Multi-Sector Nutrition Strategy

GOVERNMENT OF Punjab

Multi-sector Nutrition Strategy

For Addressing Malnutrition in Punjab

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Table of Contents Executive Summery ...... 76 1 CHAPTER 1: INTRODUCTION & BACKGROUND ...... 1211 1.1 Introduction ...... 1211 1.2 Situation Analysis (nutrition related) National level ...... 1312 1.3 Causality framework ...... 1413 1.4 Punjab profile ...... 1615 1.5 Rationale for Multi-Sectoral Strategy ...... 1615 1.6 Development Process of Nutrition Strategy ...... 1817 2 CHAPTER 2: OVERVIEW OF THE STRATEGY ...... 2019 2.1 Objectives ...... 2019 2.1.1 Strategic Objectives ...... 2019 2.1.2 Specific Objectives/Expected outcomes ...... 2119 2.2 Conceptual framework ...... 2322 2.2.1 Strategic direction ...... 2422 2.2.2 Guiding principles ...... 2524 2.2.3 Intervention Framework ...... 2624 3 CHAPTER 3: SECTORAL PERSPECTIVE – STRATEGIC SECTORAL PLANS ...... 2726 3.1 PLANNING AND DEVELOPMENT (P&D) ...... 2726 3.1.1 Overview of the sector ...... 2726 3.1.1.1 Potential role in nutrition improvement, engagement and role within the multisectoral framework ...... 2726 3.2 HEALTH SECTOR ...... 2827 3.2.1 Overview of the sector ...... 2827 3.2.1.1 Lady Health Workers (LHW) ...... 2827 3.2.1.2 MNCH program: ...... 2827 3.2.1.3 School Health & Nutrition Program:...... 2827 3.2.2 Potential role in nutrition improvement ...... 2928 3.2.2.1 Causal Pathway of Malnutrition ...... 2928 3.2.2.2 Care for Mothers and Children ...... 3029 3.2.3 Objectives ...... 3130 3.2.4 Intervention framework ...... 3231

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3.2.4.1 Strategy 1: Mainstreaming Nutrition in Health ...... 3231 3.2.4.2 Strategy 2: Equitable access to Nutrition services to poor and marginalized people .... 3332 3.2.4.3 Strategy 3: Strengthening capacity of Provincial and local governments on nutrition to provide basic services in an inclusive and equitable manner ...... 3635 3.3 WASH ...... 3736 3.3.1 Overview of the sector ...... 3736 3.3.1.1 Public Health & engineering department (PHED) ...... 3736 3.3.1.2 Achievements of Public Health & Engineering Department ...... 3836 3.3.2 Potential role in nutrition improvement, engagement and role within the multisectoral framework ...... 3837 3.3.4 Intervention framework ...... 4039 3.3.4.1 Strategy 1: Equitable access to safe & clean water ...... 4039 3.3.4.2 Strategy 2: Promote best practices & behavioral change regarding hygiene practices . 4341 3.3.4.3 Strategy 3: Equitable access to Total Sanitation Services ...... 4543 3.3.4.4 Strategy 4: Development and implementation of Policies and Strategies ...... 4847 3.4 FOOD ...... 4947 3.4.1 Overview of the sector ...... 4947 3.4.2 Punjab Food Department ...... 5048 3.4.2.1 Potential role in nutrition improvement, engagement and role within the Multisectoral framework ...... 5048 3.4.2.2 Food Security ...... 5048 3.4.3 Overall Sectoral objectives ...... 5250 3.4.3.1 Nutrition specific objectives: related to nutrition specific strategic plan ...... 5250 3.4.4 Punjab Food Authority ...... 5250 3.4.4.1 Potential role in nutrition improvement: ...... 5250 3.4.5 Overall Objectives ...... 5351 3.4.5.1 Nutrition specific objectives: related to the Nutrition Specific Strategic Plan ...... 5351 3.4.6 Intervention framework ...... 5351 3.5 SOCIAL PROTECTION ...... 5957 3.5.1 Overview of the sector ...... 5957 . Implementation of U.N. Conventions ratified by Government of Pakistan ...... 6058 3.5.2 Potential role in nutrition improvement, engagement and role within the multisectoral framework ...... 6158

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3.5.3 Food Insecurity and Vulnerability ...... 6260 3.5.4 Women Empowerment ...... 6360 3.5.6 Intervention Framework ...... 6461 3.5.6.1 Strategy 1: Strengthen social protection sector to scale-up nutrition-sensitive interventions ...... 6461 3.5.6.2 Strategy 2: Improving the economic access to address nutritional needs through poverty alleviation and social protection ...... 6764 3.5.6.3 Strategy 3: Promote nutrition awareness for healthy & safe dietary practices ...... 6866 3.6 AGRICULTURE ...... 7067 3.6.1 Crop Sector ...... 7067 3.6.1.1 Overview of the sector ...... 7067 3.6.1.1.1 Live Stock & Diary Development ...... 7168 3.6.1.1.2 The Fisheries ...... 7168 3.6.1.2 Contribution in GDP, Poverty Alleviation, Women empowerment- Workforce ...... 7168 3.6.1.3 Potential role in nutrition improvement ...... 7269 3.6.1.2.1 Casual Pathway of Malnutrition and the Agriculture Sector ...... 7270 3.6.1.3 Food Security Resources ...... 7370 3.6.1.3.1 Food Diversity and caloric Intake situation ...... 7572 3.6.1.4 Overall sectoral objectives ...... 7673 3.6.1.4.1 Nutrition specific objectives ...... 7673 3.6.1.5 Intervention framework ...... 7673 3.6.1.5.1 Strategy 1: Mainstreaming Nutrition in Agriculture ...... 7673 3.6.1.5.2 Strategy 2: Increase Productivity in nutritious food (by developing and promoting high yielding varieties of grains & pulses) ...... 7875 3.6.1.5.3 Strategy 3: Equitable access to vegetables and fruits ...... 8077 3.6.1.5.4 Strategy 4: Addressing Malnutrition through bio-fortification ...... 8279 3.6.1.5.5 Strategy 5: Scaling up of Kitchen gardening ...... 8380 3.6.1.5.6 Strategy 6: Increase accessibility of animal protein sources at household level ...... 8481 3.6.2 LIVESTOCK AND DAIRY SECTOR ...... 8582 3.6.2.1 Overview of the Sector ...... 8582 3.6.2.2 Livestock & Diary and Nutrition Connect ...... 8683 3.6.2.3 Nutrition sepecific objectives of sector: ...... 8784

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3.6.2.4 Intervention Frame work ...... 8784 3.6.2.4.2 Strategy 2: Reduce nutrient deficiency in targeted groups by increasing the physical access to livestock-based products ...... 8986 3.6.2.4.3 Strategy 3: Increase accessibility of animal protein sources at household level especially for vulnerable community ...... 9188 3.6.3 FISHERIES AND AQUACULTURE SECTOR...... 9289 3.6.3.1 Overview of the Sector ...... 9289 3.6.3.3 Overall Objective of the sector: ...... 9591 3.6.3.4 Intervention Matrix ...... 9592 3.7 EDUCATION SECTOR (PUNJAB) ...... 9996 3.7.1 Overview of the sector ...... 9996 3.7.2 Potential role in nutrition improvement ...... 10097 3.7.3 Nutrition specific objectives of the Education Sector ...... 10198 3.7.4 Intervention Matrix ...... 10299 4 CHAPTER 4: IMPLEMENTATION OF THE STRATEGY / OPERATIONALIZATION ...... 109106 4.1 Implementation Model ...... 109106 4.2 Organizational Structure ...... 110107 4.2.1 Provincial ...... 111107 4.2.2 District...... 113109 4.2.3 Community ...... 114110 4.3 Harmonization and Synergy ...... 115112 4.4 Capacity Building ...... 116113 4.5 Communication Strategy ...... 117113 4.6 Monitoring, Evaluation and Accountability ...... 117113 4.6.1 Measuring the progress: result based monitoring framework ...... 118114 4.7 Research and development ...... 120116 4.8 Public private partnership/Bussiness Network ...... 123119 4.9 Financial framework/ resource management ...... 123119 4.9.1 Financial Management ...... 123119 4.9.2 Establishment of Joint Funding Pool ...... 124120 4.9.3 Funds Flow ...... 124120

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LIST OF FIGURES

Figure 1.1: Causal pathway of Malnutrition, ...... 154 Figure 1.2: Sectors involved in reducing the burden of malnutrition & food insecurity ...... 187 Figure 1.3: process of developing Multisectoral plan in the Province ...... 198 Figure 3.4: Sources of Drinking water in Punjab ...... 4130 Figure 3.5: Percentage of house hold with availability of water & soap ...... 4332 Figure 3.6: Integrated Total Sanitation Model ...... 4634 Figure3.7: Statistics about type of Toilets used in Punjab ...... 4735 Figure 3.8: Relevance of food security & Stunting ...... 5139 Figure 3.9: Social Protection at a glance Source: adapted from de Janvry (pers. comm.) ...... 6250 Figure 3.10: Food entitlement gaps & social protection instruments...... 6452 Figure 3.11: Food Security Situation -Punjab ...... 7362 Figure 3.12: Figure 3: Relationship between Maternal education and Child Stunting (Source: NNS 2011) ...... 10190

LIST OF TABLES

Table 3.1: MTDF Targets and MDGs ...... 3837 Table 3.2: Food security resources and poverty in Pakistani provinces, 2009 – 2011 ...... 7572 Table 3.3: Area & Production of Pulses 2011-2012 and 2012-2013 ...... 7876 Table 3.4: National Production, consumption & gap of major pulses 2012-2013 ...... 7976 Table 3.5: Table Protein Quality Comparison of Fish Protein with other animal Proteins ...... 9390 Table 3.6: Aquaculture practices ...... 9490 Table 3.7: Consumption of Fish in Various Provinces of Pakistan (KGs per capita per annum) ...... 9895

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Executive Summery Punjab is the most populous province and play imperative role in the economy of Pakistan. The economy of Punjab is predominantly based on the agricultural sector along with significant contribution of industry. In spite of the major contribution (about 68%) to the annual food grain production in Pakistan, the food security and malnutrition indicators in Punjab exhibit meager condition. Pakistan National Nutrition Survey (2011) reported 58% household food insecurity in Pakistan and 59.5% in Punjab. This figure shows more food insecurity in Punjab as compared to national average and is very interesting as Punjab is a hub for agricultural production.

On the account of Nutritional Profile of Punjab, 34% of children are underweight, 42% stunted and 13% of children were wasted in under five years of age. It was also estimated that about half the children (49%) aged 0–5 months were exclusively breastfed (MICS, 2007–08). Furthermore, micronutrient deficiencies in Punjab also indicate an alarming situation. Vitamin A deficiency, that reduces immune function and impaired eyesight, influences 41.8% of women and 51.0% of children. Moderate and severe anemia, resulting in part from iron deficiency, and reducing the flow of oxygen from the lungs to the rest of the body, affects 49.3% of pregnant women in the province and 60.3% of children. Overall, there seems no major difference and improvement in nutrition indicators compared to national averages.

Planning & Development Department Punjab, while realizing its role in tackling the grave issue of malnutrition in Punjab, constituted a Steering Committee (SC) with representation of relevant sectors including government departments and international development partners. This committee was given the mandate to develop Nutrition Policy Guiding Notes (NPGN), Punjab. The Steering Committee constituted a Technical Working Group (TWG) in August 2012 and the TWG subsequently notified six sectoral technical groups namely Agriculture Sector, Food Sector, Health Sector, Education Sector, Social Protection Sector and WASH Sector. The sectoral groups were comprised of representatives of relevant Government departments, development partners, academia and civil society. These sectoral groups, through meetings and consultative process, developed their respective nutrition policy guidance notes. These notes were refined through a series of meetings at the provincial and national level and were then approved by Steering Committee in its meeting held on 07-02-2014. The same consultative process has been adopted for the development of this strategy with the support of two consultants supported by UNICEF.

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The objectives of the multi-sector nutrition strategy are to

1: Policies, plans and multi-sector coordination planned & implaced at provincial and local levels

Development and establishment of protocols for the implementation of proposed multi sectoral nutrition interventions from provincial to the local level is the focus of this outcome. The strategy will provide the well-constructed & comprehensive infrastructure for implementation along with reporting, monitoring and evaluation in order to make the approach ready to practice.

1. The multi-sectoral strategy will specifically focus on enhancing coordination in order to define the coordination mechanism among participating sectors, donors, and other implementing partners 2. Capacity building of all sectors on implementation and monitoring of progress towards scaling up nutrition through the multi-sector approach, by defining a core set of multi-sector monitoring and evaluation indicators 3. Strategy will identify technical as well as funding gaps in the government capacity and provide the single platform for all partners and donors to chip in to their priority areas to maximize the coverage, avoid any duplication and support the provincial government.

2: Well-coordinated sectoral plans to maximize the impact of nutrition ‘specific’ and nutrition ‘sensitive’ interventions leading to improved nutritional status of targeted population

This outcome of the strategy will maintain and strengthen the already existing key nutrition ‘specific’ interventions by health department, including, nutrition specific activities performed during biannual MCH weeks celebrated across the province. Like Vitamin A supplementation and de-worming for all children aged 6-59 and 12-59 months, respectively; Iron Folic Acid (IFA) supplementation and education campaign on maternal and child nutrition specially designed for these weeks. Some other routine activities of health department include the use of zinc in the management of diarrhea together with ORS and universal salt iodisation. It will also further strengthen and expand Community Infant and Young Child Feeding (IYCF) program. In addition, a modified model of the CMAM program with the major

Page 8 addition of maternal nutrition and use of micronutrient supplementation for the treatment of MAM children & PLWs will be scaled up with initial focus in high risk districts. It also supports strategies with respect to flour & oil fortification.

Furthermore, the outcome will contribute through the education sector to improve and scale up core nutrition ‘sensitive’ interventions with particular focus on enhancing adolescent girls’ education, life skills and nutritional status through its School Health and Nutrition Program. The core interventions include:

. Ensure equitable access to education, with particular focus on increasing enrollment and retention of the girl child . Introduction of Nutrition, Health & Hygiene education modules in schools and education curriculum . Improve knowledge regarding nutrition among teachers, parents/caregiver's children and adolescents engaged in schooling . To support the health department in malnutrition screening among children and adolescents and improve nutritional status among school going children through appropriate referrals, health & nutrition education and promotion activities . Introduction and promotion of Nutrition as a professional track for post-graduate education and employment The outcome will contribute to reduce incidence of infections – with a focus on reducing diarrheal diseases and ARI among young children, mothers and adolescent girls. It aims to attain this by

. Increasing access of “improved” or non-surface water . Enhancing Rural Population Coverage (Barani, Brackish and Contaminated Areas) . Improving quality control of water (by providing Water Testing Facilities and through provision of Water Filtration Plants) . Enhancing sanitation, environmental sustainability and open defecation free (ODF) environment . Functionalizing Rural Water Supply Schemes and replacing old water supply pipe lines for eradication of gastroenteritis in 15 cities of Punjab . Increasing public awareness about water safety, safe hygiene practices, and water conservation Finally, the outcome through the agriculture sector will aim to

. Mainstreaming nutrition in agriculture . Enhance productivity of grains and pulses (increase availability of nutritious foods)

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. Address malnutrition through bio-fortification . Promote kitchen gardening at household level (Equitable access to vegetables and fruits) . Create awareness on the importance of food diversification and healthy dietary practices . prioritize development of zinc rich wheat variety . Empower Women labor involved in Agriculture sector

3: Capacity building of provincial as well as local government on nutrition to provide basic services in an inclusive and equitable manner

This outcome aims to strengthen nutrition related capacities of all involved sectors in multi-sectoral approach as well as all implementing partners to integrate proposed set of interventions in provincial and district level planning and monitoring. The multi-sectoral approach will strengthen the capacity of all involved sectors and other stakeholders at all levels through cross-sectoral (between sectors) and inter-sectoral (within sectors) coordination depending upon nutrition-sensitive or nutrition-specific intervention. Capacities will be developed at three levels: the first level will be the policy making level that also includes the political participation/ownership. The second level will be the implementing institutions/ sector from province to union council level (such as Fields Assistant, School Health Nutrition Supersvisors, Teachers, etc.). Lastly, the third level will include the individuals who will be implementing these activities. Leadership is proposed from the nutrition cell at PSPU under the P&D department at provincial level to ensure that capacity is built on all levels with increased ownership and commitment.

Effective and coordinated implementation of the proposed strategy is imperative in realization of the objectives of the strategy. The implementation is proposed to be done in partnership between all responsible departments. Implementation of this strategy will be mainly through three distinct ways;

1) adjustments in already implemented or existing programmes by making them more nutrition sensitive.

2) seeking funds and implementing nutrition sensitive interventions by developing PC-1s against approved interventions in this strategy using their own resources.

3) seeking funds through Nutrition Cell from the pool of resources allocated for implementation of nutrition strategy for nutrition specific and high priority nutrition sensitive interventions. The implementation model will vary from intervention to intervention for effective implementation.

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There are interventions in all sectors, which are department specific and therefore the implementing department will take lead in its planning and implementation within the sector. Some interventions are multi-institutional within each sector and some are multisectoral, and their effective implementation requires coordinated implementation frame-work from all involved departments and/or sectors.

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1 CHAPTER 1: INTRODUCTION & BACKGROUND

1.1 Introduction Malnutrition and food insecurity are the most serious health concerns throughout the world and the significant contributors in child morbidity & mortality. These indices instigate a preventable embarrassment to global society and induce serious political, economic, and social consequences1. In developing countries, nearly one-third of children are undernourished (underweight or stunted), and more than 30% people are enduring different kinds of micronutrient deficiency that undermine economic growth and perpetuates poverty. Although, numerous efforts were directed to tackle malnutrition over past few decades, but consequential successes have not been observed, even at times, with the application of well-tested approaches or strategies. The ineffectiveness is quite evident from unsatisfactory progress towards achieving MDG to halve the global hunger by 2015 (Target 1.C). Stunting, wasting, and intrauterine growth retardation presents the most overwhelming concerns affecting the children, and cause 2.2 million deaths of children (under 5 years). Overall, nutrition-related factors result in 35% of child deaths and 11% of the total global disease burden2. Change in dietary habits and inequitable access to food, services and nutritional information are also the contributing factors for malnutrition. Excess intake, attributable to change in dietary pattern, proliferate the prevalence of over-weight and obesity. According to WHO report more than 1.4 billion adults (over 20 years) were overweight worldwide in 2008, among those 500 million (200 million men and 300 million women) found were obese. Poor nutritional status and high prevalence of malnutrition are mainly attributable to various factors like food insecurity, poverty, lack of knowledge/information, poor dietary habits (imbalance diet intake), poor maternal and child health, as well as deficiency of micronutrients (especially iodine & zinc) in soil.

The health and nutrition status indicators of Pakistan are even worse compared to countries having lower Gross National Product and lower per capita income. According to the Pakistan’s National Nutrition Survey 2011, various malnutrition indicators like stunting, wasting, and micronutrient deficiencies are endemic in Pakistan. Although, some of the nutrition indicators for Punjab are slightly better compared to other provinces, yet the situation is more than worse, as a whole and demand for effective and targeted strategic actions to tackle the issues immediately. In order to combat the severe threats posed by malnutrition and achieving the commitments towards MDGs, Government of the

1 Scrimshaw, N.S. (1986). Fed Proc., 45(10), 2421-2426. 2 Blacketal., (2008). The Lancet. 371 (9608):243-260.

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Punjab along with international development partners keenly developed “Nutrition Policy Guidance Notes (NPGN), Punjab”. The core of the policy is to adopt a Multi-Sectoral approach for effectively tackling the grave and persistent issue of malnutrition. This nutrition strategy is based on the (NPGN) and focuses on various nutrition specific / sensitive strategic actions to be implemented by various involved sectors targeted to improving nutrition indicators of masses in Punjab.

1.2 Situation Analysis (nutrition related) National level The Government of Pakistan, in the recent past, has shown its commitment to reinforce nutritional and health status, especially by improving the nutrition indicators and women empowerment and to make quick progress towards achieving MDGs. Various programs and projects are in the pipeline to improve nutrition and food adequacy for a healthy and productive life. Pakistan has also joined the Scaling-Up Nutrition (SUN), which reiterates its commitment to a healthy nation. Pakistan is now confronting transecting challenges to feed increasing population, where people are already suffering from nutrient deficiencies and do not have factual access to adequate micronutrients, protein and energy in their diet3,4. Despite the inadequate dietary intake and overburden of malnutrition, current indices revealed that in Pakistan about 33.9% mothers fall in the overweight range (according to BMI>24.9 kg/m2) and about 14.1% are categorized as underweight (BMI<18.5 kg/m2) because of imbalanced diet and change in dietary pattern3. However, positive signs have been witnessed as Economic Survey of Pakistan (2013), indicates that per capita food intake and protein availability has increased in the last two years (from 2410 Kcal/day to in 2450 Kcal/day and 71.5 g/day to 72.5g/day, respectively).

The Pakistani community largely consumes cereals based diet as staple food that contributes to 62% of total energy. However, the food consumption pattern as well as food diversification is not according to the Food Guide Pyramid and instigates various nutrition related maladies. Attributable to lifestyle modifications, inadequate access due to seasonal variation, unorganized market facilities, improper food supply chain and escalating poverty, the fruits, vegetables, fish and meat consumption are inadequate as compared to actual requirements. However, the per capita milk consumption is significantly higher in comparison to other Asian countries. According to National Nutrition Survey 2011, prevalence of micronutrient deficiencies in women were; iron deficiency anemia (37.0%), anemia (51.0%), zinc deficiency (47.6%), vitamin A deficiency (46.0%), and vitamin D deficiency (68.9%). While, the prevalence of micronutrient deficiencies in non-pregnant women were; anemia 50.4%, iron deficiency

3 NNS, 2011 [National Nutrition Survey Pakistan] Government of Pakistan. 4 Economic Survey of Pakistan, 2013

Page 13 anemia 26.8%, vitamin A deficiency 42.1%, zinc deficiency 41.3% and vitamin D deficiency 66.8%. The micronutrient deficiencies in children (<5 years of age) are also widely prevalent; iron deficiency 43.8%, anemia 61.9%, zinc deficiency 39.2%, vitamin A deficiency 54.0%, and vitamin D deficiency 40.0%. Moreover, the indicators of stunting (43.7%) and wasting (15.1%) have deteriorated in 20115compared to 20016 stunting 37% and wasting 13%. The high level of food insecurity (58%) has also led Govt to establish Ministry of National Food Security and Research at the federal level to improve the food security situation in Pakistan, which is one of the major underlying causes for malnutrition in the country.

1.3 Causality framework Malnutrition is the outcome and manifestation of either unavailability or lesser availability of one or more vital nutrients to the body, especially when they require the most. They are many key factors, which cause this nutrients’ insecurity, depending upon the situation. The key factors which might instigate the hunger and food insecurity include rapid population growth, climate change, calamities, low food productivity, incompetent supply chain, post- and pre-harvest losses, frequent food price hikes, food and water safety issues, untrained and low quality human resource in the food supply chain, inequitable access to health services and knowledge,7

Among these, climate change is persistently posing serious threats and is influencing agricultural production and food chain. Frequent floods in Pakistan have impacted large segment of the population and have left many more vulnerable. Similarly, the death toll is in hundreds due to recent drought in THAR which caused serious food and water insecurity in large geographical area. The victims are also prone to even relatively smaller shocks in future, as they lose their assets including livestock and backyard poultry. Although, irrigated agriculture is essential to meet the food demand and reduce the hunger and food insecurity by increasing the food production for vulnerable community, yet frequent calamities and disease outbreaks in one part of the world also impact big time in adjacent countries and several regions are faced with various concerns that intimidate the sustainability

5 NNS, 2011 [National Nutrition Survey Pakistan] Government of Pakistan. 6 NNS, 2001 [National Nutrition Survey Pakistan] Government of Pakistan.

7 Beddington et al., 2012. Agriculture & Food Security, 1(10), 1-9. doi:10.1186/2048-7010-1-10

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Figure 1.1: Causal pathway of Malnutrition8,9

The undernourishment (macro nutrient deficiencies & hidden hunger) may cause intrauterine growth and mental retardation; low birth weight; poor health/ high burden of morbidity; reduced physical and mental performance; and ultimately constrain community and national development. There are more different concerns that associated with malnutrition prevalence and the food insecurity situation in the different parts of the world, especially in developing countries, where the whole resources are not utilized or somewhere lack of resources create hurdles.

8 Sources: UNICEF, 1990 9 Benson & Shekar, 2006. Washington, DC: World Bank.

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1.4 Punjab profile Punjab is the most populous province and play imperative role in the economy of Pakistan. The economy of Punjab is predominantly based on the agricultural sector along with significant contribution of industry. In spite of the major contribution (about 68%) to the annual food grain production in Pakistan, the food security and malnutrition indicators in Punjab exhibit meager condition. In this province, devastating burden of under-nutrition remains a substantial health concern and induce enduring adverse consequences. The overburden of malnutrition also instigates the maternal and child morbidity as well as elevated mortality rates. The infant mortality rate in Punjab is 82 per 1000 live births, while the child mortality rate (under 5 years) is 104 per 1000 live births (MICS Punjab, 2011). It is estimated that about 92% of the population in the province have access to improved drinking water sources; whereas 58% of the population has access to proper sanitation facility (Health Department, Punjab 2014). Pakistan National Nutrition Survey (2011) reported 58% household food insecurity in Pakistan and 59.5% in Punjab. This figure, showing more food insecurity in Punjab compared to a national average, is very interesting as Punjab is a hub for agricultural production. This also reveals that the producers, especially small holders, they are food insecure due to poverty driven lesser access to food. In spite of this situation, there is also an increasing trend of obesity, especially in women and NNS, 2011 revealed that 29.9% women are either overweight or obese, while lower percentage is underweight (17.7%). This situation again reveals the increasing trends towards un-balanced dietary patterns.

On the account of Nutritional Profile of Punjab, 34% of children underweight, 42% stunted and 13% of children were wasted in under five years of age. It was also estimated that about half the children (49%) aged 0–5 months were exclusively breastfed (MICS, 2007–08). Furthermore, micronutrient deficiencies in Punjab also indicate an alarming situation. Vitamin A deficiency, that reduces immune function and impaired eyesight, influences 41.8% of women and 51.0% of children. Moderate and severe anemia, resulting in part from iron deficiency, and reducing the flow of oxygen from the lungs to the rest of the body, affects 49.3% of pregnant women in the province and 60.3% of children. Overall, there seems

no major difference and improvement in nutrition indicators compared to national averages.

1.5 Rationale for Multi-Sectoral Strategy Food insecurity and malnutrition induce considerable economic cost comprising reduced lifetime productivity, expanding poverty, slowing down economic development, lowering the quality of human

Page 16 resource and resource deprivation10. Vulnerable community (chronically hungry and/or severely malnourished) requires immediate assistance to rescue. Although, most of the world’s vulnerable communities facing hunger by some means rely on agriculture and related fields like fisheries and livestock for their survival, however, some other concerns like lack of knowledge, inadequate access to food, insufficient health and hygiene facilities also associated with their vulnerability.

World Health Organization (WHO) Assembly emphasized on nutritious and healthy foods and lifestyles in 2012-13 to decrease non-communicable diseases (NCDs) burden in entire world. The endeavors to reduce malnutrition burden and food insecurity for economic and human development in Pakistan requires involving agriculture (crop, livestock, & fisheries), food (safety, handling, storage & preservation) water, sanitation & hygiene (WASH), social welfare, women development, health as well as education sectors. These sectors along with some others have also been identified at global level and scaling-up nutrition, movement also revolves around multi-sectoral approaches to tackling malnutrition across the globe. Moreover, coordination and close collaboration between various sectoral players like government, development partners, academia and civil society is also the need of the hour for addressing immediate, underlying and basic causes of malnutrition having roots across the sectors. Consequently, improvement in nutrition indicators at reasonable pace will only be possible through multi-sectoral approach by involving relevant sectors that have substantial potential for declining chronic malnutrition in the province. WHO particularly gives emphasis on the long term sustainable contribution of “Agriculture and Food Sectors”. The consensus report further elaborated that along with ensuring food security throughout the world; both sectors must ensure the adequate access to safe and good quality foods. Multisectoral experience in nutrition from countries like Nepal, Thailand, Peru and Brazil confirm that such a centrally-placed coordination mechanism is imperative for ‘planning multisectorally, implementing sectorally, and reviewing sectorally as well as multisectorally’.

10 (FAO, 2012) http://www.fao.org/docrep/016/i3027e/i3027e00.htm

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Agriculture Crop, Livestock, Fisheries INGOs & Other development Food Partners

Malnutrition & Food Social Insecurity Health Protection

Water, Education Sanitation & Hygiene

Figure 1.2: Sectors involved in reducing the burden of malnutrition & food insecurity 1.6 Development Process of Nutrition Strategy Planning & Development Department Punjab, while realizing its role in tackling the grave issue of malnutrition in Punjab, constituted a Steering Committee (SC) with representation of relevant sectors including government departments and international development partners. This committee was given the mandate to develop Nutrition Policy Guiding Notes (NPGN), and provide strategic advice on developing nutrition strategies and operational plans of Punjab. The steering committee was also mandated to facilitate the resource generation and budgetary allocations from Punjab Government and development partners. The Steering Committee constituted a Technical Working Group (TWG) in August 2012 and the TWG subsequently notified six sectoral technical groups namely Agriculture Sector, Food Sector, Health Sector, Education Sector, Social Protection Sector and WASH Sector. The sectoral groups were comprised of representatives of relevant Government departments, development partners, academia and civil society. These sectoral groups, through meetings and consultative process, developed their respective nutrition policy guidance notes. These notes were refined through a series of meetings at the provincial and national level and were then approved by Steering Committee in its

Page 18 meeting held on 07-02-2014. The same consultative process has been adopted for the development of this strategy with the support of two consultants supported by UNICEF.

Recognizing the complexity of the issue of malnutrition for economic and human development and for efforts to achieve the Millennium Development Goals, the Government of Punjab and its partners have decided to undertake a Multisectoral nutrition plan to address the issue involving all key sectors which, collectively, have considerable potential for reducing malnutrition in the province.

The following picture illustrates the process of developing Multisectoral plan in the Province.

D-10 Meetings (Planning Commission of Pakistan)

P & D Steering Committee

Sector-specific Working Groups

Development of Policy Guideline notes

Multi-sectoral strategy

Figure 1.3: process of developing Multisectoral plan in the Province

In a nutshell targeted, well-coordinated and integrated multisectoral approach is the core of this strategy, which aims to develop ownership in involved sectors to realize their role in reducing the burden of malnutrition from the province of the Punjab. If implemented in letter and spirit, this multi- sector nutrition strategy is believed to be appropriately responding to impending crises of malnutrition from the province.

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2 CHAPTER 2: OVERVIEW OF THE STRATEGY

A casual pathway to malnutrition provokes the need of the multisectoral approach because of its effectiveness to combat the overwhelming burden of malnutrition. Keeping in view the threatening situation of nutrition indicators in Punjab, the Govt. of Punjab has decided to initiate a multisectoral strategy in order to intervene the causes of under nutrition from underlying causes to immediate ones. Multisectoral approach will be comprehensive, valuable and most effective way to adopt the both nutrition specific and nutrition sensitive interventions, involving all related sectors with their poteintial role. This strategy is going to define the implementation and coordination (both horizontal and vertical) mechanisms at all levels within the sectors in collaboration with development partners. Multisectoral strategy is mainly focused on single work plan with common objective of all sectors and partners, thus making it convenient for partners to chip in at their priority area and will help to maximize the coverage & avoid any duplication. The effective implementation of multisectoral strategic intervention will certainly play a key role in reducing ever-escalating burden of malnutrition mainly and will also be helpful in improving the food-security indicators.

2.1 Objectives

2.1.1 Strategic Objectives

The objectives of the multi-sector nutrition strategy are to

. Improve the food security indicators to reduce the chronic malnutrition by increasing the awareness, equitable access to safe and nutritious food including water . Minimize malnutrition associated damage to human capital and economic growth . Reduce acute malnutrition in order to address its long lasting effects These objectives will be achieved by considering both nutrition specific as well as nutrition sensitive interventions equally important. Nutrition specific interventions will be implemented largely through the health sector, and nutrition sensitive interventions mostly by other sectors including education, agriculture, WASH and social protection, in well-coordinated manner with developing-partners and government will add into the impact of the strategy.

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2.1.2 Specific Objectives/Expected outcomes

The multi sectoral strategy is designed in a way that every sectoral plan will work effectively at all levels from provincial to local in order to achieve a common goal of reduction in acute as well chronic malnutrition and other nutrition associated maladies. Each sector, health, education, agriculture, social work, WASH & local government will implement their assigned plans in multi-sector coordinated manner and will be monitored and evaluated sectorally as well as multisectorally. Following outcomes are defined to be achieved by the program in order to attain the main objectives of the proposed strategy. Expected results/ specific objectives

1: Policies, plans and multi-sector coordination planned & implaced at provincial and local levels

2: Well-coordinated sectoral plans to maximize the impact of nutrition ‘specific’ and nutrition ‘sensitive’ interventions leading to improved nutritional status of targeted population

Page 21 and universal salt iodisation. It will also further strengthen and expand Community Infant and Young Child Feeding (IYCF) program. In addition, a modified model of the CMAM program with the major addition of maternal nutrition and use of micronutrient supplementation for the treatment of MAM children & PLWs will be scaled up with initial focus in high risk districts. It also supports strategies with respect to wheat flour & oil/ghee fortification.

. Increasing access of “improved” or non-surface water . Enhancing Rural Population Coverage (Barani, Brackish and Contaminated Areas) . Improving quality control of water (by providing Water Testing Facilities and through provision of Water Filtration Plants) . Enhancing sanitation, environmental sustainability and open defecation free (ODF) environment . Functionalizing Rural Water Supply Schemes and to replace old water supply pipe lines for eradication of gastroenteritis in 15 cities of Punjab . Increasing public awareness about water safety, safe hygiene practices, and water conservation Finally, the outcome through the agriculture sector will aim to

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. Mainstreaming nutrition in agriculture . Enhance productivity of grains and pulses (increase availability of nutritious foods) . Address malnutrition through bio-fortification . Promote kitchen gardening at household level (Equitable access to vegetables and fruits) . Create awareness on the importance of food diversification and healthy dietary practices . prioritize development of zinc rich wheat variety . Empowering Women labor involved in Agriculture sector

3: Capacity building of provincial as well as local government on nutrition to provide basic services in an inclusive and equitable manner

2.2 Conceptual framework

The therapeutic approach to treat malnutrition are complex and vary in different situations. Inadequate access to basic human requirements such as lack of safe drinking water, poor hygiene conditions (and its associated diseases such as diarrhea, infectious disease, parasites), drought or any emergencies leading to a collapse of social networks, then it comes social beliefs and taboos (due to lack of knowledge) affecting food and specially nutrient intake. These are few highlighted causes which can determine the nutritional status of a community, household or individual. Any strategy aiming to treat or prevent malnutrition needs to identify clearly the direct and underlying causes of malnutrition in the country or province specific context. The conceptual framework of malnutrition adopted by UNICEF in 2000

Page 23 proposes a multi-sectoral analysis of malnutrition causes, which can guide for further assessments, project design, their implementation, monitoring and evaluation.

2.2.1 Strategic direction

Key strategic directions for multi-sector nutrition plan will be following:

2.2.1.1 Scaling up of nutrition specific interventions of proven effectiveness

Most of the sectors i.e. agriculture, Food, education, wash, social protection and specially Department of health Punjab has already identified and started working on nutrition specific interventions in the province. The strategy will provide direction towards scaling up of already identified & proposed cost effective interventions of proven effectiveness by sectors in an equitable and coordinated manner. The multi sectoral nutrition strategy will serve as the basis for the implementation of all sectoral plans as a government’s plan to improve the nutrition indicators.

2.2.1.2 Identification and implementation of sector specific nutrition sensitive interventions (Multisectoral approach: plan multisectorally, implement sectorally)

The strategy will identify nutrition sensitive interventions with major focus on sectors other than health and will provide the single platform for intersectoral planning. The strategy will focus on “plan multisectorally-implement sectorally & then monitor and evaluate sectorally as well as multi sectorally”.

2.2.1.3 Target groups

This strategy will be addressing the most vulnerable segments of the society in equitable manner. Target group for the proposed interventions will be adolescent, all married females with special focus to pregnant & lactating mothers, and all children of less than 5 years of age.

2.2.1.4 1000 days plus model

In order to focus on the window of opportunity when stunting occurs, from conception to two years of age, strategy is designed with 1000 days plus model to catch the problem even before conception. Adolescent & maternal component of interventions is thus mainly considered in order to prevent the issue even before it occurs.

2.2.1.4.1 Women empowerment / Women Focused Approach (As SUN countries pursue goals in a way that empowers women at every level.)

The strategy will be women & child friendly design. In order to maximize the participation of most disadvantaged segment of the society women focused approach will be introduced. Capacity of women

Page 24 already working with different sectors will be improved through trainings that leads to their empowerment. The strategy will also ensure the participation of women & most disadvantaged in the decision making process at all levels through mainstreaming their participation from provincial to local level.

2.2.1.5 Over nutrition (Childhood obesity, adolescent health)

Over nutrition, especially childhood obesity is very much associated with lifestyle and eating patterns. The strategy will also add the behavior change related to unwanted weight gain and over consumption of refined & processed foods.

2.2.2 Guiding principles

Key guiding principles of the strategy will be as following :

2.2.2.1 The fundamental right to be free from hunger

Every child born has a fundamental right to be free from hunger, thus the Multisectoral approach will be designed in a way to ensure the availability safe, enough & nutritionally adequate food to every child at all times.

2.2.2.2 Gender empowerment

Gender balance and women empowerment will be guiding principle of the strategy in order to ensure equitable access of nutrition services. Women being more vulnerable towards malnutrition will be addressed through women focused approach of the strategy.

2.2.2.3 Geographical convergence

Equitable geographical coverage with special focus to far flung and disadvantaged area will be very important principal for the implementation of proposed Multisectoral strategy.

2.2.2.4 Evidenced based interventions

All the interventions that will be proposed to be scaled up should be necessarily evidence based. So strategy will propose to pick internationally proven intervention relevant to the local context, then should be piloted and will only recommend to be scaled up once evidence is being generated.

2.2.2.5 Equity in distribution

The poorest of the poor will be the real target of the strategy. Equity in distribution of all nutrition related interventions will take up the most marginalized segment of the society in the account. And

Page 25 provide the services very much according to need based, e.g. malnourished children about food secure household will be provided with counseling of right choice not the food supplementation.

2.2.3 Intervention Framework

Figure 2.1: Intervention Framework [Source: Adapted from (Black et al., 2013) by A. Dorward]

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3 CHAPTER 3: SECTORAL PERSPECTIVE – STRATEGIC SECTORAL PLANS

3.1 PLANNING AND DEVELOPMENT (P&D)

3.1.1 Overview of the sector

The Planning and Development Department (P&D), Government of Punjab, is the principal planning organization at the provincial level. It coordinates and monitors development programs and activities of various departments of the provincial government. The department also prepares the overall medium term framework of development activities in the province. The medium term development framework lays down the development activities to be carried out in various sectors of the provincial economy. In this manner the Planning & Development department is one of the main actors in the growth of the economic potential of the province. Bureau of Statistics Punjab, Agency for Barani Areas Development (ABAD) & Directorate General Monitoring & Evaluation are attached departments of P & D Punjab.

The mandate of the P&D department includes, provision of technical support and coordination to various Government departments in their planning activities. The P&D department is also the main government agency working with foreign donors in the province.

The main objectives of the Planning and development department are:

 Assessment of the material and human resources of the province  Formulation of long and short term plans.  Recommendations concerning, prevailing economic conditions, economic policies or measures.  Examination of such economic problems as may be referred to it for advice.  Coordination of all economic activities in the provincial government.

3.1.1.1 Potential role in nutrition improvement, engagement and role within the multisectoral framework

Considering the domain of Planning & Development Department Punjab and multisectoral strategy, P&D has a central role in planning, implementation, coordination and M&E. The planning role of P&D has been discussed in first chapter (1.6 Development Process of Nutrition Strategy) and the detailed description is documented in Chapter 04 of this strategy.

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3.2 HEALTH SECTOR 3.2.1 Overview of the sector Health Department is the key with the fundamental responsibility for ensuring the health of the entire population of the province. The Health Department delivers preventive as well as curative health care services of Primary Health Care level to Tertiary level. The infrastructure in the province consists of 2,461 Basic Health Units (BHUs), 293 Rural Health Centers (RHCs), 88 Tehsil Headquarters Hospitals (THQs), 34 District Headquarter Hospitals (DHQs) and23 Teaching/ tertiary Care Hospitals.

Keeping in consideration the key role of the health sector in addressing malnutrition, the Punjab health department has already started implementing an RMNCH & Nutrition program in an integrated manner through its vertical programs i-e LHW Program & MNCH program.

3.2.1.1 Lady Health Workers (LHW)

The Lady health worker program is operating in all 36 districts of Punjab with 47000 thousand LHWs working in the community. After the floods of 2010 LHW program remained main implementer of the CMAM & nutrition programs in the flood affected districts of Punjab. More than 15000 LHWs are fully trained in basic nutrition and IYCF.

Moreover the community component of the nutrition program is also responsible of LHWs. It includes, screening, referral and follow up of identifying malnourished cases in the community. Provision of iron, folic acid tablet to all females of child bearing age, micronutrient supplements for suspected cases of MAM children, & BCC with special focus to nutrition is added to LHWs routine jds now.

3.2.1.2 MNCH program: Community midwives are engaged in community based nutrition related programs like MCH week, and special weeks like breast feeding weeks. All CMWs will be trained on IYCF & basic nutrition under the RMNCH & Nutrition program.

3.2.1.3 School Health & Nutrition Program: Total 1,754 School and Nutrition, Health Specialists (SH&NS) are appointed at a Basic Health Unit level. The School Health and Nutrition Specialist (SH&NS) visits every primary and middle school in the catchment area, preferably once in a month for delivering lectures on health education and health lifestyle. The SH&NS also carries out screening of students for eye, ENT, dental, skin and general physical problems. The trained school teachers also assist in these activities.

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3.2.2 Potential role in nutrition improvement The combination of inefficient health services and burden of malnutrition has been identified impediments in achieving MDGs. High levels of malnutrition are consistent with high rates of infant and maternal mortality. The infant mortality rate in Punjab is 81 per 1000 live births, higher than the national average. At the same time, relation between health especially infectious disease and malnutrition cannot be ignored. In a well-nourished child, a common infectious disease is usually a passing illness. While for an already malnourished child the same disease can precipitate, life-long disabilities such as Vitamin A deficiency can cause even blindness. Similarly rapid sequence of infections can leads towards malnutrition.

A slow sequence of disease accompanied with malnutrition & poor health services leads to stunting, wasting, and affects mental development, decisively handicapping the affected millions that do not die. The survivors remain with difficulties in terms of cognitive and physical development. Their handicap though invisible, marks lifelong effects, leaving them less productive throughout their life.

The Malnutrition–Health complex is drain on human resource. One condition aggravates the other. Infections lead to malnutrition and malnutrition may exacerbate infections increasing the duration, severity, morbidity, and mortality. Malnutrition, health and poverty are closely linked with each other; already poor people who are also malnourished and unhealthy and vice versa. It is envisaged that health status improvements will enable individuals to avail more choices/opportunities that can help in improving quality of their lives like attaining education, competing for better employment opportunities and contributing towards their families and society’s betterment, hence enjoying their life.

Improved health behaviors and ensured access to primary health care package including the nutrition as an important component of primary health care services will not only reduce the suffering at individual level but will also reduce the cost of treatment. In the end, investment in treatment of complicated cases will be decreased and would allow planning for the development projects. It is difficult to put these benefits in figures, but their significance cannot be overlooked.

3.2.2.1 Causal Pathway of Malnutrition Casual pathway for Malnutrition clearly shows linkages between health and nutrition. As poor health and insufficient health, surfaces are the main contributor towards increasing the malnutrition Burdon.

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Figure 3.1: Health sector specific area of interventions mapped on the causal pathway of malnutrition

3.2.2.2 Care for Mothers and Children Adequate nutrition influences the health status of women and children to a great extent. The prevalence of anemia is significantly high amongst pregnant women; this coupled with low caloric intake during pregnancy has a negative impact on the growth of the fetus, resulting in nearly 28% of births being low weight. Women and children in Punjab also suffer from high rates of deficiencies in essential

Page 30 vitamins and minerals. The MMR for Punjab (227 per 100,000 live births11) is lower as compared to other regions of the country; however, it is still high when compared with neighboring countries of South Asia. The High TFR and MMR in the province are also indicative of the fact that the experience of pregnancy and other reproductive health related aspects among women in Punjab predispose them to a high risk of morbidity and mortality. This data reflect the abysmal conditions of Nutrition among the more vulnerable segments of the population that include the women and children of the province. This snapshot of Nutritional status indicates that Punjab is far from achieving the health related MDG targets. Such nutrition indicators on the part of the provincial health department also warrant a comprehensive and effective plan of action on a war footing, to improve the existing deplorable health & nutrition conditions and indicators for the women and children. Moreover the nutrition indicators could be improved only by adopting integrated primary health care approach as all indicators are interlinked with each other. Health sector alone may not be able to achieve MDGs but its prime importance and role in multi-sectoral approach cannot be overlooked Nutrition Specific

3.2.3 Objectives Following are nutrition Specific Strategic objectives of health sectors By the end of 2020:

. To develop Policy framework to create an enabling environment for mainstreaming Nutrition in Sector & improving multi-Sectoral coordination mechanisms by the year 2015

. To develop nutrition communication strategy and development of IEC material for other sectors by December, 2015

. To reduce 50% micronutrient deficiencies among maternal Infant & young Child (MIYC) micronutrient status (Vitamin A, Iodine, Iron) improved from an existing baseline (NNS 2011) by 2020

. TO 20% reduced in prevalence of stunting among children under -5 Years

. To reduce acute malnutrition from 15% to 9% by 2020

. To 50% reduce prevalence of underweight among children under-5 Years

. To 50% reduce low birth weight babies (<2,500 grams)

. To train 80% of Health Care providers on Nutrition

11 The Pakistan Demographic and Health Survey 2006-07

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3.2.4 Intervention framework 3.2.4.1 Strategy 1: Mainstreaming Nutrition in Health Integration of nutrition services into routine healthcare system is being experimented globally, although the patterns of integration and the issues related to the integration process. Mainstreaming nutrition in regular channels of the Directorate General of Health Services can address the malnutrition issues directly.

Apart from current initiatives, routine health system of the province lacks nutrition lens. Proposal for integrated services is a way forward not only to continue existing interventions through an integrated approach, but also to expand their scope and introduce new nutrition interventions. Currently the department of health is initiating integrated nutrition services approach into primary health care as well as a tertiary health care system through a PC1 in selected target districts with the aim to expand into all over the province. However, in order to harmonize the system in all over the province following strategies are recommended to be initiated on war footing basis.

INTERVENTION MATRIX Nature of Intervention

Impact on Strategy Objective Strategy Action(s) Nutrition

specific

sensitive

Nutrition Nutrition Nutrition To develop Policy 1.1 Develop and promulgate rules for Development, framework to implementation of Breast feeding √ -- promulgate and create an enabling Act 2009 implementation 1.2 Policy decision to integrate environment for of nutrition nutrition as part of EPHS and mainstreaming √ -- sensitive revision of JDs of HCPs & SHNS Nutrition in Sector accordingly policies will & improving 1.3 To take up with PFA and other ultimately lead multi-Sectoral stakeholders regarding to uptake of coordination development of, mandatory nutrition √ -- mechanisms by legislation on wheat flour indicators fortification with iron and folic acid, the year 2015 salt iodization 1.4 Policy to institutionalize Gender Sensitive and pro poor approach in √ -- all health plans ( PC1s) 1.5 Advocacy with BISP to convert its √ -- cash transfer scheme into

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conditional cash transfer To develop 1.6 Develop consensus among Impact on lives nutrition stakeholders of each sector in of women and √ -- communication communication framework by children by strategy and December, 2014 sensitizing them development of 1.7 Develop linkages and provide to adopt IEC material for support to other sectors in positive health √ -- other sectors by implementation of communication behavior December , 2015 strategy and training of their staff. 1.8 Create awareness among the community on use of nutritious √ -- food, healthy dietary habits, hygiene and health

3.2.4.2 Strategy 2: Equitable access to Nutrition services to poor and marginalized people Nutrition Program Punjab is currently working in seven target districts of Punjab (D.G. Khan, RajanPur, Muzaffargarh, Layyah, Mianwali, Rahim Yar Khan, Bhakkar). The Punjab Nutrition Program is modified version of CMAM (Community based treatment of acute malnutrition) as SAM (Severe Acute Malnourished children) are treated by provision of RUTF (Ready to use therapeutic food).

To address micronutrient deficiencies, MMS (multi-micro nutrient supplementation) is proposed intervention to be provided to MAM children and PLWs, in addition to nutritional counseling. Currently the high default rate in the OTP (Outpatient therapeutic program) is a challenge in the treatment of SAM children. Extended health house is another intervention proposed to reduce the default rate & maximize the SAM treatment coverage. In extended health houses, SAM child will be provided follow-up visits services. SAM child is expected to visit the facility after every 7 days, while in this approach LHW will examine and provide RUTF at home during follow up visits and child will visit the facility after every 14 days.

Community Health workers (SHNS, LHWs, CMWs) are proposed to be trained on IYCF & Basic Nutrition in order to provide all communities based services to address malnutrition that include, Screening, Referral, Follow-up, support in breastfeeding, all components of IYCF & nutrition counseling. Health care providers are also proposed to be trained on facility level treatment protocols of malnutrition in addition to the same IYCF & Basic Nutrition.

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INTERVENTION MATRIX

Nature of Intervention

Impact on Strategic Objective Strategy Action(s) Nutrition

specific

sensitive

Nutrition Nutrition Nutrition 80% of children 2.1 Establish nutrition treatment centers Early detection with SAM (OTPs) for SAM children from 80 to 930 and treatment of -- √ accessing services by the year 2017 wasting will on Severe Acute ultimately reduce Malnutrition stunting. (SAM) management as per National 2.2 Establish nutrition treatment centers guidelines, (SC) for SAM children with complication -- √ especially in the from 8 to 36 by the year 2017 most affected districts by 2020

Maternal Infant & 2.3 Enforcement mechanism of salt By addressing young Child iodization developed and implemented √ -- Micronutrient (MIYC) by 2015 deficiencies stunting can be micronutrient 2.4 Ensure quality of iodized salt by prevented. status (Vitamin A, strengthening and up gradation of √ -- existing lab system by 2015 Iodine, Iron) improved by 50% 2.5 Advocate with PFA for effective implementation regarding fortification from existing √ -- of oil & Ghee with vit A & D by 2014 baseline (NNS 2011) by 2020 2.6 Assessment of existing mechanism of provision of Vit A biannually with NIDs by √ -- 2014 2.7 Increase in coverage of Vit A from 73% to -- 95% during NIDs by 2016 √ 2.8 Conduct research to assess absorption and storage of iron. √ -- 2.9 Research on compliance on uptake of iron √ -- 2.10 Provision of iron folic acid to PLW and adolescent girls through community -- √ health workers

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2.11 Exploring & establishing protocols for nutrition screening of adolescent girl -- √

2.112.12 Promote and provide deworming tablets to children and -- √ adolescent girls. 2.122.13 Provision of iron syrup and tablets in all health facilities -- √ 2.132.14 Ensure develop and enforce of flour fortification law by 2014 √ -- 2.142.15 Demand Generation of fortified foods through Lady Health √ Workers Reduction in low 2.152.16 Promote healthy timing and Low birth weight birth weight spacing of pregnancy √ -- babies are more babies by 50% of 2.162.17 Increase coverage of ANC by prone towards existing baseline health care providers √ -- malnutrition and (NNS 2011) by infections 2020 by 2.172.18 Provision of calcium and -- √ Improving vitamin D supplements to PLW maternal health 2.182.19 Counseling of pregnant women to take one extra meal and food √ -- diversity in accordance with the food pyramid Reduce prevalence 2.192.20 Increase in early initiation Reduction in of stunting among within one hour from 15% to 60%. -- √ stunting is the children of under 2.202.21 Increase exclusive main goal of the five years from breastfeeding from 22% to 50% -- √ nutrition strategy 39% to 27% ( 2% to decrease reduction annually 2.212.22 Increase the number of malnutrition. by 2020 children fed in accordance with all three IYCF practices (breast milk consumption, -- √ timely introduction of solid foods, food diversity, frequency and consistency of weaning food.) 2.222.23 %age of mothers aware of at least two benefits of exclusive √ -- breastfeeding. 2.232.24 Percentage of mothers aware of all components of IYCF √ -- practices. 2.242.25 %age of mothers able to identify at least two signs of childhood √ -- illness (e.g. Pneumonia) Reduction in acute 2.252.26 Increase in coverage of fully Timely malnutrition from immunized children from 34.6% to 90%. √ -- identification and

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15% to 9% by 2020 2.262.27 Establishment of nutrition treatment of treatment sites at 30% BHUs and all -- √ wasting/acute RHCs of Province malnutrition 2.272.28 Establishment of prevent stunting. Stabilization Centers (SCs) in all DHQs & -- √ Teaching Hospitals.

2.282.29 Increase in percentage of identifying SAM children enrolled for -- √ treatment at nutrition site. 2.292.30 Increase percentage of registered children successfully treated for severe acute malnutrition, according √ -- to national guideline protocols. 2.302.31 Provision of MMS sachet to 60% of identified MAM children. -- √ 2.312.32 Increase in percentage of children suffering from diarrhea treated -- √ with ORS & Zinc. 2.322.33 Develop facility for local production of RUTF for MAM √ children.nutritional products like RUTF, and supplementray food at local level 2.34 Explore and establish appropriate protocols for the treatment of MAM -- √ keeping the local context in mind.

3.2.4.3 Strategy 3: Strengthening capacity of Provincial and local governments on nutrition to provide basic services in an inclusive and equitable manner

The above described nutrition services are quite new to the department of health, and there is an intense need to build capacity of the existing system as well as health care providers for quality provision of nutrition services. The Punjab Policy guidance note on Nutrition shows that there is a strong association between factors such as poverty and women’s education and malnutrition. Special efforts are thus needed to reach the poorest households and the communication for behavior change needs to be designed in a way to effectively communicate with illiterate and less educated mothers.

INTERVENTION MATRIX

Nature of Impact on Strategic Objective Strategy Action(s) Intervention Nutrition

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specific

sensitive

Nutrition Nutrition Nutrition 80% of Health 3.1 Development of training modules for Well-trained Care providers different cadres √ -- professionals trained on can identify Nutrition malnutrition 3.2 Trainings of Provincial master trainers √ -- timely and provide quality services in order 3.3 Trainings of Community health workers and health care providers on √ -- to minimize the Nutrition complications.

3.3 WASH 3.3.1 Overview of the sector

By 1978 Public Health Engineering Department (PHED) was finally evolved and then placed under the umbrella of H&PP. However, very soon this sector was also renamed called “Housing Physical & Environmental Planning” (HP & EP) in 1978 plus attached this was “Environmental Protection Agency” (EPA). In 1996, EPA was detached and HP& EP was given another name “Housing, Urban Development & Public Health Engineering Department (HUD & PHED)” and consist of the following sectors: Punjab Housing and Town Planning Agency (PHATA); Public Health Engineering Department (PHED); Lahore Development Authority (LDA); Rawalpindi Development Authority (RDA); Gujranwala Development Authority (GDA); Faisalabad Development Authority (FDA); Multan Development Authority (MDA); Water and Sanitation Agency, Lahore; Water and Sanitation Agency, Rawalpindi; Water and Sanitation Agency, Gujranwala; Water and Sanitation Agency, Faisalabad; Water and Sanitation Agency, Multan; Traffic Engineering and Transport Planning Agency (TEPA), Lahore; Parks & Horticulture Authority (PHA), Lahore; Parks & Horticulture Agency (PHA), Faisalabad; Parks & Horticulture Authority (PHA), Multan; Improvement Trusts (Murree & Sargodha).

3.3.1.1 Public Health & engineering department (PHED)

The main objective of “PHED” is to improve quality of life of the people of Punjab through the provision of “Safe Drinking Water” in areas like Brackish, Barani (Fig. 1) and areas where ground water is polluted or contaminated or else inappropriate for drinking purposes. Similarly PHED aimed to provide clean

Page 37 atmosphere “Pollution Free Environment” through improving Sewerage / Drainage Schemes and Construction of Sewage Treatment Plants to meet MDGs).

3.3.1.2 Achievements of Public Health & Engineering Department

Govt. of Punjab sectoral policy aimed to achieve MDGs within due time to provide safe Water Supply & Sanitation facilities as appropriate. PHED have allocated and provided enough financial resources asunder.

Population Coverage (%) MDG’s Projected Year of Description 2006- 2007- 2008- 2009- 2010- 2011- Targets Reaching MDG 07 08 09 10 11 12 2015 in % Urban Water 66.2 71.9 75.5 83 85 87 2009-10 80 Supply Rural Water 30.8 32.7 36.1 38 45 48 2020-21 65 Supply Urban Sewerage/ 68.5 72.0 76.0 79 83 85 2010-11 82 Drainage Rural Sewerage/ 41.3 43.8 48.6 50 53 56 2015-16 70 Drainage

3.3.2 Potential role in nutrition improvement, engagement and role within the multisectoral framework

The one of the main objectives of the sector is achieving MDG7, which is broadly defined by UN, covering environmental policy, preservation of biodiversity, access to water and sanitation and urban development. The target to measure MDG7 is” Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation”.

Progress in provision of safe drinking water and sustainable sanitation services is imperative as these conditions have a direct impact on targets in other MDGs goals. The effectiveness of preventive health measures and risk of communicable and waterborne diseases is dependent on the quality water and sanitation services provided to the population. Enrolment rates are also affected by the lack of water and sanitation facilities in schools, thereby having a major impact on the achievement of education indicators as well.

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Poor environment (unsafe drinking water and poor sanitation and hygiene, or WASH), the underlying determinants of malnutrition, often lead to increases in diarrheal disease, a leading cause of child death in Pakistan, which decreases the absorption of nutrients consumed. Accordingly, even when food consumption is sufficient, such bacterial, infection can lead to malnutrition in children12. Additionally, open defecation, improper sanitation facilities and unsanitary waste disposal contaminate food in the household as well as food production.

While a large majority of households in Punjab utilizes piped water or water from a tube well or bore well for drinking, (88.9%), it is important to note that there are numerous opportunities for pathogens to make their way into the water prior to ingestion, during water collection, transport, storage and/or transfer to drinking vessels. The Punjab Municipal Water Act has been drafted and should reduce the misuse of ground water. Nearly 22% (PLSM 2011) of households do not have access to hygienic sanitary facilities. In addition, while hand washing after defecation and before the preparation of a meal (99.0% and 97.4%, respectively) is substantially higher than that in many developing countries, soap is available only in an estimated 77% of Punjabi households. The likelihood of women being free of anemia in Punjab is twice as high where toilet facilities are available at home (73% vs. 36 %.)

Odds of stunting at 24 months of age increase by a factor of 1.05 with each episode of diarrhoea (Lancet 2008, data pooled from 9 studies)

Improvements in sanitation were associated with increases in height ranging from 0.8cm to 1.9cm (Esrey 1996, multi-country analysis, sample size almost 17.000)

Children with worst conditions for water source, water storage and sanitation were 1·0 cm shorter in stature (Lancet 2004, Peru)

“The total number of deaths caused directly and indirectly by malnutrition induced by unsafe water, inadequate sanitation and insufficient hygiene is 860,000 deaths per year in children under five years of age” (WHO 2008)

Figure 3.2: Linkages with Nutrition Indicators

12 WHO, 2008

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Figure 3.3: WHO pathway linking WASH & malnutrition

3.3.3 Overall Sectoral objectives . To increase access of to “improved drinking water” or non-surface water: MDG 7 . To enhance Rural Population Coverage (Barani, Brackish and Contaminated Areas) . Improving quality control of water (by providing Water Testing Facilities and through provision of Water Filtration Plants) . To enhance sanitation, environmental sustainability and open defecation free (ODF) environment . To make dysfunctionally Rural Water Supply Schemes functional and to replace old water supply pipelines for eradication of gastroenteritis in 15 cities of Punjab . Increase public awareness about water safety, safe hygiene practices, and water conservation

3.3.4 Intervention framework

3.3.4.1 Strategy 1: Equitable access to safe & clean water

Background/Rationale: While recognizing that access to safe drinking water is the basic human right of every citizen and that it is the responsibility of the state to ensure its provision to all citizens, Provincial government is committed to provision of adequate quantity of safe drinking water to the entire population at an affordable cost and in an equitable, efficient and sustainable manner.

While Government of Punjab (GoPb) to fulfill its commitments and responsibilities in achieving MDGs has developed and approved Punjab Drinking Water Policy in May 2011. Inadequate and unsafe water,

Page 40 poor sanitation, and unsafe hygiene practices are the main causes of diarrhea, which results in at least 1.9 million under-5 child deaths annually.

Around 80% of all diseases are attributed to water and sanitation related causes. Inadequate disposal of human excreta and personal hygiene are associated with a range of diseases including polio, diarrheal diseases, jaundice, typhoid, malaria, dengue viral fever and cholera. Sanitation is both a public and a private good, and that individual hygiene behavior can affect the whole community if your neighbors defecate in the open, then your children risk excreta-related diseases even when the members of your own household use a sanitary toilet, wash their hands, and practice good hygiene. Factors related to water, sanitation and hygiene affect children’s right to education in many ways. In an atmosphere of poor health, children are unable to fulfill their education potential for example; 400 million school-aged children a year are infected by intestinal worms, which, research shows, sap their learning abilities.

Figure 3.4: Sources of Drinking water in Punjab source from where they put

INTERVENTION MATRIX

Nature of Strategy Intervention Impact on Strategy Action(s) Objective Nutrition Nutrition nutrition Sensitive Specific To increase the 1.1 Provide drinking water under Access to safe access to water in Changa Paani Programme through drinking water √ -- Punjab by early implementation and will ultimately 2020and reduce completion of project in all districts reduce the risk

Page 41 the arduous of Punjab by 2020 (Implementation of water-borne labour of women level) depends upon approval and diseases and in carrying it in all avaibility of resouces lead to uptake vulnerable 1.2 Provide clean drinking water by of nutrition communities by installing filtration plants under Saaf indicators 2020 Paani Programme through early implementation and completion of √ -- Formatted: Adjust space between Latin and Asian text, project by 2020 (Implementation Adjust space between Asian text and numbers level) consultation with saaf pani company 1.3 Provide hand pumps in areas where Formatted: Indent: Left: 0" the provision of tap water facility is currently not feasible √ -- (Implementation Level) subject to provision of fincial resouces 1.4 Rehabilitation of dysfunctional rural Formatted: Indent: Left: 0" water supply schemes 172 (2015)schemes are arpproved and √ -- rest are subjected to approval and finicial (Implementation Level)

1.5 Ensure availability of safe drinking Formatted: Indent: Left: 0" water by installation of small water filtration plants in schools -- √ (Implementation Level) mandare of school dept To increase access 1.6 Ensure scaling and sustain Access to safe to clean/safe functioning of installed water √ -- drinking water drinking water in filtration plants saaf pani company will ultimately all vulnerable 1.7 Initiate water treatment projects reduce the risk communities with special awareness campaign at of water-borne punjab by 2020 household and community level by diseases and distribution of chlorinating tablets √ -- lead to uptake etc. subject to availability to of nutrition functional resources or (initiate a indicators project) 1.8 Establish water quality testing facilities and regular sampling of water from various water projects starting from water source to √ -- household level water qualiy testing lab (mobility) strengthing of water quality labs and ensuring regular provision of water testing servicing 1.9 Introduce community based effective monitoring mechanism √ -- comprising elected UC representatives, school council

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members and CBOs for provision of safe drinking water mechanism under process 1.10 Plan and introduce proper operation and maintenance mechanism for √ -- keeping the facilities functional To reduce misuse 1.11 Increase water conservation with and depletion of increased and improved water √ -- ground water storage capacity

1.12 Launch a campaign for awareness to √ -- reduce water wastage and misuse

3.3.4.2 Strategy 2: Promote best practices & behavioral change regarding hygiene practices

Background/Rationale: Wash is an important prerequisite for ensuring the right to basic education with a water-related disease. Hand washing practices reduce the risk of infectious diseases associated with microbial infections. Hand washing practices with soap are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings.

90 80 76.8 70 60 50 40 30 19.4

Percent Household 20 10 2.5 0 Water + Soap Available Only Water AvailableBoth Water + Soap not available

Figure 3.5: Percentage of house hold with availability of water & soap13

Proposed hygiene promotion actions should aim to encourage healthy behavior changes among target

13 MICS 2011

Page 43 communities. Interventions will follow a community driven approach to hygiene promotion and focus on personal hygiene promotion relating to hand washing (at critical times), latrine usage, water transport, storage, and consumption as well as infrastructure maintenance and management related to latrines and water points. The community workers should equip with basic skills on community participation, awareness raising methodologies and basic prevention and control of water and sanitation related infections. Likely training topics will include personal hygiene, latrine use & maintenance, hand washing, safe water use, diarrheal disease prevention and management, ORS, and malaria prevention and treatment.

Hygiene promotion should aim to motivate beneficiaries to use latrines by explaining the health benefits they are going to gain through such practices and in connection to other healthy behaviors and maintaining clean latrines. Messages need to be delivered in a way that they can be readily understood by target group and language, design of IEC materials for illiterate people, gender considerations, cultural norms etc.

INTERVENTION MATRIX

Nature of Strategy Intervention Impact on Strategy Action(s) Objective Nutrition Nutrition nutrition Sensitive Specific To Launch 2.1 Conduct awareness campaigns an Access to campaign and community sessions through educational awareness integration approach by community materials and programs to workers like SH&NS, LHW, CMW, awareness promote hygiene agriculture field assistant, school √ -- about practices teachers, civil society, union council, sanitation and CBOs, KHATTEEB of local MASAJIDS hygiene (AUQAF Dept.) and local media practices (Policy Level) (especially 2.2 Celebrate the Mother & Child Week, among Global Hand Washing Day, World females) Toilet Day and World Water Day, √ -- will ultimately Anti-Dengue Day to promote hygiene reduce the practices (Implementation Level) health risk

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2.3 Develop IEC material on nutrition containing guidelines of health and √ -- hygiene practices (Policy Level) 2.4 Creative inclusion of sanitation, hygiene and preventive approaches adressing malnutrition in school curriculum in coordination with the √ -- School Education Department and Punjab Curriculum Authority (Policy Level)

3.3.4.3 Strategy 3: Equitable access to Total Sanitation Services

Background/Rationale: UN declared that access to proper sanitation services is a basic human right to improve public health and quality of life. It is widely recognized and documented that lack of access to this essential basic service is associated with adverse impact on public health and environment. The Millennium Development Goal 7 (MDG-7) assigns the signatory nations to extend access to improved basic sanitation to at least half of the un-served population by 2015 and to 100% population by 2025.

Sanitation is one of the significant hygienic means of promoting health through prevention of human contact with the hazards of wastes. “The Pakistan Approach for Total Sanitation (PATS) is towards achieving and sustaining an open defecation free environment both in rural and urban context with clear emphasis towards behavior change and social mobilization enhancing the demand side of sanitation. The approach endorses the use of a number of branded total sanitation models, having a key role of communities, which include:”

 Community Led Total Sanitation  School Led Total Sanitation  Component Sharing  Sanitation Marketing  Disaster Response

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The literature review revealed that every model has proved its own success in different context. The above models may be adopted by the provincial and local governments in accordance to suitability of their local context. The integrated approach of “Total Sanitation” which is comprised of sanitation demand creation interventions, sustaining demand through supply side interventions, health hygiene promotion intervention, and drainage & water treatment interventions of “Component Sharing Model.”

Integrated Total Sanitation Model

Participatory Health & Attaining 100 % Adequate Demand Creation Sustaining the Demand Hygiene Promotion Drainage, Waste water Interventions for ODF through Supply Side Promotion treatment and solid waste Communities Interventions collection disposal through Component Sharing CLTF, SLTS Sanitation Marketing 1. Launching a behavior 1. Technical training of 1. IEC material on active 1. Waste water disposal in change communication masons health and hygiene key a hygienic way including campaign based on 2. Construction of low cost massages small sewerage treatment baseline information environment friendly 2. Mass Media/ units, oxidation ponds etc regarding Knowledge latrines for demonstration Communication Campaign 2. Underground/ covered Attitude and Practices & of technical solutions 3. IEC campaigns drainage system Formative Research 3. Piloting concept of promoting low-cost 3. Solid waste collection findings sanitation mart appropriate and informed and disposal system 2. Finalization and Trainings of sanitation sanitation solutions triggering of PRA tools for entrepreneur and sanitation mobilizing communities enterprises through Community 4. Facilitation to develop Activists/ sanitation linkages with the Ambassadors(Adapting a microfinance institutions cascading model) 5. Incentivizing outcomes

Figure 3.6: Integrated Total Sanitation Model sources

This integrated approach will have the chance to produce sustained results. Before the implementation strategy of “Integrated Model” is delineated, the existing situation is analyzed.

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Figure3.7: Statistics about type of Toilets used in Punjab source

The above picture shows overall provincial status of toilets used in Province. Further break up of data, into rural & urban and district wise status shows big differential. According to Multiple Indicator Survey (MICS), Punjab (2011), 32% of the rural population defecates in open environment, which puts a significant challenge for Government of Punjab to create an open defecation free environment in the Province.

LG&CDD has the legal role and mandate of community development in order to improve water supply, sanitation, hygiene including rural communities, which are more vulnerable and are excluded so far water, sanitation, and hygiene services are concerned.

Further analysis of MICS 2011 reveals that 61.8% people of Rajanpur, 51.2% of Muzaffargarh, 50.3% of DG Khan, 48.4% of Chinniot and 44.2% of Jhang defecates in open environment as compared to provincial average which is 22%.

INTERVENTION MATRIX

Strategy Strategy Action(s) Nutrition Level Impact on

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Objective Nutrition Nutrition nutrition Sensitive Specific To decrease ODF 3.1 Scaling up PATS in Punjab to have ODF Clean 23 22% to 10% in villages Conduct pilot project of PATS environment province of in high risks districts (Rajanpur, will be helpful Punjab by 2020 Muzaffargarh, DG Khan, Chinniot and √ -- in decreasing 23-18% 2015 Jhang) by 2015 RYK, Layyah, Chakwal, health risk Vehari, Bahawalpur, DGK (PATS factors and project are running ) reduce the Installation of 3.2 Install small scale sewerage treatment malnutrition sewerage units especially with prioritization in burden √ -- treatment units those large villages (Implementation by 2020 Level) resources Installation of 3.3 Improve solid waste management solid waste schemes and mechanism through management establishment of solid waste plants by 2020 management plants in all over the √ -- Punjab to treat agriculture, sewerage and domestic solid waste (Implementation Level) local govt 3.4 Install composting plants in large cities to manufacture compost √ -- fertilizers from this waste (Implementation Level)local govt To ensure 3.5 Provide WASH facilities, like soap and availability of toilets, in schools in collaboration facilities of with School Education Department quality hygiene (Policy Level) Schoold dept and sanitation practices at √ -- 100% schools by 2019 (especially in girls school)

3.3.4.4 Strategy 4: Development and implementation of Policies and Strategies Background/Rationale: Government of Punjab (GoPb) to fulfill its commitments and responsibilities in achieving MDGs has developed and approved Punjab Drinking Water Policy in May 2011. Recognizing the significance of sanitation, GoPb is formulating Sanitation Policy for the province. The Policy may provide a broad framework and policy guidelines to provincial institutions, District Governments and

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Tehsil Municipal Administrations in order to improve sanitation coverage and services in the province. The Policy document may envisage a structure for addressing the institutional, administrative, legal, regulatory, fiscal, social & environmental issues and challenges faced by the sector actors.

INTERVENTION MATRIX

Nutrition Level Strategy Impact on Strategy Action(s) Nutrition Nutrition Objective nutrition Sensitive Specific Formulation of 4.1 Approval and dissemination of Sanitation and nutrition and Punjab Drinking Water Strategy hygiene √ -- gender sensitive by 2015 (Policy Level)inprocess will ultimately policies & draft complter reduce the risk of strategies of 4.2 Approval and dissemination water-borne WASH sector Punjab Sanitation Policy and diseases and lead Strategy by 2015 (Policy √ -- to uptake of Level)CM approved and move nutrition to canbient division indicators 4.3 Approval and dissemination Behavior Change Communication Strategy by √ -- 2015 (Policy Level) draft completed and comments are incorporating 4.4 Approval, dissemination & implementation of Punjab Municipal Water Act 2013 √ -- (Policy Level)inprocess of approval move to CM

3.4 FOOD

3.4.1 Overview of the sector

Punjab economy is mainly agricultural and province is playing a leading role in agricultural production. It contributes about 68% to the annual food grain production in the country. 51 million acres of land are cultivated and another 9.05 million acres land is lying as cultivable waste in different parts of the province (Govt. Punjab). Although, Punjab is predominantly an agricultural province yet 60%14 of its

14 NNS-Pak 2011

Page 49 households are food insecure (higher than the countrywide figure of 58 %). Of these, 18% are classified as food “insecure with hunger,” and 11.5% are food insecure with severe hunger.

The number of surplus food producing districts in Punjab decreased from 21 to 14, while the food deficit districts increased from 7 to 14 between the years 2003-04 to 2008-09. During the same time period, the number of districts with “low” to “extremely low” access to food increased from 35% to 53%15 .Part of this deterioration in Punjab has been the result of an economic and industrial crisis relating to power shortages, increased production costs and non-significant growth in household income.

3.4.2 Punjab Food Department

This department was initially developed to distribute important food items, but current government decided to limit its function to procuring what at support price and supply to the flour mills at subsidized rates and subsidy may be withdrawn gradually within the next few years. Unfortunately, price of ATTA became a very sensitive issue and rulers could not gather the political will to withdraw subsidy.

3.4.2.1 Potential role in nutrition improvement, engagement and role within the Multisectoral framework

Food Department is safeguarding the interests of growers through purchase of wheat on support price fixed by the Government, maintenance of strategic reserves as well as improving the quality of life of citizens of Punjab by providing them quality and nutritious flour at reasonable price. Under the Food Stuff (Control) Act, 1958, Food Department is responsible for regulating the business of food grains, which include purchases, storage, sales, transfer, and milling. Furthermore, Food Department is responsible for procurement of wheat for issuance to the mills, to act as government agents to provide a wheat purchase window to the farmers at support price.

3.4.2.2 Food Security

The concept of food security has emerged and expanded over time to integrate a wide range of food- related issues and reflects the complexity of the role of food in human society (Cook, 2006). The Rome Declaration on World Food Security in 1996 defined food security as a situation where ‘All people at all times, have physical and economic access to sufficient, safe and nutritious foods to meet their dietary needs and food preferences for an active healthy life’ (World Food Summit, 1996).

15 SDPL et al,2009

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Food insecurity, the limited or uncertain availability of or access to nutritionally adequate and safe foods throughout the year, is associated with malnutrition as a key underlying determinant of overall food intake in the household, depicted in a causal framework of malnutrition. Food insecurity may also be a more sensitive measure of food issues experienced by low-income families than household income alone, especially the psychological and social ramifications of a lack of food.16

Wheat is the staple diet of Pakistan. There is major link b/w poverty and consumption pattern of wheat. The poorest of the poor obtain the highest proportion of energy and nutrients from the wheat as flour based CHAPPATI is the major food item or, at times, the only food item of their daily meals. Therefore, focusing on the production of wheat, its proper storage, ensuring its nutrient quality and controlling price will certainly help in improving food security, especially in population, which is food insecure with severe hunger. The production of food including wheat rests with Agriculture sector, i.e. Agriculture, Livestock and Fisheries Departments, however, the food after harvesting, picking, catching, slaughtering etc. comes under the domain of Food Department. The Food Department is therefore key provincial department to ensure safe, wholesome, good quality and nutritious food at a reasonable price in consumer table, thus having a major role in food security in the province. This strategic plan has taken care of this significant issue to address malnutrition. Additionally, the micronutrient fortification of food products like flour, edible oil, ghee and salt, and targeted food subsidies will be the key interventions of this sector, helping to tackle the ever-escalating burden of malnutrition.

Figure 3.8: Relevance of food security & Stunting17

16 Frangillio, 1999 17 Nutrition Policy Guidance Notes, Punjab 2013

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3.4.3 Overall Sectoral objectives

The objective of the Food Sector Plan:

. Improved quality of common mans diet by providing them quality wheat flour (staple diet) at affordable prices ( with special focus to maximum utilization of micronutrients) . Ensure the food security in Punjab province to maximum population

3.4.3.1 Nutrition specific objectives: related to nutrition specific strategic plan

. Ensure food security related to wheat and wheat products . Transportation of wheat from surplus to deficit regions . Provision of quality of wheat by protecting it from insect pests and other hazards . Targeted food support programs . Fortification of wheat flour with micronutrients

3.4.4 Punjab Food Authority

The Government of Punjab has taken an initiative to establish Punjab Food Authority under the "Punjab Food Authority Act 2011" to ensure availability of safe and wholesome food for human consumption. The basic purpose is to lay out standards for food articles and to regulate their manufacturing, storage, distribution, sale and import. Its main function include formulation of standards, procedures, processes, and guidelines in relation to any aspect of food including food business, food labeling, food additives, and specify appropriate enforcement systems; Specify procedures and guidelines for setting up and accreditation of food laboratories; Formulate method of sampling, analysis of samples and reporting of results; Specify licensing, prohibition orders, recall procedures, improvement notices or prosecution; Provide scientific advice and technical support to the Government in matters related to food; Collect and analyze relevant scientific and technical data relating to food; Establish a system of network of food operators and consumers to facilitate food safety and quality control; Organize training programmes in food safety and standards; Promote general awareness as to food safety and standards; Levy fee for registration, licensing and other services; certify food for export.

3.4.4.1 Potential role in nutrition improvement:

. Ensuring food safety and quality . Collect and analyze relevant scientific and technical data relating to food safety

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. Standardization including legislation on mandatory fortification of food products i.e. edible oil, ghee, flour and salt.

3.4.5 Overall Objectives

. To ensure availability of safe and wholesome food for human consumption . To enhance quality perspective of the food products

3.4.5.1 Nutrition specific objectives: related to the Nutrition Specific Strategic Plan

. Take measures to enhance food safety and quality in the Province . Ensure that the food is safe for human consumption at all stages of food supply chain . Improving the hygienic system and environment of food production / processing . Action against food business operators selling, storing, marketing, etc. adulterated, injurious, sub-standard, contaminated or unsafe food or food products . Ensuring the effective food control system, including the implementation of voluntary and mandatory food fortification

3.4.6 Intervention framework

Multi-sectoral efforts are required to eradicate malnutrition and improve health of citizens of the province. Reduction in nutrient deficiency and malnutrition are likely to be multi-sectoral task, but clarity on sectoral responsibilities is an essence. The proposed strategic actions by the food sector involving the Food Department and Punjab Food Authority to address malnutrition through Multi- Sectoral Nutrition Plan (MSNP) in Punjab is as under:

3.4.6.1 Strategy 1: Physical access to food throughout the year for all targeted groups

Background and Rationale: Food security emerged as a priority issue during the Food price hike in 2007–08 and most recently in 2012-13 and with the realization that global food prices likely to remain either high and/or frequently fluctuate, with strong adverse implications on food security. There is a major link b/w poverty and consumption pattern; the poorest of the poor obtain the highest proportion of energy and nutrients from the wheat as wheat based chappati are the major food item or, at times, the only food item of their daily meals. Therefore, focusing on the production of wheat, its proper storage, ensuring its nutrient quality and controlling price will certainly help in improving food security, especially in population, which is food insecure with severe hunger. Therefore, improving the storage

Page 53 capacity and quality control mechanism of staple food (wheat) is of utmost importance, which is housed with this sector i.e. Food Department

INTERVENTION MATRIX

Nutrition Level Strategy Impact on Strategy Action(s) Objective Nutrition Nutrition nutrition Sensitive Specific

Increase in 1.1 Replace wheat storage from bag Access to food storage capacity to silos storage (Policy level) throughout the √ -- from existing year will level to 80% by improve the 2020 food security Ensure access to 1.2 Explore avenues for Public and situation and food throughout Private partnership to preserve ultimately the year and increase storage perishable commodities at their peak √ -- reduce the harvesting for year-long malnutrition availability at affordable price burden (Policy level) 1.3 Improve Food supply chain and promote the applications of modern technology and √ -- engineering to reduce post- harvest losses 1.4 Introduce and promote cold supply chain to increase the -- √ safety of high risk food i.e meat

3.4.6.2 Strategy 2: Ensure and improve food quality from farm to fork Background/Rationale: Wheat and other grains quality testing within due time is necessary because low quality food/grains pose health threats and economic losses to the farmers as well as to the consumers. Among present day challenge is to introduce a well-managed tracking system where a particular area grain is diseased or nutritionally unsuitable should be withdrawn from the market or supply chain. In this regard Interlinking/networking of different food analysis labs with each other is important and there should be skill development of analyst such as yearly training and time-to-time awareness workshop regarding field problem as well as how to eradicate them?

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INTERVENTION MATRIX

Nutrition Level Strategy Impact on Strategy Action(s) Objective Nutrition Nutrition nutrition Sensitive Specific

Strengthen lab 2.1 Up-gradation of the existing lab Up-gradation & facilities for testing of micro- establishment of facilities to nutrients in foodsflour, wheat lab will be ensure food quality & safety testing in √ -- helpful in regions, where the labs are provision of safe safety and already present but are with and nutritious quality by 2016 limited capacity or non- food and operational(Policy level) ultimately 2.2 Establishing new lab testing improve facility in regions where there is √ -- nutrition need but there are no labs indicator (policy level Level)

3.4.6.3 Strategy 3: Provision of safe food Background and Rationale: Low quality food/grains pose health threats and economic losses to the farmers as well as to the consumers. “A safe and nutritionally adequate diet is a basic individual right and an essential condition for sustainable development, especially in developing countries” (Gro Harlem Brundtland). Therefore, establishment of effective and integrated food control system throughout the province is critical for ensuring food safety. For this purpose, scaling up of Punjab Food Authority to whole of Punjab and its capacity development in terms of access to sophisticated lab facilities, availability of trained manpower in food safety, improvement and harmonization of rules, standards and regulation with international standards is of utmost important. Currently the domain of Punjab food authority is only in Lahore and is likely to extend its network from Lahore to four other divisional headquarters of Punjab i.e. Faisalabad, Gujranwala, Rawalpindi, and Multan in 2014. It is recommended to extend its network in all 36 districts of Punjab province by 2020. Moreover, purposeful action will

Page 55 need to be initiated to produce manpower capable of inspecting food and food premises by starting / scaling-up of professional programs in food safety.

INTERVENTION MATRIX

Nutrition Level Strategy Impact on Strategy Action(s) Objective Nutrition Nutrition nutrition Sensitive Specific

Strengthen and 3.1 Phase-wise extending the Improvement in expansion of Punjab Food Authority to whole food safety √ -- Punjab Food of Punjab by 201720 (Policy increase Authority to level) nutrition status improve food safety and reduce 3.2 Establishing lab facilities at disease burden district level parallel with the extension of Punjab Food Authority for safety & quality √ -- testing of food products & testing facility of micro nutrient (Policy level) Improve the food 3.3 Improving the capacity of Provision of safe safety inspection services through food ultimately management revising and harmonizing the lead to uptake of food rules with (Codex √ -- systems by nutrition Alimentarious legislation, Commission(CAC), OIE, and indicators promulgate and IPPC) (implementation Level) implement 3.4 Continuous professional Awareness to development, capacity food safety enhancement, trainings and awareness campaigns for all will reduce involved in food supply chain √ -- health risks and starting from producers to ultimately lead consumer desk to uptake of nutrition indicators

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3.5 Promoting and advising to get Certification will Food Safety Management be beneficial in Certification like HACCP, BRC, food safety and ISO-22000 etc. by food business √ -- it will also operators, targeting specifically the large industries and high will reduce risk food processors for 3 years health risks

3.6 Mandatory Food Safety Certification will Certification of large food effective in food √ -- industries in five years, medium safety and it will size in 10 years, and all food also business operation in 15 years 3.7 Roadside should be upgraded will reduce to minimum hygine standards √ -- health risks

3.4.6.4 Strategy 4: Ensure Economic Access To Food Background Rationale: Majority of the nation faces financial problem and hence pose with limited access to the food. Targeting poor group and making subsidies on wheat flour/or-other grains would have positive impact on decreasing malnutrition in the country. Similarly, production of wheat is not much satisfactory to the extent it should be and need careful consideration. Although food production on large scale is necessary however, where indicated or people with limited resources need home livestock and garden production (home scale agribusiness). Monthly cash system like BISP, Zakat and other Charity has to be properly in place for targeted groups particularly, women and children.

INTERVENTION MATRIX

Nutrition Level Impact on Strategy Objective Strategy Action(s) Nutrition Nutrition nutrition Sensitive Specific

Improve the 4.1 Targeted and conditional food Access to food at economic access to subsidies for poor instead of economical price √ -- food by subsidies generic subsidies and may be will improve the and price control linked with inflation rate by food security and regulation 2014(Policy level)

Page 57 mechanism 4.2 Putting in place the price situation and control and regulation ultimately reduce √ -- mechanism especially for staple the malnutrition food (Policy level) burden

3.4.6.5 Strategy 5: Reduce micronutrient deficiency in adolescents girls, pregnant & lactating mothers and children’s through fortification Background/Rationale: Globally 79 countries have legislation to mandatory fortification at least one major cereal grain. Of these, 78 countries fortify wheat flour, 12 countries fortify maize products, and 5 countries fortify rice. Currently 78 countries require fortification of wheat flour produced in industrial mills. All the countries fortify wheat flour with at least iron and folic acid except Australia which does not include iron, and Venezuela, the United Kingdom, and the Philippines which do not include folic acid. Additionally, seven countries fortify at least half their industrially milled wheat flour through voluntary efforts. We estimate that 31% of the world’s industrially milled wheat flour is fortified with at least iron or folic acid through these mandatory and voluntary efforts.We define mandatory as legislation that has the effect of requiring fortification of one or more type of grain with at least iron or folic acid. Most countries permit fortification. Encouraging and advising on minimal, nutrient friendly and innovative food processing techniques for qualitative and quantitative retention of vital nutrients.

INTERVENTION MATRIX

Nutrition Level Impact on Strategy Objective Strategy Action(s) Nutrition Nutrition nutrition Sensitive Specific

Develop 5.1 Create awareness on benefits Promulgation Promulgate and for use of fortified flour, salt √ -- and legislation implement, and edible oil (Policy level) of fortification legislation eventually lead regarding the 5.2 Legislation of mandatory wheat to the uptake of fortification of flour fortification with iron and food by 2014 nutrition folic acid by 2014 for flour √ -- indicators milling industry and in five years in flour grinding industry (chakki flour) (policy level)

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5.3 Develop supplu chain mechanisim for micro feeders √ -- and premix.

5.35.4 Start enforcement of mandatory legislation after one √ -- year of enactment.

5.45.5 Develop mechanism for pass through of fortification cost to √ -- consumer.

5.55.6 Establish market based, sustainable, suppy chain √ mechanism for premix and microfeeders for flour millers.

5.7 Legislation on mandatory universal salt iodization by December 2016 4 (policy level) √ -- Formatted: Font: Not Bold, Not Italic

5.6 (legislation target is 2014, Formatted: Indent: Left: 0.07", Space After: 0 pt, Line implementation target is 2016) spacing: single, No bullets or numbering 5.75.8 Devise robust implementation strategy to ensure Vitamin A and Vitamin -- √ D fortification in ghee and oil(Implementation level)

3.5 SOCIAL PROTECTION 3.5.1 Overview of the sector

Social Welfare initiatives of the Punjab Government provide social welfare, protection and development that may lead to improvement in quality of life. The base of “Social Welfare” in Pakistan is “Adl-o-Ehsan and Haqooq-ul-ibad” that according to Islamic law stand affluent society and the state responsible for the welfare of the people. Similarly, the constitution of Pakistan enforces the state to ablate misery and sufferings of citizen living in the state irrespective of caste, gender, creed or race. The Secretary to Department of Social Welfare & BAIT-UL-MAAL oversees all matters. BAIT-UL-MAAL committees have

Page 59 been established at the district level to assist the council in the distribution of funds to vulnerable and needy families. To keep fairness in this sector, Punjab Social Service Board (Governor Punjab is the president of the board) was established in 1970 to enhance efficiency and departmental coordination within welfare/voluntary organizations (NGOs) in the private sector. The board provides financial and technical assistance to the Voluntary Social Welfare Agencies (Registration & Control) ordinance, 1961.

Social Welfare & BAIT-UL-MAAL is chaired by “Deputy Director” at divisional level who controls and monitors ongoing Social Welfare Programmes in the public and private sector. Each Deputy Director is further assisted by Assistant Directors at District level and social welfare officers who are in control of Projects at Tehsil/sub-Tehsil level. Social protraction has tremendous role in provision of financial support for Health. Social Health Insurance provides shelter to insured people who cannot pay high treatment costs during sickness. The concept has also been adapted to newly industrialized and developing countries.

Social Protection Sector has key component departments including federal & provincial departments; Social Welfare, Bait-ul-Maal, Zakat, Women Development & Benazir Income Support Programme.

Some of the functions being performed by this sector, which reflect the objectives of its component departments

. Promote sustainable socio economic development

. Voluntary participation in community development programs for socio economic development

. Reviews and propose amendments in the existing laws

. Training & rehabilitation services for economically and socially oppressed and vulnerable groups

. Training and rehabilitation of the disabled persons

. Mass education, motivation and advocacy campaigns and NGO development for poor community

. Social and economic welfare of women

. Coordination of women development effort and gender mainstreaming

. Implementation of National Plan of Action through cash transfers and women development

. Implementation of U.N. Conventions ratified by Government of Pakistan

. Provision of social & monitory assistance programs for poor, disabled, widows, orphans, the indignant, the destitute and the sick

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. Provision of professional, medical and financial assistance to patients and addicts and their families through professional social workers, hospitals, Health Welfare Committees (Zakat), Patients Welfare Societies (NGOs) and District BAIT-UL-MAAL Committees . Welfare and poverty alleviation of poor segments of the society

Although all the departments included in social protection sector are working, may be in different ways, to provide social & financial protection to the poor segment of Pakistan but still reach only to small proportion of the >50 million poor. Furthermore, the protection being provided, although very important, seems to be insignificant to cope with the miseries of the poor. In addition to this, persistent high inflation rate, price hikes, escalating population, and growing number of people under the poverty lines are serious threat to the success the programmes of the social welfare & protection sector. The support programmes, initiated in recent past like BISP or proposed to be initiated in near future like Khidmat Card are right steps to reduce some of the miseries of the deprived segment of our population. However, such activities need to be targeted for improving food security of the households and should be linked with attainment of certain free services, like education, vaccination etc.

3.5.2 Potential role in nutrition improvement, engagement and role within the multisectoral framework One reason for importance of social protection department is that it tackles poverty and vulnerability directly, so its impacts can be immediate and very effective in order to prevent malnutrition. The causal framework of malnutrition clearly indicates the poverty as one of the significant underlying determinants. Social protection covers a wide range of instruments and objectives, covering both safety nets and so- called ‘safety ropes’ (i.e., instruments that can enhance income generation and opportunities for the poor and vulnerable). These can be seen in below figure

Social Protection at a Glance

Risk management Crop and livestock insurance Index-based weather insurance Grain reserves/Precautionary savings Contributory social insurance Income diversification Page 61

Income Gain Safety ropes Risk reduction

Food Poverty Line pricestabilization

National grain

reserves

Trade policies Social assistance Cash transfers Food subsidies Income generation School feeding Asset creation Supplementary feeding Human capital Access to services ( SHI) formation

Scalable safety nets Employment Income, Consumption Income, Right to food approach opportunities Access to land Input subsidies

Twin-track approach Conditional cash transfers Productive safety nets Public works programmes

Destitution Poverty Traps

Figure 3.9: Social Protection at a glance Source: adapted from de Janvry (pers. comm.)

3.5.3 Food Insecurity and Vulnerability

Food insecurity refers to both the inability to secure an adequate diet at present (i.e. hunger) and the risk of being unable to do so in the future. People who are already poor & have less to pay for health services are vulnerable to hunger and malnutrition because they lack the resources to meet their basic needs on a daily basis (they face chronic food insecurity). They are also highly vulnerable to even small shocks that will push them closer to destitution, starvation, even premature mortality. Timely and appropriate social protection in response to poverty-related food insecurity is closely linked to address malnutrition. People who are not poor, but now face the risk of future poverty are vulnerable to hunger

Page 62 if these risks materialize and they are inadequately protected. Vulnerability to food insecurity operates at several levels – national, household and individual – and social protection responses are extremely desired to play its role at each level. Current situation of food insecurity and vulnerability in province highlights the less focused social protection.

A classification of food insecurity can be better understood from the Amartya Sen’s’entitlement approach’, originally conceived as a tool for analyzing famines. This approach identifies four food sources, that include production (what one grows), labor (what one works for), trade (what one buys), and transfers (what one is given). And then this approach defines food insecurity as “when the sum of all food derived from these four sources is inadequate to meet minimum consumption needs at the individual, household or national level”.

The below table explains the role of the social sector in addressing different sources of insecurity.

3.5.4 Women Empowerment

Social protection efforts to generate employment and income and to protect households against the manifestations of poverty and against household shocks (e.g. Serious illness and hospitalization), can be particularly useful for addressing malnutrition, especially if interventions are targeted to women. Studies have shown that additional income tends to be spent on food and on family health when women are the recipients of the cash transfers, and that this increased spending, if the transfer is large enough, and thus it can ultimately lead to a reduction in levels of malnutrition within the household.

The Pakistan Government’s Benazir Income Support Program (BISP) is an unconditional cash transfer program that delivers Rs. 1,000 (US$11) to female beneficiaries in households with a monthly income below Rs. 6,000. In 2010, about 7% of the country’s population was benefiting from the transfers. The BISP also includes microcredit financial assistance, and is pilot testing, health and life insurance coverage and vocational skills training in different parts of the country.

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Product Transfe Labour Trade ion Food price r input public works stabilization school subsidies program feeding

crop & conditional food Livestock cash subsidies insurance transfers

unconnditio grain nal cash reserves transfers

Figure 3.10: Food entitlement gaps & social protection instruments

3.5.5 Overall sectoral objectives

To alleviate the misery of poor people, especially targeting food insecure with severe to moderate hunger, by protecting their health and providing cash benefits through various initiatives (Zakat, Charity, BISP etc.)

3.5.6 Intervention Framework

3.5.6.1 Strategy 1: Strengthen social protection sector to scale-up nutrition-sensitive interventions

Social protection sector is executing various responsibilities such as provision of income (cash) or consumption (food), protection against livelihood risks, enhancement of the social status to the socially excluded, marginalized and vulnerable community. Household food security develops the perspective that leads to individuals access to adequate food as established in international human rights law. The right to adequate food is realized when every man, woman and child, alone or in community with others, has physical and economic access at all times to adequate food or means for its procurement. The right to adequate food shall therefore not be interpreted in a narrow or restrictive sense that equates it with a minimum package of calories, proteins and other specific nutrients. The social protection sector has responsibilities to perform such actions that may be beneficial for the scaling-up of nutrition-sensitive

Page 64 interventions and adequate access to food throughout the life-cycle. The best delivery of services by social protection sector can be achieved only by strengthening the sector.

INTERVENTION MATRIX

Nature of Intervention Impact on Strategy Objective Strategy Action(s) nutrition

Nutrition Nutrition Sensitive Nutrition Specific Formulation and 1.1 Establishment of Social Scaling-up social implementation of protection authority (Policy protection nutrition & gender level) √ -- sector will be sensitive policies helpful in and strategies of economic social protection 1.2 Prioritize the preparing the access as well as sector existing policies/legislation of various nutrition- Social Protection sectoral more nutrition-responsive and sensitive √ -- its effective implementation interventions (Policy level) that ultimately will help to improve nutrition

1.3 Develop nutrition specific indicators legislations about Zakat, Bait- ul-Mall, and PVTC (policy √ -- level)

1.4 Increase coordination between federation and federating units on nutrition- sensitive social protection √ -- (Policy level)

To create enabling 1.5 Develop and strengthen √ -- These strategic environment for linkage with LHWs, SH&NS, actions will

Page 65 mainstreaming teachers, local NGOs for improve the nutrition in sector & promoting social aspects of coordinated improving multi- addressing malnutrition implementation Sectoral for multi- coordination by (Develop a mechanism of coordination sectoral year 2015 to effectively implement strategies) integrated (Implementation level) nutrition strategy 1.6 Initiate screening through through various School Health and Nutrition nutrition- Supervisors, response in sensitive coordination with health interventions department to integrate √ -- that ultimately nutrition intervention with will help to women and children focused improve approach (Implementation nutrition level) indicators

1.7 Mapping of districts through impartial surveys, and utilization of this data to strengthen nutrition √ -- interventions of social welfare department (BISP data can be used at this time) (Implementation level)

1.8 Create linkages of livestock department with BISPs program “Wasela-e-Rozgar” and upcoming new social protection schemes to support for ultra-poor √ -- segment of the society by up- scaling home based livestock & Agriculture through backyard poultry farming & kitchen gardening (Implementation level)

1.9 Advocacy with BISP for linking √ -- BISP beneficiaries with

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“Kitchen gardening Scheme” (Implementation level)

3.5.6.2 Strategy 2: Improving the economic access to address nutritional needs through poverty alleviation and social protection The access to safe and nutritious food is among basic human right. Currently, 963 million people are malnourished and living in dire poverty across the world attributable to lack in economic access. Nutrient deficiencies and insufficient economic access ultimately directs to unhealthy life of children and burden on GDP. Food security through enhancing purchasing capacity (economic access) is definitely an enormous challenge and it requires an integrated approach with the dedicated involvement of the Governmental and civil society including NGOs, CBOs and development partners. Punjab although produce three quarters of the food and feeds the other provinces as well yet food security in Punjab (60%) is higher than national average (58%) of the country. It means the producers (poor farmers) themselves have not access to the adequate food, and the compromised economic access to the food is by far the most critical factor. Therefore, the NNS, 2011 data itself makes the case for improving the economic access to food. The exercise should be targeted for comprehensive nutrition services to all of the population especially targeting and prioritizing the first 1000+ days, preschoolers, kids in elementary schools and adolescent female.

INTERVENTION MATRIX

Nature of Intervention Impact on Strategy Objective Strategy Action(s) Nutrition Nutrition nutrition Sensitive Specific

By 2015, introduce 2.1 Link the cash transfer via Economic cash transfer vouchers and assistance from access to system for BISP with evident based health/ food improving the nutrition need (Implementation √ -- will ultimately economic access to level) lead to an adequate food to improvement in meet minimum nutrition nutritional needs indicators 2.2 Cash transfer amounts should be √ -- linked to provincial food price

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indices so that real value remains constant throughout the year (Policy level)

2.3 Conduct research intervention to assess the impact on improving nutrition through cash transfer scheme (BISP data could be √ -- used), and implement impartial program monitoring with third party validation (Policy level)

By 2015, introduce 2.4 Introduce conditional cash Economic conditional cash transfer (CCT) and make BISP or access to transfer (CCT) any other such program health/ food √ -- policies with the conditional for beneficiaries to will ultimately intention of enroll their daughters in schools lead to an targeted approach (Policy level) improvement in nutrition 2.5 Piloting of a conditional cash indicators transfer program using vouchers and linked to the utilization of health and nutrition services by target population √ -- groups, while being particularly attentive to supply side constraints which may be encountered by these groups (Policy level)

2.6 Targeted and conditional food subsidies for poor instead of generic subsidies and will be √ -- linked with inflation rate by 2014 (Policy level)

3.5.6.3 Strategy 3: Promote nutrition awareness for healthy & safe dietary practices Awareness regarding healthy & safe dietary practices can play a tremendous role in eradication of malnutrition. Various recent reports revealed a significant inverse association between awareness and

Page 68 nutritional deficiency indicators. Hunger and malnutrition affects huge segment of the population in countries where education level is low. In relation to the manifestation of nutrition-related information- seeking behaviors during whole life, the poor can be targeted to be exposed to nutrition information from a variety of sources, including the family doctor. In many countries, variety of nutrition education interventions and social marketing initiatives are being used by the Food Stamp Program to improve food resource management, food safety, dietary quality, and food security for low-income households. The policy should link comprehensive sequential nutrition education, access to nutritious meal, promotion of child nutrition programs to reinforce positive health outcomes for all children in socially & economically excluded population. Pregnancy-specific nutrition information for married couples especially in poor (in Dar-ul-Amaans, PVT Centers, Sanat Zaars, Zakat councils) is equally important because it is one of the few things that they can apply in their daily lives to protect the health of the fetus.

INTERVENTION MATRIX

Nature of Intervention Strategy Impact on Strategy Action(s) Objective Nutrition Nutrition nutrition Sensitive Specific

To use Social 1.1 Seminars/ targeted Access to Protection inclusion of nutrition educational Sector platform module in Sanat-Zars (1 day materials and for promoting - 1 week nutrition specific awareness about √ -- nutrition trainings) (Implementation dietary practices awareness for level) (especially healthy & safe among females) dietary will ultimately practices in 1.2 Seminars/ targeted lead to uptake of poorest inclusion of nutrition nutrition community of module / workshops in indicators Punjab PVTC (1 week-15 days √ -- nutrition module to Zakat families)

(Implementation level)

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1.3 Seminars/ workshops in Rescue homes (Darul-Aman) √ -- (Implementation level)

1.4 Enhance nutrition awareness through distributing IEC material poorest 2,50,000 zakat √ -- families of Punjab using zakat committees (25,000) (Implementation level)

3.6 AGRICULTURE 3.6.1 Crop Sector 3.6.1.1 Overview of the sector The economy of Punjab, Pakistan is one that is largely based on agriculture and industry. Punjab is the largest province of Pakistan in terms of population, and also has the largest and fastest growing economy in the country compared to other provinces and administrative units.

Agriculture is backbone of Pakistan's economy. It accounts for 21% of the GDP and with addition to agro-based products, it almost fetches 80% of the country’s total export earnings. More than 45% of the labour force is engaged in this sector.

The Province of Punjab covers 29% of the total reported, 57% of the total cultivated and 69% of the total cropped area of Pakistan. And this way Punjab contributes a major share in the agricultural economy of the country by providing about 83% of cotton, 80% of wheat, 97% fine aromatic rice, 63% of sugarcane and 51% of maize to the national food production. Among fruits, mango accounts for 66%, citrus more than 95%, guava 82% and dates 34% of total national production of these fruits18.

During 2012-13, agriculture sector exhibited a growth of 3.3 percent against growth of 3.5% of last year19, on the back of positive growth in agriculture related sub sectors, Crops grew at 3.2 percent, Livestock 3.7 percent, Forestry 0.1 percent and Fishing 0.7 percent. The agriculture subsector component which includes important crops, other crops, grew by 2.3 percent and 6.7 percent, respectively except cotton ginning that declined 2.9 percent. Important crops accounted for 25.2

18 Economic survey of Pakistan 2013 19 Economic survey of Pakistan 2013

Page 70 percent of agricultural value added and has experienced a growth of 2.3 percent in fiscal year 2012-13 against growth of 7.4 percent in 2011-12.

The per capita food intake has increased from 2410 calories daily in 2011-12 to 2450 calories in 2012-13. The per capita protein availability has also increased from 71.5grams per day in 2011-12 to 72.5 grams in

2012-13.

3.6.1.1.1 Live Stock & Diary Development Livestock is an important sub sector of agriculture, which accounts for 55.44 percent of agriculture value addition. Its share in GDP is 11.9 percent. This sub-sector is highly labor intensive. It has also emerged as a major source of income for the small farmers as well as the landless rural poor. Livestock has recorded a growth of 3.7 percent against the growth of 3.9 percent last year. Livestock plays an important role in poverty reduction in the rural areas of Punjab, actively involves the participation of women, and has been identified as a priority investment area by the provincial government.

3.6.1.1.2 The Fisheries The fisheries sub sector of agriculture, having 2.05 percent share in agriculture recorded a growth of 0.7 percent against the growth of 3.8 percent last year. The development of the fishery sector also will have an impact on poverty reduction and the availability of nutritious food.

3.6.1.2 Contribution in GDP, Poverty Alleviation, Women empowerment- Workforce Agriculture share towards national income shows steady decline in previous years, currently it accounts for just over a fifth of the GDP, and still it continues to employ 45% of the total work force.

Year Agriculture in GDP % Labour force in Agriculture %

1995-1996 26.1% 46.8% 1999-2000 25.9% 48.4% 2003-2004 22.9% 43.7% 2007-2008 21.3% 44.7% 2010-2011 21.2% 44.9% Source: Economic Survey of Pakistan

A comparison of overall economic growth rate with the rate of growth in agriculture shows that agriculture has grown slowly compared with the GDP. Agricultural growth rates declined in all periods since the 1980s except for the last five years which witnessed a minor improvement over the previous

Page 71 half decade. The gap between agricultural and GDP growth rates was particularly high between 2000 and 2005 which was a period of relatively high GDP growth – agriculture recorded its lowest growth in the said period.

3.6.1.3 Potential role in nutrition improvement Agriculture department is critically important in alleviating all forms of malnutrition due to their impact on diversity of output, impact on food prices (levels, relative prices, fluctuations, and spatial variation) and levels of incomes. The food and agriculture sector therefore has a major role to play towards improvement of nutritional status of the province. NNS shows wealth has an important link with nutrition, but the presence of malnourished children, even in high-income groups indicates that nutritional outcomes are more complex than a household’s economic status.

With agriculture being the source of income and livelihood for 70 to 80% of people suffering from hunger in developing countries, it is clear that sustainable reductions in poverty, food insecurity and under nutrition cannot be obtained without special attention to the development of the agriculture sector in these countries. Focusing on the distinctive relationship between agriculture, food and nutrition, Govt. needs to focus, to protect, promote and improve food-based systems to ensure sustainable food and nutrition security, improve diets, combat micronutrient deficiencies, and raise levels of nutrition, and in so doing, achieve the nutrition-related Millennium Development Goals (MDGs).

Not only are there high levels of malnutrition and micronutrient deficiency in Punjab but there has been a lack of improvement in nutritional outcomes in last decade. Nutritional outcomes are correlated with income and food consumption, but also depend on a range of other factors such as health, disease and water and sanitation conditions. The results of the latest nutrition survey, which showed no improvement in nutrition indicators, have highlighted the urgency of making nutrition improvement an important agenda in future social policy planning in Pakistan & Punjab.

3.6.1.2.1 Casual Pathway of Malnutrition and the Agriculture Sector It is important to understand the casual pathway of malnutrition in order to identify its linkages with different sectors. As shown in figure malnutrition is lined with house hold food insecurity and this way Agriculture sector can play an important role.

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3.6.1.3 Food Security Resources Food security is one of the contributors of under nutrition; however, addressing food security alone, as seen from the experience of many countries, is not enough to improve under nutrition. The Rome Declaration on World Food Security in 1996 defined “food security as a situation where all people at all times, have physical and economic access to sufficient, safe and nutritious foods to meet their dietary needs in accordance with their food preferences for an active and healthy life”. Overall, 58% of Pakistan is food-insecure; with Punjab has 60% food insecurity – despite being labeled as the food basket of Pakistan.

Food Security in Punjab

8.8 Food Secure

18.5 40.5 Food Insecure Without Hunger

Food Insecure With Hunger 32.2 Moderate Food Insecure With Hunger Severe

Figure 3.11: Food Security Situation -Punjab20

Food security in Pakistan is inter-dependent on local food production, the extent to which local farmers own the land and the produce grown, food inflation, and consumption of food by women and children. Agriculture, although a key sector of the national economy (one-fifth of the net GDP), has been experiencing stagnation. Punjab is the main food-producing province; however, surplus food-producing districts in Punjab have decreased from 21 to 14. (SDPI, 2009). More importantly, in Punjab where

20 NNS 2011

Page 73 agriculture is vibrant, its benefits are not being translated into nutrition unless emphasis is given to what is grown and its capture by the local population. Emphasis within agriculture in all provinces remains on cash crops, which have higher income gains than kitchen farming. Although kitchen farming has lower income gains, it directly benefits food-insecure households. Agriculture policies have tended to be dominated by economists with agriculture interpreted in terms of economic growth and GDP contribution rather than adoption of a development vision focusing on equitable distribution of benefits. This has resulted in cash crop policies and the state focusing on wheat rather than crop diversification and political, economic, and technical support is required to small farmers for land cultivation and crop diversification.

Power structures are of critical importance in terms of who owns the farming land and in deciding what is grown and the capture by the local households. There is highly inequitable ownership of land, with only 44 per cent of the rural population in Pakistan owning land and the majority being landless, dependent for work, food, and shelter on large landholders, and often trapped into cycles of debt and poverty. With predominance of large landholdings, there tends to be cultivation of economically productive cash crops of direct cash benefit to landholders rather than kitchen gardening and small livestock of nutritional benefit to the local populace. Moreover, the Haari’s working at the farms have no rights over the food grown, leading to little capture of agriculture into food consumption. Poverty is highest in populations lacking land ownership and drops by at least ten percentage points with ownership of land.21

Whilst Punjab has the lowest absolute figure of landlessness, there are high pockets in Southern Punjab. Food security has also been affected by steep inflation during 2008–2012, and worst of its nature in 2013, affecting even essential food commodities.The amount spent on food is 53.86 per cent of income22, which is comparatively much higher than 30 per cent spending on food in India23 and 10 per cent in the developed economy of the USA24. Nationally, the poorest households spend around 58.75 per cent of their income on food, compared to 39.5 per cent, showing regressive impact of inflation.

21 PIDE 2001

22 SPDC 2004

23 Banerjee &Duflo 2007

24 USDA 2005

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With stretched food budgets, the poor are unable to absorb the effects of increases, leading to a diet with less nutritious foods or foregoing of meals.

Table 3.2: Food security resources and poverty in Pakistani provinces, 2009 – 2011

Food Security or Sindh Punjab KPK Baluchistan Pakistan Poverty Status Agriculturally 27.3 83.0 16.5 3.0 30.0 productive land²

Poverty incidence³ 31.0 26.0 29.0 48.0 33.0

Rural areas 38 24 27 51 35

Small towns 40 43 41 44 30 Poverty incidence ³ - No land ownership 41.3 26.0 32.0 52.5 31.8 - Land ownership 20.9 12.3 19.5 42.6 17.9

It indicates that poverty is less as compared to other provinces and better than national average. Nevertheless the poverty is more in small town as compared to rural area. This area needs more nutrition specific and sensitive interventions.

3.6.1.3.1 Food Diversity and caloric Intake situation Studies and survey shows close linkage between caloric intake& food diversity with stunting and under nutrition. Presence of malnourished children and women in food secure house hold clearly indicates poor eating practices and lack of awareness regarding importance of food diversity and required caloric intake.

MICS 2011 revealed Punjab situation showing highest stunting in southern districts of Punjab, Khanewal, R.Y.Khan, Bahawalpur, and Bahawalnagar, Muzaffargarh & Rajanpur, the crop harvesting data from same districts clears the picture by showing that most of these districts show increased production of cash crops rather nutritious/or food crops during the previous years

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3.6.1.4 Overall sectoral objectives

 To improve Access of the most disadvantaged population to Nutritious foods 3.6.1.4.1 Nutrition specific objectives . Mainstreaming nutrition in agriculture

. Enhance productivity of grains and pulses

. Address malnutrition through bio fortification

. Promote kitchen gardening at household level (Equitable access to vegetables and fruits)

. Create awareness on importance of food diversification and healthy dietary practices

. To prioritize development of zinc rich wheat variety

. Empowering Women labor involved in Agriculture sector

3.6.1.5 Intervention framework 3.6.1.5.1 Strategy 1: Mainstreaming Nutrition in Agriculture Punjab Government is contemplating to develop its Agricultural policy on the wake of devolution; hence, there is an opportunity to make it more inter-sectoral, nutrition sensitive, gender sensitive and pro-poor. The policy should focus on open the doors for small farmers to have access to latest machinery on installment and subsidized cost. Agriculture and food security is a vital component of Government planning documents and strategy papers i.e. “Vision 2030”, the Medium-Term Development Framework 2005-2010, and the Poverty Reduction Strategy Paper II (PRSP-II).

The nutrition may be mainstreamed in Agriculture Sector by captivating given policy decisions.

INTERVENTION MATRIX

Nature of Intervention Impact on Strategy Objective Strategy Action(s)

Nutrition

specific

sensitive

Nutrition Nutrition Nutrition To develop Policy 1.1 Develop and promulgate Access to food frame work to Provincial Nutrition sensitive √ -- throughout the create enabling Agriculture Policy year will environment for improve the mainstreaming 1.2 Policy decision to add nutrition √ -- food security in IEC material of the

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Nutrition in Sector agriculture sector situation and & improving ultimately multi-Sectoral 1.3 Develop Gender Sensitive and reduce the coordination by pro poor Provincial Food √ -- malnutrition year 2015 Security Strategy burden 1.4 Advocacy with BISP for linking BISP beneficiaries with “Kitchen √ -- gardening Scheme”

1.5 Policy to encourage increasing of female agriculture extension √ -- officer and field assistant

1.6 Enforcement of strict regulatory It may have measures to control the sale of effect on food uncertified seeds, harmful √ -- security at pesticides and medicine with household level adverse effect on human health and may lead to improve in food 1.7 Shifting from traditional consumption agriculture to value added Agriculture and promotion of semi-urban/ house hold agriculture / kitchen gardening √ -- through provision of quality seed on subsidized rate and technical support at the doorstep

To build capacity 1.8 Conduct training of district and It may have √ -- of implementing UC level staff impact on the staff at district and life of women UC level on 1.9 Conduct training of farmers √ -- working in nutrition manual agriculture 1.10 Create awareness by 2016 sector, More among farmers on use of than 45% nutritious food, healthy dietary women force is habits, hygiene and health √ -- engaged here, change in behavior of child care giver has directly

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effect on Child Nutrition.

3.6.1.5.2 Strategy 2: Increase Productivity in nutritious food (by developing and promoting high yielding varieties of grains & pulses)

Background/Rationale:

The objectives of Agriculture Sector are to provide food security to the community targeting especially poor and vulnerable, women, and children. The availability of pulses particularly lentil, the moon and mash is low as compared to the consumption at National & Provincial level and prices of pulses are also high and are becoming out of reach of the segment of the community that needs to buy pulses as alternate expensive source of protein, i.e. meat and fish. The focus will be to promote cultivation of pulses to make the country and province self-sufficient in the production of affordable sources of these nutrient rich commodities.

Pulses (Lentil, Gram, Moong and Mash) are a rich source of protein obtained from plants (Bio source). They are sown on about five percent of the country’s total cultivated area. The area and production under these pulses in 2012-13 in Pakistan was around 2.89 million acres and 0.863 million tons respectively. This production has been declining over the years in all provinces including Punjab.

The National Level area, production, and consumption of pulses i.e. Moong, Mash, Gram & Lentil during 2011-12 & 2012-13 is as under:

Table 3.3: Area & Production of Pulses 2011-2012 and 2012-201325

25 Agriculture department Punjab PC1

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Punjab 2011-12 2012-13

Area Production Area Production (000 ha) (000 tons) (000 ha) (000 tons)

Mung 119.6 80.7 116.8 78.5

Mash 19.5 6.4 17.9 6.1

Gram 920.1 224.7 908.1 691

Lentil (Masoor) 12.7 5.1 12.4 5.4

Reasons of declining trend of area and production of Pulses

i. Reduction in cultivated area of Moong, Mash and Lentil is ascribed to crop substitution by Cotton and other cash crops.

ii. The reason of intermittent production figures are attributed to moisture and adversaries of frost during Gram growth period.

Table 3.4: National Production, consumption & gap of major pulses 2012-201326

Production (Tons) Consumption (Tons) Gap (Tons) Crop Punjab National Punjab National Punjab National

Moong 78000 90000 65900 110000 12100 -20000

Mash 6050 10900 29990 50000 -23943 -39100

Lentil 5420 10800 33060 55000 -27640 -44200

Gram 691000 751000 414000 600000 277000 151000

The above table shows that there is a big gap between production and consumption. There is a dire need to take new initiatives for enhancement of production.

26 Agriculture department Punjab PC1

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The below given strategic actions may be taken to increase the production of high yield variety of pulses.

INTERVENTION MATRIX

Nature of Intervention Impact on

Strategy Objective Strategy Action(s) nutrition

Specific

Sensitive

Nutrition Nutrition Nutrition To develop, 2.1 Development of pre- Will be help full promote and basic/basic seed of high √ -- to address the increase the yielding varieties of pulses protein energy production of high malnutrition as yield varieties of 2.2 Promotion of certified seed by well as increase pulses distribution among farmers at the food security subsidized prices and √ -- demonstration of modern production technology and farmer gatherings

2.3 Capacity building and training √ -- of farmers

2.4 Distribution of Seed to √ -- Farmers

2.5 Awareness (Mass media campaign, Farmer days, √ -- Seminars)

2.6 Advocacy for correct √ -- processing

3.6.1.5.3 Strategy 3: Equitable access to vegetables and fruits Background/Rationale:

Vegetables play a vital role in our diets, as these support the normal functioning of the different body systemsby providing vitamins, minerals, fiber, essential oils and phytonutrients. While eating cooked vegetables is healthy, in certain instances it is advantageous to eat raw vegetables. This is because cooking process destroys essential nutrients such as vitamin C and also kills vital enzymes that help

Page 80 human body to digest such foods. Therefore, the medical researchers and nutritionists insist on increasing the share of vegetable intake in daily diet. However, per capita consumption of vegetables in Pakistan is very low i.e. 46kg/annum against the minimum requirement of 73 kg/annum. Quite recently, the increased trend in production of high quality vegetables has been realized. There is a need to boost the vegetable production to extend its availability by providing latest technology for vegetable crops. Vegetable seed production is also an important concern as Pakistan is importing major portion of the vegetable seeds.

It is proposed to enhance vegetable production in urban, semi urban & rural areas through diversification of high value vegetable crops in the province. It is a fact that this sub-sector has not been given due importance in the past, as a result of which we could not exploit it’s potential to cope with the growing demand (quantity and quality) of vegetables in the domestic as well as international markets. The increased cultivation/production of vegetables would not only meet the increasing demand of the population of Punjab province on one hand and fetch its share in addressing malnutrition.

The production of vegetables i.e. tomato, onion, chilies , and garlic is low due to sowing of traditional , low yielding varieties, use of poor quality seed, inadequate use of hybrid seeds, weed infestation, imbalance use of fertilizer, improper management of insect / pest & diseases, post-harvest losses and inefficient marketing system. Therefore, production of vegetables, especially tomato, onion, garlic, potato and chilies is not coping with the domestic demand of the increasing population and also has declining trend which resultantly inflating the prices of these commodities for the consumers.

INTERVENTION MATRIX

Nature of Intervention Impact on

Strategy Objective Strategy Action(s) nutrition

Specific

Sensitive

Nutrition Nutrition Nutrition To Develop, 3.1 Development &Provision of Will be help full to promote and Good Quality Seed and fill the gap of increase Seedlings √ -- micronutrient as production of well as energy vegetables nutritional (Vitamins and insecurity 3.2 Promotion of certified seed by √ --

Page 81 mineral sources) distribution among farmers at subsidized prices and demonstration of modern production technology and farmer gatherings

3.3 Capacity building and training √ -- of farmers

3.4 Distribution of Seed to √ -- Farmers

3.5 Awareness (Mass media campaign, Farmer days, √ -- Seminars)

3.6 Advocacy for correct √ -- processing

3.7 Promotion of quality certification as per √ international standards

3.6.1.5.4 Strategy 4: Addressing Malnutrition through bio-fortification

Background/Rationale: Zinc is one of the essential trace elements and, as such, a member of one of the major subgroups of the micronutrients that have attained such prominence in human nutrition and health. Two billion people worldwide are not getting enough zinc through their diets. Zinc deficiency is a major health problem in developing countries, especially among young children. Zinc deficiency weakens their immune system and leaves them vulnerable to conditions such as diarrhea, pneumonia and malaria. Zinc deficiency is also accountable for impairing physical and intellectual development, preventing children from reaching their full potential. UNICEF estimates that diarrhea accounts for nearly two million deaths in children every year. Diarrhea is preventable and treatable, but in developing countries, only 35% of children with diarrhea receive the recommended treatment of oral rehydration salts and zinc supplements. NNS 2011 reveal 39.2% zinc deficiency in Pakistan zinc deficiency at 38.4% in Punjab.

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INTERVENTION MATRIX

Nature of Strategy Intervention Impact on Strategy Action(s) Objective Nutrition Nutrition nutrition Sensitive Specific

To develop zinc 4.1 Development &Production Will be help full to √ -- fortified wheat of zinc enrich wheat seed fill the gap of variety to reduce micronutrient. zinc deficiency 4.2 Promotion of certified seed by distribution among farmers at subsidized prices and demonstration of √ -- modern production technology and farmer gatherings

4.3 Capacity building and √ -- training of farmers

4.4 Distribution of Seed to √ -- Farmers

4.5 Awareness (Mass media campaign, Farmer days, √ -- Seminars)

3.6.1.5.5 Strategy 5: Scaling up of Kitchen gardening

Background/Rationale:

Kitchen gardening is a globally proven cost effective strategy to increase accessibility of vegetables and fruits. The agriculture department launched kitchen gardening project in 2011. Although, the project gained limited popularity among the dwellers of urban, semi urban and rural areas due to unavailability of good quality seed and compromised capacity. Kitchen gardening program in Punjab needs to be converted into movement by involving all stakeholders working and concerned with vegetable business

Page 83 to produce healthy and nutritious vegetables at big lawns, houses, abandoned places, containers, fences, trellis. Scalability of seed provision for kitchen gardening project with immediate increase in number of seed packets from 100,000 to 450,000 per year along with increasing the seed types and quality of seed in packets.

INTERVENTION MATRIX

Nature of Intervention Impact on

Strategy Objective Strategy Action(s) nutrition

Specific

Sensitive

Nutrition Nutrition Nutrition To Increase 5.1 Promotion of kitchen Will be help full √ -- availability of gardening to fill the gap of micronutrient rich micronutrient. 5.2 Provision of quality seed at food especially for √ -- poor and subsidized rates vulnerable 5.3 Hands on training of community households on kitchen √ -- gardening

5.4 Development and promotion of micronutrient rich varities √ of seeds for farmers

5.5 Mainstreaming the research for bio fortified foods with √ micronutrients

5.6 Capacity building of farmers √ on bio fortification techniques

3.6.1.5.6 Strategy 6: Increase accessibility of animal protein sources at household level

Background/Rationale:

It is evident that at present poor segment of the society as neither access nor have the capacity to access protein rich animal foods. The home based poultry and raring of livestock is the way to increase access of poor segment to nutritious food. The livestock department may create linkages with BISPs

Page 84 program “Wasela-e-Rozgar” and upcoming new social protection schemes to support for ultra-poor segment of the society by up-scaling home based livestock and backyard kitchen farming. This will help the poor to have access the more sources of protein and enhance household income.

INTERVENTION MATRIX

Nature of Intervention Impact on

Strategy Objective Strategy Action(s) nutrition

Specific

Sensitive

Nutrition Nutrition Nutrition Up-scale 6.1 Promote backyard poultry Increase in access household farming by provision of of protein livestock subsidized layer chicken with √ -- sources/ production to cock to eligible families consumption increase the (women) protein and access to protein enhance rich foods 6.2 Provision of small cattle of excellence genetic profile on √ -- subsidized rate for raring and future reproductive growth

6.3 Livestock department will provide free of services, technical support, vaccination, √ -- and veterinary medical services

3.6.2 LIVESTOCK AND DAIRY SECTOR 3.6.2.1 Overview of the Sector Livestock & Dairy Development Department was established in 1973 in Punjab. Livestock and Dairy sector is continuously achieving value attributable to imperative role in national economic uplift, food security, rural development, poverty alleviation, employment generation, and foreign exchange earnings. Livestock & Dairy sector also play significant part in Pakistan’s economy and contributes about 11.9 percent in the GDP of Pakistan. This sector is considered a net source of invariable income for rural and middle grade agri-business holders. Livestock sector contributed about 55.4 percent in year 2012- 13.

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Livestock works as a buffer between the small farmers economy and disaster. Small animals, particularly sheep, goat and poultry and their products (milk, meat and eggs), are consumed by farmers themselves that enrich their regular diets with high quality protein (with high BV) and fulfill the need of essential amino acids. Livestock and dairy resources are similarly ubiquitous in poor communities across the world. According to estimation, poor rural households keep two thirds of resource in the form of various types of livestock. Similar information for poor urban households is scarce, but a recent survey found that more than one-half of all urban households were keeping livestock; the highest rates were found in the most densely populated, lower-income areas.

The livestock-keeping systems practiced by the poor have produced per animal or land unit well below those in the industrialized countries. There are many reasons for this pattern of lower productivity. Smallholder management systems are typically low or no input, letting animals forage for themselves, feeding on plants or waste that otherwise would not be used. In many cases, relative prices of feed and livestock products provide insufficient incentives to use purchased inputs to develop intensive production systems (e.g., milk to feed price ratios of 1:1) The poor often keep a mix of different species, trading off specialization for better protection against risks.

Livestock systems of the poor reflect the resource constraints that they face (e.g., financial, access to information and services, and landlessness), as well as their varied reasons for keeping livestock, which include the following:

. Producing Food . Generating Income . Providing Manure . Producing Power . Serving as Financial Instruments . Enhancing Social Status

3.6.2.2 Livestock & Diary and Nutrition Connect In spite of recent growth in consumption, many people have not equitable access to animal- based foods that are believed as complete, nutrient-dense, and important for the high quality protein and bio-available micronutrients sources, particularly for children and pregnant and lactating women. Animal-based foods are also imperative source for improving the nutritional status of low-income

Page 86 households. Livestock products like meat, milk and eggs provide proteins with high biological value as well as bio-available micro-nutrients such as iron, zinc, vitamin A, vitamin B12 and calcium that are critically the base of major malnutrition ailments. International dietary guidelines on levels of energy and protein consumption do not distinguish between plant and animal sources. They suggest that the intake of energy needed by an adult in a day varies from 1680 to 1990 kilocalories (kcals) in total, depending on the country. They also suggest that the safe level of protein consumption is about 58 g per adult per day 27.

3.6.2.3 Nutrition sepecific objectives of sector: . Poverty alleviation by supporting livestock subsistence farmers & women organize, empower & hand hold . Productivity enhancement through improved genetics, balanced nutrition & careful husbandry . Better functioning markets and regulatory regime . Private enterprise development to optimally realize potential of livestock assets . Provision of quality products (dairy & meat) for domestic consumers & export market apply research & technology

3.6.2.4 Intervention Frame work 3.6.2.4.1 Strategy 1: Increase the productivity by sustainable livestock farming and capacity development to combat protein energy malnutrition

Rationale/Background: Growing world population and increasing threat of protein deficiency are strategic concerns that are encouraging more struggles to raise food production along with sustainable livestock farming that upsurge the productivity of meat (protein) markets and secure the vulnerable community from protein deficiency (hidden hunger). The World Bank reported that the demand of meat would increase to 85% by 2030 (World-Bank, 2008b). Application of technology and engineering can leads to sustainable livestock production, as well as it also can improve the conversion of feed to meat that ultimately reduce the cereal consumption for feed, increase production of meat, decrease in price due to availability. All outcome aspects go in the favor of an approach to reduce the consequences of hunger (Zhou, Zhang, & Xu, 2012).

Intervention Matrix

27 WHO, FAO,UNU,2007

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Nature of Intervention Impact on Strategy Objective Strategy Action(s) Nutrition Nutrition nutrition Sensitive Specific To increase the 1.1 Enhance livestock production Increase in meat gross annual meat through adaptation of latest production will production from technology (biotechnology & surely increase 3,379,000 tons in genetic engineering, improved the access to 2013 to 5,000,000 reproductive technologies, √ -- tons as well as precision animal breeding) and protein source gross milk breed improvement that ultimately production from (implementation & policy level) reduce the 49,512,000 tons in burden of Protein 2013 to 1.2 Promote and provide various Energy 80,000,000 tons by livestock animals of excellence Malnutrition. the end of 2020 genetic profile on subsidized rate Increase in (according to for raring and rapid reproductive √ -- Economic Survey of growth (implementation & policy production will Pakistan) level) also be helpful to improve the food 1.3 Strengthen the provision of cost security situation effective and safe livestock (cattle and family & poultry) feed (implementation √ -- income of poor level) farmers.

1.4 Promote the latest embryo transfer technology and provide semen’s injections of excellence genetic profile animals at free of √ -- cost/subsidized cost (implementation & policy level)

1.5 Increase the number of dairy farms and milch animals (2-5% annually) from the existing in 2012-2013 √ -- (implementation level)

1.6 Skills enhancement of livestock sector’s individuals (staff & farmers) by conducting trainings at

UC and districts level (implementation level)

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Strengthen 1.7 Up-gradation of the existing lab Proper and in- veterinary medical facilities for proper diagnosis & time diagnosis of and diagnostic lab safety testing of feeds and food livestock animal facilities by 2020 (milk & meat) in regions, where will ultimately to control and the labs are already present but √ -- increase the reduce the risk of are with limited capacity or non- livestock outbreak operational (implementation & production policy level)

1.8 Establishing new livestock diagnostic lab facilities in regions where there is need but there are √ -- no labs (implementation & policy level)

1.9 Provide various services at free of cost (technical support, vaccination, and veterinary medical services) to control and √ -- reduce the risk of outbreak (implementation & policy level)

3.6.2.4.2 Strategy 2: Reduce nutrient deficiency in targeted groups by increasing the physical access to livestock-based products

Rationale/Background

Malnutrition are only social and moral problems that embarrass to our global society but also induce considerable economic cost comprising reduced lifetime productivity, expanding poverty, slow economic development and resource deprivation (FAO, 2012). Vulnerable community (chronically hungry and malnourished people) required immediate assistance to rescue and polices making as well as implementation to prevent the community from hunger and nutrient deficiency in future. However, most of the world’s vulnerable communities facing hunger by some means rely on agriculture and related fields like fisheries, livestock, dairy and forestry for the survival of life. Accordingly, due to this reason upgrading agricultural and food systems are critical for the advancement of vulnerable people encountering malnutrition. Accordingly, it can be expected that hidden huger (along with its consequences) can be managed or prevented by applying technological and engineering applications

Page 89 principally in two fields viz. Agricultural & livestock (production of food) and food systems (food supply chain) (Premanandh, 2011; FAO, 2012).

Intervention Matrix

Nature of Intervention

Impact on Strategy Objective Strategy Action(s) nutrition

Specific

Sensitive

Nutrition Nutrition Nutrition To increase the 2.1 Increase the awareness of Easily access to gross annual milk livestock-based protein sources animal based consumption from (meat, milk and egg) importance protein sources 39,945,000 tons in and its consumption through √ -- will ultimately 2013 to literature, extension services, mass reduce the 80,000,000 tons as media campaigns and education burden of hidden well as gross eggs (implementation level) hunger consumption from 2.2 Introduce and promote the value 13,813 million in added livestock-based (meat, milk 2013 to 20,000 and egg) products especially at √ -- million by the end school level (implementation of 2020 (according level) to Economic 2.3 Promote the consumption of egg Survey of and poultry meat (5% annually Pakistan) from existing in 2012-2013) so that poor families may also consumed √ -- protein with high biological value at very low price (implementation level) 2.4 Promote the consumption of milk and milk product (5% annually from existing in 2012-2013) to √ -- reduce the risk of various essential nutrients deficiency (implementation level) Introduce and 2.5 Promote the consumption of Introduction of promote various camel milk and its product to uplift non-conventional the economic situation of livestock-based √ -- resources will community in desert area and also products by non- increase the to reduce the nutrient deficiency conventional (implementation level) access to protein, indigenous 2.6 Introduce various milk products uplift economic resources as value (like cheese, whey protein, casein, situation, and will √ -- addition especially ice cream, chocolates, bioactive ultimately reduce peptides etc.) especially from

Page 90 in vulnerable camel milk as value addition the burden of community to (implementation level) Protein Energy reduce nutrient 2.7 Launch various research project Malnutrition. deficiency by 2017 and strengthen/scaling up the existing ones to develop various √ -- value added products from non- conventional indigenous resources (implementation level) To ensure and 2.8 Enhance the quality of the Easily access to improve safe as livestock-based products (meat, safe animal based well as quality of egg, milk etc.) by introducing the protein sources modern and safe processing √ -- livestock products will ultimately techniques, and supply chain (cold from farm to fork storage, good transportation etc.) reduce the by 2020 (implementation level) burden of hidden 2.9 Increase availability of quality of hunger livestock-based products (meat, egg, milk etc.) in local markets and √ -- develop the mechanism to control the increases in prices (policy level) 2.10 Mandatory Safety/Management Certification of large livestock farms in five years, medium size in √ -- 10 years, and all livestock farms in 15 years 2.11 Continuous professional development, capacity enhancement, trainings and awareness campaigns for all √ -- involved in food supply chain starting from producers to consumer desk

3.6.2.4.3 Strategy 3: Increase accessibility of animal protein sources at household level especially for vulnerable community

Background/Rationale:

It is evident that at the present poor segment of the society as neither access nor have the capacity to access protein rich animal foods. The home based poultry and raring of livestock is the way to increase access of poor segment to nutritious food. The livestock department may create linkages with BISPs program “Wasela-e-Rozgar” and upcoming new social protection schemes to support for ultra-poor

Page 91 segment of the society by up-scaling home based livestock and backyard kitchen farming. This will help the poor to have access the more sources of protein and enhance household income.

INTERVENTION MATRIX

Nature of Intervention

Impact on Strategy Objective Strategy Action(s) nutrition

Specific

Sensitive

Nutrition Nutrition Nutrition Up-scale 3.1 Promote backyard poultry farming Increase in access household by provision of subsidized layer of protein livestock chicken with cock to eligible √ -- sources/ families (women) (Implementation consumption of production to level) protein increases increase the 3.2 Provision of small cattle of that ultimately access to protein excellence genetic profile on reduce the rich foods subsidized rate for raring and √ -- protein energy future reproductive growth malnutrition (Implementation level) To create enabling 3.3 Create linkages of livestock environment for department with BISPs program mainstreaming “Wasela-e-Rozgar” and upcoming new social protection schemes to Nutrition in Sector support for ultra-poor segment of √ -- & improving multi- the society by up-scaling home Sectoral based livestock and backyard coordination by kitchen farming (Implementation year 2015 level)

3.6.3 FISHERIES AND AQUACULTURE SECTOR 3.6.3.1 Overview of the Sector The fisheries sector contributes about 1% to the GDP of Pakistan. According to FAO statistics, the total fish production in Pakistan was about 594,935 tons in 2011 out of total fish production53,000 tons came from capture fisheries and 141,935 tons were produced from aquaculture. However, Pakistan also exported fish to USA, Japan, Sri Lanka, Singapore, the EU and the Gulf States and the total value of commodity trade and production for the period 2008-2009 was registered at US$ 231million (FAO Statistics, 2014).This sector also has an opportunity of employment to a substantial segment of population. Growing population of Pakistan (2.2 percent growth rate/year, 2002-03) with inadequate sources of protein demands the utilization of all available resources to improve the availability and

Page 92 consumption of protein (per capita). According to FAO/WHO report, adult protein intake per day should not below than one-gram protein/kg of body weight.

According to nutrition perspective, fish is a good source of many vital nutrients (micro- and macronutrients) especially a source of protein with high biological value (BV) similar to that of land animals. However, fish consumption in Pakistan is not much satisfactory as a meager increase in per capita fish consumption (from 1.0 kg in 1961 to 2.3 kg/annum in 2010) was observed. On the other hand, world’s average fish consumption increased from 9.0 kg to 16.3 kg/annum over the same period (FAO, 2005). The statistics clarify the facts that although fish consumption is important, but trends in Pakistan is not satisfactory. Total fish production from rivers/streams are estimated to be 3,102,408, canals, drains & abandoned canals 346,803, Lakes127,109, Dams/ reservoirs195,670, waterlogged areas 3031600, deltaic area 700000, flood water area 1000000, and Fish farms 60230 (DOF, GOP&WWF-Pakistan).

Table 3.5: Table Protein Quality Comparison of Fish Protein with other animal Proteins28

(%) (%)

Ratio

grams

Source

Protein Protein protein

Gain/100

Value (%)

Biological Efficiency

Utilization

consumed

Net ProteinNet

Digestibility Fish 96.0 80.0 85.0 3.55 77.0 Beef 74.0 68.0 99.0 2.30 13 (cattle) Chicken 74.0 71.0 85.0 - 18.0

Fisheries and Aquaculture sector have greater business potential and can exert beneficial impact on GDPs of a country. In Pakistan, the fish fauna is rich, but only seven warm water species and two cold water species are cultivated on a commercial scale. It is very unfortunate that recent efforts in shrimp culture production in the Indus delta region did not succeed due to the unavailability of good quality hatchery-produced seed. Although, freshwater carp farming is carried out on a large scale in Punjab, Sindh and K.P.K. However, efforts are required to improve the potential of northern area of Pakistan for trout culture. Aquaculture in Pakistan is controlled by provincial government headed by the Director General. The office of the FDC is responsible for policy, planning and coordination with provincial fisheries departments. Besides FDC, Pakistan Agriculture Research Council (PARC) and Asian

28 Khan (1986), Progressive Farming, Volume 6, No. 5 (Sep/Oct) 1986. Pakistan Agricultural Research Council, Islamabad.

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Development Bank (ADB) continually assisted in strengthening the development of hatcheries and juvenile production, model farms, transfer of technology, human resource development, as well as the strengthening of extension services.

Table 3.6: Aquaculture practices

Place No. Hatchery Area Punjab 88 Sindh 5 Thatta, Mirpur Sacro&Sukkar KPK 38

Since 1998, overall fish production has decreased by nearly 2 percent per year. Although this downward trend may be attributed mainly to the marine capture sector, inland freshwater resources of NWFP, Northern Areas, and Baluchistan are exploited below potential, with low productivity and high poverty levels encountered amongst inland fishing communities. Despite its endowment in natural resources, Pakistan ranks 28th among fishing nations in terms of production, and 50th in terms of export earnings. Addressing lack of land, seed, feed and technology for aquaculture production are necessary steps, along with addressing post-harvest losses and improving hygiene conditions which reduce the marketability of fish products and are one of the main constraints to export earnings. In addition to the supply of sub-optimal quality fish products on domestic markets, consumer awareness of the benefits linked to increased fish consumption. Finally, institutional weaknesses in and outside the fisheries sector, and inadequate capacity of its stakeholders need to be rectified in priority to ensure that both fisheries and aquaculture develop sustainably and in harmony with other sectors of the economy, while receiving the support they need to do so.

Any word how that can benfit the poorest populations, or the socioeconomic profile of those that have access to fisheries, aquaculture?

3.6.3.2 Responsibilities of sector: . Conservation . Check on fishing without license . Restriction on catching undersized fish . Protection of fish against use of explosives/ poisons . Restriction on mesh size of nets

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. Reservation of fish breeding grounds . Observance of annual close season . Protection of fish against release of industrial effluents and solvents

3.6.3.3 Overall Objective of the sector: 1. Increase the contribution of fisheries and aquaculture sectors to national economic growth to contribute to improved diets.

2. Increase the contribution of fisheries and aquaculture sectors to improve household’s food security and nutritional status and by that contribute to alleviate poverty. Increase the contribution of the fisheries and aquaculture sectors to better nutrition among food insecure households

Key measurable indicators of progress towards the achievement of the three policy goals of national economic growth, poverty alleviation and food security, will include:

. Higher per capita fish consumption . Improved fishers and fish-farmers’ incomes . Creation of well-paid employment in the fisheries and aquaculture sectors . Increased export earnings from aquatic products

3.6.3.4 Intervention Matrix 3.6.3.4.1 Strategy 1: Capacity Development: Strengthening the fisheries sector to increase the productivity by scaling up the existing resources to combat malnutrition

Background/Rationale:

Fish contributed much to the survival and health of a significant portion of the world’s population. Fish is especially important in the developing world. In far eastern countries of Asia people derive as much as 75% of their daily protein from fish. Similarly, West African derived 30% of animal protein intake from fish. Fish is considered as “rich food for poor people” attributable to rich source of vital nutrients such as proteins (with high Biological Value), essential poly-unsaturated fatty acids, vitamins and minerals. Fisheries and aquaculture sector play significant role in providing livelihood opportunities to coastal inhabitants in developing countries. Hence, fish production can play a significant role to improve food security situation in Pakistan. However, in recent year, production of fish declined due to a number of factors due to less number of hatcheries, inappropriate fish feed, lack of expertise and climate change or increasing water pollution. Production of quality seed is one of the major constraints in fisheries

Page 95 development. It is estimated that fish seed accounts for approximately 30% of production costs. Similarly, production of poor quality seed will results in low growth/production. This ultimately decreases the profit margin of fish farmers, sometime push poor and marginal farmers into greater economic risk. A common practice is carp seed production, which suffers from inbreeding, inter-species hybridization and, overall, is genetically degraded. Hence, on priority bases it is now the responsibility of the people involves to preserve pure genetics of the breed.

Northern Areas have plenty of cold-water resources and considered fit for trout fish farming. A study was conducted in 2004 to find out cost of trout fish farming and its profitability. Their findings revealed that total cost (capital and variable costs) of Rs. 234 was incurred to achieve a kg trout fish and its selling price was Rs.310. The net revenue came to Rs.76 per kg of fish (Hassan et al. 2007). Accordingly, it demonstrated that the trout fish farming provides a great opportunity for exploiting the abundant cold- water reservoirs in northern areas for income generation.

Intervention Matrix

Nature of Strategy Intervention Impact on Strategy Action(s) Objective Nutrition Nutrition nutrition Sensitive Specific To increase the 1.1 Increase the number of Increase in fish production of fish hatcheries from 88 to 150 by the production will from 594,935 end of 2020 to ensure the √ -- surely increase tons in 2011 to availability of high quality seed the access to 800,000 tons by (implementation level) protein source the end of 2019 1.2 Promote and strengthen the that ultimately (according to economical fish-feed production √ -- reduce the FAO Statistics) (implementation level) burden of 1.3 Development and provision of protein energy seed of high yielding varieties of malnutrition and various fish species by some √ -- micronutrients genetic modification deficiencies (i.e. (implementation level) Vitamin A, 1.4 Promotion of high yielding fish- Iodine, essential seed (lowest price of available fatty acids etc.) protein) by distribution among Increase in farmers at subsidized rates and production will √ -- demonstration of modern also be helpful to production technology to reduce improve the pre & post-harvest losses food security (implementation level) situation. 1.5 Skills enhancement of fishery √ --

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sectors individuals (staff & farmers) by conducting trainings at UC and districts level (implementation level) 1.6 Increase the number of fish farms (5% annually) from the existing in √ -- 2012-2013(implementation level) 1.7 Increase the capacity of the existent fish farms (10% annually) √ -- by the end of 2020(implementation level) 1.8 Promote the trout fish farming in natural water resources to increase the trout production (5% √ -- annually from existing in 2012- 2013)(implementation level) 1.9 Initiate shrimp cultivation in the Indus delta to increase the shrimp production (5% annually from √ -- existing in 2012- 2013)(implementation level)

3.6.3.4.2 Strategy 2: Reduce nutrient deficiency in targeted groups by increasing the physical access to aquaculture/fish food

Background/Rationale:

Food from aquatic resources has been an important component of human diet and considered as an important food source in many parts of the world especially in Asia. It also contributes in food security and poverty alleviation. However, in the recent years the production of marine capture fisheries has decreased in the whole world in comparison to escalating per capita demand owing to increasing population. Hence, the challenges of meeting future world fish supply needs and improving food security are indeed daunting. However, the importance of future fish availability for food security and nutrition in highly populated developing countries will be a priority.

Fish is one of the main sources of protein providing significant amount of animal meat and is a growing food source in Asia and in other developing countries. Fish products provide an excellent source of protein due to their amino acid composition and protein digestibility that ranges from 85-90%. Fish protein also offers a variety of vitamins and minerals including vitamins A and D, phosphorus, magnesium, selenium and iodine. Moreover, fish is also perceived as healthy food by consumers,

Page 97 especially in comparison with meat, the main source of animal protein. Scientific data indicated that fish oil is a rich source of PUFA mainly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), so regular fish consumption and the intake of ω-3 PUFA play an important role in the primary and secondary prevention of blood pressure, coronary heart disease and stroke (Artham et al. 2008). Fish consumption at 40-60 g daily with high ω-3 fatty acids lower the risk of macular degeneration, that causes blindness, significantly reduced coronary heart disease mortality in high-risk populations (INFOFISH, 2002).

In Pakistan, domestic consumption of fish is estimated to be 26% with 19% being exported, while 55% of the produced going for fishmeal that indicated poor quality of fish being produced in the country. Per capita consumption of fish in Pakistan is varied; Baluchistan consumed 6.80 kg per capita/year (1975-76) and this figure further declined to 5.28 kg per annum (2002-03). In Sind, consumption rate was ablated from 4.25 kg per capita/year (1975-76) to 2.98 kg per capita/year (2002-03). Although, per capita/year fish consumption of Punjab and KPK increased from 0.12 and 0.04 kg in 1975-76 to 1.00 and 0.71 kg in 2002-03respectively, however still considered to be low.29

Table 3.7: Consumption of Fish in Various Provinces of Pakistan (KGs per capita per annum)30

Year Pakistan Punjab Sind KPK 1975-76 1.28 0.12 4.25 0.04 1980-81 1.99 0.36 4.30 0.17 1985-86 1.80 0.57 4.10 0.04 1990-91 1.70 0.74 3.71 0.74 1995-96 1.81 0.98 2.58 0.41 2000-01 1.76 1.00 2.90 0.65 2002-03 1.77 1.00 2.98 0.71

Intervention Matrix

Strategy Strategy Action(s) Nature of Impact on

29 Wasim 2007

30 Government of Pakistan (1980, 1991-92, 2002-03), Agricultural Statistics of Pakistan. Ministry of Food, Agriculture and Livestock, Islamabad.

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Objective Intervention nutrition Nutrition Nutrition Sensitive Specific To increase the 2.1 Increase the awareness of fish Increases in per per capita meat importance and its capita consumption of consumption through literature, consumption √ -- fish from 2 extension services, mass media ultimately kg/year to 5 campaigns and education reduce the kg/year by the (implementation level) burden of end of 2020 2.2 Introduction of value added fish protein energy through products such as fish cookies, fish malnutrition and awareness, value chips, fish biscuits, fish other addition and cost nan/chappaties, fish cakes, fish √ -- micronutrients effective fish salads, fish samosa, fish biryani, deficiencies. products and nimko, etc. (implementation level) 2.3 Promote the consumption of small size fish(5% annually from existing in 2012-2013) so that √ -- poor families may also consumed with low price (implementation level) To ensure and 2.4 Enhance the quality of the fish by Easily access to improve safe as introducing the modern and safe safe fish well as quality of processing techniques, cold products fish from farm to storage, good transportation and √ -- ultimately fork improvement in marketing reduce the channel, etc. (implementation burden of level) hidden hunger 2.5 Enhance the coastal aquaculture production and increase √ -- availability in local inland markets (implementation level)

3.7 EDUCATION SECTOR (PUNJAB) 3.5.1 Overview of the sector Education Sector is the largest sector of Punjab, comprising of the School Education Department (SED), Higher Education Department (HED), Special Education Department, Punjab Curriculum Authority (PCA), Staff Development Department and Literacy and Non-Formal Basic Education Departments (NFBE). The SED oversees 53,935 schools with more than 10 million students and 330 thousand teachers (REF). The SED also supervises the Boards of Intermediate and Secondary Education (BISE), Children libraries, Punjab Daanish Schools and Centers of Excellence. The HED is overseeing 458 Colleges along with eight

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BISE, 12 Public Sector Universities, 20 Autonomous Educational Institutions of Higher Education, and the Directorate of Public libraries .The PCA deals with development and supervision of curricula, syllabi, textbooks, and maintenance of standards of education. The duties of the Directorate of Staff Development include conduct of pre-service and in-service teachers training and a Continuous Professional Development (CPD) Program. Government of Punjab has established a separate Department for Literacy & Non-Formal Basic Education to address the problem of dropouts at the primary level and meet the emerging demand for Non-Formal Basic Education with functional Literacy and Livelihood skills. In collaboration with international agencies like UNESCO & JICA, the Literacy &NFBE Department has developed various Projects i.e. Punjab Accelerated Functional Literacy & Non Formal Basic Education Project, Campaign for Enhancement of Literacy (04 Districts), Community Learning Centres (Sahiwal Division) and Brick kilns Project (Multan &Khanewal Districts) to combat the menace of illiteracy and achieve the goal of 100% literacy by 2020. The Department for Literacy &NFBEhas launched the Punjab Enrollment Emergency Campaign to increase rates of enrollmentamong school-going children.

In 2009, the Government of Pakistan approved a National Education Policy which aimed to address the issues of access, equity and quality of education at all levels. The Policy highlighted governance as an issue requiring urgent attention to improve the status of education and called for increased investment in the education sector. Under this policy, the government is committed to allocate 7 percent of GDP to education and provide free universal primary education by 2015 (Economic Survey of Pakistan, 2013).. Following the 18th Amendment, Education became a Provincial subject and the Government of Punjab emphasized educational reforms and announced the School Education Reforms Roadmap with the objective to enhance access, retention and completion of quality education. The Chief Minister of Punjab has approved allocation ofa fifth of the total Provincial budget (Rs.117 billion) to Higher and Primary Education under different categories and schemes.

3.5.2 Potential role in nutrition improvement Education or literacy level and malnutrition indicators are closely interlinked, as demonstrated in the district-maps (shown below) Literacy rates and maternal education are seen to be directly related to childhood under-nutrition (underweight, stunting &wasting), indicating that increases in literacy/education level will be helpful in reduction of the burden of malnutrition in the province of Punjab.

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Maternal and child under-nutrition is also related to maternal autonomy (Nutrition Political Economy, Pakistan 2013). Further, the National Nutritional Survey 2011 reveals stunting rates among children reduce significantly with increasing maternal level of education (shown in table below).

40 38%

30% 30 27%

19% 20

15% % of children of % stuntedchildren 10

0 Illiterate Primary Middle Matric Above Matric Education Level

Figure 3.12: Figure 3: Relationship between Maternal education and Child Stunting (Source: NNS 2011)

The inextricable linkage between education, autonomy and malnutrition identify education as an essential component of any strategy seeking to improve the nutrition status of a population, particularly children. With a high burden of illiteracy among primary care givers of children i.e. women, an urgent strategy to improve education among the population in general and among women in particular needs to be pursued to reduce the burden of malnutrition.

3.5.3 Nutrition specific objectives of the Education Sector . Ensure equitable access to education, with particular focus on increasing enrollment and retention of the girl child . Introduction of Nutrition, Health &Hygiene education modules in schools and education curriculum- . Improve knowledge regarding nutrition among teachers, parents/caregivers children and adolescents engaged in schooling

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. To support health department in malnutrition screening among children and adolescents and improve nutritional status among school going children through appropriate referrals, health & nutrition education and promotion activities . Introduction and promotion of Nutrition as a professional track for post-graduate education and employment

3.5.4 Intervention Matrix

3.5.4.1 Strategy: Equitable access to Education Several recent studies have demonstrated an association between educational attainment and nutritional deficiency. Whereas hunger and malnutrition in itself affect the health of children, it further increases the chance of infections which can potentially affect learning capacity, reduce attention span, increase absences from school and affect education throughout childhood. Studies have demonstrated improved educational attainment among children treated for malnutrition and micronutrient deficiencies. Health and Nutrition Programs targeting infant, pre-school and school-going children, particularly among the poor are effective in improving health and educational attainment throughout the life cycle (Jukes et al., 2009).

Intervention Matrix

Nutrition Level Strategy Impact on Strategy Action(s) Nutrition Nutrition Objective nutrition Sensitive Specific To increase Pre- 1. Expand the existing network of Access to √ -- nursery & schools by 2020 (Policy level) educational Nursery 2. Launch enrollment campaign material and enrollment & each year especially to increase √ -- awareness of retention to 80% enrollment of girls (Policy level) dietary and of eligible girls by 3. Introduce conditional cash feeding practices 2020 transfer (CCT) policy by 2014, and (among care advocate with BISP or any other takers &female such program conditional for √ -- students)) beneficiaries to enroll their will lead to an daughters in schools (Policy improvement in Level) nutrition 4. Availability of boundary wall indicators especially in girls’ schools by √ -- 2016

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3.5.4.2 Strategy: Improve quality of Education and integrate Incorporate action oriented inter-sectoral nutrition specific messages in the school-based curriculum and build capacity of primary and secondary school teachers in the delivery of nutrition messages, education and activities strengthening nutrition as an integral part. Nutrition education involves increasing knowledge about the importance of nutrition, providing educational materials that reinforce messages about healthy dietary practices, imparting skills essential for making dietary changes and imparting life skills to sustain behavior change. Information gathered during school-based nutritional screening or assessment will provide the necessary information on which nutritional messages will be tailored during nutrition education and counseling sessions. Health professionals need to give careful consideration to the types of nutrition messages that are presented to adolescents. Most adolescents are present-oriented, which means they are generally not concerned about how their current eating habits will affect their future health status and most are unable to apply new concepts to current behaviors or situations (Croll et al., 2001). They are, however, concerned about their physical appearance, maintaining a healthy weight and having energy. While teenagers should give consideration to the potential long-term risks of an unhealthy diet and benefits of healthy eating habits, focusing on short-term benefits with adolescents is more likely to make a lasting impression on the target group and facilitate dietary change. Nutrition-focused educational materials and messages must be written in local language and in a style identifiable to the concerned target group. Some key concepts kept in mind while developing educational material includes use of active rather than passive voice when presenting information, use of local language and commonly used phrases and words instead of medical/technical terminology and inclusion of illustrative examples for all key concepts discussed. Intervention Matrix Nutrition Level Impact on Strategy Objective Strategy Action(s) Nutrition Nutrition nutrition Sensitive Specific To include 1. DoE would notify a committee Quality of nutrition in school with responsibility/ purpose to education and curricula by June develop training modules, √ -- knowledge about 2015 dietary guidelines and Nutrition curriculum (Policy level) interventions will 2. Nutrition curriculum planning improve health within Institutes of Higher and nutrition Learning in collaboration with √ -- status international institutes (Policy Level)

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3. Induct a nutrition specialist in the Punjab Curriculum Authority for revision and inclusion of √ -- nutrition modules/chapters (Implementation Level) 4. A provincial regulatory body (Nutrition & Dietetic √ -- Council) 4.5. Creative Inclusion in Access to curricula/ syllabi by the end of educational 2014 (Implementation level) materials and a) Revise the curricula for awareness about primary , middle, inter level dietary habits and make it more nutrition will ultimately focused for boys & girls √ -- improve health b) Add nutrition related text- and nutrition boxes in curricula/ syllabi status c) Prepare key messages regarding Nutrition ensuring order and consistency, for inclusion in curricula/ syllabi 5.6. New Inclusion in curricula/ Access to syllabi by June 2015 educational (Implementation level) materials and a) Introduce a chapter awareness about “Preventive Health and healthy dietary Nutrition” in curricula/ syllabi habits will consisting course contents ultimately like nutrition, health & √ -- improve health hygiene, personal and nutrition hygiene/sanitation, safe status water, food safety and communicable disease b) Introduce “Nutrition & Health” related new subject from Primary classes onward To train all the 1. Launch training modules by June Training of School Health 2015 for School Health & teachers and SN &Nutrition Nutrition Supervisor from each & HSs will enable Supervisors district in nearby well- delivery of (SH&NSs) and established Nutrition nutrition related school teachers by Departments. The training activities with a √ -- 2017 modules will contain contents focus on regarding counselling of strengthening children, teachers, parents and nutrition as an adolescent males & females and integral part screening & referral to nearest health facilities of malnourished

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children (less than five years of age) and adolescents (Implementation Level) 1. Train teachers by adding Nutrition Modules (Implementation Level) a) Training of trainers by well- established nutrition department OR by qualified nutritionist/dietician b) Inclusion of nutrition modules in teachers √ -- training programs i.e. In- Service and Pre-Service Teachers Training by School Education Department c) Introduce virtual/online training program to conduct trainings/ seminars/ workshop to ensure early completion of training programs. 2. Introduce a mechanism for Strengthen the monitoring of curriculum, nutritional facilities and validation of programs Nutrition related activities at implemented schools and universities level throughout the i.e. establish Nutrition & province; helpful √ -- Dietetic Council for monitoring in decreasing and evaluation of professional malnutrition level education in Nutrition burden along with registration of Nutritionists and Dieticians(Policy Level)

3.5.4.3 Strategy: Provide and promote quality hygiene and sanitation practices within school premises

Background/Rationale: Poor physical environment (unsafe drinking water and poor sanitation and hygiene, or WASH), is one of the underlying determinants of malnutrition, often leading to increased burden of diarrheal disease – leading cause of child mortality in Pakistan. Additionally, diarrheal disease decreases intestinal absorption of nutrients. Thus, even when food consumption is sufficient, diarrheal disease can lead to malnutrition among children by impeding intestinal absorption (WHO, 2008.)

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Resultant deficiency in energy, minerals and vitamins have considerable negative impact in about 35% of all children, leading to deaths and presenting 11% of the global disease burden (Black, Allen, et al 2008).Current evidence suggests that the achievement of good nutritional status is of vital importance towards attainment of MDG 4. Chronic under-nutrition severely reduced school attendance and diminishes health, economic and gender potential (UNICEF 2008).

Intervention Matrix Nutrition Level

Impact on Strategy Objective Strategy Action(s) nutrition

Specific

Sensitive

Nutrition Nutrition Nutrition To ensure 1. Ensure the provision of missing Prevention of availability of facilities e.g. functional toilets, diarrhoea& facilities for with proper sanitation and privacy infections, a √ - implementation of in schools/ colleges with known risk factor quality hygiene and assistance of HUD & PHED of malnutrition sanitation practices (Implementation Level) at 100% schools by 2. Ensure availability of safe drinking 2019 water by installation of water (especially in girls filtration plants in schools with -- √ school) assistance of HUD & PHED (Implementation Level) 3. Increase water conservation with increased and improved water storage capacity with assistance √ -- of HUD & PHED (Implementation Level) 4. Availability of soaps in school √ √ toilets(Implementation Level)

3.5.4.4 Strategy: Capacity Development- Introduce and Promote Nutrition as a profession The current curricula for students in school do not provide enough knowledge on the mechanisms through which micro and macronutrients interact with one another and their role in maintaining optimal body functions, interferences of these mechanisms and implementation of this knowledge for prevention of malnutrition and promoting healthy nutrition. Furthermore, tools for nutritional assessment, analysis, counseling and treatment are not well integrated within the training curricula of schools and Institutes of Technical Education. To build capacity it is necessary to promote nutrition as

Page 106 indivisible from health and provide a recognized professional track for training and employment in Nutrition related fields.

Intervention Matrix

Nutrition Level Strategy Impact on Strategy Action(s) Nutrition Nutrition Objective nutrition Sensitive Specific To promote 1. Increase opportunities for Will strengthen recognition of professional level degree and the nutritional √ -- Nutrition as a post-graduate courses in programs profession and to Nutrition (Policy Level) implemented introduce it as a 2. Strengthen already existing throughout the post-graduate degree providing province and will subject by 2019 departments/institutes by be helpful in √ -- training and capacity decreasing development of existing faculty malnutrition (Implementation Level) burden 3. Promote establishment ofNutrition departments within √ -- Institutes of higher learning (Policy Level) 4. EstablishNutrition & Dietetic Council for monitoring and evaluation of professional level √ -- education in Nutrition along with registration of Nutritionists and Dieticians (Policy Level)

3.5.4.5 Strategy: Improvement of nutritional status among school going children Background/Rationale: An integrated approach based on multi-dimension may be needed to improve nutritional status of the school-going children.

Intervention Matrix

Nutrition Level Impact on Strategy Objective Strategy Action(s) Nutrition Nutrition nutrition Sensitive Specific To perform 1. Ensure screening and delivery On time diagnosis complete of essential package of will facilitate to screening of nutrition service to school- -- √ decrease school going going childrenon a quarterly malnutrition children enrolled basis. Package of care includes burden (especially

Page 107 in public sector on screening and referral for prevalence of quarterly basis malnutrition at an early stage hidden hunger) (Implementation Level) To introduce mid- 2. Provide micronutrient fortified Enhance school day meal at all high-energy biscuits and performance and schools in high dates, to enhance school help improve risk districts by performance and improve nutrition 2015 micronutrient levels, indicators linked particularly vitamins, minerals to vitamins, -- √ and proteins. The scheme will minerals and start from Southern Districts protein which have poorer nutrition consumption status among women and children and will scale up over time. (Implementation Level) To introduce 3. Promote biannual de-worming deworming of children (Implementation services at all Level) -- √ schools in high risk areas/district by 2014 To introduce 4. Promote Availability of healthy Preventive nutritious foods nutritious foods at school approach will be &daily physical canteen: helpful in reducing activity at all a) Through encouraging malnutrition schools by 2014 availability of nutritious food burden commodities in school -- √ canteens b) Discouraging school canteens from selling junk food and carbonated drinks (Policy Level) 5. Introduce daily physical activity -- √ at schools(Policy Level) To launch 6. Raise awareness: Access to campaigns and a) Seminars, awareness educational awareness sessions, and other materials and programs awareness activities by SHNS, awareness about LHWs, CMWs, Field assistant dietary practices agriculture department (especially among teachers and respected of √ -- females) the area, involvement of will ultimately private sector, private lead to uptake of practitioners nutritionindicators b) Distribution of IEC material c) Celebration of special days like (World Food Day,

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breastfeeding day, water, egg days) d) Arrange parent- teacheradvocacy meetingsfor health promotion, Nutrition needs among children& household members, menu planning, kitchen gardening and animal raising at household level

4 CHAPTER 4: IMPLEMENTATION OF THE STRATEGY / OPERATIONALIZATION

4.1 Implementation Model Effective and coordinated implementation of the proposed strategy is imperative in realization of the objectives of the strategy. The implementation is proposed to be done in partnership between all responsible departments. Implementation of this strategy will be mainly through three distinct ways; 1) adjustments in already implemented or existing programmes by making them more nutrition sensitive 2) seeking funds and implementing nutrition sensitive interventions by developing PC-1s against approved interventions in this strategy using their own resources 3) seeking funds through Nutrition Cell from the pool of resources allocated for implementation of nutrition strategy for nutrition specific and high priority nutrition sensitive interventions. The implementation model will vary from intervention to intervention for effective implementation. There are interventions in all sectors, which are department specific and therefore the implementing department will take lead in its planning and implementation within the sector. Some interventions are multi-institutional within each sector and some are multisectoral, and their effective implementation requires coordinated implementation frame-work from all involved departments and/or sectors.

NUTRITION PLANNING AND IMPLEMENTATION FRAMEWORK – AN HOUR GLASS MODEL

Provincial technical working groups

Food Sector

Health Sector PROVINCE Education Sector Page 109 WASH Sector

Social Protection Social Welfare & Women Development Agriculture, Livestock, Fisheries Sector

DISTRICTS IMPLEMENTATION COMMITTEE DCO ↔ EDO Edu ↔ EDO Health ↔ EDO Agriculture ↔ DO Public Health Engineering ↔ ADLG/TMA

School Health & Nutrition Supervisor ↔ Teacher ↔ 4.2 Organizational StructureLHWs ↔ Field Assistant Agriculture ↔ UC Secretory

Policy level P&D

Provincial level coordination & implementation PMAC Coordination line Nutrition Cell at PSPU Coordination line

District level coordination & implementation DMAC

Tehsil level TMAC coordination & implementation

UC level UMAC coordination & implementation

Figure 131 organizational structure of Punjab multi sectoral nutrition program

The real challenge in implementation of multi-sectoral strategy is “coordination from province to districts to city council/ward/village and fixing the verifiable responsibilities at all levels”. Each intervention will be monitored by specific technical committees constituted at all levels named “Malnutrition Addressing Committees”. Coordination may be further improved by framing joint implementation framework indicating the clear roles and responsibilities of each sector.

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4.2.1 Provincial

4.2.1.1 Nutrition Cell at PSPU The Punjab multisectoral nutrition implementation program will be designed in an effective institutional framework using the existing arrangements and establishing new ones for policy direction, coordination, monitoring and evaluation

Provincial level oversight/management structure will be housed in P&D department Punjab as P&D works as central department for monitoring and evaluation of development plans, policies and programs. For this purpose, nutrition cell will be housed in PSPU, which will be reporting to P&D. This cell will be responsible to arrange quarterly progress review meetings of PMAC in order to review and track the progress. Nutrition cell will also facilitate collaboration and partnerships among different stakeholders in planning, and implementation of nutrition programs.

Nutrition cell will have three professionals (supported by partners) that will support the PMAC in the area of information management and data analysis, including different aspects of the monitoring of nutrition information across the sectors and evaluation. This cell will also support for development of multisectoral nutrition communication strategy.

4.2.1.2 A provincial malnutrition addressing committee (PMAC) A provincial malnutrition addressing committee (PMAC) is proposed at provincial level in order to provide a platform for planning of nutrition-specific and nutrition-sensitive programs, coordination, and information dissemination, to review and share progress & monitoring. The committee will also be responsible to track implementation status of program, timely identifying bottle necks, addressing problems. The secretariat of the Punjab multi Sectoral program (PMSNP) will be based in the P&D Department and nutrition cell in PSPU will facilitate the procedure of coordination & review the progress. It is proposed that under the chairmanship of P&D department, following departments will represent in the PMAC.

• Agriculture Sector (Departments of Agriculture, Livestock & Dairy Development and Fisheries) • Food Sector (Department of Food, Punjab Food Authority) • Education Sector (Departments of School Education, Higher Education, Literacy, Punjab Curriculum Authority, University(s)) • Health Sector (Departments of Health) • WASH Sector (Departments of Public health engineering (PHED) and local government)

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• Social Protection Sector (Departments of Social Welfare & Bait-ul-Maal, Women Development, BISP) Participating sectors will be responsible to mainstream nutrition into their respective sectors and implement the planned interventions with in their domain. A continuous and ongoing reporting will be part of every sector’s routine reporting system.

4.2.1.2.1 ToRs of the PMAC The PMAC will be responsible for ;

• Incorporate & prioritize nutrition in all sectors (develop nutrition specific/ sensitive plans) • Devise effective and ongoing monitoring system through reviewing/ revise routine reporting & recording tools in order to incorporate nutrition indicators of multi sectoral nutrition strategy in to it. • Finance management through mobilizing resources required for nutrition sensitive & nutrition specific activities. • Advocate and ensure political and partners commitment and support • Continuously assess and review the program implementation status • Devise outcome based accountability system for mid-term and final evaluations • Devise research based monitoring and evaluation system

P&D

Social Health Education Agriculture wash Food protection

Figure 142 Provincial malnutrition addressing committee

The PMAC will be assisted by a nutrition cell in the PSPU that will be responsible for:

• Coordination and information management: building linkages with DHIS, HMIS etc. • Development & operationalization of multisectoral nutrition strategy reporting system • Development of multisectoral nutrition Communication/advocacy strategy and uniform messages to be used by each sector

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• Support capacity development on planning & implementation of multisectoral nutrition program. • Improve coordination with donors and partners for mobilization of financial resources and technical assistance

4.2.2 District

4.2.2.1 District malnutrition addressing committee (DMAC) The DCO will notify a district level malnutrition addressing committee DMAC . District level committee will be responsible for implementation of multisectoral nutrition program in whole district and where there is phased / partial implementation this committee will perform selection and identification of CCs or wards for implementation. The committee will have the representation of all district level participating sectors and will work under the guidance provincial level PMAC. This implementing committee will work under the chairmanship of DCO in each district.

This committee will be constituted again on the same pattern of PMAC ensuring the representation from all concerned departments. Representation from civil society, and CBOs will also be given in the composition of DMAC

4.2.2.1.1 ToRs of the DMAC:  Micro plan & implementation of nutrition related interventions in line with the Punjab multi-sector nutrition program  Incorporate multisectoral nutrition indicators in the district monthly and annual monitoring plans  Ensure multi-sectoral coordination at implementation level and district level  Devise evaluation procedures and report evaluation results to PMAC and corrective actions proposed or taken, if any  Timely reporting of the all implementing sectors and PMAC and Nutrition Cell at PSPU The DMACs will rely on technical support from the health department through the district nutrition officer (one nutrition qualified school & nutrition supervisor will be nominated as district nutrition officer).

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4.2.3 Community

4.2.3.1 Union-council malnutrition addressing committee (UMAC) At union council level (now called as city council in urban set-up and ward in rural set-up) a Union Council Malnutrition Addressing Committee (UMAC) will be established in order to ensure the community level implementation. This composition of the committee will be as following.

• Convener: Facility-based Medical Officer • Secretary: School Health & Nutrition Education Supervisor • Members: Representative of Livestock (if any), Agriculture (if any), Secretary of CC or Ward, Heads of School Education Councils in CC or ward, Lady Health Supervisor, One school teacher from all schools in CC or Ward, Chairmen of Zakat Councils in CC or ward, 02 public representatives (at least one female)

4.2.3.1.1 ToRs of the UMAC: • Implement nutrition interventions under the guidelines of DMAC • Implement monitoring plan and furnish monitoring reports as per direction of DMAC • Ensure timely & quality reporting of the all implementing sectors • Improve multi-sector coordination to attain common goal of reducing chronic malnutrition- nutrition at CC or ward level.

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4.3 Harmonization and Synergy

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SH&NS

UC- education sectray MO

M&E unit livestock LHS

Agri Coordinationline

UMAC Reporting line Reporting

health

social education protection DCO

M&E unit

wash Food

Agri Coordinationline

DMAC

health Reporting line Reporting

social education protection P&D M&E unit

wash Food

Agri

PMAC 4.4 Capacity Building It is anticipated that the capacity of various sectors and departments involved in implementation of this strategy is very week including policy makers, implementers, monitors and evaluators. Therefore, capacity building itself should be taken as key pre-requisite for effective implementation. Capacity

Page 116 building of sectors from planning to implementation of multisectoral nutrition approach will be of prime importance for the successful implementation of the program. An assessment to analyses sectoral capacity should be targeted and focused in order to decide the type, level and number of human resource needed for effective implementation. For this purpose, a workshop involving all sectors will be conducted and a comprehensive plan for human resource development on the areas of strategy implementation will be developed followed by actual capacity building with the support of partners.

4.5 Communication Strategy A comprehensive targeted & uniform communication strategy is key to achieve objectives of this strategy. The development of the communication strategy will require formative research keeping the local context in view including traditional beliefs, taboos and traditions that are common in urban & especially in rural areas of Punjab.

The research will investigate the basic and underlying causes behind the maternal nutrition and infant & young child feeding practices. In this way an appropriate, uniform & effective behavior change communication packages and training modules can be designed for every sector.

4.6 Monitoring, Evaluation and Accountability The core concept of monitoring and evaluation of multisectoral nutrition strategy is based on following:

• Are the right things are being done? (The type of interventions) • Are the right things being done well? (Implementation gaps) • Are the right things being done enough? (Planning gaps) • Have the interventions made a difference? (Overall impact of the strategy), and how do we know? (Evaluation mechanism) Participating sectors will institute a systematic approach to reporting through integrating key nutrition sensitive indicators. The monitoring frame-work will be indicator based and will comprise of monitoring at all levels including inputs & services monitoring, outputs monitoring, outcomes monitoring and impact monitoring. The monitoring indicators against each intervention have been given in RFAs (Annexures----). However, complete monitoring frame-work of each intervention will be developed in PC-1 of that particular intervention.

This will be the first experience of its nature in Punjab where various sectors will have to work together on common objective of reducing the prevalence of malnutrition. In order to ensure that sectors are able to work in a coherent and adopting geographically focused approach, an inter-sectoral project

Page 117 management and monitoring team will be recruited through Nutrition Cell at PSPU at provincial level oversight and monitoring. The strategy assumes that mid-term and end evaluation of the inter-sectoral nutrition intervention would be undertaken to assess the impact of these interventions. All participating sectors will be responsible as well as accountable for their part of implementation in the joint monitoring & evaluation system.

4.6.1 Measuring the progress: result based monitoring framework

4.6.1.1 Monitoring the impact of Multisectoral interventions Impact is assessed by calculating & documenting the changes in the nutritional status of target group (women and children) as a result of implementation of proposed Multisectoral interventions.

Proposed M&E frame work will consist of three parts.

1. Impact assessment can be done by using standardized survey procedures (Demographic and Health or Nutrition Surveys, for example) and calculating the average rate of reduction for only few selected indicators – such as prevalence of acute & chronic malnutrition in children under five years of age.

2. Proposed M&E Framework will also include a description of how the contribution of all participating sectors will be measured and reported is described below.

3. Nutrition Cell will Monitor the services (outputs) provided by thesectors and assess the implementation status of the strategy. It will measure the commitments made by the sectors to monitor and report on the contribution of its services. (M&E frame work attached in annexure)

4.6.1.2 M&E unit: structure, function and use of information, feedback system Routine monitoring of the activities will be conducted at UC and district level and reporting and coordination line will be same as described in the figure 3.

The M&E Framework will provides a framework for the collection of data of all relevant indicators with a view to assess & evaluate impact, outcomes and outputs of the Multisectoral nutrition interventions through a proposed mechanisim. To measure the impact of proposed interventions the M&E Framework will use the secondary data that will be collected by routine reporting sytem of sectors at provincial level

Page 118 and collated by the Multisectoral reporting system by nutrition cell. While outcomes will be measured by the participating sectoral focal Persons (PMAC) will take the lead in collecting and reporting data.

4.6.1.3 Provincial level (Centralized M&E at P&D) Provincial level monitoring will be more result based and focused. For this purpose uniform monitoring checklist will be developed and shared with all sectors. Every sector will be responsible to share monitoring reports with timeline, as may be appropriate, with Nutrition Cell of P&D, housed in PSPU. Reports will be analyzed by nutrition cell and feedback will be shared with relevant sectors through TWG meetings at provincial level as well as with district level implementation team.

4.6.1.4 District level (Office of DCO) District level monitoring check lists will be developed at provincial level on uniform format covering district level implementation activities of all sectors. DCO office will be compiling the sectoral monitoring reports and sharing the consolidated reports at provincial level.

4.6.1.5 Community level (Office of the Medical Officer/Local Union Council) At UC level MO will be responsible to engage every sector representation in monitoring as well as implementation and reporting.

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Sosical Health protection

Education Food

P&D Agriculture (Nutrition Wash Cell) Feed back Feed back

Feed back back Feed

DCO office

UC - monitoring reports

Figure 164 Multisectoral monitoring & feedback system

4.7 Research and development

Implementation model based on evidence based interventions is key to success in realization of this strategy. Therefore, research and development has been envisioned core this strategy. An important step prior to implementation is availability of data generated through evidence based effectiveness studies. In this strategy, a three tier research based eveidence generation is proposed:

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• Exploratory research: to identify the issues related to nutritional status, its impact on health, magnitude/gravity of the issues and causal framework of the issues. This part has mostly been done by the NNS, 2011. As ~four years’ time has passed since NNS data was collected, it is proposed that the baseline data should be reconfirmed by small survey in three districts (one district each from North, South & Central Punjab) • Constructive research: Small scale piloting in on-ground conditions is proposed for evidence generation for effectiveness of the interventions. These might include 1) Implementation Trials: A valuable approach that would generate knowledge about successful implementation alternative strategies using a randomized trial design and might require multiple location and multilevel analyses to fully examine impact. 2) Research on Increasing Rates of Intervention Adoption and Participation: Research to test the rate of adoption and rate of participation of a particular program in urban, peri-urban and rural settings and communities with different ethnic background. 3) Encouragement Designs: Randomized designs to test various modalities of recruitment, incentives, or persuasion messages to influence their choice to participate in one or another intervention condition.

• Empirical research: testing the effectives of the solutions. This research will be ongoing and will make the part of continuous monitoring and evaluation process.

Sometime, programs prove to be efficacious in controlled trials, however, the effectiveness might be different under real-world conditions. In the real world, translation of science-based interventions often stumbles, might be largely unguided, and may lead towards uneven, incomplete, and disappointing outcomes and ultimately poor realization of strategic objectives. The research in constructive and empirical domain especially is linked with factors associated with the adoption and use of scientifically validated interventions by service systems also focusses on maintenance and sustainability issues at the practice level that can be used to for effective and coordinated implementation.

Translational research, will accompany with implementation of many strategic interventions of this strategy, and will help to explore the factors that influence the ongoing quality of implementation; and in such studies, implementation quality itself will be the outcome of the research.

One of the core theme of this strategy is taking “implementation as a science” and using research & development as base of this science. The ongoing process of research explores and scientifically testifies

Page 121 the adoption potential of key interventions and redesigning from the lessons learnt to achieve strategic objectives.

There will variable research requirements for various inter- and intra- sectoral interventions. A consultative workshop involving all the sectors will be conducted before the implementation of the strategy to identify research needs for effective implementation, monitoring and evaluation of proposed interventions.

31A typical research based model for community interventions adopted from adopted from (O'Connell and others, 2009)*

31 * http://www.ncbi.nlm.nih.gov/books/NBK32764/#ch11.s1-National Academies Press (US); 2009.

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4.8 Public private partnership/Bussiness Network Bussiness network or private sector can play a vital role in Multisectoral approach to address malnutrition. A research by world Economic Forum concluded that “the “business Case” for companies to engage in hunger-reduction efforts varies by industry, by company and by company’s activities. Nearly every step in the food production and consumption process offers opportunities for some type of business involvement”.32

Contribution of any company to overcome malnutrition will obviously vary depending on the type of industry, sector, stage in the food value chain, and type of intervention. It will also be influenced by other participating sectors, partners.

Involvement of business network is proposed to complement Multisectoral nutrition spproch to address malnutrition. Every participating sector will soordinate and identify relevant interventions with private sector and corporate sector will be involved in the process.

It is proposed to establish business network for nutrition at provincial level to coordinate with relevant sectors . It is further proposed that focal point should be nominated for business network, focal point is proposed to reaches out to sectoral focal Point and other Networks and liaises at provincial and district level Organise multi-stakeholder convenings to define potential contributions by the private sector and agree on ways of working with all sectors.

4.9 Financial framework/ resource management

4.9.1 Financial Management After approval of the Multisectoral nutrition strategy all sectors will develop PC-1s against approved strategic actions or if already have developed, will revise their plans to be in line with the proposed interventions in multisectoral nutrition strategy. The departments will seek funds for implementing nutrition sensitive interventions against approved interventions in this strategy using their own resource, however, funds will be allocated through Nutrition Cell from the pool of resources allocated for implementation of nutrition strategy against nutrition specific and high priority nutrition sensitive interventions.

32 Harnessing Private Sector Capabilities to meet Public needs: The potential of partnerships to Advance progress on Hunger, Malaria and basic education. The world economic forum, Geneva: 2006.

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4.9.2 Establishment of Joint Funding Pool To meet the resources against nutrition specific and high priority nutrition sensitive interventions, Joint Funding Pool at P&D level will be established for implementing this multi sectoral strategy. The government of Punjab and development partners will make their committed contributions into the pool of funds. Any development partner(s) willing to support multisectoral nutrition strategy of Punjab may join this arrangement at any point of time under the established arrangements. The P&D along with PSPU shall be responsible for coordination and release of funds. The development partners and the government of Punjab will make their annual contributions in the pool. The first installment will be based on the approved plans/PC1s recommended by the TWG and the subsequent installment(s) might be linked with expenses reported and progress made over the indicators.

4.9.3 Funds Flow Department of Health has been implementing nutrition specific interventions and has recently started implementing the integrated RMNCH & Nutrition program in Punjab. These most of the nutrition specific interventions will be now onwards DoH’s routine activities and it is proposed that these nutrition specific programmes would continue to be funded according to the current sectoral arrangements. The same approach will be followed for nutrition sensitive programs, and if some additional resources are required then these can be obtained from joint funding pool. The multi sectoral programs and budget will be prepared as per sectoral plans and on the recommendations of technical working group (TWG). The nutrition plans will be prepared by the sectors to be in line with the targets/milestones set by the Multisectoral technical working group for five years as given in result frame-work analysis. The pay for performance package will be designed by the P&DPSPU nutrition cell to encourage participating departments to increase their performance in implementation of the strategy.

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Annextures Annex-1 Result Framework Analysis of Health Sector

TIME LINE (Years) Strategy Base Means of Key Strategy Action(s) Indicators Objective Line Verifications Y Y Y Y Y Assumptions 1 2 3 4 5

Strategy 1: Mainstreaming Nutrition in Health To develop 1.1 Develop and promulgate rules Policy Policy Subject to Policy frame for implementation of Breast notification & TBD notification & political feeding Act 2009 work to create direction issued directive ownership and enabling available/ subject to environment 1.2 Policy decision to integrate implementation promulgation for nutrition as part of EPHS and TBD mainstreaming revision of JDs of HCPs & material SHNS accordingly available Nutrition in √ √ √ √ √ Sector & 1.3 To take up with PFA regarding improving development of, legislation on TBD multi-Sectoral flour fortification with iron, salt coordination iodization mechanisms 1.4 Policy to institutionalize by year 2015 Gender Sensitive and pro poor TBD approach in all health plans (PC1s)

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1.5 Advocacy with BISP to convert No. of meetings Minutes of Subject to its cash transfer scheme into held with BISP meeting political conditional cash transfer available ownership and TBD √ √ √ √ √ Subject to change in policy of BISP

To develop 1.6 Develop consensus among Meeting/Seminar Record Subject to stakeholders of each sector on nutrition Conducted Nil maintained √ √ √ √ √ implementation communication communication framework by and subject to December, 2014 strategy and funding development of 1.7 Develop linkages and provide IEC material support to other sectors in for other sectors implementation of Nil √ √ √ √ √ by December , communication strategy and 2015 training of their staff 1.8 Create awareness among community on use of nutritious Nil √ √ √ √ √ food, healthy dietary habits, hygiene and health

Strategy 2: Equitable access to Nutrition services to poor and marginalized people 80% of children # of new nutrition New operational Subject to 2.1 Establish nutrition treatment with SAM treatment centers centers/ Record availability of accessing services centers (OTPs) for SAM 200 500 930 (OTPs) for SAM available 80 on Severe Acute children from 80 to 930 by the funds children Malnutrition year 2017 (SAM ) established management as per National # of new nutrition New operational Subject to guidelines 2.2 Establish nutrition treatment centers (SC) for SAM children treatment centers centers/ Record 15 25 36 especially in the 8 availability of most affected with complication from 8 to (OTPs) for SAM available funds districts by 2020 36 by the year 2017 children with

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complication established

Reduction in Reduction in low birth weight % of babies with Health Subject to babies by 50% of existing baseline low birth weight low birth weight Department 10 % 20 % 30 % 40 % 50 % availability of babies by 50% by 2020 by improving maternal (quarterly/ funds and health of existing annual Reports) baseline (NNS implementation 2011) by 2020 by Improving 2.3 Enforcement mechanism of salt Policy notification Policy notified/ Subject to maternal health iodization developed and promulgation political implemented by 2015 TBD material √ √ √ √ √ ownership and available subject to implementation

2.4 Ensure quality of iodized salt # of districts with New operational Subject to by strengthening and up new labs labs/ Record political

gradation of existing lab system established available 10 20 30 ownership and TBD

by 2015 availability of funds

2.5 Advocate with PFA for Notification & Notification & Subject to effective implementation direction issued directive political regarding fortification of oil & TBD available √ √ √ √ √ ownership and Ghee with vit A & D by 2014 availability of funds

2.6 Assessment of existing Policy notification Policy notified Subject to mechanism of provision of TBD √ √ √ √ √ implementation Vitamin A biannually with NIDs by 2014

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2.7 Increase in coverage of Vit A % of coverage of Health Subject to from 73% to 95% during NIDs Vit A during NIDs Department 80 % 95 % availability of

by 2016 73% (quarterly/ funds and

annual Reports) implementation

2.8 Conduct research to assess Research Record Subject to absorption and storage of iron. Conducted TBD Available √ √ √ √ funding, Success of experiment

2.9 Research on compliance on Research Record Subject to uptake of iron Conducted TBD Available √ √ √ √ funding, Success of experiment

2.10 Provision of iron folic acid to % of deficient Record Subject to PLW and adolescent girls adolescent girls Available; political

100 % 100 through community health provided with iron Health 10 % 25 % 50 % 75 % ownership and workers TBD folic acid Department availability of

(quarterly/ funds annual Reports)

2.11 Promote and provide % of children & Record Subject to deworming tablets to children adolescent girls Available; political

100 % 100 and adolescent girls. provided with Health 10 % 25 % 50 % 75 % ownership and TBD deworming tablets Department availability of

(quarterly/ funds annual Reports)

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2.12 Provision of iron syrup and % of government Record Subject to tablets in all health facilities health facilities Available; political

100 % 100 provided with iron Health 10 % 25 % 50 % 75 % ownership and TBD syrup and tablets Department availability of

(quarterly/ funds annual Reports)

2.13 Ensure develop and enforce of % of industries Availability of 100(15 % %) 100(25 % %) 100(10 % %) Subject to flour fortification law by 2016 performing iron fortified 10(2 % %) 25(5 % %) implementation fortification of TBD flour flour (% of chakki)

Reduction in 2.14 Promote healthy timing and Seminar Record Subject to low birth weight spacing of pregnancy Conducted/ maintained availability of babies by 50% Campaign funds Nil √ √ √ √ √ of existing launched baseline (NNS 2011) by 2020 by Improving 2.15 Increase coverage of ANC by maternal health health care providers

2.16 Provision of calcium and % of PLW Record Subject to vitamin D supplements to PLW provided with Available; political

100 % 100 calcium and vit. D Health 10 % 25 % 50 % 75 % ownership and TBD supplements Department availability of

(quarterly/ funds annual Reports)

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2.17 Counseling of pregnant women % of pregnant Record Subject to to take one extra meal and food women aware with Available; political

diversity in accordance with food pyramid Health 20 % 30 % 40 % 50 % 60 % ownership and food pyramid TBD Department availability of (quarterly/ funds annual Reports)

Reduce 2.18 Increase in early initiation % of babies with Record Subject to

20 20 % 30 % 40 % 50 % 60 % prevalence of within one hour from 15% to early initiation 15% Available; implementation stunting among 60% Health Department children of 2.19 Increase exclusive breast % of babies with Subject to

(quarterly/ 25 % 30 % 35 % 40 % 50 % under five years feeding from 22% to 50% exclusive breast implementation 22% annual Reports) from 39% to feeding 27% ( 2% reduction annually by 2.20 Increase the number of children Addition in % of Subject to fed in accordance with all three babies fed in implementation

2020 % 100 IYCF practices (breast milk accordance with all 15 % 30 % 50 % 75 % consumption, timely TBD three IYCF

introduction of solid foods, food diversity, frequency and practices consistency of weaning food.)

2.21 %age of mothers aware of at % of mothers % 100 Subject to

15 15 % 30 % 50 % 75 % least two benefits of exclusive having knowledge TBD implementation

breast feeding

2.22 Percentage of mothers aware of % of mothers % 100 Subject to

15 15 % 30 % 50 % 75 % all components of IYCF having knowledge TBD implementation

practices.

2.23 %age of mothers able to % of mothers Subject to

100 % 100

15 15 % 30 % 50 % 75 % identify at least two signs of having knowledge TBD implementation childhood illness (e.g.

Pneumonia)

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Reduction in Reduction in acute malnutrition % of child Reports Subject to

acute from 15% to 9% by 2020 14 % 13 % 12 % 10 % (prevalence) with Available 9 % political 15% malnutrition acute malnutrition ownership and

from 15% to 9% implementation by 2020 2.24 Increase in coverage of fully % of immunized Reports Subject to

immunized children from children Available 40 % 50 % 60 % 75 % 90 % political 34.6% 34.6% to 90%. ownership and implementation

2.25 Establishment of nutrition % of BHUs and Reports Subject to treatment sites at 30% BHUs RHCs with Available political

10 10 % 15 % 25 % 30 % and all RHCs of Province nutrition treatment TBD 5 % ownership and

sites availability of funds

2.26 Establishment of Stabilization # of DHQs with Reports Subject to Centers (SCs) in all DHQs & Stabilization Available political

Teaching Hospitals. 10 15 25 36

5 Centers (SCs) TBD ownership and

availability of funds

2.27 Increase in percentage of % of unidentified Reports Subject to identified SAM children

SAM children Available % 100 political

15 15 % 30 % 50 % 75 % enrolled for treatment in approached TBD ownership and nutrition site.

availability of

funds

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2.28 Increase percentage of % of children Reports Subject to registered children successfully registered Available political treated for severe acute (successfully ownership and TBD malnutrition according to treated for SAM) availability of national guideline protocols. funds

2.29 Provision of MMS sachet to % of children Reports Subject to 60% of identified MAM provided with Available political

25 25 % 30 % 40 % 50 % 60 % children. MMS sachet TBD ownership and

availability of funds

2.30 Increase in percentage of % of children with Reports Subject to children suffering from diarrhea provided Available political

15 15 % 20 % 30 % 40 % 60 % diarrhea treated with ORS & with with ORS & TBD ownership and Zinc.

Zinc availability of funds

Strategy 3: Strengthening capacity of Provincial and local governments on nutrition to provide basic services in an inclusive and equitable manner 80% of Health 3.1 Development of training Training modules Data/Record Subject to TBD √ √ Care providers modules for different cadres developed Available implementation trained on and subject to

# of master trained Data/Record 100 200 300 500 Nutrition 3.2 Trainings of Provincial master TBD 50 funding

Available trainers % of Community Certificate of health workers and Completion,

100% 3.3 Trainings of Community health health care Record 10% 20% 50% 75% TBD workers and health care providers trained maintained,

providers on Nutrition

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Annex-2 Result Framework Analysis of Agriculture: Crop Sector

TIME LINE (Years) Strategy Base Means of Key Strategy Action(s) Indicators Objective Line Verifications Y Y Y Y Y Assumptions 1 2 3 4 5

Strategy 1: Mainstreaming Nutrition in Agriculture

To develop Policy 1.1 Develop and promulgate Policy notification Policy notified Subject to frame work to Provincial Nutrition sensitive political create enabling Agriculture Policy TBD √ √ √ √ ownership and environment for Subject to mainstreaming Nutrition in funding Sector & 1.2 Policy decision to add nutrition Policy notification Policy notified Subject to improving multi- in IEC material of the sectoral political agriculture sector coordination by TBD √ √ √ √ ownership and year 2015 Subject to funding

1.3 Develop Gender Sensitive and Policy notification Policy notified Subject to pro poor Provincial Food political Security Strategy TBD √ √ √ √ ownership and Subject to funding

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1.4 Advocacy with BISP for linking No. of meetings Minutes of Subject to BISP beneficiaries with “Kitchen held with BISP meeting political gardening Scheme” available ownership and TBD √ √ √ √ √ availability of funding, Subject to change in policy of BISP

1.5 Policy to encourage increasing Policy notification Policy notified Subject to of female agriculture extension political officer and field assistant TBD √ √ √ √ ownership and Subject to funding

1.6 Enforcement of strict Mechanism Reports and Subject to regulatory measures to control 12 visits /annum/ 12 visits /annum/ 12 12 visits /annum/ notification/ no. of result of action implementation

visits /annum/

the sale of uncertified seeds, monthly visits of taken Available districts districts districts districts and subject to harmful pesticides and market in each TBD industries medicine with adverse effect

on human health district

To build capacity 1.7 Conduct training of district and % of staff trained Certificate of Subject to of implementing UC level staff Completion, implementation

100%

20% 50% 75% staff at district Nil Record 0% and subject to

and UC level on maintained, funding

nutrition manual

Page 134 by 2016 1.8 Conduct training of farmers % of farmers Certificate of Subject to trained Completion, implementation

100%

20% 50% 75% Nil Record 0% and subject to

maintained, funding

1.9 Create awareness among Seminar Nil Record Subject to farmers on use of nutritious Conducted maintained implementation √ √ √ √ food, healthy dietary habits, and subject to hygiene and health funding

Strategy 2: Increase Productivity in nutritious food (by developing and promoting high yielding varieties of grains & pulses)

To develop, 2.0 To increase in production of the Increase in Mong: Reports 80000 85000 90000 Subject to promote and pulses 5% annually from the production 78000 available funding and increase the production of 2012-2013 tons seasonal production of variation high yield Mash: 7000 7500 8500 varieties of

6050 pulses tons

Lentil: 6000 6500 7500

5420 tons

Gram: 750000 800000 850000 69100

0 tons

2.1 Development of pre- Seed available and Seed available Subject to TBD √ √ √ √ basic/basic seed of high tested funding, Success yielding varieties of pulses

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of experiment

2.2 Promotion of certified seed by No. demo-plots Record Subject to distribution among farmers at established maintained implementation subsidized prices and and subject to demonstration of modern 276 276 276 276 No. of visits of TBD funding production technology and community farmer gatherings

2.3 Distribution of Seed (Mong, No. of seed bags of Seed available Subject to

13601 18134

9067 Mash & lentil) to Farmers 40kg distributed TBD availability of

funds

2.4 Awareness (Mass media Campaign Education Subject to campaign, Farmer days, launched; No. of Department political Seminars) children/ (girls) TBD (quarterly/ √ √ √ √ √ ownership and admitted in annual Reports) availability of schools funds

Strategy 3: Equitable access to vegetables and fruits

To Develop, 3.1 Development & Provision of Quality seed Quality seed Subject to promote and Good Quality Seed and available and TBD available √ √ √ √ funding, Success increase Seedlings tested of experiment production of vegetables 3.2 Promotion of certified seed by No. demo-plots Record Subject to (Vitamins and distribution among farmers at established maintained implementation mineral sources) subsidized prices and 276 276 276 276 TBD and subject to

demonstration of modern No. of visits of funding production technology and community farmer gatherings

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3.3 Distribution of Seed No. of seed bags of Seed available Subject to

10000 10000 10000 10000 (Vegetables) to Farmers 40kg distributed TBD availability of

funds

3.4 Formation of tunnel haring on No. of tunnels in Reports Subject to 50% cost for vegetable 1000 1000 1000

each districts TBD available availability of

cultivation funds

3.5 Awareness (Mass media No. of events Reports

campaign, Farmer days, conducted TBD available 10 72 72 72 72 Seminars)

Strategy 4: Addressing Malnutrition through bio-fortification

To develop zinc 4.1 Development &Production of Seed available and Seed available Subject to fortified wheat zinc enrich wheat seed tested funding and TBD √ √ √ √ variety to reduce success of zinc deficiency experiment

4.2 Promotion of certified fortified No. demo-plots Record Subject to seed by distribution among established maintained implementation farmers at subsidized prices and and subject to demonstration of modern 276 276 276 276 No. of visits of TBD funding production technology and community farmer gatherings

4.3 Distribution of Seed to Farmers No. of seed bags of Seed available Subject to

10000 10000 10000 10000 40kg distributed TBD availability of

funds

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4.4 Awareness (Mass media No. of events Reports TBD 10 72 72 72 72

campaign, Farmer days, conducted available Seminars) Strategy 5: Scaling up of Kitchen gardening

To Increase 5.1 Promotion of kitchen gardening No. of meetings Record available availability of by conducting meetings of conducted in each TBD 24 24 24 24 24 micronutrient community in each UC (2 UCs per annum meetings/ UC/Month) rich food especially for 5.2 Provision of quality seed at No. of seed packet Record available Subject to subsidized rates 100000 450000 500000 550000 600000 650000 poor and distributed availability of vulnerable funds community

Strategy 6: Increase accessibility of animal protein sources at household level

Up-scale 6.1 Promote backyard poultry No. of meetings Record available household farming by provision of conducted in each TBD 24 24 24 24 24 livestock subsidized layer chicken with UCs per annum cock to vulnerable community production to increase the 6.2 Provision of small cattle of excellence genetic profile on access to protein subsidized rate for raring and rich foods future reproductive growth

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Annex-3 Result Framework Analysis of Agriculture: Livestock & Poultry

TIME LINE (Years) Strategy Base Means of Key Strategy Action(s) Indicators Objective Line Verifications Y Y Y Y Y Assumptions 1 2 3 4 5

Strategy 1: Increase the productivity by sustainable livestock farming and capacity development to combat protein energy malnutrition

4,500,000 tons 4,750,000 tons 5,000,000 tons To increase the 1.0 (A) To increase the gross annual meat production 3,379,000 tons Annual Report 4,000,000 tons 4,250,000 Subject to gross annual meat production from 3,379,000 per annum in tons (Economic political meat production tons in 2013 to 5,000,000 tons Survey of ownership and by the end of 2020 (according to

from 3,379,000 Pakistan) tons Subject to Economic Survey of Pakistan) funding tons in 2013 to

5,000,000 tons as

65,000,000 tons 70,000,000 tons 80,000,000 tons well as gross 1.0 (B) To increase the gross Milk production 49,512,000 tons Annual Report 55,000,000 tons 60,000,000 tons Subject to annual milk production from milk production per annum in tons (Economic political 49,512,000 tons in 2013 to Survey of ownership and from 49,512,000 80,000,000 tons by the end of Pakistan) Subject to tons in 2013 to 2020 (according to Economic 80,000,000 tons Survey of Pakistan) funding

by the end of 2020 (according 1.1 Enhance livestock production Availability of Excellence Subject to to Economic through adaptation of latest excellence genetic genetic profile funding, Success Survey of technology (biotechnology & profile breed/ breed available of experiment genetic engineering, Pakistan) Implementation improved reproductive TBD √ √ √ √ technologies, precision of latest animal breeding) and breed technology improvement (implementation & policy level)

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1.2 Promote and provide various Policy Policy notified Subject to livestock animals of excellence notification political genetic profile on subsidized TBD √ √ √ √ ownership and rate for raring and rapid Subject to reproductive growth (implementation & policy level) funding 1.3 Strengthen the easily provision Policy Policy notified Subject to of cost effective and safe notification political livestock (cattle & poultry) feed TBD √ √ √ √ ownership and (implementation level) Subject to funding

1.4 Promote the latest embryo Availability of Excellence Subject to transfer technology and provide excellence genetic genetic profile funding, Success semen’s injections of excellence profile animal’s TBD animal’s semen √ √ √ √ √ of experiment genetic profile animals at free of semen available cost/subsidized cost (implementation & policy level) 1.5 Increase the number of dairy # of fish farms New farm Subject to

farms and milch animals (2-5% established, 10% 15% 20% 25% implementation TBD 5% annually) from the existing in Record/Reports and subject to

2012-2013 (implementation available industries level) 1.6 Skills enhancement of livestock % of staff and Certificate of Subject to

100%

sector’s individuals (staff & 20% 50% 75%

farmers trained Completion, 0% implementation Nil farmers) by conducting trainings Record and subject to

at UC and districts level maintained funding (implementation level)

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Strengthen 1.7 Up-gradation of the existing lab Percent of labs up- Operational & Subject to veterinary facilities for proper diagnosis & graded up-graded labs/ political medical and safety testing of feeds and food Record available ownership and

100 % 100 diagnostic lab (milk & meat) in regions, where 10 % 25 % 50 % 75 % TBD availability of facilities by 2020 the labs are already present but

funds to control and are with limited capacity or non- reduce the risk operational (implementation & of outbreak policy level)

1.8 Establishing new livestock # of districts with New operational Subject to diagnostic lab facilities by the new labs labs/ Record political

end of 2019, in regions where established available 10 20 30 36 ownership and

TBD there is need but there are no availability of labs (implementation & policy funds level) 1.9 Provide various services at free # of animal TBD Record Subject to of cost (technical support, vaccinated & maintained implementation vaccination, and veterinary and subject to treated per annum √ √ √ √ √ medical services) to control and funding reduce the risk of outbreak (implementation & policy level)

Strategy 2: Reduce nutrient deficiency in targeted groups by increasing the physical access to livestock-based products

To increase the 2.1 Increase the awareness of # of events/ Reports 10 72 72 72 72 Subject to gross annual livestock-based protein sources seminars available funding, Subject milk (meat, milk and egg) importance conducted annually to implementation and its consumption through consumption (2 events/districts) Nil literature, extension services, from 39,945,000 mass media campaigns and tons in 2013 to education (implementation 80,000,000 tons level)

Page 141 as well as gross 2.2 Introduce and promote the value # of new products Reports Subject to eggs added livestock-based (meat, launched available implementation

15 20 35 50 50 milk and egg) products TBD consumption and subject to especially at school level from 13,813 funding (implementation level) million in 2013 to 20,000 million 2.3 Promote the consumption of egg Annual 13,813 million Annual Reports Subject to and poultry meat (5% annually by the end of consumption of available implementation

10% 15% 20% 25% from existing in 2012-2013) so egg 5% and subject to 2020 (according that poor families may also

funding to Economic consumed protein with high Survey of biological value at very low Pakistan) price (implementation level)

2.4 Promote the consumption of Annual 39,945,000 tons Annual Reports Subject to milk and milk product (5% consumption of available implementation

10% 15% 20% 25% annually from existing in 2012- milk in tons 5% and subject to 2013) to reduce the risk of

funding various essential nutrients deficiency (implementation level) Introduce and 2.5 Promote the consumption of Policy Policy notified Subject to promote various camel milk and its product to notification/ political livestock-based uplift the economic situation of ownership, community in desert area and TBD √ √ √ √ √ products by non- Subject to also to reduce the nutrient conventional deficiency (implementation implementation indigenous level) resources as 2.6 Introduce various milk products # of new products Reports Subject to value addition (like cheese, whey protein, launched available implementation casein, ice cream, chocolates, especially in 10 15 20 20 and subject to TBD 5

bioactive peptides etc.) vulnerable funding especially from camel milk as community to value addition (implementation reduce nutrient level)

Page 142 deficiency by 2.7 Launch various research project # of project Project Subject to 2017 and strengthen/scaling up the launched each launched/ implementation existing ones to develop various Nil Reports and subject to value added products from non- year 5 5 5 5 5 available funding conventional indigenous resources (implementation level) To ensure and 2.8 Enhance the quality of the Policy notification Policy notified Subject to improve safe as livestock-based products (meat, political well as quality of egg, milk etc.) by introducing ownership and the modern and safe processing livestock TBD √ √ √ √ √ Subject to techniques, and supply chain products from (cold storage, good funding farm to fork by transportation etc.) 2020 (implementation level)

2.9 Increase availability of quality Amount of Reports Subject to of livestock-based products livestock based available implementation (meat, egg, milk etc.) in local

product sale in 10% 20% 30% 40% 50% and subject to markets (10% annually from local markets TBD funding

existing in 2012-2013) and develop the mechanism to control the increases in prices (policy level) 2.10 Mandatory Safety/Management % of livestock/ Certificate Subject to Certification of large livestock poultry farms available, implementation farms in five years, medium size certified Record 10% 15% 20% 30% by PFA and in 10 years, and all livestock TBD 5%

maintained, subject to farms in 15 years industries

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2.11 Continuous professional No. of institutes Programs Subject to

development, capacity offering CPD and launched and 20 (1000) 20 (1000) subject to funds

10 (500) 15 (750) enhancement, trainings and Training programs trained persons 5 (250) and subject to awareness campaigns for all (No. of person TBD institutes

involved in food supply chain trained)

starting from producers to consumer desk

Strategy 3: Increase accessibility of animal protein sources at household level especially for vulnerable community Up-scale 3.1 Promote backyard poultry # of meetings Record No. of meetings household farming by provision of conducted in each available conducted in subsidized layer chicken with UCs per annum TBD 24 24 24 24 24 each UCs per livestock cock to eligible families annum production to (women) (Implementation increase the level) access to 3.2 Provision of small cattle of # of animal (with Record Subject to excellence genetic profile on excellence genetic implementation protein rich available 1000 2000 5000 5000 5000 subsidized rate for raring and profile) distributed TBD and subject to foods future reproductive growth

each year on funding (Implementation level) subsidized rate

To create 3.3 Create linkages of livestock Policy notification Record Subject to √ √ enabling department with BISPs program available political environment for “Wasela-e-Rozgar” and ownership/ upcoming new social protection mainstreaming # of families Record Subject to funds/

schemes to support for ultra- 1000 5000 5000 Nutrition in provided with available/ 500 Subject to poor segment of the society by cattle families with

Sector & up-scaling home based livestock TBD beneficiaries to improving and backyard kitchen farming cattle implement on (Implementation level) multi-Sectoral 5000 10000 50000 50000 kitchen farming # of families Record coordination by (never sell out) provided with available/

year 2015 layers families with layers

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Annex-4 Result Framework Analysis of Agriculture: Fisheries

TIME LINE (Years) Strategy Base Means of Key Strategy Action(s) Indicators Objective Line Verifications Y Y Y Y Y Assumptions 1 2 3 4 5

Strategy 1: Capacity Development: Strengthening the fisheries sector to increase the productivity by scaling up the existing resources to combat protein energy malnutrition

650,000 tons 650,000 tons 700,000 tons 750,000 tons 800,000

594,935 tons To increase the 1.0 To increase the production of Fish production Annual Report tons 620,000 Subject to production of fish from 594,935 tons in 2011 per annum in tons (FAO) political fish from 594,935 to 800,000 tons by the end of ownership& tons in 2011 to 2020 (according to FAO

implementation

800,000 tons by Statistics) the end of 2020 1.10 Increase the number of # of hatcheries # of hatcheries Subject to (according to hatcheriesfrom 88 to 150 by established/ political FAO Statistics)

105 120 135 150 the end of 2020 to ensure the 88 Record/Reports 95 ownership and

availability of high quality seed available Subject to (implementation level) funding

1.11 Promote and strengthen Policy notification Policy notified Subject to the economical fish-feed political production (implementation TBD √ √ √ √ √ ownership and level) Subject to funding

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1.12 Development and provision High yielding fish Seed available/ Subject to of seed of high yielding seeds available and Record maintain political varieties of various fish species tested TBD √ √ √ √ √ ownership and by some genetic modification Subject to (implementation level) funding

1.13 Promotion of high yielding fish- Seed availability at Policy notified/ Subject to seed (lowest price of available subsidized prices √ √ √ √ √ political protein) by distribution among ownership and farmers at subsidized prices TBD and demonstration of modern availability of Farm production technology to # of demo-farm 10 20 30 50 50 funding reduce pre & post-harvest established established losses (implementation level) 1.14 Skills enhancement of % of staff and Certificate of Subject to

100%

fishery sectors individuals (staff 20% 50% 75%

farmers trained Completion, 0% implementation & farmers) by conducting Nil

Record and subject to

trainings at UC and districts maintained funding level (implementation level) 1.15 Increase the number of fish # of fish farms New farm Subject to

farms (5% annually) from the established, 10% 15% 20% 25% implementation

5% existing in 2012- TBD

Record/Reports and subject to 2013(implementation level) available industries

1.16 Increase the capacity of the # of fish farm with Farm with Subject to existent fish farms (10% increased capacity increased implementation annually)by the end of TBD capacity, 10% 20% 30% 40% 50% and subject to 2020(implementation level) Record/Reports funding available

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1.17 Promote the Trout fish Annual production Annual Reports Subject to farming in natural water of trout fish in tons available implementation

10% 15% 20% 25%

5% resources to increase the Trout TBD and subject to

production (5% annually from funding existing in 2012- 2013)(implementation level) 1.18 Initiate shrimp cultivation in Annual production Annual Reports Subject to the Indus delta to increase the of shrimp fish in available 10% 15% 20% 25% implementation TBD 5% shrimp production (5% tons and subject to

annually from existing in 2012- funding 2013)(implementation level)

Strategy 2: Reduce nutrient deficiency in targeted groups by increasing the physical access to aquaculture/fish food To increase the 2.0 To increase the per capita Per capita fish 2.0kg Annual Reports Subject to per capita consumption of fish from 2 consumption in per available 2.5 kg/year 3.0 kg/year 3.5 kg/year 4.0 kg/year 5.0 kg/year funding, Subject consumption of kg/year to 5 kg/year by the end kg/Year year to fish from 2 of 2020 through awareness, implementation kg/year to 5 value addition and cost and success of kg/year by the effective fish products policies end of 2020 through 2.1 Increase the awareness of fish # of events/ Reports Subject to awareness, value meat importance and its seminars available funding, Subject addition and cost consumption through conducted to effective fish literature, extension services, Nil 10 72 72 72 72 implementation annually (2 products mass media campaigns and education (implementation events/districts) level)

2.2 Introduction of value added # of fish products Reports Subject to fish products such as fish launched available implementation

10 15 20 20 cookies, fish chips, fish biscuits, TBD 5

and subject to fish nan/chappaties, fish cakes, funding fish salads, fish samosa, fish biryani, and nimko, etc.

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(implementation level)

2.3 Promote the consumption of Annual Annual Reports Subject to small size fish (5% annually consumption of available implementation

10% 15% 20% 25% from existing in 2012-2013)so small fish in tons TBD 5% and subject to

that poor families may also funding consumed with low price (implementation level)

To ensure and 2.4 Enhance the quality of the fish Policy notification Policy notified Subject to improve safe as by introducing the modern and political well as quality of safe processing techniques, ownership and cold storage, good fish from farm to TBD √ √ √ √ √ Subject to transportation and fork improvement in marketing funding channel, etc. (implementation level) 2.5 Enhance the coastal Amount of fish sale Reports Subject to aquaculture production and in local inland available implementation

10% 20% 30% 40% 50% increase availability(10% markets (in tons) TBD and subject to

annually from existing in 2012- funding 2013) in local inland markets (implementation level)

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Annex-5 Result Framework Analysis of Food Sector

Strategy Base Means of TIME LINE (Years) Key Strategy Action(s) Indicators Objective Line Verifications Y Y Y Y Y Assumptions 1 2 3 4 5 Strategy 1: Physical access to food throughout the year for all targeted groups Increase in 1.19 Replace wheat storage No. of districts No. of Silo in Subject to storage capacity from bag to silos storage containing silos each districts/ political

10 15 20

from existing (Policy level) facilities for TBD Food ownership and level to 80% by storage Department availability of 2020 Reports funds Ensure access to 1.20 Explore avenues for Public Policy Policy notified Subject to food throughout and Private partnership to notification political the year preserve and increase storage ownership and perishable commodities at TBD √ √ √ √ Subject to their peak harvesting for year- Private partner long availability at affordable price (Policy level) 1.21 Introduce the applications Policy Policy notified/ Subject to of cost effective modern notification promulgation political technologies to improve food material ownership and supply chain and reduce post- subject to TBD available harvest losses (i.e. preservation √ √ √ √ adoption of new by irradiation, integrated pests technologies & rodents control systems, etc.) (Policy level) 1.22 Introduce and promote cold Notification& Notification& Subject to supply chain to increase the direction issued directive political safety of high risk food (Policy TBD available √ √ √ √ √ ownership and level) availability of funds

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Strategy 2: Ensure and improve food quality from farm to fork Strengthen lab 2.5 Up-gradation of the existing lab Percent of labs up- Operational & Subject to

facilities to facilities for wheat quality & graded up-graded labs/ % 100 political

10 10 % 25 % 50 % 75 % ensure food safety testing in regions, where Record available ownership and TBD

safety and the labs are already present availability of

quality by 2016 but are with limited capacity or funds non-operational(Policy level) 2.6 Establishing new lab testing No. of districts New Subject to with new labs operational political

facility in regions where there 10 20 30 36

is need but there are no labs established TBD labs/ Record ownership and (policy level Level) available availability of funds Strategy 3: Provision of safe food Strengthen and 3.6 Phase-wise extending the No. of Districts in Active PFA Subject to which department department in political

extension of Punjab Food Authority to 15 25 36

2 5

Punjab Food whole of Punjab by 2020 of PFA established 2 respective ownership and Authority to (Policy level) districts availability of improve food funds safety 3.7 Establishing lab facilities at No. of districts New Subject to district level parallel with the with new labs operational political

15 25 36

extension of Punjab Food established labs/ Record 2 5 ownership and

1 Authority for safety & quality (parallel to available availability of testing of food products(Policy extension of PFA) funds level) Improve the 3.8 Improving the capacity of Revision of Rules Notification& Subject to food safety inspection services through directive political management Revising and harmonizing the available ownership and systems by food rules with (Codex TBD √ √ √ √ √ subject to legislation, Alimentarious Commission facilities promulgate and (CAC), OIE, and IPPC) available implement (implementation Level)

) ) 0 0 5 ) 0 2 0 ) 5 ( 5 0 ( ) 7 0 5 0 ( 0 0 0 1 1 0 5 ( 1 1 ( 0 2 0 2

3.9 Continuous professional No. of institutes TBD Programs Subject to

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development, capacity offering CPD and launched and subject to funds enhancement, trainings and Training programs trained and subject to awareness campaigns for all (No. of person persons institutes involved in food supply chain trained) starting from producers to consumer desk 3.10 Promoting and advising to % of Large food Certificate Subject to get Food Safety Management business certified available, implementation Certification like HACCP, BRC, Record by PFA and

100% ISO-22000 etc. by food maintained, 10% 25% 50% 75% subject to TBD

industries business operators, targeting specifically the large industries and high risk food processors for 3 years 3.11 Mandatory Food Safety % of medium and Certificate Subject to Certification of large food small food available, implementation

10% 15% 20% 30% industries in five years, business certified Record 5% by PFA and

TBD medium size in 10 years, and maintained, subject to all food business operation in industries 15 years Strategy 4: Economic Access to food

Improve the 4.1 Targeted and conditional food Availability of low Price of food Subject to economic access subsidies for poor instead of price food in political to food by generic subsidies and will be market ownership and subsidies and linked with inflation rate by availability of price control 2014(Policy level) TBD √ √ √ √ funds and regulation 4.2 Putting in place the price mechanism control and regulation mechanism especially for staple food (Policy level) Strategy 5: Reduce micronutrient deficiency in adolescents girls, pregnant & lactating mothers and children’s through fortification

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Promulgate and 5.1 Create awareness on benefits Seminar Record Activity is implement, for use of fortified flour, salt Conducted/ maintained supposed to be legislation and edible oil (Policy level) awareness taken initially regarding material TBD √ √ √ √ √ with support of fortification of distributed donors and food by 2016 later on from ADP

100 % 100(50 % %)

5.2 Legislation of mandatory wheat % of industries Availability of 100 %(15 %) Subject to flour fortification with iron and performing iron fortified 25 %(5 %) implementation folic acid by 2016 for flour fortification of flour

TBD (25 %) milling industry and in five flour (% of chakki)

years in flour grinding industry

(chakki flour) (policy level) % of industries Availability of Subject to 5.3 Legislation on mandatory 100 % 100 % 100 % universal salt iodization by performing iodized salt 40 % 50 % implementation TBD

fortification of

December 2014 (policy level) iodine 5.4 Devise implementation % of industries Availability of Subject to

100 % 100 % 100 % strategy to ensure Vitamin A performing Vitamin A & D 40 % 50 % implementation and Vitamin D fortification in fortification of TBD fortified ghee

ghee and oil(Implementation Vitamin A & and oil level) Vitamin D

Page 152

Annex-6 Result Framework Analysis of WASH Sector

Strategy Base Means of TIME LINE (Years) Key Strategy Action(s) Indicators Objective Line Verifications Y Y Y Y Y Assumptions 1 2 3 4 5 Strategy 1: Equitable access to safe & clean water To increase the Increase the access to water and Increase in % Report Subject to

100% 100%

95% 97% 99% access to water reduce the arduous labour of population having Available/ political100 women in carrying it in all access to improve 94.1% MICS survey ownership and and reduce the

arduous labour vulnerable communities by 2020 source of drinking report availability of of women in water funds 1.1 Provide drinking water under # of districts Programme Subject to carrying it in Changa Paani Programme (villages in launched political

10 15 20 36 all vulnerable 5

through early implementation districts) launched TBD ownership and communities and completion of project by Changa Paani availability of by 2020 2020 (Implementation level) Programme funds 1.2 Provide clean drinking water by # of districts Programme Subject to installing filtration plants under (villages in launched political

10 15 20 36

Saaf Paani Programme through districts) launched 5 ownership and

TBD early implementation and Saaf Paani availability of completion of project by 2020 Programme funds (Implementation level) 1.3 Provide hand pumps in areas # of hands pump Hand pump Subject to

where the provision of tap provided functional 1000 2000 2000 2000 2000 political water facility is currently not TBD (Record ownership and feasible (Implementation maintained) availability of Level) funds 1.4 Rehabilitation of dysfunctional Notification & Notification & Subject to rural water supply schemes direction issued to directive political (Implementation Level) release funds TBD available √ √ √ √ √ ownership and availability of funds

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1.5 Ensure availability of safe % of schools No. water % of schools

100% drinking water by installation of having functional Filtration plants 10 % 25 % 50 % having water filtration plants in schools water filtration Nil installed in functional water

(Implementation Level) plants institutes filtration plants To increase 1.6 Install of water filtration plants # of water filtration Water filtration Subject to access to to ensure provision of safe plants installed plants functional 500 500 500 500 500 political drinking water TBD (Record ownership and clean/safe drinking water maintained) availability of in all funds 1.7 Initiate water treatment projects Project launched Chlorine tablets Subject to

100000 100000 100000 vulnerable 15000 at household and community (# of packet of distributed 5000 political communities level by distribution of chlorine tablets TBD ownership and

by 2020 chlorinating tablets etc. distributed) availability of funds 1.8 Establish water quality testing # of districts with New operational Subject to facilities and regular sampling new labs labs/ Record political

10 20 30 36

of water from various water established TBD available ownership and projects starting from water availability of source to household level funds 1.9 Introduce community based Mechanism Minutes of Subject to effective monitoring defined; meeting political mechanism using elected UC Committee notified TBD √ √ √ √ √ ownership representatives, school councils and CBOs Mechanism Record Subject to 1.10 Plan and introduce proper defined; Strategy maintained political operation and maintenance planned TBD √ √ √ √ √ ownership mechanism for keeping the facilities operational 1.11 Increase water conservation # of water Record Subject to To reduce

100 100 100

with increased and improved conservation tanks maintained 50 implementation misuse and TBD

water storage capacity build and subject to depletion of funding

Page 154 ground water 1.12 Launch a campaign for Seminar Record Subject to awareness to reduce water Conducted/ maintained availability of wastage and misuse Campaign funds; Activity launched is supposed to Nil √ √ √ √ √ taken initially with donor money and later on from ADP Strategy 2: Promote best practices & behavioral change regarding hygiene practices To Launch Launch campaign and % of rural people Report of survey Subject to

100% 100% campaign and awareness programs to having knowledge conducted 10 % 25 % 50 % availability of awareness promote hygiene practices of good practices of TBD funds

programs to sanitation, health & promote hygiene hygiene practices 2.1 Conduct awareness campaigns Seminar Record an community sessions through Conducted/ maintained integration approach by Campaign launched community workers like SH&NS, LHW, CMW, agriculture field assistant, school teachers, civil society, union council, CBOs, KHATTEEB of local MASAJIDS (AUQAF Dept.) Nil √ √ √ √ √ and local media (Policy Level) 2.2 Celebrate the Mother & Child Week, Global Hand Washing Day, World Toilet Day and World Water Day, Anti- Dengue Day to promote hygiene practices (Implementation Level) 2.3 Develop IEC material on Officially Day Celebrated Subject to nutrition containing guidelines announcement of TBD & Record √ √ √ √ implementation; of health and hygiene practices dates for available Activity is

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(Policy Level) celebration of days supposed to taken initially with donor money and later on from ADP 2.4 Creative inclusion of sanitation, Curriculum Revised Subject to hygiene and preventive reviewed and curricula implementation approaches dressing Chapter added on available malnutrition in school Nutrition and Nil curriculum in coordination with Hygiene √ √ √ School Education Department and Punjab Curriculum Authority (Policy Level) Strategy 3: Equitable access to Total Sanitation Services To decrease 3.1 Conduct pilot project of PATS # of districts with PATS Subject to ODF 22% to in high risks districts (Rajanpur, PATS implemented, political

10 20 30 36

10% in province Muzaffargarh, DG Khan, implemented TBD Records ownership and in Punjab by Chinniot and Jhang) by 2015 available availability of 2020 funds 3.2 Scaling-up the Pakistan Approach for Total Sanitation

in all districts of Punjab after the evaluation of Pilot Project by 2020 Installation of 3.3 Install small scale sewerage # of sewerage Functional Subject to

sewerage treatment units especially with treatment units sewerage 100 100 100 political installed 15 25 ownership and treatment units prioritization in those large TBD treatment units

by 2020 villages (Implementation availability of Level) funds 3.4 Install small scale solar # of sewerage Functional Subject to

sewerage treatment plants treatment units sewerage 100 100 100 political

15 25

(Implementation Level) installed TBD treatment units ownership and

availability of funds

5 1 5 2 0 0 0 1 0 0 1 0 1

Installation of 3.5 Improve solid waste # of solid waste TBD Functional Subject to

Page 156 solid waste management schemes and management plants SWM plants political management mechanism through treatment units ownership and plants by 2020 establishment of solid waste installed availability of management plants in all over funds the Punjab to treat agriculture, sewerage and domestic solid waste (Implementation Level) 3.6 Install composting plants in # of composite Functional Subject to large cities to manufacture plants installed composite political

10 10 10 10

compost fertilizers from this TBD plants ownership and waste (Implementation Level) availability of funds To ensure 3.7 Provide WASH facilities, like % of schools 50 % 70 % 100% 100% 100% % of schools availability of soap and toilets, in schools in having soaps in having soaps &

facilities of collaboration with School toilets toilets quality hygiene Education Department (Policy and sanitation Level) practices at TBD EMIS 100% schools by 2019 (especially in girls school)

Strategy 4: Development and implementation of Policies and Strategies Formulation of 4.1 Approval and dissemination of Policy Policy Subject to nutrition and Punjab Drinking Water Strategy notification & notification & political gender sensitive by 2015 (Policy Level) direction issued directive ownership and policies & 4.2 Approval and dissemination available/ subject to strategies of Punjab Sanitation Policy and TBD promulgation implementation WASH sector √ √ √ √ √ Strategy by 2015 (Policy Level) material 4.3 Approval and dissemination available Behavior Change Communication Strategy by 2015 (Policy Level)

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4.4 Approval, dissemination & implementation of Punjab Municipal Water Act 2013 (Policy Level) 4.5 Prioritize the preparing the WASH sectoral Nutrition Strategy & Operational plan and its effective implementation

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Annex-7 Result Framework Analysis of Social Protection Sector

TIME LINE (Years) Strategy Base Means of Key Strategy Action(s) Indicators Objective Line Verifications Y Y Y Y Y Assumptions 1 2 3 4 5

Strategy 1: Strengthen social protection sector to scale-up nutrition-sensitive interventions

Expedition of 1.1 Establishment of Social Notification & Notification & Subject to approval, protection authority (Policy direction issued to directive political dissemination, level) establish authority available ownership and Nil √ and availability of implementation of nutrition- funds sensitive social 1.2 Prioritize the preparing the Amendments in Record Subject to protection existing policies/ legislation of related drafted policies & maintained political Social Protection sectoral more strategies and legislations ownership nutrition-responsive and its TBD √ √ √ act(s) effective implementation (Policy level)

1.3 Develop nutrition specific Revision of Rules Notification & Subject to legislations about Zakat, Bait- directive political ul-Mall, and PVTC (policy TBD available √ ownership and level) subject to funds available

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1.4 Increase coordination between MoU signed with Meetings and Subject to federation and federating units other sectors record maintain political on nutrition-sensitive social (governmental, ownership and protection (Policy level) TBD √ √ √ √ √ privates, NGOs etc.) subject to consent of other sectors

To create 1.5 Develop and strengthen Policy notification Policy Subject to enabling linkage with LHWs, SH&NS, & direction issued/ notification & political environment for teachers, local NGOs for ownership and promoting social aspects of Mechanism of directive mainstreaming TBD subject to addressing malnutrition coordination available Nutrition in √ consent of (Develop a mechanism of developed Sector & coordination to implement on partners improving strategies) multi-Sectoral (Implementation level) coordination by year 2015 1.6 Initiate screening through # of visits of 12 visits per Subject to School Health and Nutrition doctor/physician and annum per implementation Supervisors, response in School Nutrition coordination with health school Health Supervisor department to integrate TBD √ √ √ √ √ nutrition intervention with women and children focused approach (Implementation level) 1.7 Mapping of districts through # of districts of Record Subject to impartial surveys, and which survey available/ political utilization of this data to performed and map Developed map 15 25 36 ownership and TBD 2 5 strengthen nutrition developed availability of interventions of social welfare funds department (Implementation level) 1.8 Create linkages of livestock Policy notification TBD Record available √ √ Subject to department with BISPs program political

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“Wasela-e-Rozgar” and # of families Record ownership/

upcoming new social protection 1000 5000 5000

provided with cattle available/ 500 Subject to funds/ schemes to support for ultra- families with Subject to

poor segment of the society by cattle beneficiaries to up-scaling home based livestock implement on and backyard kitchen farming # of families Record (Implementation level) kitchen farming

10000 50000 50000 provided with layers available/ 5000 (never sell out) families with

layers

# of families Record

10000 50000 50000 provided with available/ 5000 vegetables & fruits families having

seeds seeds

1.9 Advocacy with BISP for linking No. of meetings held Minutes of Subject to BISP beneficiaries with with BISP meeting political “Kitchen gardening Scheme” available (Implementation level) ownership and availability of TBD √ √ √ √ √ funding, Subject to change in policy of BISP

Strategy 2: Improving the economic access to nutritional needs by poverty alleviation and social protection

By 2015, 2.1 Link the cash transfer via % of BISP Record Subject to vouchers and assistance from introduce cash beneficiaries maintained/ % 100 % 100 political

10 10 % 40 % 80 % transfer system BISP with evident based receiving voucher TBD Families ownership and nutrition need (Implementation for improving based on nutrition receiving availability of level) the economic need voucher funds

Page 161 access to 2.2 Link cash transfer amounts to % of BISP Record Subject to provincial food price indices so adequate food to beneficiaries maintained/ % 100 political

10 10 % 20 % 40 % 70 % meet minimum that real value remains constant receiving amount TBD Families ownership and (Implementation level) nutritional needs based on food price receiving availability of

voucher funds

2.3 Conduct research intervention to Research conducted/ Reports and Subject to assess the impact on improving Dissemination of research papers availability of nutrition through cash transfer knowledge available funds scheme (BISP data could be

used), and implement impartial TBD √ √ √ √ program monitoring with third party validation (Implementation level)

By 2015, 2.4 Introduce conditional cash % of BISP Certificates of Subject to introduce transfer (CCT) and make BISP beneficiaries admission political conditional cash or any other such program families admitted received from conditional for beneficiaries to ownership and transfer (CCT) their daughter in each family 100%

15% enroll their daughters in schools 30% 50% 75% availability of schools Nil policies with the (Policy level) funding,

intention of Subject to targeted change in approach policy of BISP

2.5 Piloting of a conditional cash Pilot project Reports Subject to transfer program using conducted/ available availability of vouchers and linked to the Dissemination of funds utilization of health and knowledge nutrition services by target Nil √ √ √ √ population groups, while being particularly attentive to supply side constraints which may be encountered by these groups (Policy level)

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2.6 Targeted and conditional food Availability of low Price of food Subject to subsidies for poor instead of price food for poor political generic subsidies and will be Nil √ √ √ √ ownership and linked with inflation rate by in market availability of 2014 (Policy level) funds

Strategy 3: Promote nutrition awareness for healthy dietary practices

To use Social 1.1 Seminars/ workshops in # of events Reports Subject to Protection industrial homes (1 day - 1 week conducted in each available political

Sector platform nutrition specific trainings in districts per annum Nil 12 24 48 48 48 ownership and

Sanat-Zars) (Implementation for promoting availability of level) nutrition funds awareness for healthy & safe 1.2 Seminars/ workshops in PVTC # of events Reports Subject to (1week-15days nutrition dietary conducted in each available political

module to Zakat families) 12 24 48 48 48 practices in districts per annum Nil ownership and (Implementation level) poorest availability of community of funds Punjab 1.3 Seminars/ workshops in Rescue # of events Reports Subject to homes (Darul-aman) conducted in each available political

(Implementation level) districts per annum 12 24 48 48 48 ownership and Nil availability of funds

1.4 Enhance nutrition awareness Development of IEC IEC material Subject to funds through distributing IEC material and its developed and and subject to material poorest 2,50,000 zakat distribution Nil √ √ √ institutes families of Punjab using zakat distributed in committees (25,000) families (Implementation level)

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Annex-8 Result Frame work for M&E

Results Descriptive Indicators of Work Performance Means of Responsiblity Chain Summary Verification Goal Improved human Eliminate chronic under-nutrition by the year 2020 PDHS, MICS P&D capital, especially among the poor segments of society by improved maternal and child nutrition and health status Purpose Strengthened By the end of 2020: PDHS, MICS, P&D multisector • % prevalence of stunting among children under -5 efforts years reduced below 20% and other stakeholders • % prevalence of underweight among children under-5 to improve access to years reduced below 15% quality nutrition • % prevalence of wasting among children under-5 services for years reduced below 10% improved nutrition in • % of women with iron deficiency anemia reduced Punjab below 30% • % of babies born with low birth weight (<2,500 grams) reduced • % of children and adolescents (boys and girls) not completing primary and basic school education reduced Outcomes 1: Policies, plans and By the end of 2020: Sectoral progress P&D all Sectors multi-sector • Multi-sector commitment and resources for nutrition reports Coordination are increased to at least 10% annually improved at Provincial • Nutritional information management and data & district levels. analysis strengthened and are used to track progress. • Protocol established for nutrition profiles (as basis for planning) at local level 2: Practices that By the end of 2020: Routine reporting Health, promote optimal use of • MIYC micronutrient status (Vitamin A, Iodine, nutrition ‘specific’ and Anemia) improved nutrition ‘sensitive’ • % of children decreased with Vitamin A deficiency

Page 164 services improved, % increase in households using iodized salt., leading to enhanced % increase in use of zinc in management of maternal and child diarrhoea with new ORS) nutritional status • Comprehensive Training Package on Nutrition adapted and rolled-out • % of mothers and infant and young child feeding practicing improved as per the recommendations • % of children with SAM accessing services on Severe Acute Malnutrition (SAM ) management as per SPHERE standards increased especially in the most affected districts •Prevalence of infections (especially diarrhoea and ARI) reduced Adolescent girls awareness and behaviors in relation to Routine reporting Health protecting foetal, infant and young child growth improved • Parents better informed with regard to avoiding growth faltering • Nutritional status of adolescent girls improved (especially anemia) • Primary and secondary school enrolment increased, particularly for girls • All young mothers and adolescent girls use improved Routine reporting WASH, Health sanitation facilities of sectors • All young mothers and adolescent girls use soap to wash hands at critical times • All young mothers and adolescent girls as well as children under 2 use improved drinking water

• Food and nutrition security and agriculture strategy Agriculture, aligned with nutrition objectives • % women with heavy workload during pregnancy and Post partum reduced. 3: Strengthened capacity Nutrition capacity of implementing Nutrition Strategic P&D, All participating sectors of provincial and local Plan strengthened as per evidence-based capacity governments on building strategy nutrition to provide • Nutrition integrated into local planning and basic services in an monitoring inclusive and equitable system

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manner • Collaboration between local bodies’ health, agriculture, social welfare, and education sector strengthened at district and UC level • Social protection measures designed and introduced to prevent and reduce malnutrition in marginal population groups with a focus on the critical window of opportunity– from conception to two years of age Outputs Outcome 1: Policies, plans and multi-sector nutrition coordination improved at Provincial and district levels. Output 1 Policies and plans By the 2014, annual and multiyear plan of all the Multisectoral P&D (Nutrition Cell at PSPU), updated/reviewed to relevant sectors reflect indicators and targets on nutrition progress PMAC incorporate a core set of contribution for reduction of malnutrition report (quarterly, nutrition specific/ • By the end of 2015, Nutrition related targets and annually) sensitive indicators incorporated in district level plans Indicators at Provincial and district levels. Output 2 Multi-sector nutrition High Level Nutrition and Food Security Steering Multisectoral P&D (Nutrition Cell at PSPU), coordination Committee and coordination mechanisms functional nutrition progress PMAC (all participating Sectors mechanisms functional at Provincial level ( Already Functional in P& D) report (quarterly, at Provincial and • Technical Working Group functional at Provincial annually) District levels. level ( Already functional in PSPU ) By the end of 2014, Nutrition and Food security steering committee functional at district level with necessary resources • By the July 2015, Majority of the planned nutrition programmes coordinated and monitored by DSC at district and sub district level.. • By the end of 2015, frequency of joint monitoring visits by provincial level stakeholders ( Sectors, donors & UN agencies ) increased. Output 3 Bussiness Establish Business Network for nutrition at provincial Multisectoral P&D nutrition Cell, Bussiness network/public private level: nutrition progress Network identified focal point, partnership identified Nominate focal point or steering group reports all sectors and implaced business network focal point reaches out to Government Focal Point and other Networks and liaises at provincial and district level Organise multi-stakeholder convenings to define potential contributions by the private sector and agree on ways of working with all sectors

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Outcome 2: Practices that promote optimal use of nutrition ‘specific’ and nutrition ‘sensitive’ services improved, leading to enhanced maternal and child nutritional status.

Output 3 Maternal and child Multisectoral P&D (Nutrition Cell at PSPU) nutritional care service • By the end of 2014, Nutrition Communication nutrition progress Health in lead with all utilisation improved, Strategy developed and in place to support report (quarterly, participating sectors, especially among the PINS annually), surveys unreached and poorer • % of pregnant women and mothers know the (NNS/others) segments of society. importance of food diversity & eating three times a day with animal source food at least once a day • Adolescents who report at least two preventive/dietary nutritional measures against anaemia increased • Prevalence of roundworm among school adolescent reduced • Hand washing with soap practice increased at critical times specially among adolescent girls and young mothers Output 4 Adolescent girls’ By the end of 2020: Routine reports of Education parental education, life • Class attendance and class promotion rates among participating skills adolescent girls increased sector and nutrition status • Dropout rates among school adolescents decreased enhanced. • Adolescents who report at least two preventive/dietary nutritional measures against anaemia increased. • Prevalence of roundworm among school adolescents decreased Output 5 Availability and By the end of 2020: Multisectoral Health, Agriculture, Food, consumption of • Increased consumption of diversified food, especially nutrition progress appropriate foods (in animal food or pulses , among pregnant women and report (quarterly, terms of quality, adolescent girls by increasing its production annually), quantity, frequency and • Food supply and distribution system strengthened – Surveys safety) enhanced. food security ensured particularly in food deficit areas (NNS/Others) • % infants initiated with breastfeeding within the first hour and exclusively breastfed for six months • % of children receiving immunisation and micronutrient supplements as per the schedule • Reduction in consumption of junk food by pregnant mothers, children and adolescent girls

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Outcome 3: Strengthened capacity of Provincial and local governments on nutrition to provide basic services in an inclusive and equitable manner. Output 6 Capacity of Provincial By the end of 2020, knowledge on nutrition increased Multisectoral P&D (Nutrition Cell) all and district levels among key identified staff at provincial and local level nutrition progress Participating sectors enhanced to provide by x% over the baseline of number of new nutrition report (quarterly, appropriate support to service outlets established or improved annually) improve maternal and • Starting from 2014, different sectors identify focal Child nutrition. persons for nutrition and execution of nutrition interventions are reflected in their job descriptions Output 7 Multi-sector nutrition By the end of 2015, access to the updated nutrition Sectoral progress P&D (Nutrition Cell) all information updated information system made reports quarterly, Participating sectors and linked both at available annually Provincial and district • Nutrition information system available in all the levels. sectors Bussiness Network

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