Gilgit Baltistan Integrated Nutrition Strategy

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HEALTHY MOTHER HEALTHY CHILD

INTERSECTORAL NUTRITION STRATEGY FOR GB

2016-2020

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GB – INTERSECTORAL NUTRITIONAL STRATEGY

List of acronyms…………………………………………………………………………………...3

Introduction............................................................................................................... .........4

Rationale for integrated approach to addressing malnutrition.............................................5

Objectives of the inter-sectoral nutrition intervention..........................................................6

Target Groups.....................................................................................................................7

The Guiding Principles........................................................................................................7

Underlying assumptions......................................................................................................10

Desired Result outcomes of the inter-sectoral nutrition intervention...................................10

Oversight Coordination Monitoring and Evaluation.............................................................13

Approval of inter-sectoral nutrition plan...............................................................................14

Result monitoring framework...............................................................................................14

Sectoral Interventions....................................................................................................... 15

Department of health and population welfare.......................................................................16

Department of agriculture/food/livestock/poultry and fisheries ............................................24

Department of water and sanitation......................................................................................30

Department of education sector........................................................................................... 33

CROSS CUTTING SECTOR.............................................................................................38

Cross sector one: women development department – (WDD)..........................................39

Cross sector two: social protection and poverty alleviation...............................................46

Cross sector three: NGO/civil society private sector in INSGB ........................................49

Annexure ..........................................................................................................................53

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LIST OF ACRONYMS ADP Annual Development Program BCC Behaviour Change Communication BISP Benazir Income Support Program BHU Basic Health Unit BPCR Birth Preparedness and Complication Readiness CBA Child Bearing Age CSO Civil Society Organization CMAM Community-based Management of Acute Malnutrition CMWs Community Mid wifes DHIS District Health Information System DOH Department of Health EPI Expanded Program on Immunization FWW Family Welfare Worker GB Gilgit Baltistan GDP Gross Domestic Product IDA Iron Deficiency Anemia IMR Infant Mortality Rate INSGB Intersectoral nutrition strategy for GB IYCF Infant and Young Child Feeding LBW Low Birth Weight LHW Lady Health Worker M&E Monitoring and Evaluation MI Micronutrient Initiative MNCH Maternal, Neonatal and Child Health MOU Memorandum Of Understanding NGO Non Governmental Organization NIDs National Immunization Days NNS National Nutrition Survey NPS Nutrition Program for Sind NWFFP National Wheat Flour Fortification Project PC-1 Planning Commission-proforma 1 PDHS Pakistan Demographic and Health Survey PHC Primary Health Care PLW Pregnant and Lactating Women PSLSM Pakistan Social and Living Standards Measurement PWD Population Welfare Department RUTF Ready to Use Therapeutic Food SAM Severely Acute Malnutrition TORs Terms of References

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1.0. INTRODUCTION

Pakistan reports a very high under 5 mortality rate with Pneumonia, Diarrhea and measles- as

the major killers and under-nutrition as an underlying risk factor 1 . According to UNICEF’s

report2, severely underweight children are 9.5 times more likely to die of diarrhea than a child

who is not; stunted children are 4.6. times more vulnerable to die in this age group.

Punjab

Sindh KPK Baluchistan FATA AJK GB

Stunting

Mild to

severe

65.6 72.4 66.9 76 78.7 61.7 75.1

Wasting

Mild to

severe

37.1 46.3 30.1 34.5 16.3 41.5 19.5

Underweight

Mild to

severe

61.7 71.2 47.6 64.4* 25.3 59.9 59

In comparison to the national averages, the National Nutrition survey (NNS 2011) indicates that

Gilgit-Baltistan (GB) has comparatively high prevalence of stunting 75.1 %3 when compared to

other provinces except Baluchistan. Prevalence of mild to severe wasting is 19.54% which is

lower than the other regions. On the other hand, prevalence of underweight is also high (59%).

The situation is worse in the rural areas. In addition, anemia in children of less than five years of

age in GB is 41%5 and iron deficiency anemia is 36.2%6 in the same age group. Micronutrient

deficiency in children of less than five years of age from GB is also very high (71.8%)7 and vit. D

deficiency is 37% 8

The NNS 2011-12 also highlights poor nutritional status of mothers in GB indicated by 33%9 of

pregnant women and 23.3% of non pregnant women reporting anemia. 17.110% of women in

1 Improving child nutrition-The acheiveable imperative for global progress. UNICEF, April 2013 2 Ibid 3 INS 2011 new –pag table 6.3. 4 4 INNS PPT gilgit Dec - slide 45 5 NNS 2011, new version, fig 6.10 6 NNS 2011, new version, fig 6.12 7 NNS 2011, new version, fig 6.13 8 NNS 2011, new version, fig 6.17 9 NNS 2011, new version, fig 5.10 10 NNS 2011 pg. 98

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14-49 years and 14.6% of non pregnant women11 in the survey were found to be malnourished

(BMI<18.5). Similarly prevalence of micro nutrient deficiency was also reported to be high in

women in NNS 2011. 39.1%12 of pregnant women reported moderate to severe vit A deficiency

and almost similar prevalence of Vit. A deficiency was found in non pregnant women13. GB also

reports a very high prevalence of Vit. D deficiency (80.5%) amongst pregnant women14. The

survey assessed calcium levels in the serum of the pregnant women and reported hypo-

calcemia to be as high as 46.7%15

There are gains in reducing iodine deficiency in Gilgit-Baltistan, but anemia and other

deficiencies including vitamin A remained unchanged since the last survey of 2001. NNS 2011

has highlighted that 84.9% 16 samples collected from the market had iodine content of ppm >15

ppm. Similarly reported use of iodized salt is as 95% and use awareness about benefits of

iodized salt amongst mother is excellent i.e. 79.5%17.

2.0. RATIONALE FOR INTEGERATED APPROACH TO ADDRESSING

MALNUTRITION

NNS 2011 has highlighted malnutrition in GB is a major problem (annexure 1). The UNICEF

framework clearly highlights that causes of malnutrition are multiple in nature ranging from

immediate causes, underlying causes and the basic causes (Annexure 2). These causes can be

addressed with two types of interventions: Nutrition specific intervention and Nutrition sensitive

intervention

The nutrition specific interventions are more specific to the health sector. Traditionally, these

interventions have been implemented to address the issue of malnutrition. These interventions

are health specific and require presence of a functional health system with trained and

dedicated staff and adequate logistic support. Nutrition specific interventions for the prevention

and treatment of stunting and other forms of under-nutrition are given in annexure three:18

11 Ibid 12 NNS 2011 new version fig 5.24 and 5.25 13 NNS 2011, new version, fig 5.30. 14 NNS 2011, new version, fig 5.17 15 NNS 2011, new version, fig 5.18 16 NNS 2011, new version, section 5.3.3

17 NNS 2011, new version, section 5.3.3 18Scaling Up Nutrition: What Will it Cost? Horton, et.al. 2009

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Nutrition sensitive interventions are broader in nature and address the underlying and basic

causes of malnutrition. These interventions include income generation at household level,

diversity of production and consumption, actions to enhance social status of women, special

assistance to marginalized population to ensure availability and affordability for food items such

as through provision of food vouchers, incentivising girl child education and ensuring access to

safe water and sanitation.

Analysis of sectoral strategies in GB indicates that various sectors are already implementing or

envisaging implementation of nutrition sensitive strategies in their own demarcated thematic

areas .

According to Lancet 2013, “nutrition sensitive interventions also enhance the scale and

effectiveness of nutrition-specific interventions”. The strategy rests on the principle that the

co-location or convergence of nutrition specific and nutrition-sensitive interventions in the same

vulnerable geographic areas permits synergistic benefits and is capable of producing significant

reductions in stunting (over 4 percentage points a year in Peru and parts of Bangladesh).

There is however a need for more coherent multi sectoral interventions in prioritized areas to

reach out to marginalized segment of the population. This is however, only, possible when

various sectors plan together a coordinated and coherent inter-sectoral intervention.

3.0. OBJECTIVES OF THE GILGIT BALTISTAN INTER-SECTORAL

NUTRITION STRATEGY

The overall objective of the inter-sectoral nutrition strategy is to provide guidance to the relevant

sectors in reducing the burden of chronic malnutrition in GB through sustainable, effective and

inter-sectoral interventions. The strategy seeks to reduce:

Prevalence of underweight children aged 6 to 59 months by 10 percentage points (from

an estimated 5919% to 49% by the end of 2020)

Prevalence of anemia in under 5 year old20 children rom 41% to 31% by the end of 2020

Anemia in pregnant women from 33% to 23%% by the end of 2020.

Prevalence of anemia in non pregnant women21 to decrease from 23% to 15%.

19 NNS new Table 6.3 20 NNS 2011 new page 38 21 NNS 2011 new version table 5.19

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4.0. TARGET GROUPS

4.1. Minus nine months to two years (Preconception, conception, pregnancy

and lactating women and early childhood)

Scientific evidence indicates that first 1,000 days after conception is the most critical period of

child development. A mother who is malnourished during pre-pregnancy or who receives

inadequate food and care during pregnancy is at high risk of developing a low-birth weight

infant, who, in turn, will have a decreased likelihood of survival. 22 Combined early child

development and nutrition activities show promising, additive and synergistic effects on child

development. Although, this age group is already being targeted through CMW, LHW, FWW

and community outreach programs, investments will be increased, streamlined, and further

targeted with special attention given to BCC through intensive inter personal counselling and

mass media, radio and television.

4.2. Adolescents

Inter-sectoral strategy gives priority focus to adolescent girls. Reaching adolescent girls is

important given the critical importance of pre-pregnancy nutritional status in reducing low birth

weight in babies. Eating nutritious diet and administration of weekly iron tablets has potential to

increase iron stores. Adolescent boys need to be reached as future facilitators of gender equity,

underlining also the important male role in child care.

5.0. THE GUIDING PRINCIPLES

5.1. Principle one: Recognition of right to food

The right to food is the first fundamental principle underlying this strategy. It is defined as:

"The right to have regular, permanent and unrestricted access, either directly or by financial

purchases, to quantitatively and qualitatively adequate and sufficient food corresponding to the

cultural traditions among the people to which the consumer belongs, and, which ensure a

physical and mental, individual and collective, fulfilling and dignified life free of fear."

The definition has two underlying concepts23:

22 Scaling Up Nutrition: The UK’s position paper on undernutrition, September 2011 23http://en.wikipedia.org/wiki/Right_to_food#CITEREFCommittee_on_Economic.2C_Social_and_Cultural_Rights 1999

http://en.wikipedia.org/wiki/Right_to_food#CITEREFCommittee_on_Economic.2C_Social_and_Cultural_Rights

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Right to adequate food: This implies not only the absence of malnutrition, but also

access to a variety of food, food safety and dignity,

The "fundamental right to be free from hunger": This can be measured by the

number of people suffering from malnutrition and at the extreme, dying of starvation.

Principle two: Evidence-based interventions

Nutrition interventions instituted globally with well designed policies, and interventions have

shown remarkable reduction in the rates of under-nutrition. In designing a strategy for GB,

international evidence has been studied with interventions that has impact on women and

children health.

Principle three: Geographical convergence

The strategy proposes equity in institution of the nutrition intervention. It is proposed that

malnutrition prevention and management is prioritized in the most high-risk areas identified in

the NNS 2011. Even within districts, there are UCs which are more deprived than others. The

strategy will focus on the interventions at the district level, and, within districts, in high-risk UCs.

It is proposed that all sectors reach agreement on priority districts to ensure coherent

implementation of a convergent approach.

Principle four: Gender empowerment

The status of women is strongly associated with nutritional outcomes. A strong association

exists to indicate a robust association between women’s education/literacy and nutritional

status. One study24 found that improving women’s status in South Asia would reduce the level

of underweight young children by approximately 12%. Another study found that giving 1000 girls

one additional year of primary education would prevent roughly 60 infant deaths and three

maternal deaths, while averting some 500 births25.

Principle five: Inter-sectoral interventions

The role of other sectors, in addition to the health sector, in improving the nutritional status of

the population is crucial. These multiple sectors through their coordinated interventions can

reduce vulnerability to illness and can play a vital role in healthy behavior development. Analysis

24 L. Smith, U. Ramakrishnan,A. Ndiaye, L. Haddad, and R. Martorell, The Importance of Women’s Status for Child Nutrition in Developing Countries,Research Report 131, IFPRI, 2003 25 www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/.../multi_page.pdf

http://en.wikipedia.org/wiki/Malnutrition

http://en.wikipedia.org/wiki/Starvation

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of basic and underlying causes of under-nutrition makes clear that interventions to address

them must be inter-sectoral in nature.

Principle six: Multi-sectoral planning, sectoral implementation and inter-sectoral review

Mechanisms will be established to generate effective coordination for joint planning and review

across sectors. Efforts will be made to circumvent traditional stumbling blocks expected in such

efforts, among them (a) fears of jeopardizing sectoral integrity, (b) sectoral competition, and (c)

fear of dominance by a single sector – in this case health. At the same time, the strategy

recognizes that implementation of nutrition specific and sensitive activities are best carried out

sectorally.

Principle seven: Encourage involvement of the civil society

The strategy envisions a critical and constructive role of the civil society. It is proposed that

instead of a symbolic participation, civil-society stakeholders are encouraged to actively

participate in governance, planning and in implementation, particularly in matters relating to

behavior change, social marketing, research, monitoring and advocacy. The strategy will

provide opportunities to civil society for public-private partnerships that place high premiums on

innovation and on access to affordable services. The strategy will solicit inputs from civil society

through consultation and policy dialogue.

Principle eight: Common targets and indicators

The strategy acknowledges that while inter-sectoral action is capable of producing major effects

on nutritional outcomes (e.g. stunting), not all sectors are likely to be able to affect such

indicators on their own. Hence, agriculture projects may improve household food security of

formerly insecure households; it will make a major contribution to improved nutrition when

coupled with interventions from other sectors. Similarly, education projects which increase

female school enrolment and attendance or improve female literacy will also have its significant

impact upon the nutrition outcome indicator. Comparable reporting formats across sectors

involving local, district and provincial review holds promise to enhance intersectoral nutrition

intervention implementation. The data use for evidence based decision making will also be

encouraged as well as ensuring collection of validated data.

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6.0. UNDERLYING ASSUMPTIONS

i. There is a commitment to rapidly scale up both domestic and external investment for

inter-sectoral nutrition interventions;

ii. Development partners will harmonize their external assistance, will seek to reduce

fragmentation and to enhance mutual accountability;

iii. Government is ready to embrace public-private partnerships for enhancing agriculture

and crop productivity and other sector’s upliftment

iv. Government, and non-governmental sectors and elected representatives assume

ownership of the strategy;

v. There is acceptance of the concept of one integrated provincial and district level

monitoring and evaluation system;

vi. Nutrition sensitive programs will help scale up nutrition specific intervention.

vii. Key sectors, i.e. health, agriculture, food/ livestock/poultry and water and sanitation are

committed to coordinating and collaborating intersectorally and cross sectorally and

ensure that their interventions are pro-poor, gender and nutrition supportive.

7.0. DESIRED RESULT /OUTCOMES OF GB INTERSECTORAL NUTRITION

STRATEGY INTERVENTIONS INS GB has proposed actions that will enable the region to achieve its desired aspiration to

improve the nutrition outcomes of the population through nutrition sensitive and nutrition specific

interventions. In the next 5 years, these results will be measured through clear indicators

included in the annual work plans. Achieving these results outcomes would enable the province

to embrace other developmental interventions that will not only prevent mortality and morbidity

amongst women and children but will also improve their productivity leading to a better quality of

life. It should be noted that in the section of inputs, most of the activities get initiated in 2016

based on the assumption that the INSGB will be approved in 2015. Outputs of intersectoral

strategy are given in annexure four. In the later section, outcomes for each of the sectors have

been documented; this section refers to overarching outcomes of the INS-GB.

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Intermediate outcome 1: All sectors have adopted a common vision and strategic

direction for reducing malnutrition

Outputs:

i. All nutrition sectoral strategies developed are nutrition sensitive and formulated after

review of the existing sectoral strategy

ii. Enhanced provincial capacity for stewarding and formulating evidence-based policies .

iii. Individuals and communities are informed about the benefits of good nutrition for young

adolescent girls and children and will change their attitudes towards family practices;

iv. Incentives introduced for increasing demand and access to healthy and fortified food.

v. Various sectors participated in advocacy for healthy food and nutrition.

Intermediate outcome 2: Food security and safety enhanced equitably across entire

Gilgit Baltistan with emphasis on reaching out to underserved areas

Outputs:

i. Marginalized and underserved areas received prioritized nutrition specific and nutrition

sensitive interventions

ii. The food available in the market is certified by accredited authority for its quality and

safety

iii. Households have adopted the practice of consuming fortified food and use of iodized

salt

iv. Farmers, livestock producers and fisheries are using modern and safe methods to

improve their produce.

v. Private sector have successfully launched initiatives that enhance production of bio-

diverse food at affordable price

Intermediate outcomes 3: Access to health, nutrition and developmental opportunities to

women and children is optimized

Outputs

a) Schools are offering nutrition and life skill education to children as part of their curriculum

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b) Adolescent girls are receiving weekly iron supplements from their schools

c) Gender sensitive social protection packages have enhanced economic empowerment of the

women in the population

d) Household income and food diversity increased as a result of vegetables and fruits grown in

the kitchen garden

Intermediate outcomes 4: Access to safe water and sanitation facilities enhanced in the

marginalized population and areas

a) Increased %age of households in geographically deprived areas have access to clean/safe

piped or tube well / boring water

b) Increased %age of households have access to safe sanitation facilities

c) Increased %age of population is using soap for hand-washing.

d) WASH sector has instituted gender sensitive WASH interventions by adopting inclusive

process that ensures women participation in the designing and follow-up of all WASH

schemes.

e) Schools have ensured availability of clean/safe water and sanitation facilities for children

Intermediate outcomes 5: Nutrition sensitive incentives in the social protection package

has reduced poverty and increased agricultural output

Output

a) Benazir Income Support Programme (BISP) has introduced schemes that incentivizes

parents to send their daughters to school

b) BISP has expanded its vocational training package to enable women to acquire skills and

increase their incomes.

c) BISP has offered loans that has enabled small farmers to increase their produce through

purchasing agricultural inputs in a timely manner

Intermediate outcomes 6: Increased numbers of women and children have access to

health specific intervention

Outputs

a) Increased % of infants from 0-6 months of age are breast fed within 1st hour of birth

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b) Increase % of infants aged 6-12 months of age who received exclusive breastfeeding up to

six months of age

c) Increased % of children aged 12-24 months introduced to complementary food between 6-8

months of age

d) Increased % of mothers with a child aged 0-12 months received any ANC during their last

pregnancy

e) Increased % of mothers with a child aged 0-24 months who received any micronutrient

supplements during her last pregnancy

f) Increased % of children aged 12-60 months who received vitamin A supplement in the past

6 months

g) Increased % of children aged 6-24 months who consumed multi-micronutrient powder for

atleast two months every six monthly period

8.0. OVERSIGHT COORDINATION MONITORING AND EVALUATION

Province based oversight inter-sectoral nutrition program committee

The strategy proposes establishing a province based inter-sectoral committee which will be instrumental

in planning nutrition-specific and nutrition-sensitive programs, harmonizing information dissemination and

reviewing program results. The committee will have the authority to track district annual implementation,

address bottlenecks and limiting factors quickly and efficiently, and ensure accountability for results.The

secretariat of the inter-sectoral strategy implementation will be based in the P&D Department. It is

proposed that under the chairmanship of P&D department, following departments will represent on the

committee.

Departments of Agriculture, Food, Livestock and Fisheries

Department of Education (DoE)

Departments of Health (DoH) and Population Welfare

Departments of Public Health Engineering (PHED) and Local Government

Departments of Women Development (WDD) and Social Welfare

Department of Finance

The committee will also have representation of the civil society. The ToR of the committee is attached as

Annexure 5.

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9.0. APPROVAL OF INTERSECTORAL NUTRITION PLAN

– An inter-sectoral nutrition cell is proposed in the P and D in the province, to provide guidance,

support, coordination and processing of nutrition sensitive intervention across all the sectors.

– Inter-sectoral strategy will be the central tool to provide direction and monitoring indicators to see

progress on the nutrition status

– Concerned departments will make their plans which are nutrition sensitive preferably

using the Nutrition Strategy

– Concerned department will also review their existing plans in pipeline and will aim to

make these nutrition sensitive

– P & D will ensure that plans submitted for funding are nutrition sensitive

– Plans will be funded either by ADP or foreign assistance.

10.0. RESULT MONITORING FRAMEWORK

The log frame below (Annexure 6) lays out GB’s nutrition strategy schematically.The annexure presents

matrices of the actions to be taken by each involved sector with timelines, responsible entities, and, in

some cases, expected impact. Targets for various results have been agreed with the subsectors through

the Inter-sectoral Nutrition Technical Working Group.

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SECTORAL INTERVENTIONS

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DEPARTMENT OF HEALTH AND POPULATION WELFARE

SUMMARY OF HEALTH SPECIFIC RECOMMENDATIONS

Action Area 1: Enabling environment, policy frameworks, strategies

Recommendation 1.1: Develop a comprehensive provincial specific health and nutrition policy

Recommendation 1.2: Establish an oversight intra-sectoral coordination group to harmonize various sub sectors of health aimed at reducing fragmentation in health service delivery.

Recommendation 1.3: Enforce legislation on the “Protection of Breast-Feeding and Child Nutrition Ordnance” from all private and public sector facilities

Action Area 2: Capacity Development and Coordination

Recommendation 2.1: Parents and school teachers and other outreach workers will be trained to play a key role in creating awareness about early identification and treatment of malnourished children.

Recommendation 2.2: Develop knowledge and competency of the health care providers and establish system for effective prevention of malnutrition

Recommendation 2.3: Nutrition cell in health sector will strengthen the curriculum of the health outreach workers in the area of nutrition promotion and will organize a capacity building plan that builds the capacity of 100% of the workers over the next three years

Action Area 3: Field Based Implementation

Recommendation 3.1: Revive and strengthen LHW/PHC program to enable them to play an active role in the early identification, prevention of malnutrition and promotion of health

Recommendation 3.2: Health department will facilitate establishment of formal linkages between LHW-PHC program and Education sector to ensure more than 95% of the school children receive at least once a year screening and twice a year deworming.

Recommendation 3.3: Increased emphasis would be laid on preventing malnutrition among expectant mothers and her baby through strengthening counselling, care and support from various primary and community-based clinics and programs.

Recommendation 3.4: Strengthen nutrition cell or cell? to ensure that the nutrition related activities are implemented and monitored in an efficient manner

Recommendation 3.5: Reporting system needs to be strengthened to monitor the coverage of Vitamin A capsule administration to children through diet.

Action area 4: Research and development

Recommendation 4.1: Undertake research to identify underlying reasons for malnutrition in GB context;

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RESULT FRAMEWORK FOR HEALTH AND POPULATION SECTOR

outcome 1 NNS 2011 Indicator 2018

Indicator 2020

MoV

Child stunting (H/A <2)26 50.6% 35% 30% Semi-annually HMIS

Output 1.1: . Evidence based and gender-sensitive health and nutrition policy will be enforced in GB.

Activities

Means of verification Timeline Sectors Budget

The policy dialogue held with the stakeholders to define the scope of nutrition policy;

Approved Nutrition Policy

document

May 2016

DoH, Stakehlders

Lobbyist, CSOs

Needed

Output 1.2:. Establish an oversight intra-sectoral coordination group to harmonize various sub sectors of health aimed at delivery of 1000 days healthy

mother and baby program.

Activities Means of verification

Timeline Sectors

Intrasectoral nutrition platform commissioned to play a leadership role in the development of the complementary initiatives through mobilizing the subsectors around nutrition

Notification of intra-sectoral oversight nutrition platform

Jan 2016 DoH-sub sector, Nutrition cell

Proposal is submitted to Pand D for strengthening the capacity of the nutrition cell and to enable it to play a catalytic role in the implementation of the intersectoral nutrition strategy

Approved proposal and budget allocation

March 2016 Pand D, DoH

Include nutrition specific indicators in DHIS along with mechanism for reporting from various sub sectors of health.

DHIS report with nutrition specific indicators

June 2016 DoH-sub sectors Nutrition cell MIS department

All the sub sectors of health will report to the oversight committee on the progress of various milestones identified in

Quarterly report for the oversight committee

2016 March onwards

DoH-sub sectors Oversight group

26 PINS and operational plan presentation – slide 2

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the INS along with reporting on monitoring and evaluation when ready and institutionalized

BCC strategy developed with key nutritional messages to be disseminated from various platforms for behavior change and re-enforcement

List of key nutritional messages March 2016 DoH focal person Nutrition focal person BCC specialist

Continuity of care ensured and missed opportunities reduced for identification and treatment of malnourished children through building functional linkages between various levels of health service delivery

MoU between nutrition cell and LHW, FWW, MNCH and EPI program for identification and referral of malnourished children and women

March 2016 onwards

DoH focal person Nutrition focal person

Design and participate actively in the mid-term and end term evaluations

Evaluation reports June 2018 June 2020

DoH, Technical partners

Intermediate Outcome Indicator 2:

Baseline YR 3 Target (2018)

YR 5 Target

(2020-21)

Frequency of Collection

% of infants 0-6 months of age for whom breastfeeding was initiated within 1 hour of birth27

61.8% 70% 80% Annual HMIS and NSS28

Output 2.1.: “Protection of Breast-Feeding and Child Nutrition Ordinance” enforced from all private and public sector facilities

Activities MoV Deadlines Sectors

Lobby with policy makers /legislators and media through campaign for development and effective enforcement of “Legislation of the code of marketing of breast milk substitute”

- Report/clips of media campaign

Sept. 2016

Nutrition cell

Policy makers particularly women caucus,

Legislators

Registered hospitals and BHU / FWC/ MSU/RHC would implement the bill and ensure that the formula milk are only prescribed in extenuating circumstances

- Field monitoring report

Dec. 2016

onwards

CSO representatives/ media

Intermediate Outcome Indicator 3: Baseline YR 3 Target YR 5 Frequency of

27 NNS 2011- PAGE 84 28 NSS: Nutrition surveillance system

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(2018) Target (2020) Collection

% of infants aged 0-23 months of age who received exclusive breastfeeding up to six months of age29

14.5% 40% 70% Annual HMIS and NSS

% of children aged 12-24 months who were introduced to complementary food between 6-8 months of age30


Output 3.1.: Knowledge and competency of the health care providers strengthened in IYCF

Activities MoV Deadline Sectors Budget

Establish a task force comprising of representatives from PMDC,

pediatrician, nutritionist and nurses to define the strategies for inclusion of

IYCF in the curriculum and practice guidelines of the doctors. The in

service training MBBS curriculum should also sensitize doctors about the

harmful health effects of pesticide.

Notification of

the task force

June 2016 DoH Nutrition PMDC

Not needed

KAP survey designed and implemented in mid year and end year to

assess the improvement on knowledge about IYCF amongst health care

providers when compared with baseline.

KAP survey

report

June 2018 Dec. 2020

DoH Nutrition Research org. Technical partners

Needed

29 NNS 2011 PAGE 85 30 NNS 2011 -2013 fig. 7.5.

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Intermediate Outcome Indicator 4.0 Baseline YR 3 Target (2018)

YR 5 Target (2020)


% of mothers with a child aged 0-12 months who received any ANC during their last pregnancy31

80% 85% 90% Annual HMIS and NSS

% of mothers with a child aged 6-24 months who received micronutrient supplements during the last six months of her last pregnancy


Output 4.1 Competency of health care providers would be enhanced in BPCR and preconception counselling to provide good quality of antenatal

care


- BPCR and Pre conception counselling curriculum will be

developed with emphasis on maternal nutrition and its

implication on the new born babies

Copies of the approved

curriculum

September 2016 DoH and sub sector

- All the Primary health care centres ‘ staff and those

working in PWD clinics iin the marginalized areas will be

trained to provide pre-conception and BPCR counselling

to married couples through LHW, CMW, EPI and FWW

platform to ensure that new born is nutritionally health

Training report

March 2017

DoH and sub sectors, Population welfare

department

- All cadres of health care providers (LHWs, CMW and

FWW) would be trained to deliver messages about

adolescent nutrition, anemia prevention in young adults,

healthy cooking, dietary eating practices.

Training report

Dec 2017

DoH and sub sectors

PWD

31 in I n t e r - S e c t o r a l C o n s e n s u s B u i l d i n g O n Nutrition Strategic/Operational Planning, October 3-4, 2012, Serena Hotel Gilgit page 11

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YR 5 Target (2020)


% of children aged 12-60 months who received vitamin A supplement in the past 6 months

-

80% 90% Annual HMIS and NSS

% of children aged 6-24 months who consumed multi-micronutrient powder during the past week

- 30% 40% Annual HMIS and NSS

Output 5.1: By 2018, KAP survey will indicate that parents of under five children and school teachers of pre- nursery/nursery schools have 50% more

awareness compared to baseline about prevention, signs and symptoms and the importance of seeking timely care for malnutrition and other

childhood illnesses such as diarrhea and Pneumonia


CMWs, LHWs, EPI and outreach worker's (Agriculture extension

workers, school curriculum, WASH worker's and WDD workers)

curriculum would be revised to include key messages around nutrition.

Copy of the revised

curriculum

Dec. 2016 Nutrition, DoH sub sectors, such as

CMW, LHW, EPI, Dev..partners

Technical expert

CMWs, LHWs, EPI and outreach workers would receive training to

enhance competencies to transfer skills and exploit opportunities for

educating parents around those key messages.

Training evaluation

report

June 2017 Nutrition, DoH and tertiary care facility,

CMW, LHW, EPI, Dev..partners,

Technical expert

Create models of Public-Private Partnership, to reach out to the

population in the uncovered areas using different platforms

Coverage report

Dec 2017

Private sector

Nutrition cell

DoH

Mass communication campaign will be designed and rolled out to

reach out to the population with nutrition promotion messages

Campaign report June 2017 Nutrition, DoH, CMW, LHW, EPI,

Dev..partners, Technical expert, BCC

specialist

One stabilization unit with CMAM facility unit will be established in

each district and will be linked to OTP. Free indigenously prepared

Nutrition information

system

June 2016 NSS, DoH

22

nutrition supplements will be made available for nutrition

deficient ultra poor ladies/children.

Output 5.2. Prevalence of Vit A deficiency amongst children under 5 years of age will reduce from 71.8% to 50%


Awareness raising campaigns and activities will be implemented for promoting healthy diet amongst women of less than 5 year old children which includes consumption OF green leafy vegetables and fruits

Campaign report Dec. 2016

DoH, Nutrition cell, Dev. Partner, BCC specialist

Ensure availability of micronutrient supplies of Vit A supplementation for administration during Polio and other such mass vaccination campaign

Mass vaccination program activity report

June 2016

Polio program Nutrition cell Dev. Partner

Introduce indicators to monitor the coverage of Vitamin A from different areas by including a separate indicator in its DHIS.

Vit A coverage report Dec. 2016

Dev. Partner, BCC specialist

Polio department, MIS department


YR 5 Target (2020)


% of union council covered by LHWs, CMWs, NGOs or CSOs

- - Annual HMIS and NSS

Output 6.1. High risk UC identified and mapping of the local resources undertaken

Activities MoV Deadline Sectors

Mapping of the high risk UCs its gaps and

existing resources including LHWs, CMWs

carried out

Report covering the gap

analysis and existing

resources

April 2016

DoH and sub sectors, Technical expert, LHW program, Dev. partner

23

Capacity building plan will be developed for

enhancing coverage of integrated health

and nutrition services in these areas

Copy of the plan June 2016

DoH, Technical expert, LHW program, Dev. partner

Output 6.2. Improved effectiveness of LHW in high risk UC which are LHW covered

Activities MoV Deadline Sectors

A task force will be formed to undertake a

critical review of the LHW program, its

challenges particularly related to logistics and

medicines, bottlenecks and address gaps to

revive the program

Report of the task force

June 2016 DoH Technical expert LHW program Dev. partner

Nutrition indicators in the current LHW- MIS

will be critically analysed and proposal

submitted to improve the scope and quality of

information being forwarded on real time

basis to ensure timely actions

Revised tool Dec 2016 DoH Technical expert LHW program Dev. partner

24

DEPARTMENT OF AGRICULTURE/FOOD/LIVESTOCK/POULTRY AND FISHERIES

SUMMARYOF AGRICULTURE SECTOR SPECIFIC RECOMMENDATIONS

Action area 1- Creating enabling environment

Recommendation 1.1: Enhance food security through approving and enforcing integrated pro-poor gender sensitive provincial agricultural and food security policy

Recommendation 1.2: Increase production of diverse sources of food through upscaling innovative partnership approach

Action area 2: Capacity Development and coordination

Recommendation 2.1: Establish food authority to ensure food safety of the food products, pesticide and fertilizers available in the market

Recommendation 2.2:Ensure safety of medicinal inputs for treatment, enhancing milk and meat production of the livestock

Recommendation 2.3: Improve the effectiveness of the role of agriculture extension workers to enable beneficiaries particularly marginalized ones to produce more crops and

contribute to enhancing food security.

Recommendation 2.4: Enhance the skills of the outreach workers to enable them to perform their responsibilities as multi-skilled, agricultural extension competent to influence

the knowledge, attitude and skills of the farmers, livestock growers and fishery owners by strengthening their competency in respective areas of work.

Recommendation 2.5:Enhance the capacity of existing capacity of the livestock extension workers training units

Recommendation 2.6. Food security monitoring section to be established in the Live stock department

Recommendation 2.7: Engage and empower underserved women to develop locally tailored healthy food, produce diverse sources of food and adopt processing techniques' for

perishable food items.

Action area 3: field level implementation

Recommendation 3.1: Upscale fish farming capacity particularly in small fish farmers through financing and provision of better quality inputs

Recommendation 32: Home stead food production of livestock, dairy and poultry products upscaled through extending micro finance and micro credit loans to poor and

marginalized

Recommendation 3.3.Improved intake of good affordable protein through increased awareness from various platforms about benefits of eating fish and meat

Recommendation 3.4: Role of the food department expanded and synergies built with other sectors to ensure availability of fortified food

Recommendation 3.5: Ensure availability and access of affordable and quality supply of pure seeds to farmers in GB through investing in research for varietal evaluation

Recommendation: 3.6. Revive fish farming in GB with support of the private sector


Recommendation 4.1: Research and advocacy fund established with participation of sectors in the technical advisory group. Here do you mean the TWG? Or a TAG?

25

Result framework for actions from agriculture/livestock/fisheries sector

Annexure 3: Agriculture/livestock/fisheries Matrix

Key Agriculture/livestock/fisheries/Food Sector Indicators NNS 2011 NNS 2018 NNS 2020 Source

% of households “food secure”32 60% 70% 85% Nutrition survey

% of children consuming at least four of seven food groups on the previous day 45% 65% Annual monitoring and NSS

% of landless or small holder rural households reached in the past 6 months

with assistance in garden production, small livestock or fisheries

- 40% 70% Annual monitoring via MoA

management information system

% of commercial wheat flour-consuming households consuming fortified wheat

flour

- 30% 50% Annual surveillance

site data

% of commercial edible oil-consuming households consuming fortified edible oil - 30% 70% Annual surveillance site data

% of households consuming iodized salt (min 15 ppm) 85% 90% 95% Annual surveillance site data

% of poultry famers and livestock breeders producing better quality of eggs,

meat etc

- 50% 70% Annual surveillance site data

Intermediate level outcome 1 Indicator 2018

Indicator 2020

MoV

% of food secure households increased 70% 85%

KAP survey

Output 1.1: Gender sensitive and pro-poor provincial , livestock and food security policy enforced.


Timeline Sectors

32 Source: NNS 2011

26

Advocacy and lobby to the legislator for food security policy Collection of information and research data for policy advocacy

Approved food security

policy

June 2016

DoA All stake-holders Civil society

Output 1.2: Several public private projects (PPP) are implementing interventions to increase access and supply of the diverse sources of food in the

marginalized population

Activities

Means of verification

Timeline Sectors

Establish a task force to develop ToR for public private partnership projects (PPP) projects

-Mechanisms are in place to protect private sector’s commercial risk, policy risk and regulatory risks

- ToR for PPP around food fortifications

Dec 2016

DoA

Private sector

Intermediate level outcome 2.0.

Indicator 2018

Indicator 2020

MoV

Enhanced level of knowledge, attitude and skills amongst farmers,

livestock growers and fishery owners about good practices for

farming, cattle rearing, poultry and fish and fishling resulting in

increased production and reduced post harvest loss.

40% of the farmers, livestock

growers and fishery owners

70% of the

farmers, livestock

growers and

fishery owners

KAP survey

Output 2.1 : >95% of landless or small holder rural households reached in the past 6 months with research, technical and financial assistance in

garden production, small livestock or fisheries


Timeline Sectors

- Strengthening of Human resource development centre (physical and technical infinrastructure) to enhance the capacity of >95%% of extension workers and field assistants all subsector of agriculture (agriculture, poultry, livestock and fisheries)

Annual monitoring report DoA information system

June 2017 DoA- training department Technical expert

27

- Nutrition component added to the master trainers curriculum and approach to learning strengthened with inclusion and emphasis on backyard gardening, importance of consuming all food groups for health and establishing and maintaining small scale livestock and fishery

Revised curriculum Annual monitoring report

Dec. 2016 Technical experts

DoA

- Innovative approaches such as hotlines will be developed to provide access to updated knowledge about safe and good quality farming inputs including small level fish farms

Annual monitoring report

Dec. 2016 DoA

IT experts

- Financing schemes based on easy conditions will be developed by Waseela-e-rozgar programme / social welfare program / ZaraiTarqiyati bank to provide initial small credit and financing packages and extended to small farmers and agriculture producers to promote aquaculture practices and backyard fish farming

Financial products Annual monitoring report

Dec. 2016

DoA Financial institution BISP

Better quality, affordable, safe and certified fish feed that enhances the nutrient values and good protein availability of the fish protein as a result of research will be available to small and poor farmers at affordable price

Market survey

report

Dec. 2016

Research organization

Micro credit loan provider

Standards will be set for certifying safety of medicines and hormones used for enhancing milk and milk products

Copies of the

standards

Dec. 2016

Technical assistance

Dev. Partners

Methods to improve poultry farming (meat and egg production) introduced

DoL report

Dec. 2016 Technical assistance Dev. Partners

Improve the national breed improvement program enhance the quality

of livestock through cross breeding of the cattle with better genetic

endowment;

Research

development report

June 2017

Academia

Research experts

DoA

R&D to produce better quality of seeds, plant varieties, women friendly

technology and safe medicinal inputs in dairy farming

28

Intermediate level outcomes 3.0:

Indicator 2018

Indicator 2020

MoV

% of commercial wheat flour-consumers/households consuming fortified wheat flour

30% 50% Nutrition Survey

% of commercial edible oil-consumers/ households consuming fortified edible oil

30% 70% Nutrition Survey

% of households consuming iodized salt (min 15 ppm) 90% 95% Nutrition Survey

Output 3.1: By 2016, Food department with support from Pakistan Standards and Quality Control Authority (PSQCA), legislators and CSOs will ensure that fortified food items are available in the market

Activities

Means of verification Timeline Sectors Budget

Food inspectors inducted in the food department to enhance vigil on the sale of fortified food in the market.

Market survey report from the

food department

June 2016

Food Department PSQCA

Needed

Certification at the products from down country to GB will be enforced with support from the law enforcement agencies posted on the border.

Market survey report from the food department

June 2016

Food Department PSQCA Consumer protection bodies

Needed

Mass media will be mobilized to create wide spread awareness about importance of consuming a balanced and healthy diet along with consuming fortified food, meat and fish items in the market.

Clips/records of mass media

awareness

June 2017

DoA and DoLs Manufacturers Private sector CSO Mass Media

Needed

29

Intermediate level outcome 4.0.

Indicator 2018

Indicator 2020

MoV

% of children consuming at least four of seven food groups on the previous day

45% 65% Annual monitoring and KAP survey

50% of the farming women will be growing and processing variety of foods for family consumption and sale.


Professional and technical capacity building of private sector fish farmers to enhance their productivity


Output 4.1 : Social marketing and awareness campaign would be launched to create awareness amongst parents and population about eating

diverse sources of food

Activities


Timeline Sectors

Massive social Marketing campaigns instituted to promote fish and meat consumption culture across the province

Mobilize various community based actions such as fish days or meat days to create awareness about benefits of consuming these sources of meat and protein.

Campaign reports IEC material

June 2016 DoA, livestock and fisheries

DoH-Nutrition cell

Technical agencies

:

30

11.0. DEPARTMENT OF WATER AND SANITATION

SUMMARY OF WATER AND SANITATION SPECIFIC RECOMMENDATIONS

Action Area 1: Enabling environment, policy frameworks, strategies

Recommendation1.1: Create enabling environment for the provision of safe water and sanitation through instituting policy and strategy

Recommendation 1.2: Create enabling environment through adopting an inclusive process that ensures women at the centre of designing

and follow-up support for all water supply, sanitation and hygiene schemes to make it more gender sensitive.

Action Area 2: Capacity building

Recommendation 2.2: Strengthen the service provider's ability to provide safe water and sanitation

Action Area 3: Field-Based Implementation

Recommendation 3.1: WASH sector in collaboration with other sectors (public and private partners) would raise awareness about importance of

maintaining WASH schemes in good condition and adopt appropriate health and hygiene practices including hand-washing.

Recommendation 3.2: Incorporate community oversight monitoring and supervision of the water and sanitation system through building community

ownership and commitment to provide follow up care to WASH interventions

Recommendation 3.3: Review and strengthen health and hygiene promotion messages in the curriculum of different sector’s outreach workers

Recommendation 3.4: Increase access to safe water and sanitation through adopting a systematic plan of introducing new schemes and rehabilitating

already instituted schemes in the prioritized UCs/districts


Recommendation 4.1: To undertake research activities to collect evidence for policy advocacy and developing feasible interventions.

31

Result framework for actions water and sanitation sector

Intermediate level outcome 1 Baseline Indicator 2018

Indicator 2020

MoV

Increased % dwellings will have piped or tubewell/boring water

Increased % households have access to hygienic sanitation facilities 73% 80% 90%

Survey report

Output 1.1: Provincial water policy and strategy and sanitation policy and strategy are approved and enforced.


Timeline Sectors

Lobbying and advocacy to legislators for approval of Water and sanitation policy;

Copy of approved provincial

water policy and strategy

June 2016

WASH

Legislative department


Timeline Sectors

Implement gender-sensitive WASH interventions along with other sectoral interventions (pipe networks, water treatment units, sanitation system sewage treatment) in prioritized, marginalized area

Physical survey report of hard to

reach areas

June 2016 WASH

Legislative department

Community Operation and Management groups would be instituted for every new schemes to ensure these are functional after five years

Physical survey report of hard to

reach areas

June 2016 WASH

Legislative Dept.

New WASH scheme would seek village consultation from

women groups and foras during planning process Physical survey report of hard to

reach areas

June 2018 WASH

Rural Support Prog.

Establish intra sectoral monitoring cell to ensure that water and sanitation schemes meet the minimum required standards;

Annual report June. 2016

WASH tech. experts, Environment specialist, Water quality assessment laboratories

A system of a fortnightly water quality testing from each UC

for safety and quality

MIS from water system June 2016

32

Intermediate level outcome 2 Baseline Indicator 2018

Indicator 2020

MoV

Households have soap available at the washing place 17% 55% 70%

KAP survey

Output 2.1: Awareness raising about hand washing amongst population


Timeline Sectors

A multisectoral expert group will develop key messages about

hand washing, hygiene of sanitation facility and proper disposal

of solid waste

Report of formative research June 2016 DoA All stake-holders Civil society

Clear and focused BCC strategy will be implemented through

schools, outreach workers and mass media campaign to

promote health and hygiene messages

Report and news clips about

the advocacy campaign

Dec. 2016 DoA BCC specialist

Environmental hygiene and personal hygiene related messages

will be incorporated in the school curriculum with WASH sector

providing necessary support if needed

Copy of the school curriculum Dec. 2016

DoA DoE Nutrition expert

33

RESULT FRAMEWORK : KEY EDUCATION AND WOMEN SECTOR

Key Education and Women Sector Indicators

Baseline

2011

Indicator 2018

Indicator 2020

MoV

% of schools including nutrition in school curricula at any level

- 45% 95%% Annual DoE management information system data

% of secondary schools offering life skills education and weekly iron tablets to adolescent girls

- 25% 60% Annual DoE management information system data

Output 1.1: 30% more children from marginalized families (source: BISP/AKRSP database) will complete their primary schooling


Timeline Sectors Budget

Mapping of the schools in high risk areas with low girls

attendance; Mapping report June . 2016

DoE Academia Researchers

Needed

Formative research undertaken to identify barriers to school

attendance amongst girl children Formative research report June 2017

DoE Academia Researchers

Needed

Introduce incentives such as food vouchers to poor families

registered in BISP database to encourage them to send

their children to schools

Quarterly report of the food

vouchers distribution

Dec. 2016

onwards

DOE/School management committee/ private sector philanthropists

Needed

The information system will have district wise nutrition

indicators about school enrolment, school retention and

promotion to next class indicating the effectiveness of the

intervention;

Quarterly DEIS report Dec. 2016

DoE MIS department

Needed

34

Output 1.2: 70% Children from marginalized families attending schools in high risk districts receive mid day food as incentive and also to improve

school attendance


Timeline Sectors

Lobby for instituting policy for mid day food

Media clips or info briefs used for

lobbying Dec 2016

DoE CSO

Policy on mid day food enforced and implemented in the

high risk districts on priority basis

Copy of the approved policy

June 2016

DoE Legislative body

SMC’s will receive training to develop community

mobilization strategy, process of procurement and

distribution strategy for the mid day meal;

Training report

Copy of the Strategy document

Sept 2016

DoE BCC specialist CSO

Project monitoring system will be instituted to ensure

transparency of the mid day food program

Project monitoring team report

June 2016 DoE /CSO

Schools will organize awareness activities for children about

benefits of eating a healthy diet and health and hygiene

alongside distribution of mid day food.

Awareness campaign reports

News articles

Dec 2016 DoE

CSO

By June 2017, 70% of schools in the target districts and

UCs will get a glass of milk daily with a fruit or some dry

biscuits

Report of the implementation of the

mid day food program

June 2017

DoE / P&D/ SMC/Private Sector


Indicator 2020

MoV

% of schools including nutrition in school activities from the curricula 45% 95%% Annual DoE Management information system data

Output 2.1: Development and inclusion of nutrition promotion activities school curricula

35

Activities

Means of

verification

Timeline Sectors

A task group comprise of educationist and nutritionist would be established

to identify gaps in the school curriculum for nutrition component and

propose standardized action oriented nutrition activities

Curriculum review

report

June 2016 DoE

DoH-

nutritionist

PDCN will develop curriculum for building capacity of SMC33 and MSG34 Copy of the

curriculum

Sept 2016 DoE, PDCN Curriculum review

department

Seek approval from approving authority on the inclusion of the proposed

sets of activities in the revised curriculum

Copy of the approval

from the designated

authority

Dec 2016 DoE, Curriculum review

department

Proposal approved for provision of budget for reprinting as well as building

of the skill lab for students to inform students about the nutritious diet

Budget approval

notification

Dec. 2016 DoE, P and D

DOE with support from UNICEF and FAO will incorporate community

based activities including kitchen garden in the school curriculum

Survey report June 2018

DoE, SMC, FAO

Agriculture extension workers

Schools will identify community areas that can be used for developing

kitchen garden

Children will be asked to bring seeds from home or get it from the

agriculture extension farmers and plant it in the school garden and learn

the skill of producing vegetables and fruits.


Indicator 2020

MoV

33 School Management Commitee 34 Mother support groups

36


25% 60% Annual DoE management information system data

Output 3.1: : Upscale schools on child friendly school concept across Gilgit-Baltistan with priority in hard to reach areas


Timeline Sectors

Mapping out schools for prioritizing schools for up-gradation to child friendly school

Survey report June 2016

DoE / AKES Technical assistance

DoE will link up with agriculture sector for technical assistance and access to inputs i.e. seeds for enabling students to learn to grow community and school backyard garden;

DoE performance report

Manual on building community garden

Dec. 2016

DoE DoA

DoE will link up with LHWs in the catchment area of the school for skill development activities, annual health screening of children, de-worming of children, and school health screening.

DoE performance report

School health screening report Dec. 2016

DoE DoH-LHW program Civil Society

Teacher’s trainers would be equipped with latest

knowledge and skills of nutrition education and

administration of iron tablets

Training report Dec. 2016

DoE PDCN

90% of the schools in GB would have “Parent teacher

committee/ SMC” active and ready to take

responsibility to monitor the functioning of the school

drinking and washing facility

School survey report June 2018

DOE Parent community

90% of the schools in GB would have functioning

water and sanitation and hygiene system

School survey report June 2020

DoE Engineering deprtt Parent teacher committee members

Output 3.2 : Strengthen the role of mothers support groups in creating healthy conditions for nutrition and health in schools and homes.

37

Activities


Timeline Sectors Budget

Mothers support groups established in all

educational institutions of GB

Mothers support group should be prepared to extend support in creating awareness about healthy nutrition amongst parents of the children.

Performance report of MSG

Plan of MSG activities

Dec. 2016 DoE MSG LHW Private sector

38

CROSS CUTTING SECTOR

39

14.0. CROSS SECTOR ONE: WOMEN DEVELOPMENT DEPARTMENT – (WDD)

“Women Development Unit” is a project based in P&D until 2001. In 2006-7, the scope of WDD enhanced to include focus on the

status of women, promote women's rights, ensure their active participation in provincial life at all levels, facilitate their serving as

agents of change in society, and to improve their legal access to economic resources and employment. WDD also has a sub-office

established at Skardu. In 2014, the project achieved the status of “Women Development Directorate” (WDD) with its mandate to

focus on “Gender growing issues” in GB.

Role of WDD in addressing nutrition problem

WDD through its mandate to empower women at social, economic and political level can play a very powerful role in improving

women status- one of the underlying determinants for good nutrition. By prioritizing its intervention in the most high risk areas, the

department can play a key role in reducing gender inequality.

Role of WDD in improving malnutrition

NNS 2011 data presents a mixed picture of women status in GB. Although according to NNS 2011, 80% women attend ante natal

care (ANC), PDHS 2012-13 shows a lower coverage of 64%. The education level of girls demonstrates gender parity of 0.73

indicating inequity in access to education. NNS shows that 31 percent of women in GB had 6 or more pregnancies (higher than the

national average 24%) and 35% women reported anemia. Prevalence of severe Vitamin A deficiency is as high as 32%. In GB, more

than one third of the households are food insecure and women are most affected in these households in terms of nutrition. Social

customs and role definition of women that subscribe hard labour for women, practice of eating last, bearing many children, little

control over finances, social marginalization with limited decision making power has its effect on overall health and nutrition of

mothers and their off springs.

Such dire situation puts huge responsibility on WDD to mobilize Government support, to enhance women status ensure creating an

environment which allows very sectors to work effectively for improving adolescent and child bearing age women social, physical,

psychological and nutritional status. WDD does get into direct service delivery for women such as vocational training programs for

women, it also understands its role in creating models of empowerment of that could be scaled up in other areas of the region.

40

Action 1: Create an enabling environment for action

Recommendation: WDD should aim to build strong and sustained government commitment, through developing favourable policy

environment, and allocating and timely releasing resources for improving women status based on the agreed plan

OUTCOME INDICATORS

By June 2017, policies and legislations will be in place for providing an enabling environment for women development

PROBLEM AND RATIONALE

Opportunities for income generation are vital for empowering women. Laws, counseling, support services, and medical care are quite

important for prevention and management of gender-based violence and discrimination particularly in those areas where women

traditionally have a very low social status such as in certain parts of GB. Lack of availability of schools and female teachers pose

cultural constraints to girls’ education. Likewise, in the area of health care, lack of availability of functional health services with

women provider pose other threats to women’s life and her ability to take timely care for various conditions affecting her health.

Women caucus and women development directorate can provide excellent forum for raising awareness and mobilize support for

action to enhance women’s status. Forum could advocate law and legislation as well as enforce legislation for prevention of domestic

violence and sexual harassment as well as preventing discrimination. In addition, advocacy by women caucus for equitable

distribution of health services will have huge bearing on the decisions around resource allocation from ADP and for innovative

approaches to reaching out to poor women including through mobilization of religious leaders, council members and women

legislators.

PROPOSED ACTION:

WDD should:

undertake impact assessment of its income generating interventions on health and social status of women to enable policy

makers to understand the value of allocating more resources for scaling up such initiative to reach out to as many areas as

possible;

41

advocate and lobby to the women legislators to35 develop mechanisms that provides free legal aid to women who are victim of

domestic violence and sexual harassment;

Expedite the establishment of Family Protection Centre (Crisis Centre for Women in G-B) and link these with income

generation capacity building of the inmates.

Form public policies and laws to assure full female access to education and health services

Ensure that summary of every maternal death is reported to WDD to ensure that barriers to care are identified and

addressed through advoacy

Protection and promotion of women's rights relating to employment and inheritance and social protection

WDD should join hands with other sectors in lobbying for:

o availability of female health care providers in the rural areas through agreements with the academic institutions by

adopting mandatory rotation of physicians;

o establishment girl friendly schools such as establishing girls madrassah schools, scaling up of home schools and

platforms such as “religious dars meeting” to promote women status, culture and practices in light of the Islamic

teaching

WDD should become the voice of people in particular women through developing sensitization package comprising of

advocacy seminars and newsletter that sensitize legislators, council members and policy makers about issues confronting

women and the actions needed.

WDD should organize advocacy training for journalist and other media personnel including for the female political member at

municipal, union and district level each year to promote and present performance of the WDD and advocate on women’s

rights and issues in GB

ACTION AREA 2: CAPACITY BUILDING AND COORDINATION

Recommendation: WDD should aim to expand its vocational training to be integerated with other support service and focus

on nutrition related businesses trade also

42

OUTCOME INDICATORS:

By June 2017,

WDD will have at least five more nutrition skill based vocational training program in its list of training

More than 70% of the graduates from vocational training centres would be gainfully employed or have their small business

with at least 30% increase in their monthly income

PROBLEM AND RATIONALE:

Review of the current programs of WDD highlights more vertical nature of intervention such as emphasis on vocational training that

builds women skills with an aim to enhance income generating capacity of women. The review of the documents however did not

highlight any arrangements for placement or marketing of these skills.

Women social status has a key role to play in improving nutritional status of women. WDD is working to enhance livelihood

opportunities through 68 vocational training centers established across Gilgit Baltistan in all districts. 6000 women from 110 villages

of G-B have been trained in basic vocational training certificate courses and 100 girls have been trained in short technical courses

e.g. Emboss painting, glass painting, fabric painting, tie & dye. Unfortunately, assessment of how household income has impacted

upon women’s health and nutrition status have not been carried out.

PROPOSED ACTION

WDD would build a network of business organizations, corporate, representatives from health, agriculture, education, mcro-

finance and private investors to enable WDD to identify emerging needs and potential market and placement for such

individuals.

WDD should expand the range of courses in light of the feedback received from stakeholders. It is desirable for WDD to

include vocational training program that enable availability of diverse sources of foods such as jams, jelly, etc. In the market

or products which indirectly contribute to enhancing health such as soap making.

WDD should map out the most high risk areas for women empowerment and poverty. It should develop a coordinated plan

with other private sector investors such as Hashoo foundation and AKRS, P to take these skills to the areas where it is not

possible to reach by WDD through its own resources.

43

Vocational training platform should also be used for educating women about their own health, child health and nutritional

health.

Promotion of cottage industries which boost women’s employment and household income and control on food choices

Map out and prepare a database of all the organization in GB for women gender equity

ACTION AREA 3: FIELD BASED IMPLEMENTATION

Recommendation: WDD should celebrate women’s and children international day in collaboration with other sector

focusing on how women’s social status, nutrition status and education status could lead to better health for family

RESULT OUTCOME

By June 2017:

WDD would lead twice a year campaign on women issues and development primarily from rural areas

WDD will support other sectors in organizing and launching their campaign

PROBLEM AND RATIONALE

Malnutrition in women and girls is directly linked to societal norms and practices. Women status, her mobility, cultural restriction on

her travel all pose a barrier to her development, which indirectly results in poor nutrition and health outcomes. The society considers

investment in son's education and food to be a worthwhile investment as they are expected to be the main bread winner and

responsible for procreation. Gender role and poverty further translate into higher prevalence of intra house power dynamics such as

restricting daughters after 12 years to move out of the house in some of the ethnic and conservative community needs to be

addressed on a priority basis using a women friendly and socially acceptable platform. It is important that priority for such

sensitization campaigns is given in hard to reach areas where the need is more instead of carrying it out in urban areas like Gilgit.

PROPOSED ACTIONS

WDD should celebrate Women’s International day each year with following points in mind:

Give priority to more rural areas

44

Adopt an integrated approach so that almost similar yet different messages are disseminated from various platforms

such as Mother and child days, enrolment campaigns from education and women social status up-liftment from WDD.

Inform communities about opportunities available to women to seek micro credits and loans for enhancing their small

ventures

ACTION AREA 4: RESEARCH

Recommendation: WDD should carry out researches to advocate for evidence based interventions to address unmet needs

for improving women’s health and nutrition

RESULT OUTCOME

By June 2017, WDD will develop and get funding for its research agenda approved

By Dec. 2017, WDD would have launched at least one research that will generate knowledge and evidence for improving

health and nutrition of women and children

PROBLEM AND RATIONALE:

Advocacy activities can only be effective when it is evidence based collected through relevant and context specific research

activities. It is important that WDD undertakes women oriented research activities that can lead to policy action:

1. Research to understand barriers to improving nutrition amongst women

2. Knowledge development and dissemination around models of governments and non-governmental models of health and

nutrition services for reaching out to women in rural areas

3. Trends in the emerging market for enterprise development with women and girls in the center of such development;

4. Collection of best practices of improving women status in rural mountainous areas

5. Review of the current vocational training curriculum to incorporate nutritional component in there

6. Collection of case studies to improve awareness about human & women’s rights issues that ultimately impacts upon the

health of the women.

Action area 5: Project Management, Reporting, Monitoring and Evaluation (for nutrition-related and nutrition-specific

interventions)

45

Recommendation 5.1: Develop, monitor and report the progress on various programs to ensure coordination with other players

RESULT OUTCOMES

By June 2018, WDD in coordination with various departments will achieve 70% of the planned activity

PROBLEM AND RATIONALE: WDD plans and actions are very activity oriented and therefore will need to develop some impact

indicators which can be assessed at five year interval. These impact indicators would very much depend upon receiving the support

from various departments. WDD by participating actively in oversight monitoring forum will be able to gather the required support.

PROPOSED ACTION

1. Develop MoU with different sector to agree on potential role;

2. Develop indicators in consultation with participating sectors to report to oversight committee

3. Develop action plan and milestones with timelines and report it on a quarterly basis to the oversight committee

4. Identify red flag issues with reference to joint intervention or road blocks and see support from the forum.

46

15.0: CROSS SECTOR TWO: SOCIAL PROTECTION AND POVERTY ALLEVIATION

There is a widespread perception that malnutrition is closely related to poverty. Poverty is one of the underlying determinants and

basic causes of malnutrition identified in UNICEF causality framework 36 . Persistent malnutrition also leads to ill health, poor

education performance, low labor productivity and poverty. The data from NNS 2011 indicates that large family size and low income

has close linkage with stunting. Study shows that stunting is higher (53.1%) in the lowest quintile group, but it also exist in the highest

quintile (28.9%) and is mainly related to behavioral issues in this group37.While the relationship cannot be denied, it is complex. It

must also be recognized that nutrition is more than food, and poverty is more than mere income or assets. The poverty-nutrition

interaction in Pakistan is particularly strongly influenced by female social status which mostly affects girl child and other determinants

including education status of the population and access to safe water and sanitation intervention.

Social protection is one of those strategies concerned with preventing, managing, and overcoming situations that adversely affect

population well-being[1] Social protection consists of policies and programs designed to reduce poverty and vulnerability by promoting

efficient labor markets, diminishing people's exposure to risks, and enhancing their capacity to manage economic and social risks,

such as unemployment, exclusion, sickness, disability and old age.

Benazir Income Support Program (BISP) is the Pakistan’s 1stlarge scale national social protection program, launched in October

2008 through parliamentary act to cope with increase inflation after 2008 global economic crisis38 with the intention to assist 40% of

population below poverty line39. In the social protection area, the country has introduced cash transfer to families through BISP, but

there has, to date, been little effort to orient the program toward nutritional concerns – either through the provision of nutritional

supplements or counseling. TAWANA – well functioning school feeding programs – had sought to adopt an inter-sectoral approach

by developing a tripartite agreement among the Ministry of Social Welfare, the Ministry of Education and the Ministry of Women

Development. TAWANA, however, has faced numerous problems to date.

BISP is one and probably the only social welfare initiative currently active in GB. Target population for BISP is mother of poor

households. Initially BISP was an unconditional cash transfer program but as unconditional cash transfers found to increase

dependency so BISP took a step towards conditional cash transfer by introducing Waseela-e-Taleem, Waseela-e-Rozgar and

36http://www.unicef.org/nutritioncluster/f...nutritionTechnicalNotes.pdf

37 Inter-Sectoral Consensus Building On October 3-4, 2012, Serena Hotel Gilgit

38 Benazir income support program (http://www.bisp.gov.pk)(accessed 20/5/2013)

39 Ibid

http://en.wikipedia.org/wiki/Social_protection#cite_note-1

47

Waseela-e-Sehat. Intersectoral nutrition strategy proposes to advance or remodel following components in achieving the effective

implementation of the program:

Waseela-e Rozgar program:

Social protection policies generally has both active and passive component. Passive component in the form of unemployment

benefits etc. is currently not present. These components are not designed to improve their employability. The second component

which is active social protectionis aimed atincreasing the access of unemployed workers through providing them the opportunities

to participate in vocational skills or micro-finance to reduce the risk of unemployment and to increase the earnings capacity of

workers. BISP has included this in the form of “waseela-e rozgar” program.

Proposed role of waseela-e rozgar in INSGB

The strategy envisage BISP expanding vocational training component to include skill development options in the area related to food

and nutrition such as food processing, backyard poultry hatchery management, community based veterinary workers training etc.

These trainings should primarily target women beneficiaries and translate into reducing household food insecurity and access to

diverse source of food in the market

Social Insurance:

Social Insurance component included in the BISP is in the form of “Waseela-e-Sehat” and Waseela-e Taleem. Purpose of these

components is to mitigate the risks associated with poverty by providing access to health care and education.

Proposed role in INSGB

INS-GB advocates that Waseela-e- Sehat program should be expanded to reach out to those areas where currently the program

services are not available and population is poor. Under this program, life insurance cover of Rs 100,000 has been provided to the

bread winners of one million beneficiary families since January 1, 2011 while Health Insurance for all beneficiary families is being

launched in selected four districts. It is strongly recommended that the facility is expanded to selected high risk districts of GB to

protect poor families from such catastrophic shock and prevent them from dipping below the poverty line.

Social Assistance component:

http://en.wikipedia.org/wiki/Social_Insurance

http://en.wikipedia.org/wiki/Social_Insurance

48

Social Assistance component of BISP social protection program includes transfer of cash to vulnerable individuals or households

with no other means of adequate support. This component is included in the current package in the form of cash transfer to the

female head of the family. Such unconditional cash benefit has been critiqued immensely by intellectuals in GB on the basis that it

creates a sense of dependency amongst beneficiaries.

As an exit strategy Waseela-e-Haq has been started as one of the BISP initiative. This is a targeted scheme to provide loan

amounting upto Rs.300,000/- to the randomly selected beneficiary families currently receiving the cash transfers under BISP to be

validated through the programme eligibility criteria. The loan for “Waseela-e-Haq” can only be used for establishing mutually

identified businesses.

Proposed role in INSGB

It is proposed that Waseela-e-Haq program priorities should be set in line with the local market support needed to increase

availability of diverse food sources. Utility stores with diverse food at affordable rate could be one of the proposed priorities for

Waseela-e-Haq. Other business options include initial seed funding for establishing backyard poultry hatchery, purchase of livestock

for increasing household income as well as supply diverse food in the market. Such loans should also be available for buying seeds

and other inputs for agriculture

Other potential contribution of BISP in GB

To increase economic opportunities for BISP nominees for poverty reduction such as encashment of food vouchers at BISP

beneficiary established utility stores

Share BISP data with other sectors to enable them to develop intersectoral intervention such as food vouchers to those

students who are members of BISP beneficiary data base

Established data bank of skilled workers and share it with other partners.

Pilot testing of vouchers for the purchase of items of particular needed by households in efforts to prevent malnutrition, e.g.

soap, micronutrient powders, particular non-perishable food commodities.

Inclusion of social protection in provincial disaster risk reduction strategy.

49

16.0.CROSS SECTOR THREE: NGO/CIVIL SOCIETY PRIVATE SECTOR IN INSGB

Evidence from the countries such as Bangladesh, Peru illustrate that NGOs/Civil society has played a critical role in advocacy, policy

dialogue, collecting evidence and creating innovative intervention models.

Civil society in the INSGB strategy refers to “an umbrella term for a range of non‐state and non‐market citizen organizations and

initiatives, networks and alliances operating in a broad spectrum of social, economic, and cultural fields. These include formal

institutions, non‐governmental organizations, trade unions, professional associations, philanthropies, academia, independent

pressure groups, think tanks, and traditional informal formations, such as faith‐based organization, seminaries, and neighborhood

associations.” Pakistan and particularly GB has a very vibrant civil society and private sector role. During Attabad crisis and other

natural disasters, CSOs and NGOs have played an important role in resource mobilization and service delivery. NGOs and CSO in

other provinces of Pakistan have shown their powerful presence through advocating and successfully legislating law for “breast

feeding protection and child nutrition ordinance." NGOs from academia have been actively involved in nutrition-related research and

surveys.

Following sections identify the cross-cutting role of civil society / private sector in intersectoral strategy of nutrition in GB.

Potential role of private sector in WASH:

Analysis of the strategic documents from WASH sector highlights tan active role of private sector in GB in providing access to

community based, sustainable models of safe water and sanitation. The strategy envisions further expanding the role of private

sector and local support organization in reaching out to un-reached i.e. in Diamer. Following are some of the specific

recommendations for collaboration and support expected from the private sector presented in the strategy papers:

Private sector should play an active role in social mobilization and awareness raising about importance of WASH and its links

with health and nutrition;

Private sector participation is anticipated in positively influencing community attitudes for use of flush latrine, low cost

approaches to treatment of water and provision of safe water facility;

Private sector with their experience in community development activities and presence in the community is better placed to

persuade the community to support WASH intervention through in kind contribution such as by providing unskilled workers,

50

playing oversight follow up monitoring and maintenance role in the post intervention phase of the water and sanitation

facilities;

Private sector with their insights and research skills will be able to replicate and scale up technology that has been

successfully used in private sector programs for WASH intervention

Role of private sector in women development

The INSGB strategy envisages private sectors and CSOs playing a critical role in empowerment of women and thereby enabling

them to make healthier choices easier choices for themselves and their families. Strategic documents from WDD state private sector

and civil-society organization, an important resource in alliance building for advocacy for women development. INSGB considers the

support of faith-based leaders’ essential in helping to dispel some of the myths around women’s health and care.

Private sector is anticipated to support in improving women’s social status through up scaling opportunities for education, skill

development and providing access to market for economic development activities and thus to enable women to increase their share

in the household income and decision making. Local support organizations and women's organizations have the local community

representation and hence can play a key role in mobilizing women, particularly in hard to reach areas. The strategy envisages private

sectors to establish local community based economic development activities, which link the locally manufactured goods into the

larger markets. In order to create an enabling environment for working women to enable them to exclusively breast feed for six month

and introduce proper complementary food, private sector will be encouraged to create women friendly workplace with child care

facilities for working mothers to breast feed their babies and have access to safe chiild care support activities. Such services can also

be used to impart education and awareness around child health and nutritional health.

Sector Three: Role of private sector in health intervention

GB already has a network of private providers who are working for bridging the gaps in promoting health and addressing gaps in

health service delivery. Among the key, non governmental players currently operating in GB include PPHI and AKHS, P.

PPHI initiated its operation in GB and Skardu in 2007 after signing its MoU. The three stakeholders for this intervention are the

Federal Government, the Provincial government and RSPs. Today. Annexure two gives the details of the facilities operated by PPHI.

PPHI’s main contribution has been in turning non functional basic-level health facilities into functional through infrastructure

development, HR development and comparative small-scale community mobilization activities.

51

Aga Khan Health Service Pakistan is another major player in GB in health service delivery including playing a very active role in

implementing a community-based model of health promotion, mostly in hard to reach communities. AKHS, P works collaboratively

with other AKDN and Governmental organization in social mobilization activities, operating a network of NGO managed health care

facilities which range from basic health care facilities to small hospitals

INS –GB considers a very important role for private sector in health. INS-GB has proposed several roles of private sector in

improving health and nutritional health of the population:

The strategy (INSGB) expects to have private sectors commit to delivery of integerated health service package in the uncovered

areas; it aims to persuade the private sector to undertake researches needed for policy advocacy and report on certain key indicators

related to nutrition in DHIS and the agreed indicators in the oversight committee so that a compiled district based health outcome

report can be generated.

It anticipates ensuring implementation of regulation to ensure private sector hospitals and private sector managed BHUs have strict

rules to discourage use and prescription of formula milk unless medically indicated.

The strategy relies heavily on private sector to ensure health and nutrition outcomes of the population through mandating

manufacturers, producers and suppliers of salt and fortified wheat for food fortification and supply of iodized salt.

Role of private sector in agriculture, livestock and fishery promotion

Strategic document such as PC1s of agriculture sector, fisheries highlight conceptualizing, developing and institutionalizing models of

public private partnership. Such models will impact upon increased production and commercialization of trout and fisheries, research

and promotion of women friendly farming, revival of fish hatcheries backyard poultry farming and market mobilization to enable

access to diverse food products at affordable rates. INSGB anticipates private sector’s role in research activities to enhance

production of fish feed, safe medicinal products to enhance milk and meat production. Other areas for promoting partnership with

private sector include research and development arounf new technologies, inputs, and farm practices that may result in efficiency

and increased produce. Efficient use of water for agriculture growth, provision of agricultural credit and role in improving extension

services are other areas to be targeted through public private partnership.

INSGB proposes establishing “food authority” for defining and implementing standards and procedures to regulate and monitor the

food business, food labelling, food additive etc. Technical expertise and research through mobilizing private sector would indeed be

most beneficial particularly to define strategies for implementing these standards in private business market.

52

Role of mass media to create wide spread awareness about importance of consuming a balanced and healthy diet along with

consuming only fortified food items in the market will be most needed.

Role of private sector in promoting nutrition from education sector

Private sector particularly Aga Khan Education Services plays a key role in promoting girls education through establishing and

managing a network of primary, secondary and higher secondary schools. INSGB envisions scaling up child friendly schools that

provides healthy and safe environment, action oriented nutrition promotion activities and screening of children. Another intervention

that has been suggested to attract girls students to school is introduction of food voucher which would be a community based

intervention and will probably need mobilization of community organizations for implementing the program of distributing food

vouchers conditional to funds being made available for this intervention. Academic organizations are also expected to play a key role

in collecting evidence to support link between various incentives and implementation model with nutritional outcomes.

Proposed actions for promoting public private partnership and support

INSGB has highlighted an extensive role for private sector in each sector and building bridges between different sectors. This is

however only possible if:

Concrete measures are taken to enhance private sector’s trust for entering into public private partnership intervention;

Business rules and terms of engagement are clearly defined which may require establishing a task force that formulates and

articulates policies and provides platform for dialogue and joint decision making

Public sector reorgranizes and reviews its mechanisms of monitoring and funds disbursement so that they can play steward’s

role in all such interventions in an objective and efficient manner with expectation and key performance indicators for regular

reporting.

Undertake a study to analyse existing public private partnership interventions to identify barriers and problems faced that

cause delays in the decision making process as well as the fund releasing mechanism are avoided.

53

ANNEXURES

54

Annexure 1: Key findings of NNS 2011

• Pakistan has the second highest number of severely wasted children, 43.7% children are stunted, 15% wasted and 31.5%

are underweight in the country.

• Iron deficiency anaemia and Vitamin A deficiency remain widespread across the country.

• When compared with NNS, 2001 over the decade there has not been much change in the nutritional status in Pakistan.

• Over the past 20 years, “there has been little change in the prevalence of malnutrition in the population, despite greater food

availability and an overall increase in caloric intake per capita”.

Key findings of NNS-GB 2011

• Prevalence of wasting in children: 8%, stunting : 45%

• High prevalence of stunting indicates that the problem is a long-term and chronic in nature and need urgent priority attention

• Majority of the seven districts (six out of seven districts) in GB have severe deficiency of wheat.

• In case of maize, three out of seven districts are extremely deficient; one district is deficient, another is one sufficient and one

district is surplus producer.

• GB annually import 200,000 metric tons of wheat from Punjab at the subsidized rate through Pakistan Agricultural Storage

Services Corporation (PASSCO) under the federal Ministry of Food Security and Research (MFSR).

• Women and children in the marginalized group are most vulnerable to malnutrition. The marginalized group consumes low

nutritional food with inadequate protein and vitamins and limited food intake.

• 20% mothers are malnourished (BMI<18.5), Anemia in non pregnant women is 23.3% and in non pregnant it is 33.6%

• Ferritin level in non pregnant women is highest in GB and ferretin level of 14.9% is lowest in GB compared to other regions40

• 87.5% salt samples found in the market is iodized, indicates gains in this programming area.

40 New NNS page 53

55

• Calcium levels in the serum of the mothers of index child indicate that 44.5% of women from Gilgit had Hypocalcaemia.

• Food security mostly affects small and poor farmers who dominate the agricultural workforce.

• 60.2% of the house-holds are food secure, and 39.8% were food insecure;

• 9.2% of households are food insecure without hunger, 21.5% are food insecure with moderate hunger and 8.9% are food

insecure with severe hunger

• Increasing food prices make access to food a challenge for farmers and population in poor class.

• The unemployment rate, inequitable production and distribution systems are other compounding factors that make small

farmers with low income, food insecure.

• 53% population live in the borderline group that consumes food with low nutrition value and does not have meat as part of

their daily food consumption.

• Only 28 % population falls in acceptable level of food consumption group and 2 percent in the poor groupn in the survey from

Gilgit had Hypocalcaemia.

• Access to piped water: 73% of the household has access to piped water, 4% has access to well water, 6% has access to

community tap and 17% rely on water from other sources.

• 93 % of families never treat water before drinking,

• Soap availability in household is 17% (lower than the national average 58% )

• Children currently reporting worm infestation is 12.1%41,

• Prevalence of stunting among children is higher (48.2%) in the case of illiterate mothers, while it is lower (22.4%) where the

mothers are educated up to ten grades or more.

41 Figure 6.33 NNS 2011

56

Annexure two

Nutrition Conceptual Framework

Social, economic

and political context

Lack of capital: financial, human, physical, social and

natural

Inadequate education

Income poverty:

employment, self-employment, dwelling,

assets, remittances,

pensions, transfers etc

Inadequate care for

Women and Children

Insufficient health

services & unhealthy

environment

Household food

insecurity

DiseaseInadequate dietary intake

Short-term consequences:

Mortality, morbidity, disability

Long-term consequences:

Adult size, intellectual ability, economic productivity,

reproductive performance,

metabolic and cardiovascular disease

Maternal and child undernutritionImmediatecauses

Basiccauses

Underlying causes

Pakistan Integrated Nutrition Strategy

Short Term

Medium

Term

Long Term

57

Annexure three

58

Annexure four

59

Annexure five

ToR of the Provincial inter-sectoral nutrition committee

Following is the ToR of the provincial intersectoral nutrition committee

a) Ensure that various departments are able to work in a coherent and coordinated manner;

b) Ensure the annual district based work plans have been produced in consultation with other sectoral partners;

c) Provide oversight during implementation to ensure that the province achieves its targeted objectives and activities;

d) Carry out arbitration and mediation role in case of any conflict and differences between various sectors

e) Ensure that an overarching, intersectoral MIS has been developed that reports key performance indicators by all sectors on a quarterly basis;

f) Provide support and approval for mid term and end term evaluation.

g) Provide policy guidance and support in case it is needed.

g) Perform any other functions assigned to the intersectoral nutrition committee by Chief or assistant chief secretary.

60

Annexure six: Result based framework

GB Multisectoral Nutrition Results Monitoring Framework

Primary Impact Indicators42 Baseline YR 3 Target (2018)

YR 5 Target (2020)


Child stunting (H/A <2)43 45%% 35% 30% Semi-annually HMIS

Child wasting (W/H <-2)44 8% 4% 3% Semi-annually HMIS

Child severe acute malnutrition (W/H<-3) - Semi-annually HMIS

Iron deficiency anemia in children45 36.2%% 30% 25% NSS

Vitamin A deficiency in children46 71.% 60% 40% NSS

Zinc deficiency in children 33% 25% 15% NSS

Prevalence of low birth weight (<2.5 kg) or “smaller than usual” NA Annual HMIS plus surveillance site data

Pregnancy iron deficiency anemia47 33.6% 20% 10% Semi-annual HMIS & NSS

Vitamin A deficiency (in pregnant women)48 44% 25% 15% NSS

KEY AGRICULTURE/Livestock/Fisheries/FOOD SECTOR INDICATORS

Intermediate Outcome Indicators Baseline YR 3 Target (2018)

YR 5 Target (2020)


% of households “food secure”49 60% 70% 85% NSS surveys

42 “Child” = Children under age 5. “Maternal” = Reproductive age women. 43 PINS and operational plan presentation – slide 2 44 PINS and operational plan presentation – slide 2 45 PINS and operational plan presentation – slide 3 46 NNS 2011 – Page 73 47 NNS 2011 revise version figure 5.10 48 NNS 2011- page 55 49 Source: NNS 2011

61

% of children consuming at least four of seven food groups on the previous day

45% 65% Annual monitoring and NSS

% of landless or small holder rural households reached in the past 6 months with assistance in garden production, small livestock or fisheries

- 40% 70% Annual monitoring via MoA management information system

% of commercial wheat flour-consuming households consuming fortified wheat flour


% of commercial edible oil-consuming households consuming fortified edible oil


% of households consuming iodized salt (min 15 ppm) 85% 90% 95% Annual surveillance site data

KEY EDUCATION AND WOMEN SECTOR INDICATORS % of schools including nutrition in school curricula at any level - 45% 95%% Annual DoE management

information system data


- 25% 60% Annual DoE management information system data

KEY WASH SECTOR INDICATORS


YR 5 Target (2020)


% of dwellings with piped or tubewell/boring water 73% (NNS

2011) 80% 90% Annual WASH sector MIS plus

NSS

% households using hygienic sanitation facilities 76% 85% 95% Annual WASH sector MIS plus NSS

% of households with soap available at the washing place (observation) 17% 55% 70% Annual WASH sector MIS plus NSS

62

KEY SOCIAL PROTECTION SECTOR INDICATORS % of BISP beneficiaries with at least one female school age child who has at least one school age girl enrolled in school

- 40% 70%

HEALTH AND POPULATION INDICATORS


YR 5 Target (2020)


% of infants 0-6 months of age for whom breastfeeding was initiated

within 1 hour of birth50 61.8% 70% 80% Annual HMIS and NSS

% of infants aged 0-23 months of age who received exclusive

breastfeeding up to six months51 14.5% 40%% 70% Annual HMIS and NSS

% of children who were introduced to complementary food between

6-8 months of age52 51.3% 60% 70% Annual HMIS and NSS

% of mothers with a child aged 0-12 months who received any ANC

during their last pregnancy53 80% 85% 90% Annual HMIS and NSS

% of children aged 12-60 months who received a vitamin A supplement in the past 6 months


% of children aged 6-24 months who consumed multimicronutrient powder within the past week


% of children aged 6-60 months with diarrhea in the past two weeks who received ORS with zinc


% of communities in pre-determined food insecure districts with functioning CMAM

- - Annual HMIS and NSS

% of unions covered by LHWs, CMWs, NGOs or CSOs - - Annual HMIS and NSS

50 NNS 2011- PAGE 84 51 NNS 2011 PAGE 85 52 NNS 2011 Fig. 7.5 53 in I n t e r - S e c t o r a l C o n s e n s u s B u i l d i n g O n Nutrition Strategic/Operational Planning, October 3-4, 2012, Serena Hotel Gilgit page 11 ‘

63

Annexure seven

SECTOR 1: HEALTH AND POPULATION WELFARE

BACKGROUND AND RATIONALE:

1. Overall nutritional status of GB is significantly better than rest of the country. It is lowest in wasting (8%), and in stunting (45%); it

is better than other provinces except AJK & Punjab. In pregnant women, iron-deficiency anemia (IDA) is highest (30.4) but in non-

pregnant women, IDA (10%) is lowest in GB when compared with all the provinces of Pakistan. In order to sustain its

achievement and improve poor health indicators, the province needs urgent measures to address nutrition problems and issues.

Nutrition policy that advocates inter-sectoral actions is vital for creating an enabling environment for policy and program options to

be enacted to address the problem directly (e.g. food subsidies to the poor) and/or indirectly (e.g. income generation or job

creation). Absence of a clear nutrition policy is stated to be an important reason for lack of enough focus on malnutrition in a

country.

2. Health strategy background document indicates that there are many overlaps and fragmentation in various departments of health

sectors such as MNCH, LHWs, EPI and Nutrition. These departments have developed their own HMIS that has much duplication

and does not support in decision making. Lack of effective communication and coordination among these departments, have

compromised the opportunity for building on synergies and also pose a major barrier in providing continuity of care. Mapping of

different departmental role, activities and development of integrated outcome indicators would be most essential for reducing

fragmentation in health service delivery.

3. in 2002, Pakistan introduced the “Protection of Breast-Feeding and Child Nutrition Ordinance." The Ordinance in Chapter III

Under (2) states that "No person shall in any manner assert that any designated product is a substitute for mother's milk, or that it

is equivalent to or comparable with or superior to mother's milk. "Protection of Breast-Feeding and Child Nutrition Ordinance

2002” also stress upon formation of a National Board/forum to monitor the implementation of the said Ordinance.

64

Right after the devolution, three provinces, Punjab, Sindh and Balochistan have also introduced legislation on breastfeeding and

child nutrition in line with the “Protection of Breast-Feeding and Child Nutrition Ordinance 2002”. GilgitBaltistan has not yet

introduced the legislation. As a result, it was shared during stakeholder discussion that many public and private sector hospitals

and care provider prescribe formula milk to babies which harms the health of the baby.

4. Current curriculum of physicians has minimal information on IYCF and nutrition. On the other hand, curriculum of nurses and

paramedical staff has comparatively more information to enable them to render counselling on benefits of balanced diet,

importance of maternal nutrition and impact of malnutrition on the early childhood period. With the inclusion of IMCI in the medical

college curriculum, emphasis on breast-feeding and child nutrition has considerably increased, but it still does not cover some

important areas such as management of breast feeding problems, exclusive breast-feeding and other aspects of infant and child

nutrition. Discussion and content lack any emphasis on CMAM and stabilization protocols to be used in stabilization center.

Similarly, curriculum lacks any discussion on links between nutrition sensitive and nutrition specific interventions in the curriculum

to enable health care providers to appreciate the value of inter-sectoral collaboration in addressing the issue of malnutrition.

5. In order to strengthen curriculum of other sectors in nutrition sensitive interventions, it is essential to mobilize outreach workers

from these sectors to disseminate and re-enforce key messages around nutrition, customized according to their own setting.

Presently, non health sector such as agriculture and education are not mobilized enough to reinforce and strengthen the

dissemination of health messages from different platforms. This is a missed opportunities because agriculture/livestock/fisheries,

WASH, Education and LGRD has a large force of outreach workers who work in the rural and distant communities and potentially

have opportunities to influence rural population and farmer’s behavior around any topic including nutrition of adolescent girls,

expectant women and children. DoH can provide technical support and assistance to other sectors and can seek input to

strengthen its own focus on multi-sectoral nutrition approach.

65

6. LHW/PHC program has a central role in changing the household behaviours around nutrition. Unfortunately, LHW program has

faced severe financial and budgetary constraints which have affected its role tremendously. Refresher training on LHWs Manual

and MIS tools to LHWs was a routine part of Program activity since its inception but due to Lack of funds these routine activities

have not been conducted for the last four year. Effective implementation of information system has also been compromised due

to resource constraints inspite of the fact that LHW MIS is literally one of the most powerful systems currently in place if

implemented accordance to the standards. Logistic Supply system has also been compromised as a result LHWs do not have

access to necessary supply and medicines. Finally, effective implementation of the LHW program will ensure the reliability of data

and information and monitoring and supervision. Unfortunately, out of order vehicles and unavailability of vehicles is another

major challenge in carrying out monitoring supervision activity.

7. Currently, Education sector has “Child-Friendly Friendly School” concept instituted that requires annual health screening of

children and parental awareness programs as well as de-worming. Up scaling of the CFS model will require close collaboration

with LHW-PHC program. Meanwhile, there is no formal MoU agreed between Health sector and Education sector to carry out

this activity. Having such an arrangement will enable LHWs to achieve their own targeted objectives more efficiently.

8. Another important area that needs attention relates to availability of fortified wheat, edible oil and salt. Current absence of

legislation for wheat fortification does not mandate wheat millers to fortify their flour. Wheat is the main staple diet of the

population. Cost of the iron mix is not very high but in the absence of any demand from the informed buyers, the manufacturers

do not feel obligated to produce flour. While intersectoral action would be central to introducing these interventions, it is important

to ensure that their one central department i.e. food department that is able to mobilize range of stakeholders to lobby for

enforcement of legislation in the province.

9. Vitamin A deficiency implies is a lack of vitamin A in humans. It is common in developing countries but rarely seen in developed

countries. It is present in green leafy vegetables and fruits. Micro-nutrient initiative and UNICEF are supporting Vitamin-A

supplementation on Polio NIDS for children of 06 to 59 months. However, in the current HMIS, there is no indicator that could

http://en.wikipedia.org/wiki/Vitamin_A

66

inform Vitamin A coverage. Micro nutrient initiative has also committed resources for the assessment of the national Vitamin-A

coverage survey for the years 2011 and 2012 which before devolution was planned to be conducted under the rubric of Nutrition

Wing, of previous Federal Ministry of Health. However, under the devolved set up it will now be taken under this plan through

operational research. Once the NIDs come to an end, alternate models for delivering vitamin-A after the NIDs need to be tested

out.

10. Inter-sectoral intervention on nutrition is first such initiative for GB and the rest of the country. Topography of GB is different from

other parts of Pakistan. Therefore, it is imperative for the region to carry out operational researches, which are context specific

and enables GB to pilot and scale up its initiative.

67

SECTOR 2. BACKGROUND AND RATIONALE FOR AGRICULTURE/LIVESTOCK/FISHERIES

INTERVENTION

1. Current food insecurity in GB has several reasons but poverty and lack of assets in marginalized poor population are the key

reasons. Agriculture systems have a critical role in the provision of food, livelihoods, and income. Women in most of the rural

areas play a very crucial role in the agriculture production. Hence, policies that support their empowerment through skill

development as well as investment in pro-women credit schemes and women friendly agricultural machinery would be most

needed.

2. Poor and small landowners, including women landowners who are very few have fragmented land holdings, do not produce

enough crop for the sustenance of their entire family through-out the year. Fragile topography to natural calamities and food

prices has further contributed to malnutrition by playing a critical role in compounding the prevalence of malnutrition. The

three pillars mentioned above can only be addressed through a provincial agriculture/livestock/fisheries and food security

policy that is pro-poor and pro women.

3. Lack of measures to ensure “food safety” is another reason for malnutrition caused by consuming harmful effect of poor

quality diet. Food safety implies that food available for consumption at public and retail store is safe for human health. Food-

borne illnesses take a huge toll on the productivity of the affected individuals and populations. Diarrhea, Typhoid and other

more serious diseases can be life threatening particularly when it affects children. Low quality of edible oils and other food

products, crops sprayed with harmful pesticide and use of chemical fertilizer and sale of poor quality of wheat, etc. may have

injurious effects on health but in the absence of enforcement of any law, these are freely available in the market.

4. There is no check or control on the import of pesticide available in the market. These pesticides are known to have serious

environmental and health implications for man and other life forms if their use is not contained beyond certain limits. If not

used at the correct time and accurate amount, i.e. during the period when crops and other plants are blooming, it could

impact upon the bees much needed for cross pollination.While, state has a major role to play through enforcing a legislative

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framework54 for food safety, civil society and consumer also have a critical role to play. Pakistan has a set of laws, which

deals with various aspects of food safety. These laws include Pakistan Pure Food Laws of 1963, Pakistan’s Hotels and

Restaurant Act of 1976, The Pakistan Standards and Quality Control Authority, 1996. These laws, if enacted and enforced

will have tremendous capacity to achieve an at least minimum level of food safety. Details of these laws are attached as

annexure one

5. Currently, the medicines being used by the veterinarian for treatment or enhancing the production of milk and meat

production are being approved at the federal level but at the implementation level, concerns were raised in a similar exercise

in another province indicating that the lack of monitoring of the quality of medicines and other inputs available and used for

increasing the meat and milk production has huge implications for human health;

6. Agriculture and livestock departments and its sub sectors have quite a large force of extension workers. Rapidly changing

environmental and ecological conditions, investment in research and development as well as access to information

technologies requires means to keep extension workers also updated with the new knowledge. In turn, the extension workers

must have the ability to transfer this information to the beneficiaries. This will enable them to keep beneficiaries (farmers)

updated with changing approaches and emerging technology with its positive impact on agricultural development and out puts

leading to agricultural growth and poverty reduction.

7. Malnutrition is more common in rural areas of Gilgit-Baltistan. In addition, rapidly changing ecological situation and

globalization requires agriculture and live stock sector to keep pace with new knowledge being generated globally in the area

of agriculture through integrating it in the curriculum of the extension workers and DoA, Fisheries and Department of

Livestock (DLS) . DoA and DLS, livestock and fisheries are already cognizant of these challenges and are adopting

measures to improve the outcomes.

54MazharSiraj. “Food Safety Legislation in Pakistan: Identifying Entry Points for Public Intervention”. Research Fellow CRCP

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8. Majority of the farmers in the hilly and mountain areas of GB are small land-holding families, cultivate less than one hectare of

land each. Unfortunately, as a result of declining soil fertility, the quality of the produce is also deteriorating. Such challenges

have the potential to contribute to the chain reaction process of poverty–resource degradation–scarcity–poverty55.

9. Small farmers also lack facilities to reduce the post harvesting loss primarily resulting from small and scattered volumes of a

highly uneconomical scale; poor knowledge on harvest maturity and harvest timings; poor harvesting and field handling

practices; poor packing, transportation and storage; lack of physical infrastructure, including access roads and market places

and lack of proper value addition.

10. Literacy level of women in GB is considerably better than in other provinces of the country. Many women are also active in

small and home based income generation activities therefore, there are less challenges to mobilizing women and equipping

them with up to date knowledge and skills in good farming, food processing, kitchen gardening, apiculture (bee keeping), and

other such activities that on one hand increases income and on the other hand, can contribute to providing diverse sources of

nutrition to the population.

11. Fish feed plays a very important role in improving fish breed and enriching its nutrient value. With increasing demands,

investment in aquaculture and community based or backyard fish farming would become an important means of poverty

alleviation. Fish feed play a very vital role in promoting nutritional value and protein content of the fish meat. Unfortunately,

there is not enough information available about the type of fish feed that would be beneficial. The choice of fish feed in GB is

limited and expensive because of the additional cost incurred in bringing these seeds from down country as a consequence

absence of availability of a local market. Farmers on the basis of trial and error use various cheap, local variety of fish food.

Sometimes, poor quality of fish feed may put entire produce of fish farm at risk. Feed is the highest proportion of operational

costs and, therefore, the profitability of the operation depends largely on the performance of a feed.

55Jodha, N.S.;Shrestha, S., 1993. Sustainable and more productive mountain agriculture: problems and prospects. In Mountain Environment and Development –Part 3 (Thematic Papers),pp 1-65.

Kathmandu: ICIMOD.

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12. Situation analysis suggests that at present poor segment of the population has very limited access to capital and finances for

such home based facility to produce and rear livestock. Several scientific literature reviews of homestead food production

systems have been done in the past decade56, 57, 58. These reviews focused on different types of programmes and nutritional

outcomes. One consistent message from these studies is that nutritional effect is more likely when

agriculture/livestock/fisheries interventions target women and include women’s empowerment activities, such as improvement

in their knowledge and skills through behavior-change communications or promotion of their increased control over income

from the sale of targeted commodities

13. High level of food insecurity and malnutrition across the country warrants creation of alternative source of food and protein

such as aquaculture and livestock with potential to provide a good source of protein and other nutrients to the population.

Lack of awareness about benefits of these produce has resulted in poor demand which poses a barrier for investors who

might be keen to invest in this business. Social marketing approaches have been successful in creating demand for various

health behaviours such as birth spacing, vaccination, as well as for introducing foods like Kentucky Fried Chicken, McDonalds

and Pizzas etc. Instituting social marketing and awareness strategies for consuming fish, milk and meat diet and products will

result in increased demand which in turn will incentivise tradition fish farmers and livestock producers to produce and market

more of these healthy foods at affordable rates. Similarly, various platform such as education, agriculture and health will

disseminate messages around eating good quality yet affordable and within their means through improved cooking practices.

14. Although intake of balanced diet is vital for health and prevention of disease, food fortification is recognized as a highly cost-

effective way to improve the micronutrient intake of populations. Such an intervention however, requires close regulatory

monitoring by which the private and public sector collaborate to produce quality fortified food. Legislation for universal salt

iodization has been implemented in GB which is evident from the NNS 2011 report that most of the salt available in the

56World Bank. From agriculture to nutrition.Pathways, synergies and outcomes. Washington, DC: The International Bank for Reconstruction and Development, World Bank, 2007. 57Leroy JL, Ruel M, Verhofstadt E, Olney D. The micronutrient impact of multisectoral programs focusing on nutrition: examples from conditional cash transfer, microcredit with education, and agricultural programs. http://www.micronutrientforum.org/innocenti/Leroy-et-al-MNF-Indirect-Selected-Review_FINAL.pdf (accessed May 16, 2013). 58Arimond M, Hawkes C, Ruel MT, et al. Agricultural interventions and nutrition outcomes: lessons from the past and new evidence. In: Thompson B, Amoroso L, eds. Combating micronutrient deficiencies: food-based approaches. Rome: CAB International,Food and Agriculture Organization, 2011: 41–75.

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market is iodized; much is however left to desire for ensuring availability of fortified wheat and edible oil to the population.

One of the key reasons for this phenomenon is lack of supply for such a product which in itself is dependent upon poor

demand from the population because of lack of awareness. As a result manufacturers do not see much market for slightly

expensive but better quality product in as they have to GB.

15. In order to enable GB to exploit the potential of market through provision of off season vegetables, farmers will need to have

access to good quality and continuous supply of safe seed. In order to provide access to the farmers with improved varieties

and reliable access to quality seeds for produce which is more appropriate for GB climate, GB agriculture department has

planned in its PC1 to develop its own capacity in the production of quality and safe seeds. It is however important to

recognise the success can only be achieved if the production of seed is sustainable, if the seed supply system is within easy

reach of the population and if the training of the farmers and seed grower ensures emphasis on quality seed production.

16. The Department of Agriculture, livestock and fisheries needs urgent support through research and development activities for

increased local production of seeds, fertilizers and safe inputs for increasing meat and milk production. In the absence of

these supports, farmers and cattle grower are dependent on using whatever quality of these inputs available in the market. In

the agricultural sector, seeds and plant varieties/species need to be evaluated and updated with more value additions, on

production and post-harvest practices, and above all the capacity of the farmers and the Department of Agriculture. Already

some research & development support is available to the Department of Agriculture/livestock/fisheries with developmental

partners support, it is essential to upscale the current capacity and broaden the scope to include other subsectors of

Agriculture.

17. PPP offers an alternative approach to instituting projects that are traditionally financed and operated by the public sector. One

of the most appealing aspects of PPP is sharing of risks related to the projects between the partners. When well structured,

PPP helps addressing specific costs and investment challenges, creates improvements in efficiency i.e. improved service

qualities (expertise, new technologies, a potential to attract and retain better performing staff) and low cost management.

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18. Partnership can be of different types: Financing by private sector is one approach whereby private partnerships allow faster

and efficient construction of big-scale projects, which might otherwise require longer time for approval for financing. One of

the opportunities is in the areas of commercial fish farming where partnership with private sector may result in increased profit

margin and better sustainability. The private investor in a PPP project is bound to be extra diligent when assessing its longer-

term risks for financing, construction, quality of service, and maintenance.

19. The sector has various departments working independently to produce sustainable results and promote change. Intra-

sectoral coordination forum will allow dedicated teams to undertake relevant tasks carried out by trained staff in that area of

work while also ensure a strong monitoring mechanism.

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SECTOR 3: WATER AND SANITATION SECTOR

Background and rationale

1. National Sanitation Policy and National Drinking Water Policy have been approved in 2006 and 2009 respectively with the

objective to improve water and sanitation coverage and quality59. Aim of the policy is to provide safe drinking water to the

entire Pakistani population by 2025, including the poor and vulnerable, at an affordable cost. Main objective of these policies

is a clearer separation between the functions of service provision and regulation. Since devolution, it has become imperative

that the provincial policies and strategies are approved.

2. Provincial water supply strategy has also been developed. It is envisaged that after enforcement, the policy will have a huge

potential to provide sustainable system drinking water to the entire population of GB by 2015, for improving quality of life and

reducing death due to water borne disease. The focus of the strategy is on adequate supply of water, affordability and

equitable and sustainable distribution system of water.

3. The provincial sanitation strategy has also been developed and awaiting approval. The strategy aims to provide adequate

coverage of safe sanitation by the year 2015 and aims to provide an open defecation free environment by the year 2015 to

meet the requirement of MDG.

4. MDG seven “to ensure environmental sustainability” and target 10 is “to halve the proportion of people without access to safe

drinking water and sanitation by 2015” cannot be achieved without actions to promote gender equality and women’s

empowerment. Women and young girls are most affected in the absence of access to water and sanitation close to their

homes or in their homes. According to one estimate, women and girls in low-income countries spend 40 billion hours every

year fetching and carrying water from sources, which are often far away and may not, after all, provide clean water60. One of

the reasons why women remain marginalized and are not involved in these discussions, example in Indonesia and Malawi, is

because of pre-judices about their lack of ability to participate in the technical discussion. Their participation in such an

infrastructure-related project is viewed as stepping out of their traditional role although, in reality, women are the primary

59 a b c Government of Pakistan. Ministry of Environment (September 2009). National Drinking Water Policy. Draft. Retrieved 2010-03-07 60 Ibid

http://en.wikipedia.org/wiki/Water_supply_and_sanitation_in_Pakistan#cite_ref-NDWP_37-0



http://en.wikipedia.org/wiki/Ministry_of_Environment_(Pakistan)

http://www.environment.gov.pk/NEP/DWPolicyOct2009.pdf

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users of water, and hence are the most qualified to comment on n appropriate design for a water system when given an

opportunity as noted in these countries. Similarly, they are the most powerful actor for ensuring the follow-up maintenance of

these schemes such as repair of tube wells or maintenance of the sanitation system because it increases their workload.

5. In spite of availability of technical support and systems, delivery of safe water and sanitation service is many times

compromised. One of the reasons for this state of affairs is lack of competency of the staff operating and managing the water-

supply system or maintenance of sanitation services. There could be several reasons for this but lack of required training in

managing a proper and context-specific system is of crucial importance. This in turn would require incorporating these

messages in the curriculum of the staff responsible for such services. Concurrently, a system of monitoring is very vital for

ensuring that the water being supplied meets the required standards of provision of the good quality of water.

6. Nutrition affects multiple sectors but unfortunately, there is no coherence and uniformity in the communication messages

linking the role of the sector in improving nutrition. In GB, reason for people to desire better sanitation facility is for gaining

status and of practical reasons such as greater privacy, convenience and comfort especially for women. Public awareness

about safe drinking water, good sanitation is also lacking. As a result, open defecation practices are widely practiced.

7. For any behaviour change communication strategy to sustain, re-enforcement of the health awareness messages from

multiple platforms will bring about a sustainable behaviour change. Each of these sectors offers a platform that can be

mobilized for community awareness purpose. in its “Provincial behavior change communication strategy (BCC strategy)61”,

GB has committed to create awareness amongst every citizen through various means of communication to adopt safe

sanitation, healthy environment, healthy living measures, use of clean drinking water and use of improved personal hygiene.

8. The BCC intervention for GB should also promote good practices and innovations such as those launched by BACIP (Aga

Khan Planning and Building Services) i.e. efficient use of fuel leading to low cost approaches to boiling water which is much

needed for maintaining good personal hygiene in severe cold weather before cooking and after defecation, use of soap for

washing. More awareness also need to be created about how water can get contaminated even after collection from a safe

source.

61Planning and Development Department, GB. (2011). Behaviour Change communication (BCC) strategy

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9. Most of the infrastructure projects for water and sanitation require follow up maintenance of the project. In the absence of

availability of such a support, delivery mechanism, safe water and sanitation service is compromised. Communities in GB are

very well organized and are quite able to play their role effectively. AKRSP has applied this model and lessons can be learnt

from their experience.

10. Access to safe drinking water and proper and functional system for disposal of waste is vital for reducing diarrhea and other

water borne illnesses amongst children and adults. District Diamer has the lowest coverage of piped water of only 34% as

against 91% for Hunza-Nagar. In addition to that Diamer district has the highest percentage of non functional system (11%).

Inspite of the fact that heavy investment in this sector has been made in the past, it is unfortunate that only 58% of these

schemes are functional. Considerable investment has been made by the Government and various NGOs to provide drinking

water to the population. About 849 drinking water supply schemes have so far been constructed by various Government

department and NGOs. 74% of the villages have been provided with pipe water but due to low quality of construction and non

existence of a full proof mechanism, under which the beneficiaries are bounded to operate and maintain in a sustainable

manner, only 60% are functional, 21% are semi functional and 19% are non functional. Similarly, while water schemes have

been instituted with very high budget, its utility and maintenance does not exist in those rural areas. Sanitation system varies

from area to area with open defecation common in all the province and flush latrines limited to those where families can either

afford it or are aware of its importance.

11. GB has extensive experience of working with private sector such as AKRSP, WASEP etc. “Feasibility study of environmental

integrated water and sanitation and hygiene practices” refers to the technology used by WASEP as being better. AKRS, P’s

model of community participation has instilled a sense of ownership in the community. It is very important to unravel the

underlying models of this technology and disseminate it as well as incorporate the learning in the new intervention. In

addition, there is now technology invasion in the cultural mileu of GB which pose a challenge in institutionalizing these

initiatives.

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SECTOR 4: EDUCATION SECTOR

BACKGROUND AND RATIONALE

1. GB has already invested considerably in girl child education. The gross enrolment rate is 75% and more than two-thirds (67%) of

girls now attend primary school as opposed to only 29% in 1994. The gender parity index (ratio of girls to boys) of 0.73 for

primary school is in line with the national figure, though still low by international standards62. The region can only achieve its

desired economic development outcomes and prosperity if upward trend in education is maintained and priority is given to

education in general and girls’ education in particular. Studies63 have shown impact of education on reducing in-equality,

improving economic growth and labor skills, increased opportunities for well paid employment. In addition, the study argues that if

girls are deprived of education, there will be a negative impact on economic growth.

2. The strategy has aims to address some of the barriers in achieving gender equity through focusing on policies that incentivizes

families on one hand and improves nutritional status on the other. It aims to mobilize communities with messages around

importance of girls’ initial enrolment, attendance and continuation of education between levels but to put in place incentives for

enrolment of girls students at primary level. The paper envisages training of teachers to make their behaviour more gender

sensitive. Likewise, the curriculum will be reviewed to make it gender sensitive.

3. According to WHO, anaemia is highly prevalent globally in school-age children than in pre-school children, although data is

limited64. In poor areas, children often come to school without a good and balanced breakfast. The experiences from other

developing countries65 indicate the benefit of offering mid day meal on nutrition outcomes. For example, Food-for-school

programmes, such as ‘take home’ food to children with high attendance records in India, have shown increased enrolment and

attendance, particularly for girls. In Indonesia, the new school feeding program was implemented but first in ‘poor’ villages and is

62Gilgit-Baltistan education strategy, 2013–2025 63Sattar.T. et al. “ Socio-Political and Economic Barriers of Development in Education Sector of Southern Punjab (Pakistan). 64Nutrition of the Scholl-Aged Child: www.unsystem.org/scn/archives/scnnews16/ch03.htm 65State Statistical Office of Mongolia.Mongolian economy and society in 1996.Uaanbaatar, 1997.

http://www.unsystem.org/scn/archives/scnnews16/ch03.htm

77

still in its early days. Experience from Kenya66 indicates that it is essential that once started, the program receives political

commitment for long term funding support even during economic crises. In Pakistan and other countries, vitamin and mineral

fortification of biscuits have shown significant improvement of micronutrient status when given as a snack to school

children.Lesson from Kenya highlights the key role of parents in sustaining school feeding programm, in assuring safety and

quality of food from vendors and hawkers, and the problems of money given to children for food being spent on drugs. In light of

these experiences, it is recommended that every child should receive one glass of milk with fresh fruits from all schools but

particularly to children from school in the areas where high prevalence of mal-nutrition is reported. During education stakeholders

meeting in GB, it was shared that in GB, it is a norm is for a child to bring a piece of chappati or bread with them to school. Mid

day food program has vast potential not only to improve nutritional status of the children but in GB context where some areas are

very poor, it can attract school children to schools and thereby improve the school performance. Stakeholders during discussion

expressed their concern about long term sustainability of such donor funded projects and strongly suggested that any feeding

program would only be accepted if it is funded through regular budget i.e. ADP instead of donor funding; in addition, it should

have strong commitment for continuing even during difficult economic times.

4. Hand washing has a very critical role in maintaining health and hygiene and preventing illness. Schools provide ideal platform for

instituting such healthy habits. In addition, lack of good water and sanitation facilities is a disincentive for girls’ enrolment into

schools as they have to travel on foot long distances which is very challenging when there is absence of a proper sanitation

facility in school. Department of Education has already achieved quite a significant success in ensuring water and sanitation

facilities from almost 80% of the schools. Fortunately, since DoE has its own engineering department, it has the capacity for

maintenance of such schemes. Strengthening of school management committee’s role in monitoring of these schemes is vital for

long term functional sustainability and approaching authority in timely manner particularly because the weather also has the

tendency to affect these schemes.

66Oniang’O., R, A. school feedsingprogrammes: lessons from Kenya

78

5. Child friendly school (CFS) is a successful intervention in GB. This began with 40 schools in Gilgit district and has expanded to

now included 260 schools in Gilgit, Hunza- Nagar and Skardu district. Child friendly school67 in GB is built on the model of WHO

“health promoting school” based on the following key components: parent-teacher school health committee, mothers support

groups, healthy school environment, school health components in the curriculum, annual school health checkup of children and

also of teachers, school canteen or feeding program and field based activities and actions. CFS aims to provide an enabling

environment for children to achieve highest potential for performance in their education and this is not possible if the child is

physically and nutritionally healthy. CFS schools have maximum potential to provide opportunity to DoE to incorporate

components around nutrition, determinants of nutrition, food and skill based activities around kitchen gardening etc. DoE will

coordinate with health sector/LHW program in the catchment area of the school to undertake the health awareness activity for

school community, de-worming of children and school health screening.LHWs will use WHO road to health chart for school

children and will refer the sick children identified for further treatment to the next level care facility. Health sector will establish

links across different level of health facility so that children identified with a problem is referred and the family is counseled for

seeking care and adopting corrective measure at home.

6. In order to improve the nutritional status of children, teacher’s skills will need to be developed in the area of skilled based nutrition

education and identification and prevention of malnutrition. PDCN is currently a resource for CFS and its capacity could be

upscaled further to include establishment of a skill lab to enable teachers to transfer the critical learning about consumption of

healthy food to their student and nutrient values of different food products. The teacher’s curriculum should include ideas for

activity oriented learning approaches on nutrition such as organizing various community nutrition projects and activities. Most of

the targeted schools if identifies community planting areas, they could teach the art of growing school vegetable garden. PDCN’s

expertise could be exploited to enable it to serve as a resource for the training of the educators working from other sectors such

as health, agriculture/livestock/fisheries etc. PDCN can also play a key role in building capacity of SMC and MSG in sensitizing

the important change agents for consuming healthy diets.

67Khan, A.S., Mir, K., Parveen, M,.andTaj, Z. (2012) “A jouney from a haunted school to a child friendly school in GilgitBaltistan under UNICEF child friendly schools project: a case study99

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7. Parents can play a very powerful role in influencing child’s nutritional habits. Parental education is therefore essential for

improving nutritional outcome. On one hand, educated parents have opportunities for earning more household income and

thereby procuring adequate and good quality food for the family. On the other hand, educated mothers are more informed about

what to eat and how to select a healthy combination of food. Mothers support groups established in school have the potential to

play a very important role in improving the cleanliness of school environment and giving awareness to mothers regarding physical

cleanliness of children, and reducing absenteeism rate.

8. GB has huge potential for developing innovative approaches in the area of education such child friendly schools. Education

sector with AKES support is also in the process of reviewing agriculture curriculum and testing models for inducting girls into

school. It is also implementing several activities in close collaboration with private sector but these activities need to be properly

evaluated by a third party to ensure that that programs are effective enough for scaling up.

9. Severe death for documenting operational effectiveness is being felt particularly for policy and planning. One of the reasons for

this dearth is lack of enough resources to allocate to such activities. INSGB provides an excellent opportunity to education sector

to address this gap.

10. Education strategy paper for GB has outlined their resolve to review their district education information system. This is a unique

opportunity to incorporate few nutrition sensitive indicators in the sectoral strategy. The proxy indicators in the MIS such as

around school attendance rate, school performance rate, boys versus girls school admission rate, # of children that received

deworming tablets and # of children that received annual health screening etc.

Documents

Gilgit Baltistan Integrated Nutrition Strategy