Copyright © UNICEF Pakistan Printed in 2018 Graphic design by Human Design Studios COST OF THE DIET ANALYSIS REPORT IN 12 DISTRICTS, 17 LIVELIHOOD ZONES PAKISTAN CoD 2018 Acknowledgments I am grateful to the UNICEF Pakistan team for their enormous support for the Cost of the Diet study and especially to Dr Saba Shuja for making the practical arrangements for training, data collection. My special appreciation goes to the Research and Development Solutions team and especially to Dr Adnan A. Khan and Safoora Malik for mobilizing the team of data collectors and supervisors. This analysis would not have been possible without the assistance of the market traders in the 102 villages studied, and of the women who participated in the interviews and focus group discussions. Their time, hospitality and insights are greatly appreciated. Mesfin Beyero Lead researcher The study has been made possible with the financial assistance of the Department for International Development (DFID), United Kingdom. The views expressed herein should not be taken, in any way, to reflect the official opinion of the DFID. 5 CoD COST OF THE DIET ANALYSIS REPORT IN 12 DISTRICTS, 17 LIVELIHOOD ZONES PAKISTAN 2018 Foreword Appropriate feeding practices are essential for the nutritional status, growth, development and survival of infants and young children. Infants should be exclusively breastfed for the first six months of life, and thereafter should receive nutritionally adequate and safe complementary foods, while breastfeeding should continue up to at least two years. Poor or suboptimal breast feeding practices are important determinants of all forms of undernutrition, especially during the 1000 days of child life. It is recommended that babies should receive complementary foods from six months of age because they require adequate nutritious foods in addition to breast milk. Complementary feeding is the least explored area as limited data on this subject are available in Pakistan. As part of the National Complementary Feeding Assessment, a Cost of the Diet Analysis has been carried out to determine the accessibility, availability and affordability of nutritious diet. This analysis also includes market and dietary pattern surveys and focus group discussions with mothers and caretakers of children under the age of two years. The study was conducted in geographic areas/districts with the highest burden of stunting and micronutrient deficiencies. The selection of districts was based on vulnerability criteria and included emergency- affected and emergency-prone districts (flood and drought-affected and food insecure) across Pakistan. The analysis answers the following key questions. What is the cost of a nutritionally adequate diet for typical households? What nutrients have the greatest influence on the cost of a nutritious diet? What local foods are inexpensive sources of essential micronutrients and could be promoted through programme interventions? How affordable is a nutritious diet for a typical household in different wealth groups? How might nutrition, food security and social protection interventions improve access to a nutritious diet by households in the assessment area? The Nutrition Wing at the Ministry of National Health Services, Regulation & Coordination highly appreciates the financial support by the United Kingdom Department for International Development in conducting this analysis. The efforts of Research & Development Solution in carrying out the fieldwork and the international consultant Mesfin Beyero are also acknowledged. The role and contribution of different stakeholders and partners in carrying out the research and later on review and finalisation of the report is highly appreciated. I would like to mention the hard work put in by the UNICEF team: Ms Melanie Galvin, Dr Wisal Khan and Ms Sumra, as well as my whole team at the Nutrition Wing during the entire process. Special appreciation is due to Dr Saba Shuja of UNICEF and Dr Khawaja Masuood Ahmed from my team for their devoted work and inputs as well as review and finalisation of the document. Dr Abdul Baseer Khan Achakzai Director Nutrition/ NPM Ministry of National Health Services, Regulation & Coordination Islamabad 6 COST OF THE DIET ANALYSIS REPORT IN 12 DISTRICTS, 17 LIVELIHOOD ZONES PAKISTAN CoD 2018 Acronyms BISP Benazir Income Support Programme CoD Cost of the Diet EO Energy-only diet FAO Food and Agriculture Organization FGD Focus Group Discussion FHAB Food Habits Nutritious diet GB Gilgit-Baltistan HIES Household Integrated Economic Survey hyv high-yield variety [of wheat] ICT Islamabad Capital Territory KP Khyber Pakhtunkhwa MAC Macronutrient diet MICS Multiple Indicator Cluster Survey NFE Non-Food Expenditure NNS National Nutrition Survey NUT Nutritious diet PDHS Pakistan Demographic and Health Survey PKR Pakistani Rupee RNI Recommended Nutrient Intake UNICEF United Nations Children’s Fund WHO World Health Organization 7 CoD COST OF THE DIET ANALYSIS REPORT IN 12 DISTRICTS, 17 LIVELIHOOD ZONES PAKISTAN 2018 Acknowledgments 4 Foreword 6 Acronyms 7 Executive Summary 10 1. Introduction 14 1.1 Nutritional status of children and women in Pakistan 14 1.2 Micronutrient deficiencies 14 1.3 Infant and young child feeding practices 15 2. Cost of the Diet Analysis 16 2.1 Methods 16 2.2 Data collection 18 CONTENTS 2.3 Recommended intakes 21 2.4 Affordability of diets 21 2.5 Modelling nutrition, food security and social protection interventions 22 2.6 Limitations of the study 23 3. Cost of the Diet Analysis in Khyber Pakhtunkhwa (KP) Province 26 3.1 Charsadda district, livestock/poultry livelihood zone 26 3.2 Tank district, agriculture livelihood zone 38 3.3 Tank district, livestock/poultry livelihood zone 53 4. Cost of the Diet Analysis in Islamabad Capital Territory (ICT) 68 4.1 Islamabad employment/labour (paid/unpaid) livelihood zone 68 5. Cost of the Diet Analysis in Punjab Province 84 5.1 Faisalabad district, agriculture livelihood zone 84 5.2 Rajanpur district, agriculture livelihood zone 97 6. Cost of the Diet Analysis in Azad Jammu & Kashmir (AJK) 114 8 COST OF THE DIET ANALYSIS REPORT IN 12 DISTRICTS, 17 LIVELIHOOD ZONES PAKISTAN CoD 2018 6.1 Haveli district, agriculture livelihood zone 114 6.2 Haveli district, livestock/poultry livelihood zone 127 7. Cost of the Diet Analysis in Balochistan Province 142 7.1 Loralai district, agriculture livelihood zone 142 7.2 Naseerabad district, agriculture livelihood zone 154 8. Cost of the Diet Analysis in Sindh Province 168 8.1 Jacobabad district, agriculture livelihood zone 168 8.2 Sanghar district, agriculture livelihood zone 180 8.3 Sanghar district, livestock/poultry livelihood zone 192 9. Cost of the Diet Analysis in Gilgit-Baltistan (GB) 206 9.1 Gilgit district, agriculture livelihood zone 206 9.2 Gilgit district, livestock/poultry livelihood zone 218 10. Cost of the Diet Analysis in Tribal Districts of KP (formerly known as the Federally Administered Tribal Areas) 232 10.1 Khyber Agency, agriculture livelihood zone 232 10.2 Khyber Agency, employment/labour (paid/unpaid) livelihood zone 244 11. Annexes 258 9 CoD COST OF THE DIET ANALYSIS REPORT IN 12 DISTRICTS, 17 LIVELIHOOD ZONES PAKISTAN 2018 Executive Summary This is the report of the Cost of the Diet Analysis conducted in 17 livelihood zones in 12 districts across four provinces (Balochistan, Khyber Pakhtunkhwa including the former Federally Administered Tribal Areas, now known as the tribal areas of KP, Punjab and Sindh) and three administrative regions (Azad Jammu and Kash- mir, Gilgit-Baltistan and Islamabad Capital Territory) of Pakistan. The study was commissioned by UNICEF Pakistan with funding from the Department for International Development of the United Kingdom. The CoD analysis set out to answer the following five questions: • What is the cost of a nutritionally adequate diet for typical households? • What nutrients have the greatest influence on the cost of a nutritious diet? • What local foods are inexpensive sources of essential micronutrients and could be promoted through programme interventions? • How affordable is a nutritious diet for a typical household in different wealth groups? • How might nutrition, food security and social protection interventions improve access to a nutritious diet by households in the assessment area? Prior to the training of the data collection team, lists of foods available in the local markets of the 17 livelihood zones were obtained with the assistance of local experts. Training was given to a team of enumerators and supervisors on how to collect weight and price data from traders and conduct interviews and focus group discussions with mothers of children aged 6–23 months. Research and Development Solutions, a local firm, performed the data collection with close supervision from the UNICEF team. The consultant was responsible for providing day-to-day remote technical assistance. A total of 102 villages were visited; weight and price data of foods available in the local markets where the poor purchase from were collected; 102 focus group discussions were conducted and 816 mothers of children aged 6–23 months were interviewed. The study was conducted during the winter season, and weight and price data for the other three seasons were collected retrospectively. Secondary data on annual income, food and non-food expenditure of five wealth groups was obtained from the Household Integrated Economic Survey of Pakistan. The typical Pakistani family of seven embedded in the software was used as the basis for calculating the daily and annual cost of the diets. Data were entered by two data entry clerks in the Cost of the Diet Software version 2.3.9 under the close supervision of the consultant. A standard analysis was conducted, including: • The cost and composition of three different types of diets: Energy-Only (EO), Nutritious (NUT) and Food Habits Nutritious (FHAB) diets; • Seasonal fluctuations in the cost of the FHAB diet; • The contribution of food groups to the cost of the FHAB diet; and • Affordability of the diets for the five wealth groups. In addition, different interventions were modelled, selected and modified depending on the specific circum- stances of the livelihood zone under discussion.