 265 Bajour 151 64.5 83 35.5 234 DI Khan 133 50.8 129 49.2 262 Hangu 141 50.0 141 50.0 282 Hangu Camp 80 31.4 175 68.6 255 Jalozai IDPs Camp 66 37.1 112 62.9 178 Kohat 122 47.8 133 52.2 255 Kurram 117 47.6 129 52.4 246 Mohmand 1 111 43.0 147 57.0 258 Nowshera 131 53.7 113 46.3 244 Peshawar 165 56.3 128 43.7 293 Tank 216 59.0 150 41.0 366 1433 45.7 1705 54.3 3138

3.2.3 Continued breast feeding two years Similarly, the camps have shown higher proportion of continued breastfeeding.

Table 8:Continue breastfeeding Districts No Yes Kurram Camp 20 7.55 245 92.5 265 Bajour 63 26.92 171 73.1 234 DI Khan 62 23.66 200 76.3 262 Hangu 61 21.63 221 78.4 282 Hangu Camp 37 14.51 218 85.5 255 Jalozai IDPs Camp 14 7.87 164 92.1 178 Kohat 56 21.96 199 78.0 255 Kurram 28 11.38 218 88.6 246 Mohmand 1 72 27.91 186 72.1 258 Nowshera 56 22.95 188 77.0 244 Peshawar 38 12.97 255 87.0 293 Tank 60 16.39 306 83.6 366 567 18.07 2571 81.9 3138

The analyses for continued breastfeeding at 1 year also showed higher level of children are still breastfed.

Table 9: Continued breastfeeding at age 1 year. No % Yes % Kurram Camp 0 0.0 42 100.0 42 Bajour 8 20.0 32 80.0 40 DI Khan 9 19.1 38 80.9 47 Hangu 4 10.5 34 89.5 38 Hangu Camp 0 0.0 35 100.0 35 Jalozai IDPs Camp 4 16.0 21 84.0 25 Kohat 13 29.5 31 70.5 44 Kurram 7 14.9 40 85.1 47 Mohmand 1 7 15.2 39 84.8 46 Nowshera 4 11.4 31 88.6 35 Peshawar 10 18.5 44 81.5 54 Tank 4 6.3 60 93.8 64 70 13.5 447 86.5 517

3.2.4 Exclusive breast feeding at age 6 months

The overall exclusive rate was at 45.9% whereas the highest was reported in Tank district at 70.6 even though the number of children in the Tank district sample was found very few.

Table 10: The exclusive breast feeding none EBF Powder Cereals Plain Fruit sugar Vegeta Green Total other or based water Juice water bles tea than animal diet breast milk Milk Kurram Camp 56 50.0 0 54 0 0 0 0 2 112 Bajour 20 40.0 14 0 3 0 0 1 12 50 DI Khan 19 48.7 6 0 1 0 0 0 13 39 Hangu 25 26.0 7 0 12 0 34 0 18 96 Hangu Camp 17 17.5 3 0 14 1 52 1 9 97 JalozaiCamp 26 59.1 2 10 1 0 0 0 5 44 Khot 21 48.8 3 6 2 2 4 0 5 43 Kurram 24 55.8 1 8 0 0 0 0 10 43 Mohmand 1 37 62.7 9 4 3 0 0 4 2 59 Nowshera 38 64.4 9 1 0 1 1 1 8 59 Peshawar 30 61.2 8 0 0 1 0 1 9 49 Tank 12 70.6 1 0 1 0 0 0 3 17 325 45.9 63 83 37 5 91 8 96 708

3.2.6 Child Feeding during Diarrhea The large proportion (56.68%) of mothers’ provided less or same feeding amount for their children during diarrhea against the recommendation of more feeding. Only 14.5 of the mothers reported more feeding was given to the children during diarrhea.

Table 11: Child feeding practice during illness Nothing was less than same as More than Never had given usual usual usual diarrhoea Kurram Camp 0 0 43.2 0 56.8 229

Bajour 20.9 12.4 37.8 9.8 19.1 225 DI Khan 16.9 25.10 46.7 7.06 4.3 255 Hangu 5.5 19.9 48.9 18.75 7.0 272 Hangu Camp 3.3 27.5 47.5 20.9 0.8 244

Jalozai IDPs Camp 17.0 28.5 24.2 26.1 4.2 165 Khot 16.9 0.3 29.8 7.3 15.3 248 Kurram 17.9 19.7 44.4 3.0 15.0 234 Mohmand 1 32.0 32.0 26.4 7.2 2.4 250 Nowshera 14.5 13.7 56.0 12.4 3.4 234 Peshawar 25.5 28.4 28.0 5.0 13.1 282 Tank 8.6 5.8 16.3 45.4 23.8 361 Total 442 595 1105 435 422 2999

3.3 Child Nutrition, immunization and Morbidity status 3.3.1 Sex pyramid of the children

The Bajour sex male to female ratio reveled there was biases in selection of the children.

Figure 10: Sex pyramid by district Children sex

52.2 47.8 TANK 48.2 51.8 PESHAWAR 51.2 48.8 NOWSHERA 52.3 47.7 MOHMAND 1 53.7 46.3 KURRAM 52.9 47.1 KHOT 50.5 49.5 JALOZAI IDPS CAMP 48.0 52.0 HANGU CAMP 50.8 49.2 HANGU 50.8 49.2 DI KHAN 45.9 54.1 BAJOUR 74.3 25.7 KURRAM CAMP 47.3 52.7 0.0 20.0 40.0 60.0 80.0 100.0 120.0

Male Female

3.3.2 Nutritional service

Quite number of children 382 were severely and moderately malnourished however the service provision wasn’t able to address these children.

Table 12: Beneficiaries by program and gap In OTP In SFP treated by the malnourished program program not in program Kurram Camp 0 0 83 39 Bajour 5 1 0 78 DI Khan 4 14 0 6 Hangu 6 7 5 20 Hangu Camp 4 32 4 4 JalozaiCamp 5 26 38 6 Khot 17 45 3 19 Kurram 13 23 5 51 Mohmand 1 3 5 0 31 Nowshera 7 7 2 7 Peshawar 19 36 13 13 Tank 46 53 1 108 129 249 154 382

3.3.3 Child morbidity

As the red part of the char highlights the percentage of sick children for past two weeks was very high. Except in Hangu district where the percentage of sick children was reported low at 20.8% as compared to the rest of the areas, almost half of the study children were sick two weeks prior to the assessment with the highest reported figure at 72.8% in Kohat district. Diarrhea is the first major cause of sickness followed by fever and cough respectively.

Child Morbidty 120.0 100.0 20.8 80.0 40.0 52.7 46.4 48.9 54.8 58.3 43.0 49.4 60.0 72.8 46.3 68.7 40.0 46.1 75.7 38.0 60.0 52.3 56.4 20.0 39.1 46.2 41.7 47.9 44.7 19.4 23.7 29.7 0.0

No Yes

Table 12 Type of illness Not fever Cough Diarrhea Skin Eye Other Sick Infections infections Kurram Camp 222 25 35 36 12 5 0 Bajour 202 65 46 53 7 6 2 DI Khan 175 69 21 77 4 2 13 Hangu 284 45 9 19 3 0 2 Hangu Camp 166 112 20 81 11 2 4 JalozaiCamp 75 41 17 75 8 2 4 Khot 89 113 38 98 10 2 11 Kurram 169 42 30 86 18 14 3 Mohmand 1 168 75 41 79 25 4 11 Nowshera 182 68 22 62 9 3 11 Peshawar 116 74 28 142 5 0 18 Tank 211 49 39 45 9 12 7 2059 778 346 853 121 52 86

3.3.4 Child Nutritional status results for MUAC

Table 13. The prevalence of Malnutrition using MUAC and analyzed using ENA software. Prevalence of global acute Prevalence of moderate acute Prevalence of severe acute malnutrition: MUAC < 125 mm or malnutrition: MUAC < 125 and malnutrition : MUAC < 115 mm or edema MUAC >= 115 mm edema All (3422): (635) 18.6% (16.7- All (3422): (454) 13.3% (11.7- All (3422): (181) 5.3% (4.4- 5.9 19.2 95% CI) 13.9 95% CI) 95% CI) Boys (1794): (311) 17.3% (15.2- Boys (1794): (228) 12.7% (10.9- Boys (1794): (83) 4.6% (3.6- 5.5 18.6 95% CI) 13.9 95% CI) 95% CI) Girls (1628): (324) 19.9% (17.3- Girls (1628): (226) 13.9% (11.8- Girls (1628): (98) 6.0% ( 4.8- 7.0 21.0 95% CI) 15.0 95% CI 95% CI)

3.3.5 Measles vaccination coverage Measles vaccination was the lowest in Mohmand followed by DI Khan, Tank and Hangu. No % Yes with EPI % Yes recall % with card Kurram Camp 1 0.4 170 68.5 77 31.0 248 Bajour 37 14.5 333 130.1 0 0.0 256 DI Khan 177 73.8 109 45.4 32 13.3 240 Hangu 151 62.4 88 36.4 78 32.2 242 Hangu Camp 24 10.0 182 75.8 173 72.1 240 Jalozai Camp 9 3.6 108 43.0 97 38.6 251 Kohat 144 55.8 168 65.1 26 10.1 258 Kurram 65 28.8 181 80.1 41 18.1 226 Mohmand 1 225 88.6 129 50.8 44 17.3 254 Nowshera 98 38.7 235 92.9 5 2.0 253 Peshawar 104 41.4 212 84.5 24 9.6 251 Tank 143 64.4 83 37.4 39 17.6 222 1178 40.1 1998 67.9 636 21.6 2941 *167 of the children were found under nine months.

4. Conclusion and recommendation

The prevalence both Severe and moderate acute malnutrition is at critical level even though MUAC is sensitive measurement and it is a proxy indicative deepening on the type of population measured.Therefore, the nutrition cluster response need to consider the following recommendations.

 In addition to the high SAM prevalence in this assessment there has always been high rate of MAM with low coverage of SFP interventions attributes to the high rate of SAM beneficiaries. It is therefore necessary to have an SFP to run a long side the already existing OTPs to avert the situation where children deteriorate to severe malnutrition.  Close follow up of the nutrition situation and giving special attention to areas with very high SAM and GAM rates and possibly increasing outreach sites to cater for the IDPs household that travel from far areas for OTP services.  Up scaling the nutrition interventions in the most affected areas. Community mobilization activities to be increased and continued creation of community awareness of malnutrition since some cases seem to be reporting at a later stage when the child is extremely malnourished and in some cases getting a child in the community with MUAC less than 10cm. Furthermore, most households are food insecure as reflected by overreliance on food aid and food purchase in the face of high market food prices hence need for initiation of SFP to run alongside the operational OTP.  There is need for continued and more intensive health and nutrition education focusing on: importance appropriate IYCF feeding practices with special focus on the value and duration of exclusive breastfeeding and the importance of timely introduction of complementary feeding, dietary diversity and appropriate frequency of feeding;  Promote income generation on households and community level to increase market dynamics and service provision, and households’ purchasing power. Establish and promote an active hunger safety net facilitated through cash or in kind, to support vulnerable households during the cultivation period to prevent depletion of productive assets or consumption of seed material;  Explore the possibility of shelter provision for the IDPs as the majority are living in the rented household.

 Promote immunization activities and prevention of communicable disease that directly impact the nutritional status of children