© United Nations Children’s Fund (UNICEF) Photographs: UNICEF Pakistan Designed by Human Design Studios CONTENTS Acknowledgements 8 Foreword 9 Acronyms 10 Map of Pakistan 12 Executive Summary 13 1. Introduction 20 1.1 SitAn Approach and Methodology 21 2. Context 30 2.1 Pakistan’s National and International Commitments 33 2.2 Governance and Policy Framework 34 2.3 Public Financing: Child-Specific Investments 38 2.4 Multidimensional Poverty in Pakistan 44 3. All Children Survive and Thrive 50 3.1 Nutritional Status 52 3.2 Maternal, Neonatal and Child Survival 63 3.3 Child Immunization 68 3.4 Key Conclusions and Considerations 72 4. All Children Learning 78 4.1 Out-of-School Children 81 4.2 Children in School 86 4.3 Children’s Learning Outcomes 94 4.4 Key Conclusions and Considerations 99 CONTENTS 5. All Children Protected from Violence and Exploitation 104 5.1 Birth Registration 108 5.2 Protection from Violence and Exploitation 110 5.3 Key Conclusions and Considerations 118 6. All Children Live in a Safe and Clean Environment 124 6.1 Safely Managed Water 126 6.2 Sanitation Services 129 6.3 Key Conclusions and Considerations 135 7. Cross-cutting Priorities for Children in Pakistan 140 7.1 Gender Equality 140 7.2 Equity 146 7.3 Other Cross Cutting Issues 147 7.4 Key Conclusions and Considerations 152 8. Conclusion and the Way Forward 158 Glossary 164 References 167 Annexes 179 List of Tables Table 1: Pakistan’s key demographic indicators 31 Table 2: Public sector health and education expenditure (provincial and federal) (PKR billion) 40 Table 3: Total budget and allocations for child-specific programmes (PKR billion) 42 Table 4: Breakdown of food insecure households in Pakistan 55 Table 5: Percentage of out-of-school children (OOSC) 84 Table 6: Birth registration across provinces and regions 108 Table 7: Comparisons of violence against children by province/region 111 Table 8: Regional GDI and GII (2015) 142 List of Figures Figure 1: Pro-poor expenditure as a proportion of GDP 41 Figure 2: Multidimensional child poverty and income poverty: Country comparison 46 Figure 3: Stunting, wasting and underweight children under-5 53 Figure 4: Provincial maps for stunting 54 Figure 5: Key proven interventions to prevent and treat stunting and other forms of undernutrition 57 Figure 6: Breastfeeding practices in Pakistan (2006-2012) 58 Figure 7: Micronutrient malnutrition in children 60 Figure 8: Maternal Mortality Ratio (MMR) 63 Figure 9: Trends in child mortality (1990-2012) 65 Figure 10: Child mortality across provinces 66 Figure 11: Immunization coverage across provinces (2006-2012) 68 Figure 12: Provincial rural maps for out-of-school children (aged 6-16) 83 Figure 13: Primary school Net Attendance Ratio (NAR) (2006-2012) 87 Figure 14: Middle and secondary Net Attendance Ratio (NAR) (2006-2012) 89 Figure 15: Average number of years of schooling for youth (aged 20-24) (2013) 91 Figure 16: Percentage birth registration for children under-5 109 Figure 17: Child labour in Pakistan’s provinces 113 Figure 18: Status of drinking water in Pakistan 127 Figure 19: Estimated sanitation coverage trends (1990-2015) 129 Figure 20: Access to improved sanitation facilities 130 Figure 21: Provincial maps for open defecation 131 Figure 22: Multidimensional poverty in provinces 146 Figure 23: Key interventions for young children and their families 148 List of Text boxes Text box 1: Key elements of Vision 2025 related to children, women and vulnerable groups 35 Text box 2: Concluding observations of the CRC Committee related to child health and nutrition in Pakistan 52 Text box 3: A glimpse at maternal survival in Pakistan 63 Text box 4: The impact of HIV on children in Pakistan 67 Text box 5: Concluding observations of the CRC Committee related to education and development in Pakistan 80 Text box 6: Concluding observations of the CRC Committee related to child protection in Pakistan 106 Text box 7: Children with disabilities and special needs in Pakistan 115 Text box 8: Concluding observations of the CRC Committee related to WASH in Pakistan 126 Text box 9: Concluding observations of the CEDAW Committee 141 Text box 10: Five bottlenecks and barriers contributing to gender inequality 144 Annexes Annex A: Table Child Well-Being Dimensions as Per CRC, CEDAW and CRPD, and Corresponding SDGs 179 Annex B: Data Availability Matrix 182 Annex C: Regional Countries’ Selected Indicators on Human Development 185 Annex D: List of Selected Acts/Regulatory Bodies Relevant to Child Rights 186 Annex E: Deficiency of Micronutrients among Under-5 Children and Pregnant Women 187 Annex F: Child Malnutrition in Pakistan (0-59 Months) 188 Annex G: Food Insecurity in Pakistan 189 Annex H: Early Childhood Mortality Rates 190 Annex I: Immunization Coverage in Pakistan 191 Annex J: Antenatal Care, Deliveries and Postnatal Check-Ups 191 Annex K: Out-of-School Children (Aged 4-12) and Wealth Quintiles 192 Annex L: Child Labour Force Participation (10–14 Years) 193 Annex M: Women Married Before the Ages of 15 and 18 and Incidence of Child Marriage in the Provinces 194 Annex N: Open Defecation by Quintiles, Improved Sanitation Handwashing with Soap 194 Annex O: Relevant Global Evidence 196 Acknowledgements This report is a result of a long consultative process among UNICEF programmes and their relevant partners including Federal and Provincial Government ministries and departments, as well as civil society organizations. The robust data collection methodology was supported by multiple methods and techniques to triangulate available data from diverse sources, in order to formulate an evidence-based analysis. This multi-layered process began in 2016, with the preparation of in-depth Child Deprivation Analysis reports for each sector i.e., health, nutrition, education, water and sanitation, and child protection. UNICEF Pakistan’s respective sector teams conducted focused and detailed discussions with their counterparts to ensure the relevance and validity of their analysis both at national and provincial level. Provincial Prioritization Workshops were held in Karachi, Quetta, Lahore and Peshawar with government counterparts, NGOs and UN agencies. Later a national workshop was organized in Islamabad with national and regional counterparts. To further augment the analysis, a broader desk review was conducted to provide an overview of the country-level situation regarding all identified deprivations. The multi-phased approach highlights the participatory and highly consultative nature of the situation analysis process and large range of actors and stakeholders who have contributed to it. The support and inputs provided by the Government of Pakistan, Azad Jammu and Kashmir, Gilgit-Baltistan, Balochistan, Khyber Pakhtunkhwa, Federally Administered Tribal Areas, Punjab and Sindh has been critical to the completion and quality of the report. Inputs provided by UNICEF’s civil society partners have been a great contribution to the well-roundedness of this report. Special thanks is due to Ms Marriyum Aurangzeb, State Minister for Information and Chairperson Parliamentary Taskforce on SDGs, for her continued engagement with UNICEF and endorsement of this report. Within UNICEF, Angela Kearney (Representative), Cristian Munduate (Deputy Representative) and Shaheen Hussain (Chief of PMER Section) provided leadership for the process. Each UNICEF sectoral programme chief (Ellen Van Kalmthout from Education; John Agbor from Polio; Kennedy Ongwae from Health; Kitka Goyol from WASH; Melanie Galvin from Nutrition and Sarah Coleman from Child Protection) and their teams provided comments on multiple drafts. Faateh ud Din Ahmad provided critical data quality check, Ann Rosemary Arnott and Sadaf Zulfiqar ensured gender and social policy integration in the analysis, Masooma Qazilbash reviewed elements of disaster risk reduction and Kausar Tasneem Suhail provided excellent administrative and logistical support for all the workshops. From the provincial offices, David Igulu and his team from Balochistan; Douglas Higgins and his team from Punjab; Francois Kampundu and his team from KP; and Nargiza Khodjaeva and her team from Sindh were instrumental in conducting provincial workshops and providing feedback on the draft report. Special thanks are due to Isa Achoba and Inoussa Kabore, Regional Chiefs of Programme and Planning, who provided guidance and feedback throughout the process and all sectoral advisors from UNICEF’s South Asia Regional Office for their valuable inputs. The writing and finalization of the report was proficiently done by a team of consultants including Vardah Malik, who led the desk review report and provincial summaries, and a thorough and extensive quality assurance provided by Paul Dudley, Ruya Leghari, Kay Dorji, Dirk Westhof and Fatimah Mazhar, and designed by Human Design Studios. The entire SitAn process and report writing was led and supervised by Mussarrat Youssuf, Research and Evaluation Specialist of UNICEF Pakistan. The information, wisdom, time and inputs shared by all the above and multiple others, evident in the quality of this report, are sincerely acknowledged and profoundly valued. 8 Situation Analysis of Children in Pakistan | September, 2017 Foreword As the era of the Sustainable Development Goals (SDGs) dawns, the Government of Pakistan is pleased to present the report titled ‘Situation Analysis of Children in Pakistan 2017’, in partnership with UNICEF. The analysis offers an objective review of specific issues relating to the rights of children in Pakistan, examining progress to date and highlighting what more needs to be done to improve the lives of all girls and boys across the country; ensuring their right to survive and thrive, to learn, to be protected from violence and exploitation, and to live in a safe, clean environment. The most vulnerable and disadvantaged girls and boys are at the forefront of this analysis, reaffirming Pakistan’s commitment to the central aim of the global 2030 Agenda – leaving no one behind. The situation analysis preparation process has exemplified the partnerships that are critical for the achievement of the SDGs, the pursuit of equitable, sustainable economic and human development, and the fulfilment of child rights.