PAKISTAN-BALOCHISTAN IPC ACUTE MALNUTRITION ANALYSIS August 2019 – Projection Until November 2019 Report # 0001

Home , Dera Bugti District

PAKISTAN-BALOCHISTAN IPC ACUTE MALNUTRITION ANALYSIS August 2019 – Projection until November 2019 Report # 0001 | Issued in September 2019

Key Figures August 2019

SAM* 199,811 Number of cases 395,654 MAM* Number of 6-59 months children acutely malnourished 195,843 Number of cases IN NEED OF TREATMENT GAM* 395,654 Number of cases

How Severe, How Many and When – Acute malnutrition is affecting around 0.4 million under 5 children, more than half of all children age 6-59 months in the 14 drought affected districts of Balochistan, making it a major public health problem in these districts. Of the 14 drought affected districts, 1 district has extremely critical levels of acute malnutrition (IPC AMN Phase 5) while 11 have critical levels of acute malnutrition (IPC AMN Phase 4) and 2 are in Phase 3 with serious levels of acute malnutrition according to the IPC AMN scale. Around 396,000 of the approximately 738,000 children of age 6-59 months are suffering from acute malnutrition during the drought period of May-August. 2019. Where – Panjgur district is affected by extremely critical levels of acute malnutrition and is classified as being in the highest phase of 5, according to the IPC AMN scale – where about one in 3 children under 5 are suffering from acute malnutrition. Although 11 other districts have critical levels of acute malnutrition (IPC AMN Phase 4), Kachhi, Pishin, Jhal Magsi and Dera Bugti districts have acute malnutrition levels that are close to IPC AMN Phase 5 thresholds. Awaran and Gwadar districts have serious levels (IPC AMN Phase 3) of acute malnutrition. Why – Although information on several contributing factors are limited, available information suggests that very poor quality and quantity of food consumed by children and high acute food insecurity are of major problems across all the 14 districts. Poor water and sanitation conditions and sub-optimal feeding practices (particularly exclusive breastfeeding and complementary feeding) are of major issues in most of the drought affected districts in Balochistan. Low vaccination coverage is also of concern in several districts.

IPC ACUTE MALNUTRITION CURRENT AND PROJECTED SITUATION MAPS

Contact for further information: This analysis has been conducted under the patronage of the Balochistan Nutrition Program for Mothers IPC Global Support Unit Jahangeer, Raja and Children (BNPMC) – Health Department, Government of Balochistan and National Nutrition Program, www.ipcinfo.org IPC Coordinator Ministry of National Health Services, Regulation & Coordination, Government of Pakistan. It has benefited [email protected] from the technical and financial support of IPC Global Support Unit. . It has benefited from the technical and financial support of European Commission, UK Government. Classification of food insecurity and malnutrition conducted using the IPC protocols, which are developed and implemented worldwide by the IPC Analysis Partners: IPC Global Partnership - Action Against Hunger, CARE, CILSS, EC-JRC, FAO, FEWSNET, Global Food Security Cluster, Global Nutrition Cluster, IGAD, Oxfam, PROGRESAN-SICA, SADC, Save the Children, UNICEF and WFP. IPC ACUTE MALNUTRITION ANALYSIS PAKISTAN-BALOCHISTAN August 2019 – Projection until November 2019 Report # 0001 | Issued in September 2019 0000 IPC ACUTE MALNUTRITION ANALYSIS CURRENT IPC ACUTE MALNUTRITION SITUATION FOR AUGUST 2019August 2019 – Projection until Nov ember 2019 2 Report # 0001 | Issued in September 2019 0000

What’s on the map? Of the 14 drought affected districts in the province of Balochistan, one district is in IPC AMN Phase 5 (extremely critical levels of acute malnutrition) and 11 districts are in Phase 4 (critical levels of acute malnutrition) during the current period of analysis (May-Aug. 2019). Of the 34 districts in the province, 20 districts were not included in the current IPC AMN analysis, thus not classified.

What’s in the table? Around 396,000 children of age 6-59 months in the 14 drought affected districts are affected by acute malnutrition – this is every second child in these districts is acutely malnourished. Total number of children with moderate and severe acute

malnutrition is, 195,843 and 199,811 respectively. The top 3 districts with the highest number of acutely malnourished children are namely Pishin, Kech, and Killa Abdullah.

District GAM (%) No. of Children No. of Children (6-59 Months) in Need of Treatment 6-59 months GAM Treatment MAM Treatment SAM Treatment Awaran 11.6 18,252 5,293 3,696 1,597 Chagai 16.5 31,453 12,975 5,583 7,392 Dera Bugti 26.5 46,890 31,065 16,294 14,770 Gwadar 12.6 39,527 12,451 6,917 5,534 Jhal Magsi 28.2 22,384 15,781 7,778 8,002 Kachhi 29.6 35,555 26,310 12,533 13,777 Kech 19.1 136,367 65,115 32,728 32,387 Kharan 20.6 23,423 12,063 4,567 7,495 Killa Abdullah 15.5 113,637 44,034 20,455 23,580 Loralai 17.8 59,610 26,526 11,028 15,499 Nushki 23.1 26,819 15,488 6,236 9,253 Panjgur 31.6 47,458 37,492 19,339 18,153 Pishin 29.0 110,472 80,092 42,808 37,284 Washuk 16.6 26,431 10,969 5,881 5,088 Total N.A. 738,278 395,654 195,843 199,811 PAKISTAN-BALOCHISTAN IPC ACUTE MALNUTRITION ANALYSIS August 2019 – Projection until November 2019 Report # 0001 | Issued in September 2019 0000 IPC ACUTE MALNUTRITION ANALYSIS PROJECTED IPC ACUTE MALNUTRITION SITUATION FOR SEPTEMBERAugust-NOVEMBER 2019 – Projection 2019 until Nov ember 2019 3 Report # 0001 | Issued in September 2019 3 3 0000

What’s on the map? The current acute malnutrition situation is expected to get worse in 3 of the 14 drought affected districts namely Jhal Magsi, Kachhi, and Pishin and they are all likely to move from IPC AMN Phase 4 (critical levels of acute malnutrition) to IPC AMN Phase 5 (extremely critical levels of acute malnutrition) during the projection period (Aug.-Nov. 2019). Panjgur district, which currently is in IPC AMN Phase 5 is expected to remain in the same Phase during the projection period. All other districts will also maintain at their current IPC AMN Phases in the projection period. Regardless of their IPC AMN Phases, acute malnutrition will remain a major public health problem in all the 14 drought affected districts. It should be noted that, of the 34 districts in the province, 20 districts were not included in the current IPC AMN analysis, thus not classified.

IPC ACUTE MALNUTRITION ANALYSIS PAKISTAN-BALOCHISTAN August 2019 – Projection until November 2019 Report # 0001 | Issued in September 2019 0000 IPC ACUTE MALNUTRITION ANALYSIS SITUATION OVERVIEW AND TREND ANALYSIS 4 August 2019 – Projection until November 2019 Report # 0001 | Issued in September 2019 Current situation overview 0000

Acute malnutrition is a major public health problem that needs urgent attention and response in all the 14 drought affected districts of the Balochistan province included in the current IPC AMN analysis – more than half of all under 5 children in these districts are acutely malnourished. Panjgur district has the highest prevalence of acute malnutrition and is classified as being in Phase 5 according to the ICP AMN scale (with nearly 1 in every 3 children in the district is acutely malnourished). Eleven other districts are in IPC AMN Phase 4 with extremely critical levels of acute malnutrition and two districts are in IPC Phase 2 (acute malnutrition is in serious levels).

Information on contributing factors are limited in most of the 14 districts. However, with the available information, major contributing factors to acute malnutrition are likely extremely poor quality and quantity of food intake by children and high level of food insecurity (according to the IPC Acute Food Insecurity analysis findings). Poor water and sanitation situation coupled with sub-optimal feeding practices (especially very low levels of exclusive breastfeeding and introduction of complementary feeding at the age of 6 months) are of major concerns in the majority of the 14 drought affected districts – see below for details on major contributing factors to acute malnutrition by district. Low vaccination coverage (particularly measles coverage) is also of concern several districts.

Projected situation overview

The critical level of acute malnutrition (IPC AMN Phase 4) is likely to get worse in 3 districts (Jhal Magsi, Kachhi, Pishin) and become extremely critical (IPC AMN Phase 5). The current level of acute malnutrition situation is likely to remain the same at extremely critical levels in Panjgur and critical level in 8 other districts of Balochistan during the projection period. Awaran and Gwadar districts, which at present have serious levels of acute malnutrition, will also likely to remain the same during the projection period.

Although historical information on both outcome indicators and contributing factors is limited, the available information inferred with expert opinion suggests that most contributing factors to acute malnutrition are either expected to remain at the current levels (poor) or slightly deteriorate further in some districts during the projection period. The factors that are likely to deteriorate in some districts are diseases based on the seasonal changes and food consumption (both quality and quantity) because of the deterioration expected in the food security situation, due to prevailing high food prices.

Trend Analysis

Available information on outcomes that is comparable is limited in all districts, particularly in the recent past. However, it has been acknowledged that acute malnutrition has consistently been high in all districts of the Balochistan province. According to the National Nutrition Survey of 2018, the situation has further deteriorated in several districts. The current drought appears to have further deteriorated the acute malnutrition situation in the 14 affected districts included in this IPC AMN analysis.

IPC ACUTE MALNUTRITION ANALYSIS PAKISTAN-BALOCHISTAN August 2019 – Projection until November 2019 Report # 0001 | Issued in September 2019 0000 IPC ACUTE MALNUTRITION ANALYSIS RECOMMEN DATIONS FOR ACTION 5 August 2019 – Projection until November 2019 Report # 0001 | Issued in September 2019 Response Priorities 0000

Providing treatment for all children with acute malnutrition is an urgent priority. The available information on acute malnutrition treatment is extremely limited. Where available, the treatment coverage data shows very low coverage. It is recognized that the acute malnutrition treatment is likely less than adequate in all districts. The very high severity and magnitude of the acute malnutrition situation calls for urgent scaling up of the treatment programmes. While improving the treatment capacity and coverage, improving early detection of children with acute malnutrition (particularly children with moderate acute malnutrition in order to prevent them from becoming severely malnourished) and referring them for treatment may also be necessary.

The Government of Balochistan Health Department is implemeneting the “Balochistan Nutrition Project for Mothers and Children” in Kharan, Panjgur, Noshki, Kohlu, Sibi, Zhob and Killa Saifullah, both at the community level and health facility level, for improving the nutrition services in these districts.

While ensuring universal treatment for acute malnutrition is the first priority, attention must also be given to addressing other factors identified as major contributing factors to acute malnutrition as a way to prevent acute malnutrition in the future. The prevention efforts should focus on improving quality and quantity of food consumed by children, enhancing household food security, and ensuring adequate quantity and quality of water and sanitation facilities. It is recommended that a response analysis involving all nutrition, health, food security, as well as water and sanitation stakeholders in the province be carried out to identify specific interventions to improve these contributing factors and address acute malnutrition. This response analysis should cover all the 14 drought affected districts and ideally carried out at the provincial level.

Situation Monitoring and Update of Activities

Given the very high levels of acute malnutrition, there is an urgent need for an immediate scale up of existing treatment programmes. The coverage as well as the quality of these treatment programmes should be monitored to ensure that the no child with acute malnutrition is left behind.

Furthermore, as programme interventions are put in place to address the contributing factors to acute malnutrition, there is a need to strengthen a monitoring mechanism to monitor these interventions.

In the medium-long term, it is also important to monitor the levels of acute malnutrition in these droughts affected districts to monitor and ensure that the acute malnutrition levels are brought to acceptable levels. Once new data is available, another IPC Acute Malnutrition analysis may be carried out for all the 14 drought affected districts to take stock of the situation.

PAKISTAN-BALOCHISTAN IPC ACUTE MALNUTRITION ANALYSIS August 2019 – Projection until November 2019 TOTAL NUMBER OF CHILDREN AFFECTED BY ACUTE MALNUTRITION Issued in September 2019

TOTAL NUMBER OF CHILDREN AFFECTED BY ACUTE MALNUTRITION AND IN NEED OF TREATMENT AS OF AUGUST 2019

The total number of children who are acutely malnourished and in need of treatment was calculated using the total number of children 6-59 months in the districts, the prevalence of GAM based on WHZ, and an incident factor of 2.5. It should be noted that children with GAM based only on MUAC were not included in the calculation; thus, the numbers given below are likely to underestimate the total magnitude of the acute malnutrition.

District Total population Population of children GAM (%) Estimated no. of GAM Estimated no. of Estimated no. of SAM 6-59 months of age cases MAM cases cases

Awaran 121,680 18,252 11.6 5,293 3,696 1,597 Chagai 209,689 31,453 16.5 12,975 5,583 7,392 Dera Bugti 312,603 46,890 26.5 31,065 16,294 14,770 Gwadar 263,514 39,527 12.6 12,451 6,917 5,534 Jhal Magsi 149,225 22,384 28.2 15,781 7,778 8,002 Kachhi 237,030 35,555 29.6 26,310 12,533 13,777 Kech 909,116 136,367 19.1 65,115 32,728 32,387 Kharan 156,152 23,423 20.6 12,063 4,567 7,495 Killa Abdullah 757,578 113,637 15.5 44,034 20,455 23,580 Loralai 397,400 59,610 17.8 26,526 11,028 15,499 Nushki 178,796 26,819 23.1 15,488 6,236 9,253 Panjgur 316,385 47,458 31.6 37,492 19,339 18,153 Pishin 736,481 110,472 29.0 80,092 42,808 37,284 Washuk 176,206 26,431 16.6 10,969 5,881 5,088 Total 4,921,855 738,278 N/A 395,654 195,843 199,811 PAKISTAN-BALOCHISTAN IPC ACUTE MALNUTRITION ANALYSIS August 2019 – Projection until November 2019 Issued in September 2019 RESULTS IN FIGURES

ACUTE MALNUTRITION CURRENT SITUATION AUGUST 2019 ACUTE MALNUTRITION PROJECTED SITUTION SEP-NOV 2019

1 District Extremely Critical

11 Districts Critical

2 Districts Serious

0 Districts Alert

0 Districts Acceptable

PREVALENCE OF ACUTE MALNUTRITION

Awaran Chagai Dera Gwadar Jhal Kachhi Kech Kharan Killa Loralai Nushki Panjgur Pishin Washuk Bugti Magsi Abdullah District KEY DRIVERS

% MAM* 8.1 7.1 13.9 7.0 13.9 14.1 9.6 7.8 7.2 7.4 9.3 16.3 15.5 8.9 POOR DIETARY POOR WATER AND % SAM* 3.5 9.4 12.6 5.6 14.3 15.5 9.5 12.8 8.3 10.4 13.8 15.3 13.5 7.7 QUANTITY SANITATION FOOD INSECURITY POOR DIETARY LOW VACCINATION % GAM* 11.6 16.5 26.5 12.6 28.2 29.6 19.1 20.6 15.5 17.8 23.1 31.6 29.0 16.6 QUALITY COVERAGE *Severe, Moderate, and Global Acute Malnutrition PROJECTION SEPTEMBER-NOVEMBER 2019

03 AUGUST 2019 DETERIORATE DISTRICTS

IN NEED OF URGENT ACTION ## ACUTE REMAIN 11 Number MALNUTRITION STABLE DISTRICTS IN 199,811 SAM* of IS EXPECTED 6-59 months caseload 738,278 Districts TO 0 IMPROVE 395,654 195,843 MAM* Total pop. of children DISTRICTS 6-59 months children acutely malnourished 6-59 months caseload 6 -59 months

PAKISTAN-BALOCHISTAN IPC ACUTE MALNUTRITION ANALYSIS August 2019 – Projection until November 2019 SUMMARY OF FACTORS CONTRIBUTING TO ACUTE MALNUTRITION Issued in September 2019

SUMMARY OF CONTRIBUTING FACTORS TO ACUTE MALNUTRITION BY DISTRICT Contributing factors Awaran Chagai Dera Gwadar Jhal Kachhi Kech Kharan Killa Loralai Nushki Panjgur Pishin Washuk Bugti Magsi Abdullah Inadequate Minimum Dietary Diversity (MDD) dietary intake Minimum Meal Frequency (MMF)

Minimum Acceptable Diet (MAD)

Minimum Dietary Diversity – Women

(MDD-W)

Diseases Diarrhoea

Dysentery

Malaria

HIV/AIDS prevalence

Acute Respiratory Infection

Disease outbreak

Food security Food dimensions

Inadequate Exclusive breastfeeding under 6 care for months children Continued breastfeeding at 1 year

Continued breastfeeding at 2 years

Introduction of solid, semi-solid or soft

foods

Legend Major Contributing Factor Minor Contributing Factor No Contributing Factor No Data

PAKISTAN-BALOCHISTAN IPC ACUTE MALNUTRITION ANALYSIS August 2019 – Projection until November 2019 SUMMARY OF FACTORS CONTRIBUTING TO ACUTE MALNUTRITION Issued in September 2019

SUMMARY OF CONTRIBUTING FACTORS TO ACUTE MALNUTRITION BY DISTRICT

Contributing factors Awaran Chagai Dera Gwadar Jhal Kachhi Kech Kharan Killa Loralai Nushki Panjgur Pishin Washuk Bugti Magsi Abdullah Insufficient Measles vaccination health services & unhealthy Polio vaccination environment Vitamin A supplementation

Skilled birth attendance

Health seeking behaviour

Coverage of outreach programmes – CMAM

programme coverage (SAM, MAM, or both)

Access to sufficient quantity of water

Access to sanitation facilities

Access to an improved source of drinking

water

Legend Major Contributing Factor Minor Contributing Factor No Contributing Factor No Data

PAKISTAN-BALOCHISTAN IPC ACUTE MALNUTRITION ANALYSIS August 2019 – Projection until November 2019 Issued in September 2019

RESULTS OF OTHER IPC CLASSIFICATIONS 10

Other Relevant IPC Analyses

As per IPC Acute Food Insecurity Analysis conducted in April 2019, around 1.79 million people (48% of the rural population) in 14 drought-affected districts (Awaran, Chagai, Dera Bugti, Gwadar, Jhal Magsi, Kacchi, Kech, Kharan, Killa Abdullah, Loralai, Nushki, Panjgur, Pishin and Washuk) were estimated to be in IPC Phase 3 (Crisis) and Phase 4 (Emergency). An estimated 0.42 million people were classified in IPC Phase 4 (Emergency) across the 14 drought-affected districts, whereas around 1.37 million people were in IPC Phase 3 (Crisis).

Out of 14 districts analysed, rural areas of 2 districts (Chagai and Washuk) have been classified in IPC Phase 4 (Emergency), whereas drought affected areas in 12 districts (Awaran, Dera Bugti, Gwadar, Jhal Magsi, Kacchi, Kech, Kharan, Killa Abdullah, Loralai, Nushki, Panjgur and Pishin) are classified in IPC Phase 3 (Crisis).

The analysis for the projection period (July to November 2019) indicates that the number of people in Phase 3 and Phase 4 is expected to reduce slightly to 1.78 million. Rural areas of two districts (Chagai and Washuk) currently in Phase 4 (Emergency) are likely to remain in the same emergency phase; however, rural areas of the Dera Bugti district are likely to move from Phase 3 (Crisis) to Phase 4 (Emergency) during the projection period. Drought-affected rural areas in the remaining 11 districts are likely to remain in Phase 3 (Crisis) between July and November 2019.

PAKISTAN-BALOCHISTAN IPC ACUTE MALNUTRITION ANALYSIS August 2019 – Projection until November 2019 PROCESS AND METHODOLOGY Issued in September 2019

PROCESS AND METHODOLOGY 11

Process and methodology: What is the IPC and IPC Acute Malnutrition:

A team on nutrition, health, food security and statistics experts working at The IPC is a set of tools and procedures to federal as well as provincial levels in Pakistan carried out the analysis process classify the severity and characteristics of using the standard IPC Acute Malnutrition protocols. These experts represented acute food insecurity and acute malnutrition Ministry of National Health Services, Regulation and Coordination, Ministry of crises as well as chronic food insecurity based National Food Security & Research, Nutrition Program for Mothers & Children of Health Department Balochistan, Bureau of Statistics Balochistan, Agha Khan on international standards. IPC consists of University, Action Against Hunger (ACF), Concern Worldwide, Deutsche four mutually reinforcing functions, each Welthungerhilfe, Islamic Relief, HANDS, Tameer-e-Khalq Foundation, Taraqee with a set of specific protocols (tools and Foundation, Azat Foundation, BRSP, FAO, UNICEF, WFP and WHO. The support procedures). of analysis team in completing the analysis is highly acknowledged. The IPC Global

Support Unit (GSU) supported the analysis. The core IPC parameters include consensus An initial analysis was conducted in May 2019 in Karachi, Pakistan. This initial building, convergence of evidence, analysis also involved a training on IPC AMN malnutrition. The results of the first accountability, transparency and analysis were updated in Islamabad, Pakistan in July 2019 when new data became comparability. The IPC analysis aims at available after the release of the National Nutrition Survey results. informing emergency response as well as

The data used in this analysis mainly came from the National Nutrition Survey medium and long-term food security policy (NNS), and SMART Nutrition Survey of 2017 (carried out in 2017-18). Where and programming. applicable, localized SMART surveys were also used. Additionally, District Health Information System (DHIS) and the results from the drought assessment in IPC Acute Malnutrition provides information Balochistan were also used. on the severity of acute malnutrition, highlights the major contributing factors to acute malnutrition, and provide actionable knowledge by consolidating wide-ranging evidence on acute malnutrition and contributing factors.

Limitations of the analysis

Availability of recent data, representative at the district level, was a major limitation for some indicators. In these cases, inference was made based on available data and expert opinion.

Contact for further information: This analysis has been conducted under the patronage of the Balochistan Nutrition Program for Mothers IPC Global Support Unit and Children (BNPMC) – Health Department, Government of Balochistan and National Nutrition Program, Jahangeer, Raja www.ipcinfo.org IPC Coordinator Ministry of National Health Services, Regulation & Coordination, Government of Pakistan. It has benefited from the technical and financial support of IPC Global Support Unit. [email protected]

Classification of food insecurity and malnutrition conducted using the IPC protocols, which are developed and implemented worldwide by the IPC Global Partnership - Action Against Hunger, CARE, CILSS, EC-JRC, FAO, FEWSNET, Global Food Security Cluster, Global Nutrition Cluster, IGAD, IPC Analysis Partners: Oxfam, PROGRESAN-SICA, SADC, Save the Children, UNICEF and WFP.