Scaling-up Nutrition (SUN) Proposal for DRT-F 2015 (under SPA 6)[1]

Outcome 6.2: (as in OP II Joint Work-plan) Nutrition security increased, especially for the vulnerable and excluded groups

Joint Output level: (as in Joint Work-plan, 6.2.1) Provincial/regional governments have developed and implemented nutrition policies, strategies, and plans to address malnutrition among the most disadvantaged/vulnerable population groups / Annual Common Budgetary Framework (2015)[2]
UN Entities / Total (USD) / Core/regular/ assessed (USD) / Non- core/other/extra budgetary (USD) / To be mobilized/ funding gap (USD)
Policy Initiative: Technical assistance for scaling-up nutrition (SUN)[3] / FAO,WFP, UNICEF, WHO / 3,969,862 / 38,577 / 921,107 / 3,010,000

Key activities towards which the DRT-F will contribute (include UN Entities to implement)

·  Continued and expanded technical support to multi-sectoral nutrition coordinating mechanism and institutional structures at the federal, provincial and regional level, including policy, strategy, surveillance and assessment units

·  Enhance support to review and institutionalize provincial strategies, prepare operational plans, budget plans and monitoring framework

For each Policy Initiative – Output level

1.  How was the policy gap for this initiative identified by the UNCT and the government? Which international norms and standards will this integrated policy initiative assist the government in better realizing?

Pakistan faces a high burden of malnutrition, including under-nutrition, micronutrient deficiencies, overweight and obesity. The National Nutrition Survey conducted in 2011 highlighted that 43% of the children under five years of age are stunted, 32% children age are underweight and 15% are wasted. With the exception of lowering of iodine deficiency, no improvements have been identified in the nutrition indicators in the past decade. Anemia and zinc deficiencies remain at high levels indicating a serious public health concern. Poor infant and young child feeding practices contribute to childhood under-nutrition. Moreover, the series of natural disasters in the recent past—including floods and droughts—further deteriorated the nutrition status of the population especially for mothers and children. Studies show that levels of chronic malnutrition were decreasing up until the early 90’s, but thereafter began and continued to trend upwards[4]. Low birth weight, another key indicator of under-nutrition, showed a similar trend[5] and the overall hunger indicators have also been increasing.

During the rollout (2011 and 2012) of OPII (2013-17), the results of the CCA/meta-analysis highlighted the need for focused attention to nutrition. Similarly the federal and provincial consultations for the development of the 5 year UNDAF/ OPII also showed the government need for UN technical and policy support on nutrition. The Government of Pakistan (GOP) has increasingly recognized the importance of nutrition within the development agenda and has included this topic in national annual and five year plans. It is also highlighted under Pillar IV (Food security) of the recently launched Pakistan Vision 2025 issued by the Planning Commission. The signing and the launch of the global movement on “Scaling-up Nutrition” (SUN), which was followed by declaration of commitment, are important and significant steps in this process. The UN together with other nutrition development partners are supporting the GOP at national and provincial levels to formulate multi-sectoral policies and strategies fully aligned with the Scaling-up Nutrition approach, which promotes both the scaling-up of nutrition-specific and nutrition sensitive interventions (food security, agriculture, education, social protection, water and sanitation, among others). This policy initiative will assist the GOP to better perform with respect to global targets and strategies including World Health Assembly Indicators, the second goal of the proposed Sustainable Development Goals, the global SUN movement and the Rome Declaration and Framework of Action endorsed by the member countries of FAO in the International Conference on Nutrition in November 2014. The focus will be on the continuation and expansion of initial activities having started in 2014 (under DRT-F 2014) plus an emphasis on the formulation of a national multi-sectoral policy to support the provinces and regions.

2.  Briefly describe the activities to be implemented above (with DRT-F fund contributions) and how they will contribute towards the country achieving the desired change at the output and outcome level?

The proposed action contributes to improving the nutrition actions and systems at the federal and provincial levels, in order to address the malnutrition especially among mothers, adolescent girls and children. It will lead to the overall Scaling-up Nutrition (SUN) Initiative in Pakistan by strengthening the linkages and coordination between the provincial and federal governments, and establishing standards, and mechanisms for policy coherence and evidence-based decision-making. The action will complement other Strategic Priority Areas of the One UN Programme II in Pakistan. The table highlighting key activities and value addition to DRTF support 2014 is mentioned below:

Activities / Value addition and difference from previous DRT-F support
Continued and expanded technical support to multi-sectoral nutrition coordinating mechanisms and institutional structures at the federal, provincial and regional level, including policy, strategy, surveillance and assessment units / Strengthening the support at national level and creation of SUN Units in Provincial Planning and Development Departments of KP, Sindh, Punjab, Balochistan and AJK /GB
Sector-specific policy alignment
Scope of the guidelines now includes fortification and the LNS type products standards and revision of the Food Composition Table and dietary guidelines
Enhance support to review and institutionalize national and sub-national strategies, prepare operational plans, budget plans and monitoring framework / This is in line with the SPA 6 SUN Proposal and the activities will strengthen the sector-specific annual work plans and budgeting along with sector-specific communication plans

Through the DRFT support, the activities will be delivered at provincial level by partners as a complete package. The work in Balochistan will be led by FAO, KP-FATA and AJK will be led by UNICEF, WFP will support Sindh and National Level and will collaborate with WHO in Punjab. The main activities foreseen are described as under:

1.  Continued technical support to multi-sectoral nutrition coordinating mechanism and institutional structures at the federal, provincial and regional level, including policy, strategy, surveillance and assessment units

·  Strengthen SUN coordination system at national and sub-national level

The SUN coordination system at the national, provincial and regional level will be strengthened along with continuation of ongoing SUN efforts in Pakistan. This will be achieved by making coordination mechanism more effective and efficient at federal and provincial levels by providing technical and other necessary support. This will include formulation of a national nutrition task force, the secretarial and technical assistance to the Ministry of Planning and Development at national level and support to planning and development departments at provincial and regional levels. In addition, it will be tasked for the necessary coordination with the departments in charge of health, food, agriculture, education, water, sanitation and hygiene (WASH), social welfare as well as local governments. It will ensure the alignment of the multi-sectoral strategies within all networks and sectors to scale-up nutrition efforts. Dedicated staff will be deployed at these SUN units to support project coordination and provide technical assistance. The following flow chart describes the coordination flow between the national and provincial SUN Secretariats and Units respectively and the other government structures. Already the support is being provided to the National Fortification Alliance Secretariat and to the SUN Secretariat at national level. However, the coordination in provinces is a missing link. It is important to consider this issue since following the adoption of the 18th Amendment,[6] enforcement of strategies and subsequent legislation is now a provincial subject. Therefore, this coordination at provincial level is crucial for achieving the results.

Flow Chart of Coordination between National and Provincial SUN Units

·  Policy coherence and sector-specific alignment

The provincial multi-/inter-sectoral policy guidance notes on nutrition followed by sector-specific strategic directions are already endorsed. However, their internal collaboration and alignment is a missing link, which needs to be addressed by harnessing all relevant sectors. With DRTF support, the said link will be established with planning and development departments to lead and support all relevant sectors in order to further streamline their strategies and align them accordingly. In this regard, technical support will be furnished to P&D and other departments at provincial and regional levels on need basis. Furthermore, a national nutrition strategy needs to be devised at the federal level in light of the provincial policy guidance notes and inter-sectoral nutrition strategies. This will be carried out through DRFT policy support, aligned to the Pakistan Vision 2025, the Pakistan Country Paper on Nutrition for ICN 2014 and the Rome Declaration and Framework on Nutrition 2014. It would not only guide the nutrition action at the federal level but also contribute to greater allocation of budgets, while preparing national and provincial action plans, and projects along with the mobilization of resources through different channels.

·  Assist in the development of guidelines, normative guidance, standards and protocols

As part of the Scaling-up Nutrition Approach, the country needs to develop, revise and adopt national guidelines, standards and protocols on nutrition. This normative work will help the departments at the federal and provincial levels in devising policies and implementing nutrition activities and programmes. It will guide the public as well as the private sector to strategize their work in the field of nutrition. Food composition tables and dietary guidelines are essential tools for providing information about the nutrient composition of selected food and beverages regularly consumed in a given country. It serves as a guide to the population on recommended portion sizes of food and drinks from each food group, which are necessary to maintain an optimal nutritional status and health. The nutrient composition of food and drinks are influenced by soil fertility, environmental factors and agricultural practices, which vary from country to country and within country. A review consultation of Pakistan’s Food Composition table (last revised 2001) and National Food Based Dietary Guidelines (last prepared 2005) has already been undertaken by the Planning Commission and FAO with the support of DRTF 2014, involving relevant national and provincial universities in the country. It has identified various gaps, highlighted the need to update the Food Composition Table and proposed recommendations for revising the dietary guidelines. This would entail the analysis of regional variations in the macro- and micronutrients of key foods according to agro-ecological zones, dietary value of raw and cooked foods and an analysis of different commonly prepared recipes at the household level.

The standards related to premixes for wheat flour in Pakistan are yet to be aligned with WHO recommendations globally. Apart from that, the production of lipid based nutrient supplements has been initiated in Pakistan with the support of the private sector and WFP. However the policy cover and the setting up of national standards in line with codex recommendations need to be done. Under the current proposal, discussion will be initiated at the SUN secretariat involving the National Fortification Alliance and the SUN business networks to ensure that this work critical work is initiated and completed.

·  Strengthen surveillance and analytical capacity of public sector at national and sub-national level

While health and nutrition surveillance is a highly important tool, it loses its relevance if there are delays in disseminating crucial data or if it suffers from lack of ownership by provincial and district governments. There is also an inherent risk common to all reporting systems that the data may be treated routinely, that they are not aligned across the different data sources in the health and nutrition sectors and that are not treated with the urgency it deserves. Through the DRTF, necessary technical support will be provided resulting in capacity building of staff and in strengthening the system to render decision-making in nutrition a high priority for the policy makers at the provincial level.

Through DRT-F support, the provincial governments will be assisted through the nutrition surveillance in viewing the entire nutrition problem along holistic lines and link surveillance results to decision-making on a perpetual basis. This will enable the government to view an investment in nutrition as a major leap towards economic growth in the long term by addressing the adverse impacts of the current dismal indicators. By drawing attention to the surveillance findings, the provincial and district governments will be advised on the most cost-effective ways of rectifying the situation based on international best practices and UN current experience in the country.

2.  Enhance support to appraise and institutionalize national and sub national strategies, prepare operational plans, budget plans and monitoring framework

·  Support and strengthen sector-specific action plans

Alignment of nutrition interventions within different sector-specific action plans is necessary to ensure that an multi-sectoral approach is implemented to address under-nutrition holistically. The relevant sectors like health, WASH, agriculture, education and social protection need to develop nutrition sensitive plans for better-integrated actions. Under this proposal, efforts will be taken to develop sector-specific plans with budgetary estimations and linked monitoring frameworks. It is important to note, that—without having done this effectively—the true essence of multi-sectoral strategies will not be achieved.

·  Develop and consolidate sector-specific national and provincial communication and media strategies

To address under-nutrition comprehensively and to get concrete outcomes, nutrition-specific and sensitive sectors such as WASH, health, agriculture, food security and social protection need comprehensive communication strategies in order to raise nutrition awareness among the general population, in particular with regard to mothers, caregivers and families. Hence, under this proposed action, integrated national and provincial communication and media strategies will be developed and aligned in a multi-sectoral manner.

·  Technical support to public sector for multi-sectoral Public Sector Development Plan

Sector-specific operational plans will need the thrust to be translated into actions, once public sector allocations to Annual Development Program schemes are significantly increased at the provincial level. While the World Bank supported nutrition program secured sizable government counterpart funding, there is a need for much greater public sector spending in the sector vital to human progress and economic development. Capacity gaps in this regard are foreseen and would therefore be matched with provision of assistance to all the relevant sectors such as WASH, health (the main implementers), agriculture, information, education and social protection.