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Political Economy of Undernutrition National Report: Pakistan

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Political Economy of Undernutrition National Report: Pakistan THE POLITICAL ECONOMY OF UNDERNUTRITION NATIONAL REPORT: PAKISTAN March 2013 Shehla Zaidi and Zulfiqar Bhutta Division of Women & Child Health, Aga Khan University Shandana Khan Mohmand and Andres Mejia Acosta Institute of Development Studies, University of Sussex Report from Maximising the Quality of Scaling up Nutrition Programmes (MQSUN) About Maximising the Quality of Scaling up Nutrition Programmes (MQSUN) MQSUN aims to provide the Department for International Development (DFID) with technical services to improve the quality of nutrition-specific and nutrition-sensitive programmes. The project is resourced by a consortium of eight leading non-state organisations working on nutrition. The consortium is led by Program for Appropriate Technology in Health (PATH). The group is committed to: Expanding the evidence base on the causes of undernutrition. Enhancing skills and capacity to support scaling up of nutrition-specific and nutrition-sensitive programmes. Providing the best guidance available to support programme design, implementation, monitoring, and evaluation. Increasing innovation in nutrition programmes. Knowledge-sharing to ensure lessons are learnt across DFID and beyond. MQSUN partners Aga Khan University Agribusiness Systems International ICF International Institute for Development Studies International Food Policy Research Institute Health Partners International, Inc. PATH Save the Children UK About this publication This synthesis document is made up of two separately produced reports. The background and federal narrative were produced by Shandana Khan Mohmand and Andres Mejia Acosta of the Institute of Development Studies, while the provincial narrative was produced by Shehla Zaidi and Zulfiqar Bhutta of the Division of Women & Child Health, Aga Khan University. All recommendations have been jointly developed. It was funded by the Department for International Development‘s (DFID) Maximising the Quality of Scaling up Nutrition Programmes (MQSUN) project. The correct citation for this report is: Zaidi, S., S. K. Mohmand, Z. Bhutta, and A. M. Acosta. (2013). The Political Economy of Undernutrition in Pakistan. DFID-MQSUN: Islamabad. This document was produced through support provided by UKaid from the Department for International Development. The opinions herein are those of the author(s) and do not necessarily reflect the views of the Department for International Development. ii TABLE OF CONTENTS ACKNOWLEDGMENT ......................................................................................................................... 1 ABBREVIATIONS ................................................................................................................................. 2 EXECUTIVE SUMMARY ...................................................................................................................... 3 INTRODUCTION ................................................................................................................................... 7 METHODOLOGY ................................................................................................................................................ 10 OUTLINE OF THE REPORT ........................................................................................................................... 11 1. SOCIAL DEVELOPMENT AND THE CONTEXT OF SOCIAL POLICY ............................... 13 1.1 INSTITUTIONAL DEVELOPMENT AND SOCIAL POLICY .................................................................. 14 1.2 SOCIAL CONTEXT ................................................................................................................................ 17 1.3 IMPLICATIONS FOR SOCIAL POLICY.................................................................................................. 20 1.4 DECENTRALISATION ........................................................................................................................... 21 2. NUTRITION GOVERNANCE AT THE FEDERAL LEVEL ...................................................... 29 2.1 HORIZONTAL COORDINATION BETWEEN FEDERAL ACTORS ....................................................... 30 2.2 VERTICAL INTEGRATION AND MONITORING .................................................................................. 39 2.3 FUNDING ............................................................................................................................................... 46 3. PROVINCIAL COMPARISIONS ................................................................................................. 49 3.1 NUTRITION SITUATION IN PROVINCES ............................................................................................ 49 3.2 CONTEXTUAL RESOURCES AND CONSTRAINTS IN THE PROVINCES ............................................ 49 3.3 HORIZONTAL COORDINATION FOR NUTRITION: NUTRITION PROFILE, CONSTRUCT, AND STAKEHOLDERS ................................................................................................................................................ 55 3.4 HORIZONTAL COORDINATION: LEADERSHIP, STRUCTURAL, AND COORDINATION CHALLENGES ..................................................................................................................................................... 60 3.5 FUNDING ............................................................................................................................................... 62 3.6 VERTICAL COORDINATION ................................................................................................................ 66 3.7 MONITORING ....................................................................................................................................... 68 4. KEY RECOMMENDATIONS ...................................................................................................... 70 4.1 OPPORTUNITIES AND WAY AHEAD.................................................................................................. 70 4.2 LESSONS FROM THE EXPERIENCE OF OTHER COUNTRIES ........................................................... 70 4.3 INTERVENTIONS IN PAKISTAN .......................................................................................................... 72 4.4 CONCLUSION ........................................................................................................................................ 75 ANNEX 1: INTERVIEWS CONDUCTED – ISLAMABAD OCTOBER 2012 ........................... 76 ANNEX 2: NUTRITION PLANNING AND IMPLEMENTATION FRAMEWORK – AN HOUR-GLASS MODEL ...................................................................................................................... 77 REFERENCES ...................................................................................................................................... 78 ACKNOWLEDGMENT This study was conducted by the Women & Child Health Division of Aga Khan University and the Institute of Development Studies, Sussex. Funding was provided by the Department for International Development – UK (Pakistan) and is gratefully acknowledged. Facilitation and support was provided by Program for Appropriate Technology in Health (PATH), Washington DC, as part of the Maximising Quality of Scaling up Nutrition (MQSUN). The team is grateful for fieldwork support and insights provided by federal and provincial entities, including the Planning and Development Department (P&DD), Health Department, Food Department, Agriculture Department, Public Health Engineering (PHE) Department, and Education Department, as well as the Executive District Officers (EAD), Planning Commission (PC), Provincial Disaster Management Agency (PDMA), Benazir Income Support Programme (BISP), United Nations Children‘s Fund (UNICEF), World Food Programme (WFP), Food and Agriculture Organization (FAO), World Bank, the bilateral agencies, Micronutrient Initiative (MI), nongovernmental organisations (NGOs), media resource persons, and experts. The report draws upon contributions and suggestions made at the Provincial Roundtables and the subsequent National Roundtable. Aga Khan University, Karachi Institute of Development Studies, Sussex Shehla Zaidi Shandana Mohmand Zulfiqar Bhutta Andres Meija Acosta 1 ABBREVIATIONS ACR Annual Confidential Reports AKU Aga Khan University ANM Auxiliary Nurse Midwife ANP Awami National Party ASHA Accredited Social Health Activist AusAID Australian Government Overseas Aid Program AWC Anganwadi Centres AWW Anganwadi Worker BDO Basic Democracies Order BHU Basic Health Unit BISP Benazir Income Support Programme BNP Baluchistan National Party BSU Basic Health Unit CIDA Canadian International Development Agency CMAM Community Based Management of Acute Malnutrition CNV Community Nutrition Volunteer CSOs Community Support Organisations CSS Centrally Sponsored Schemes DC District Commissioner DCO District Coordination Officer DFID Department for International Development (UK) DHIS District Health Information System DHO District Health Officer DHS Demographic and Health Surveys DRGO Distribution of Revenues and Grants-in-Aid Order EAD Economic Affairs Division EDO Executive District Officer EPI Extended Programme on Immunisation EU European Union - EuropeAid Development and Cooperation FAO Food and Agriculture Organization FAPF Foreign Assistance Policy Framework GAIN Global Alliance for Improved Nutrition GDP Gross Domestic Product GST General Sales Tax ICDS Integrated Child Development Services IDA International Development Association IDS Institute of Development
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