MI - FINAL REPORT - SITUATIONAL ANALYSIS FOR ADVOCACY PROJECT

FINAL REPORT
SITUATIONAL ANALYSIS FOR THE
NUTRITION ADVOCACY PROJECT
“Advocacy to Secure Policy and Financial Commitments
for Nutrition from the Government of Pakistan”
SUBMITTED TO
Pakistan
BY
Dr. Moazzam Khalil
Dr. Muhammad Khalid

SITUATIONAL ANALYSIS FOR THE NUTRITION ADVOCACY PROJECT
Acknowledgements
The researchers wish to express their gratitude to the Micronutrient Initiative Pakistan for providing the
opportunity to conduct this study.
We furthermore thank the entire team of Micronutrient Initiative for the successful completion of this study.
Our thanks are due to Dr. Naseer Muhammad Nizamani, Country Director MI and Mr. Muhammad Irshad
Danish, National Coordinator Scaling Up Nutrition Civil Society Alliance Pakistan (SUNCSA,Pak), who
guided us with their extensive knowledge and experience. We are also grateful to Micronutrient Initiative
home office officials for their valuable comments and feedback.
Ownership
All the ideas, know-how, processes, information, drawings, documents, designs, models, inventions,
copyrightable material and other tangible and intangible materials included in this document, including
without limitation computer programs, computer systems, data and documentation, (collectively, the
“Works”) are the sole and exclusive property of Micronutrient Initiative Pakistan. All rights for the Works are
reserved. No part of the Works may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or by any information storage or retrieval system, without
the written permission from Micronutrient Initiative Pakistan, except for the inclusion of quotations in a review.
List of Notations
Team: Dr. Moazzam Khalil, Dr. Muhammad Khalid
Client: Micronutrient Initiative, Pakistan, the Secretariat of SUNCSA, Pak
Study: Baseline Situational Analysis for Nutrition Advocacy
Report:Draft Report
Disclaimer: We have made every effort to provide the most accurate information, data, statistics, facts,
figures, drawings and procedural descriptions contained in this document. The limitations of the accuracy of
the information at the source, however, remain. The document may thus contain human or mechanical errors
or omissions. No liability for such errors, or omissions, or un-intentional misrepresentations will be accepted.
The Development Strategies Pakistan reserves the right to make corrections and changes in any information
contained in this and in subsequent versions of this document.
Either as part of this document or any other written material produced by the researchers, wherever a
reference is made to any person using ‘He’ please read it as ‘He/She’.

Abbreviations
ACF Association for Charitable Foundations
ADB Asian Development Bank
BISP Benazir Income Support Program
CSO Civil Society Organization
DFID Department For International Development
DG Health Director general Health
DS Development Strategies
FATA Federally Administered Tribal Areas
GAIN Global Alliance for Improved Nutrition
GFSI Global Food Security Index
IDI In Depth Interview
IDP Internally Displaced People
KP Khyber Pakhtunkhwa
LHWs Lady Health Workers
MI Micronutrient Initiative
MQSUN Maximizing Quality of Scaling up Nutrition Programme
N4G2 Second Nutrition for Growth summit
NFA National Fortification Alliance
NHSRC National Health Services Regulation and Coordination
NNS National Nutrition Survey
NVF New Venture Fund
ODF Open Defecation Free
P&DD Planning and Development Department
PARC Pakistan Agricultural Research Council
PC Planning Commission
PDMA Provincial Disaster Management Authority
PFA Provincial Fortification Alliances
PHNP Provincial Health and Nutrition Programme
PINS Pakistan Integrated Nutrition Strategy
SDG Sustainable Development Goals
SUN Scaling up Nutrition
SUNCSA Scaling up Nutrition Civil Society Alliance
TWGs Technical Working Groups
UN United Nations
WB World Bank
WFP World Food Program
WHO World Health Organization
WINS Women & Children Improved Nutrition in Sindh

CONTENTS
Acknowledgements...................................................................................................................... 2
Abbreviations ............................................................................................................................... 3
1 INTRODUCTION .................................................................................................................. 5
1.1 Background................................................................................................................ 5
1.2 Context of Assignment ............................................................................................... 6
1.3 Study Objectives and Key Determinants..................................................................... 7
1.3.1 Objective ........................................................................................................................7
1.3.2 Key Determinants ..........................................................................................................7
1.4 Methods ..................................................................................................................... 7
1.5 Scope of Work............................................................................................................ 7
1.5.1 Review of relevant documents.......................................................................................7
1.5.2 Development of data collection tools .............................................................................8
1.5.3 Data collection – In-Depth Interviews (IDIs) ..................................................................8
2 FINDINGS............................................................................................................................. 9
2.1 Role of Public and Private Sector, and Civil Society ................................................... 9
2.1.1 Nutrition specific interventions .......................................................................................9
2.1.2 Nutrition sensitive interventions ...................................................................................10
2.2 Key Nutrition Stakeholders for Multi-Sectoral Approach ........................................... 13
2.2.1 Federal Level ...............................................................................................................13
2.2.2 Provincial Level............................................................................................................15
2.2.3 Development Partners for Nutrition Group ..................................................................18
2.3 Policy and Legislative Environment for Nutrition & Food Security............................. 18
2.4 Financial Commitment at Federal and Provincial Level ............................................ 20
2.4.1 Provincial overview ......................................................................................................20
2.5 Mechanisms to Monitor Policy and Financial Commitment ....................................... 22
2.6 Awareness and Capacity of Opinion Makers, Media & Civil Society ......................... 23
2.7 Findings from In-depth Interviews (IDIs) ................................................................... 24
2.7.1 Key actors working on nutrition issues in Pakistan......................................................24
2.7.2 Perceptions around nutrition policy and food security .................................................25
2.7.3 Legislations to translate national policies into action...................................................26
2.7.4 Financial commitment for nutrition at federal and provincial level ...............................26
2.7.5 Monitoring mechanisms at federal and provincial level ...............................................26
2.7.6 Role of legislators, opinion makers, media and CSOs ................................................26
3 CONCLUSIONS.................................................................................................................. 27
4 RECOMMENDATIONS....................................................................................................... 29
REFERENCES .......................................................................................................................... 30
List of Tables
Table 1: Nutrition specific interventions given in the Provincial Nutrition PC-1s ..........................................10
Table 2: Nutrition sensitive interventions by main actors..............................................................................12
List of Figures
Figure 1: Comparative ranking of Pakistan by GFSI (Source GFSI 2016) .....................................................5

1 INTRODUCTION
1.1 Background
Food is a basic need of everyone and therefore, access to adequate nutritious food is the
fundamental right of every human being. Malnutrition results from either eating too little or
eating an unbalanced diet. Adequate nutrition not only benefits the individual health and
survival, but it also enhances collective human capital and economic development, which is
particularly true for children [1].
Food is different from other usual commodities in that there is no substitute. All humans require
adequate food for survival and with security over the next meal. The 1996 World Food Summit
defined food security as “when all people at all times have access to sufficient, safe, and
nutritious food to maintain a healthy and active life”. Food security, according to the World
Health Organization (WHO), rests on three pillars [2]:
1. Food availability covers the supply side, and is determined by food production and
technology, inventory, efficiency of supply chains, and local and international trade.
2. Food access is the ability to obtain
adequate quantities of food, the
purchasing power needed, and
adequate delivery mechanisms,
including social safety nets; and
3. Food utilization refers to the need
to meet dietary needs and cultural
preferences.
Pakistan is facing a silent crisis of
malnutrition and has not improved for
decades. According to GFSI, Pakistan
scored 47.8 in 2016 which was slightly
higher than its score (43.7) in 2012 however it secured 78th position in 2012 as well as in 2016
amongst the 113 countries [3]. Figure 1 compares position of Pakistan with the best GFSI
(United States) and the worst GFSI (Burundi) in 2016.
Results from the 2011 National Nutrition Survey (NNS) indicated minimal change over the last
decade in terms of core maternal and childhood nutrition indicators in Pakistan. Among
children under 5 years of age, 43.7% were found stunted as compared to 41.6% in 2001;
15.1% were found wasted compared to 14.3% in 2001, and 31.5% were underweight
compared to 42% in 2001.
Vitamin A status has been deteriorated and there has been little or no improvement in other
micronutrients e.g. Iron Deficiency Anemia 61.9%, zinc deficiency 39.2%, and Vitamin D
deficiency 40.0%. The only success story has been iodine status which has improved
nationally as the survey indicates. Currently about 69% of the households are using iodized
salt as compared to 17% in 2001. This has also led to the conclusion that sincere efforts carried
down from the policy to the implementation level could have positive impact.
SUN (Scaling up Nutrition) is a distinctive movement founded on the principle that all people
have a right to food and good nutrition. It unites and works through people, from governments,
0
25
50
75
100
1)
AFFORDABILITY
2) AVAILABILITY
3) QUALITY AND
SAFETY
Pakistan
Best
Worst
Figure 1: Comparative ranking of Pakistan by
GFSI (Source GFSI 2016)

INTRODUCTION
FINAL REPORT 6
civil society, the United Nations, donors, businesses and researchers, and focusses at
collective efforts to improve nutritional status.
Pakistan joined the Global SUN Movement in 2013. Government of Pakistan signaled its
commitment to scaling up nutrition; Ministry of Planning Development and Reform is
spearheading the movement in the country and has established SUN movement Unit for
coordination among all SUN stakeholders, alliances/networks at international, national and
sub-national level. Currently, government, civil society alliance, donors, UN business networks
and SUN Academia and Research network have been established with support from
development partners. Similarly, all provincial governments have developed and endorsed
multi-sectoral nutrition strategies while Pakistan multi-sectoral nutrition Strategy is under
process of development by the federal government.
In Pakistan, funding for nutrition interventions mainly comes from donors and much of this is
project-based and goes directly to the provinces. The overall share of funding for nutrition from
federal and provincial governments is meager, which is a major challenge in ensuring state
leadership and ownership. Nutrition-specific interventions are key to accelerating progress but
it is also critical that other sectors namely agriculture, food, education, WASH and social
welfare, develop nutrition-sensitive interventions. A truly multi-sectoral approach will achieve
optimal nutrition outcomes through greater coverage, and will also help other programs in
achieving much better results.
The share of government expenditure in annual budget is the key indicator to evaluate the
government priorities in real term. This may also be used as a tool that enables us to monitor
and hold government accountable for the service delivery which lead to reforms in public
policy, establish a path for transparent, effective and efficient budgeting principles and
capacitate to provide concrete recommendations for program improvement. Solutions to
malnutrition are practical and basic but the desired improvement in current status of nutrition
cannot be achieved unless a sufficient amount is allocated in the budget.
Keeping in view the poor nutrition indicators in Pakistan, federal and provincial governments
will have to demonstrate their political will by investing more financial resources for
implementation of multi-sectoral nutrition interventions which can translate into a demographic
dividend in socio-economic development in the long run.
1.2 Context of Assignment
Micronutrient Initiative (MI) as Secretariat of Scaling Up Civil Society Alliance Pakistan
(SUNCSA, Pak) received a grant from New Venture Fund (NVF), to secure political and
financial commitments from government of Pakistan during the Second Nutrition for Growth
(N4G2) Summit scheduled in August 2016 in Rio de Janeiro, Brazil. This summit provides a
platform of global visibility for these governments, especially compared to prior summits that
placed less emphasis on governmental pledges. Specific objectives of the project for which
this assignment was conducted included:
 Sensitize policy makers to the challenge of malnutrition and the need for additional
financial resources for nutrition.
 Generate public debate on the impact of malnutrition on the social and economic
development of the country.
 Improve capacity of civil society organizations on nutrition advocacy.

INTRODUCTION
FINAL REPORT 7
 Promote accountability on the delivery of policy and financial commitments.
This situation analysis was conducted to establish a baseline status of awareness of various
stakeholders regarding nutritional issues, financial allocations by the government, the policy
and legislative environment, and advocacy efforts on nutrition.
1.3 Study Objectives and Key Determinants
1.3.1 Objective
The main study objective was to establish baseline indicators for the project.
1.3.2 Key Determinants
Following key determinants were considered for conducting the assignment:
1. The landscape of civil society organizations, public sector agencies, and private entities
working on nutrition-related issues, to understand the role and contribution of different
actors in addressing malnutrition.
2. Policy and legislative environment for nutrition and food security.
3. Current level of financial commitment by federal government around scaling up nutrition
program.
4. Mechanisms to monitor policy and financial commitment at federal level.
5. Awareness and capacity of opinion makers, media and civil society to generate demand
for additional resources for nutrition.
1.4 Methods
This study gathered both the primary and secondary data. The primary data was collected
through interviewing the federal level key personnel whereas secondary data was gathered
through reviewing the project documents, and national and international relevant publications.
1.5 Scope of Work
Following key activities were undertaken to achieve assignment objectives:
1.5.1 Review of relevant documents
All the relevant documents for the project including policies, plans, project proposal,
performance measurement framework, and detailed implementation plan, etc. were reviewed
to understand the nature of the proposed interventions for the project and to ascertain the key
areas/themes to be explored in the baseline assessment. The following documents were
reviewed in this regard:
1. Pakistan Food Fortification Scoping Study - Maximizing the Quality of Scaling up
Nutrition Programmes (MQSUN);
2. The Political Economy of Undernutrition National Report: Pakistan;
3. Punjab Province Report: Nutrition Political Economy, Pakistan;
4. Sindh Province Report: Nutrition Political Economy, Pakistan;
5. Nutrition Policy Guidance Note – Balochistan;
6. Inter-sectoral Nutrition Strategy Sindh;
7. Inter-sectoral Nutrition Strategy KP;

INTRODUCTION
FINAL REPORT 8
8. Strategic Plan (2016 – 2020) SUN CSA Pakistan;
9. Mapping of Nutritional Initiatives in Pakistan.
10. GFSI Model 2016
11. Asian Development Bank, Food Security in Asia and Pacific, 2013
1.5.2 Development of data collection tools
Data collection tools were developed in line with the study objective and key determinants and
were finalized after incorporation of the feedback and inputs from MI team.
1.5.3 Data collection – In-Depth Interviews (IDIs)
In-depth interviews were conducted with the federal level authorities to explore the key
determinants of the assignment. A total of 6 IDIs were conducted:
1. Chief Nutrition, Ministry of Planning Development and Reforms / SUN Focal Point
2. DG Health / Director Nutrition, Ministry of National Health Services, Coordination and
Regulations;
3. Secretary / DG Ministry of National Food Security and Research;
4. Representative from media;
5. Member of Standing Committee on health;
6. Representative from UN agencies; and
7. Representative from Civil Society
***********

2 FINDINGS
The findings are structured to give description on each of the study key determinants.
2.1 Role of Public and Private Sector, and Civil Society
The recent move towards nutrition, led by international donors, is positioned towards cross-
sector action on nutrition contrary to the initiatives in the past which were mainly
operationalized within the Health sector. This emerging move has gained momentum in the
post-devolution period and involves the provincial Planning and Development Departments
(P&DD) as the focal point for coordinated actions. Pressure by development partners has also
resulted in the establishment of provincial Inter-Sectoral Nutrition Committees headed by the
P&DD.
Regular and frequent data is required to quantify and monitor the problem, and motivate
political action, whilst disaggregation is necessary for planning and targeting. Unfortunately,
the data collection efforts greatly suffer from low frequency, compromised quality, and limited
detail.
At the provincial level, among all relevant departments, Department of Health has most
elaborately defined its role around nutrition through employing preventive health strategies
specifically targeted towards women and children.
After becoming signatory to the Global SUN Movement, the process of moving towards multi-
sector approach has been initiated in Pakistan. At this stage, other related sectors have only
recently been drawn into the loose nutrition coalition, and role of each sector is still emerging.
The coordination and liaison between donors to avoid redundant initiatives, has improved in
the post-devolution scenario, however the partnerships between donors have not grown
enough to pool funds and have a unified initiative for nutrition sector [4].
In order to understand the role and contribution of different actors, the landscaping of these
actors is provided by the nature of the interventions i.e. a) Nutrition specific and b) Nutrition
sensitive interventions.
2.1.1 Nutrition specific interventions
The government has progressively increased funding through health sector–related nutrition-
specific interventions; however, sustainability of these interventions is an area of concern. A
larger share of nutrition-related funds is contributed by the development partners in all
provinces. This leads to concerns regarding continued funding stream beyond the project life.
For nutrition-specific interventions, the provincial health department is the major actor
supported by the development partners in implementation. The governments of Punjab and
KP, have developed Minimum/Essential Health Service Package and the nutrition specific
interventions are part of the overall package. As the lead funding is provided by the
government, hence it is more likely that these interventions would be sustainable beyond the
project life. The scope of these interventions is also wider and these would be implemented
across all the districts [5] [6].
DFID, under its Provincial Health and Nutrition Programme (PHNP), does contribute to the
health PC-1s in Punjab and KP. In Sindh and Balochistan, the funding is in siloes and is
restricted to a separate nutrition programme within the respective provincial Health
Departments and is supported mainly by donor funding. This poses greater risk of discontinuity

FINDINGS
FINAL REPORT 10
after the project life. Table 1 presents a summary of nutrition-specific interventions by province
[7].
Lady Health Workers (LHWs) have a great responsibility in delivering many of the nutrition
specific interventions outlined in Table 1, especially for the rural population. However, the
evaluation of LHW programs indicates that LHWs have effectively implemented some of these
nutrition specific interventions such as management of diarrhea.
Table 1: Nutrition specific interventions given in the Provincial Nutrition PC-1s
INTERVENTIONS BAL’N KP PUNJAB SINDH
Iron-folic acid supplementation in Pregnancy ✓ ✓ ✓ ✓
Infant and Young Child Feeding (IYCF) practices ✓ ✓ ✓ ✓
Vitamin A supplementation ✓ ✓ ✓ ✓
Expansion of salt iodization program ✓ ✘ ✓ ✘
Wheat flour fortification program (with iron and folate) ✓ ✘ ✓ ✘
Fortification of edible oil/ghee ✓ ✘ Un clear ✘
Use of micronutrient powders through LHWs and CHWs ✓ ✘ ✓ ✓
Zinc supplementation during treatment of diarrhea ✓ ✓ ✓ ✓
Community-based management of acute malnutrition (CMAM) ✓ ✓ ✓ ✓
Deworming ✘ ✘ ✓ ✘
Behavior Change Communication Strategies ✓ ✓ ✓ ✓
The development partners have been contributing to the implementation of nutrition specific
interventions for some time now. Merlin, Save the Children, and Association for Charitable
Foundations (ACF) are conducting activities in three districts of Sindh to provide social
protection alongside nutrition-specific interventions, under the European Union (EU) Women
and Children/Infant Improved Nutrition in Sindh (WINS) program.
World Food Program (WFP) is implementing a pilot project in one district of Sindh to determine
relationship between provisions of nutritious foods and chronic malnutrition (stunting).
International Medical Corps (IMC) is treating people with acute malnutrition among Internally
Displaced Persons (IDPs). HANDS is operating in most of the areas of Pakistan, with activities
around nutrition and IYCF education [8].
DFID is supporting a food fortification program that aims to reduce anemia and vitamin A
deficiency in women and children under five. This program intends to improve access and
consumption of wheat flour fortified with at least iron and folic acid, and edible oil/ghee with at
least vitamin A. This program targets to reach 85% of the urban and 65% of the rural population
in consuming fortified wheat flour, and 85% of the urban and 75% of the rural population in
consuming fortified edible oil/ghee. In addition, a GAIN-supported project aims to develop a
roadmap for a sustainable, and effective large-scale food fortification program at national level,
a functioning regulatory monitoring system, and increased consumption of fortified foods in the
country.
2.1.2 Nutrition sensitive interventions
In order to have cross-sectoral action on nutrition, in contrast to only health sector initiatives
in the past, it is important to ensure inter-sectoral coordination and a concerted effort to make
these interventions nutrition sensitive across all relevant sectors.
Pakistan has approved Integrated Nutrition Strategy and in all four provinces, the Steering

FINDINGS
FINAL REPORT 11
Committees have been established. Moreover, provinces have increased social sector
spending after the devolution. However, the provincial planning for nutrition-sensitive
interventions has a slow pace.
A few schemes (currently in draft form) have been proposed by two of the provinces i.e., Sindh
and Punjab, for this year’s annual budgetary cycle, with financing entirely from provincial
government funds. While this indicates initiation of commitment towards nutrition-sensitive
interventions, proper technical designing is needed to better position the schemes towards
undernutrition, geographical convergence with nutrition-specific interventions, and scaling up.
Provincial support for nutrition-sensitive interventions for two sectors was planned for year
2015-16 in Sindh with support from government funds. Similar modality was followed for
nutrition specific interventions and involved a PC-1, supported by annual development funds
in the concerned sectors. Punjab developed draft PC-1s in the areas of WASH, livestock
support, and school feeding for 2015-16 budgeting cycle. However, it is not clear whether
these projects converged on the same districts which are being targeted by the nutrition-
specific interventions in Punjab.
KP had an uncertain situation in this regard, as draft PC-1s to be supported by government
funds, were not finalized till late part of 2014. As in Sindh, the PC-1s in KP intend to be specific
to the respective sectors and the possibility of moving towards developing a joint PC-1 seemed
weak [9].
Balochistan is positioned to target the 2016-17 Annual Development Plans (ADPs) and is open
to launching a multi-sectoral nutrition-sensitive program in the districts being targeted by the
health-focused nutrition-specific interventions [7].
It is important to discuss here the federal coordination structures especially in the post-
devolution scenario. There is low buy-in from provinces for a federal role in view of the
provincial autonomy over the social sector, provided by the constitutionally supported
devolution. The desired role for the federal platform is overall coordination rather than policy
steering or monitoring. Important areas required for coordination include: 1) bringing together
provinces for sharing updates; 2) mutual sharing of ideas and experience; 3) provision of
technical capacity in required areas; and 4) implementation of evaluation surveys.
The placement of a federal nutrition platform in the Planning Commission, rather than the
Health Ministry or Food Security Ministry, intends to have buy-in of the federating units. The
Planning Commission is believed to provide a cohesive link with the provincial P&DDs, but its
capacity remains a major constraint. With limited staff dedicated to nutrition and a lack of direct
programmatic experience of Planning Commission, would contribute to more nuanced
technical understanding.
Table 2 provides a detailed landscaping of the nutrition sensitive interventions being carried
out by the provincial departments with the support of the development partners in nutrition
related sectors.

FINDINGS
FINAL REPORT 12
Table 2: Nutrition sensitive interventions by main actors
INITIATIVES
IMPLEMENTING
PARTNER(S)
EDUCATION AND RELATED INITIATIVES, INCLUDING
 School feeding schemes; Early Childhood Development (ECD); Female enrolment schemes
Sindh government initiatives:
 Recruitment and development of female teachers
 Improved facilities in schools such as separate toilets for girls
 Assistance to Girls Primary Education in Sindh (AGPES): provision of edible oil and milk
powder are to girl school children in 500 schools in five rural districts with low enrolment
ratios
Department of
Education, Sindh
government
KP government initiatives:
 Introduction of gender training of teachers and school curricula
 Stipends to girl students in seven backward/low-literacy districts
 Establishment of 199 Girls Community Schools with community participation
 Establishment of 116 Community Learning Centers for women empowerment through
income-generation and adult-literacy schemes
Department of
Education, KP
government
Punjab government initiatives:
 Provision of nutrition facilities to the children in primary schools in District Muzaffargarh
(pilot project)
Department of
Education, Punjab
All provinces:
 Early childhood education is being phased in for preschool children
Varied implementation
in all provinces
WATER, SANITATION, AND HYGIENE (WASH) INITIATIVES
Public-sector water and sanitation schemes
Sindh government’s scheme:
 Sindh government’s sanitation scheme for Open Defecation Free (ODF) villages in
districts where nutrition-specific interventions are underway 2015 budgetary
 Municipal Services Delivery Program and Sindh Cities Development Program are
primarily hardware-focused support and do not cover villages.
Provincial government
Public Works
Department initiatives
USAID and ADB;
principally urban in
Sindh
Punjab government’s scheme
 to rehabilitate 100 dysfunctional water treatment facilities for brackish water targeted at
rural poor 2015 budgetary cycle
 For revitalization of ODF Phase II scheme for rural areas—2015 budgetary cycle.
 Changa Pani Scheme and Saaf Pani Scheme are already underway but are primarily
targeted towards urban areas. There are plans for a scheme for reduction of open
defecation in four districts of Punjab, but as yet there has not been movement towards
an action plan.
City/Local government
initiatives Go of Punjab
DFID-funded project
DFID’s humanitarian program
DFID’s humanitarian program includes WASH activities for internally displaced persons
(IDPs) in KP/FATA under the Predictable Emergencies Program (PEP) 2013-2015 and
WASH activities for people displaced by flooding and conflict under the Multi-Year
Humanitarian Program (2015-2019). DFID is also supporting the provision of WASH
interventions to reduce vulnerability in the Building Disaster Resilience in Pakistan
program (2015-2021) in Sindh, with one of the objectives being to increase access to safe
drinking water and reduce open defecation and unhealthy hygiene practices, thereby
contributing to improvements in the nutritional status of women and children.
DFID
Pakistan component of DFID-UK’s WASH Results Program
WASH interventions by Plan International in Ghotki, Bahawalpur, Lodhran, Muzaffargarh,
Rahim Yar Khan, Mardan, Swabi, Umerkot, and Islamabad districts.
WASH interventions by WaterAid in Badin, Thatta, and Rajanpur districts.
Unilever working on “school of five” hygiene promotion campaigns in schools in 21
districts.
DFID
AGRICULTURE INITIATIVES, INCLUDING HOME GARDENING
Sindh government’s nutrition-sensitive agriculture scheme for 2015 budgetary cycle,
Agriculture & Food PC-1, promotes milk and meat through livestock promotion and
support to small land holders for vegetable and fruit growth for local consumption in
districts where nutrition-specific interventions are active.
Agriculture
Department, Sindh
Punjab government’s livestock support scheme for women, in 2015 budgetary cycle,
involving provision of heifers, sheep, and goats in Punjab.
P&DD, Government of
Punjab
Harvest Plus project is in the process of developing and implementing a zinc-enriched
wheat program in Pakistan
DFID and Harvest Plus

FINDINGS
FINAL REPORT 13
The South Asia Food & Nutrition Security Initiative (SAFANSI) aim is to increase the
commitment of governments in South Asia and development partners (such as donors,
the United Nations, and NGOs) to tackle undernutrition. It is implemented by the World
Bank, as part of the Multi Donor Trust Fund. The Australian Department of Foreign Affairs
and Trade (DFAT) co-funded the first phase with DFID, which ends March 2015. The
second phase is co-funded by DFID and EC
World Bank (WB),
DFID, DFAT, European
Commission,
Government of
Pakistan
The Leveraging Agriculture for Nutrition in South Asia (LANSA) program, funded by DFID,
aims to understand the apparent “disconnect” between agriculture and nutrition in the
region, since agriculture growth in South Asia has not translated into improvements in
nutrition outcomes.
DFID and EC
The government launched a kitchen garden project in 1999 to 2001 that was focused on
urban areas of Islamabad Capital Territory but this did not yield any significant results.
Recently the National Ministry of Food Security and Research has launched a further pilot
project on kitchen gardening in Islamabad and Rawalpindi. Project implementation is
through imparting training on vegetable growing and is primarily focused on urban
populations.
Food Security and
Research through the
PARC, Collective for
Social Science
Research
FOOD SAFETY MEASURES
Safe food is an essential requirement for meeting nutritional requirements. All the
provinces are required to enact their food laws. Punjab has already promulgated Food
Laws and established a Food Authority.
Provincial governments
SOCIAL PROTECTION AND CASH TRANSFER PROGRAMS
Benazir Income Support Program (BISP)
BISP targets women in eligible households.
Provinces post devolution have control over design and implementation of Zakat and Bait-
ul-Mal departments, but these are yet to be effectively targeted to support nutrition-
sensitive interventions, and systematic targeting of low-income women and children is
missing.
Government of
Pakistan
The DFID-funded Research on Food Assistance for Nutritional Impact (REFANI) project is
currently conducting a study to test the effectiveness and cost-effectiveness of different
cash transfer programs on reducing the risk of undernutrition in children 6 to 59 months
old and their mothers in Dadu District, Sindh Province, using ACF’s program as a vehicle
for the research.
DFID and ACF
2.2 Key Nutrition Stakeholders for Multi-Sectoral Approach
Nutritional status is not only an outcome of economic or dietary factors alone, rather multiple
socio-economic factors including hygiene-sanitation, education, individual life style,
knowledge, behavior, awareness and access to safe food and drinking water are associated
with it. Hence, nutrition has close linkages to a number of sectors and requires a cross-sectoral
approach to deal with chronic and persistent malnutrition. The key stakeholders belonging to
nutrition related sectors that play critical role in having a holistic approach to address the issue
of malnourishment are discussed below.
2.2.1 Federal Level
2.2.1.1 Nutrition Section, Ministry of Planning, Development and Reforms
In April 2010, the parliament of Pakistan passed the 18th Amendment, which devolved 17
ministries from the center to the provinces, including the Ministries of Agriculture, Education,
Food, Health, Women’s development and Social Welfare.
The federal nutrition section is established in the Ministry of Planning, Development and
Reforms and is housed at National Institute of Health (NIH) in Islamabad. The role of Nutrition
Section is to provide overall coordination between provinces, share updates and experiences
with provinces, and provide technical support. The 18th constitutional amendment does not
give it powers to monitor or steer the provincial governments in this regard [10] [11].
The main functions of nutrition section are the following [12]:
1. Prepare annual and long term plan for nutrition and consumption.

FINDINGS
FINAL REPORT 14
2. Prepare national food balance sheets including per capita food intake, food supply
and demand projections.
3. Study and analyze existing data on food consumption pattern and nutrition status in
Pakistan.
4. Support and initiate research studies in food consumption, dietary intake and nutrition
status for policy development.
5. Develop and maintain adequate database for realistic nutrition planning.
6. Identify and justify empirically proven set of nutrition interventions/ tested projects
7. Development of indicators for evaluation and impact assessment of food and nutrition
situation and plans.
8. Study and evaluate ongoing food and nutrition programme and to recommend
additional programmes in the field of food consumption and nutrition.
9. Formulate long term plans, annual plans, and annual development programmes for
food and nutrition programmes.
10. Monitoring and evaluation of projects in the field of food and nutrition.
11. Prepare policy papers and recommendations and/or comments thereon.
12. Secretariat of the federal nutrition syndicate (high level inter-ministerial coordination
body for nutrition).
13. Act as focal point for all national and international agencies in the field of food and
nutrition.
14. Support nutrition education on a mass media campaign.
15. Coordinate inter-sectoral food and nutrition programmes across sectors/regions.
16. Capacity building for food and nutrition programmes
2.2.1.2 Politicians, Media and Civil Society Networks
In order to prioritize and scale up any issue of public importance, it is pivotal to have political
will at the top. During the events, such as flash floods in recent years, food shortages in interior
Sindh, and IDPs in KP, the media has played its role in sensitizing the political representatives
of different parties about the issues of malnourishment and the nutrition related issues.
The past experiences reflect that politicians tend to have a reactionary approach to the social
issues, as and when they are brought up on the media. Unfortunately, the prominence of the
malnourishment, as an issue on the print and electronic media, quickly fades away the moment
natural or manmade disaster is over.
It is important that the politicians, media and civil society networks are sensitized about the
issue and importance of nutrition as a national development goal to wither the misconception
of nutrition being an issue during natural or manmade disaster.
2.2.1.3 SUN Unit at Federal Level
In 2013, Pakistan became signatory to the Scaling Up Nutrition (SUN) Movement. The SUN
focal point for the government is Chief of Nutrition in the Planning and Development Division
of the Planning Commission. Different development partners are supporting the development
of SUN coordination structures and planning documents at federal and provincial level; the
UN’s World Food Programme (WFP) is providing support at the federal level while UNICEF,

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FINAL REPORT 15
the Micronutrient Initiative (MI), and FAO are supporting provincial structures. The SUN
structures yet to be made operational at provincial level, which is critical given that social sector
responsibility and interventions are devolved to the provinces.
2.2.1.4 SUN CSA (Scaling Up Nutrition Civil Society Alliance)
In 2014, Civil Society Alliance (SUN-CSA) was launched in Islamabad, and adopted a Civil
Society Declaration on Nutrition and Food Security. In order to ensure the creation of a strong,
coordinated and vibrant civil society constituency to promote multi-sectoral developmental
approaches to support nutrition agenda, the SUN CSA Pakistan has defined four broader
areas of focus: 1) Advocacy and Awareness Raising; 2) Monitoring and Accountability; 3)
Networking; and 4) Capacity Building. The establishment of the SUN-CSA spanned throughout
2014 starting with membership in response to the advertisements [13]. The number of SUN
CSA members have increased to 108 by September 2015 and had representation from all
federating units of Pakistan.
2.2.1.5 National Fortification Alliance (NFA)
National Fortification Alliance (NFA) constituted under the Ministry of NHSR&C play a key role
in policy making, coordination, over sight and monitoring of food fortification programs in the
country. It is an important body to address the issue of harmonization and collaboration and
serves as a platform for bringing together all the provincial governments, UN agencies,
nutrition partners and stakeholders. Provincial Fortification Alliances (PFA) were established
in May 2016, which are the provincial chapters of the National Fortification Alliance. These
PFAs will act as a platform for coordination and oversight of fortification activities at the
provinces [14].
2.2.2 Provincial Level
2.2.2.1 Structures and Capacity
Provincial Planning and Development Departments (P&DDs) are responsible for coordinating
subjects across departments to develop a common provincial development framework, acting
as counterparts to the federal level’s planning commission and nutrition section. In all four
provinces, there is a consensus for a central provincial Nutrition Section within the provincial
P&DD. The establishment of a Nutrition Section in the P&DD offers not only structural space
and authority for coordinating across nutrition-relevant sectors on project design and
monitoring, but also provides opportunity to follow up the implementation of Integrated
Nutrition Strategy (INS) [10].
The progress with regards to P&DD as the lead for multi-sectoral nutrition interventions, varies
across the provinces and there are also variances in terms of structures, designs, and
responsibilities. Sindh is leading the progress in this regard and has preferred to have specific
nutrition cell to coordinate across different sectors and develop/modify programs. Punjab and
Balochistan are also inclined to set up a separate nutrition cell within the P&DD, for effective
coordination and making program adjustments across all sectors. KP has followed a different
approach and considers the placement of nutrition as an added responsibility within the health
section of the P&DD, while involving loose coordination across other sections of P&DD [7].
Moreover, there are two particular areas of concern that are highlighted. Firstly, as one
respondent put it, “the administrative structure is still trying to catch up with devolution”, which
is most evident in provincial governments’ ability to plan, design, and implement large nutrition

FINDINGS
FINAL REPORT 16
programmes, and even if staff positions were to be increased, “expertise on nutrition is at a
premium in Pakistan”. Secondly, the network of sub-provincial staff for implementation is weak,
and the bureaucracy’s limited capacity to deliver social services predates devolution.
In 2002, the Ministry of Health (MoH) established a Nutrition Wing with the responsibility to
implement and monitor health-related nutrition activities. This wing itself had no direct role or
presence in the districts for the actual implementation. This is the crucial missing link in any
effort to reduce undernutrition, because greater coordination at the federal and provincial
levels, in the absence of effective delivery systems at the district level and below, will not bring
any change.
2.2.2.2 Politicians, Media and Civil Society Networks
Low civil society and media activism on nutrition, as well as lack of championing by politicians,
further weaken nutrition’s place on the list of provincial priorities. Politicians at the provincial
level have tended to pay more attention to food distribution than to nutrition, and food
distribution continues to be a political priority at the federal and provincial level. For instance,
during the flash floods in 2011, Provincial Disaster Management Authority (PDMA) distributed
food rations to flood victims in Balochistan, and it was continued beyond the flood recovery
period with popular support from elected representatives [15] [16].
There is a definite need to raise awareness of the media and civil society networks to highlight
the issue of malnourishment as one of the development need for the country and pitch it as
one of the performance indicators for the political parties in government. The media and civil
society projection of social issues has shown to be effective in attaining political action and
response.
Recently, pressure by development partners has resulted in some preliminary moves towards
provincial integrated nutrition strategies and the establishment of provincial intersectoral
nutrition committees headed by the P&DDs. Levels of interest vary across the respective
P&DDs, with Punjab having made the fastest progress in constituting an intersectoral nutrition
committee. However, there is low level of acceptance within the P&DDs to take primary
responsibility for nutrition. In at least two provinces the new momentum is being interpreted as
multi-sectoral coordination for health activities rather than the larger agenda of cross-sectoral
action with visible pro-nutrition planning in each sector.
2.2.2.3 Intersectoral Steering Committees and Technical Working Groups (TWGs)
All the four provinces have established Intersectoral Steering Committees presided over by
the provincial P&DD. The Steering committees are supported by Intersectoral Technical
Working Groups (TWG). These TWGs advise on the design of nutrition-related interventions;
however, their meetings have been infrequent and are not synchronized with the government
planning and budgeting processes. In Sindh, Punjab, and Balochistan, the provincial Health
Departments coordinate the activities of TWGs. Whereas in KP, there is a TWG specific for
each sector rather than an over-arching TWG, and these essentially involve public-sector
officials [10].
2.2.2.4 Health Department
The role of the provincial health departments has been more pronounced in the nutrition
specific interventions. In Sindh and Balochistan, there are PC-1s funded district level positions
of District Nutrition Coordination Officer/Focal person reporting to the District Health Officer

FINDINGS
FINAL REPORT 17
[10].
The interim period during which the specified Nutrition Coordination posts are realized, all the
provinces need to make interim arrangements to fill these posts. There is also need to have
structures at the district level for coordinating a multi-sectoral approach.
2.2.2.5 Food Department
The role of the food department is critical in ensuring quality of foods that conform to the
nutritional standards. In order to assert this role, all the provinces need to enact food quality
and safety laws. Market quality assurance of fortified foods and pricing has overlapping and
unclear roles between Health and Food. Punjab is the only province to have set up a Food
Regulation Authority to pull together quality assurance functions under single entity [10].
2.2.2.6 Agriculture Department
While nutrition is an outcome of complex processes, and has come to be framed largely as a
health sector concern, a broader range of factors, including food adequacy and quality, play
an important role to improve nutrition outcomes.
Agriculture has a direct impact on household food security through drivers such as food
availability and income distribution. The agricultural sector plays an important role in the
availability of diverse and nutrition-dense foods. After the devolution in 2011, much of
agricultural policymaking have been shifted to the provincial level of government while
retaining some food security-related issues at the federal level.
Agricultural policy, moreover, has not paid explicit attention to nutrition or food consumption
until relatively recently [17]. In the current scenario, the provincial Agriculture departments
need to be sensitized regarding the importance of making nutrition sensitive agriculture
policies and work on the apparent Agriculture-Nutrition disconnect.
2.2.2.7 Public Health Engineering Department (PHED)
It is the responsibility of the provincial Public Health Engineering Departments to design,
operate, and maintain drinking water and sanitation facilities in the rural areas. After the
development of Integrated Nutrition Strategy by provinces, a number of WASH-related
nutrition-sensitive projects for rural, low-income areas have been planned (Table 2) [7].
2.2.2.8 Education Department
After the devolution, education sector plans and strategies for 2013-17 have been developed
by all the provinces; however, these plans and strategies did not include nutrition sensitive
interventions. The provincial education departments do not envision nutrition as one of the
considerations for intervention designing. As a consequence, nutrition is not one of the
targeted outcomes of existing education sector strategies. Provinces lack expertise on
designing nutrition-sensitive interventions. Some recent and ongoing initiatives have
attempted to address undernutrition but lack effective design and positioning (Table 2).
2.2.2.9 Benazir Income Support Program (BISP)
BISP is a cash transfer program started in 2008 for low-income women in all four provinces,
aiming to reduce poverty by cushioning the impact of food inflation and financial crises. An
impact evaluation of the BISP program was conducted by Oxford Policy Management which
showed that the BISP beneficiaries largely spend the cash transfer on food (56%), followed by
fuel (9%) and housing expenses (6%). The evaluation did not find that the BISP had an impact

FINDINGS
FINAL REPORT 18
on food consumption expenditure. However, when regularity of consumption of specific items
was investigated a positive impact of the BISP was found on the consumption of fish, eggs
and wheat for households.
The BISP beneficiary households had reduced rates of malnutrition amongst girls (aged 0-59
months) as measured by wasting, a measure of short-term malnutrition [18]. These findings
indicate that targeting the low-income households does help in providing some cushion to the
inflation of food prices and thus contribute indirectly to better nutrition outcomes.
2.2.3 Development Partners for Nutrition Group
The provincial devolution of 2011 gave development partners an opportunity to have easier
direct coordination and interaction with implementers, avoiding the centralized and slower
planning processes. A number of initiatives by the development partners have been put in
place in collaboration with the provincial governments. The summary of the initiatives is
provided in the Table 2. The key development partners that are contributing to the nutrition
sector are mentioned below:
 UNICEF
 World Food Program
 Food and Agriculture Organization
 World Health Organization
 World Bank
 DFID
 Government of Australia
 Government of Canada through Micronutrient Initiative (MI)
 International NGOs such Micronutrient Initiative, Save the Children, ACF, GAIN,
Islamic Relief, etc.
2.3 Policy and Legislative Environment for Nutrition & Food Security
The earliest institutional presence for nutritional interventions in Pakistan, goes back to 1970
in the National Planning Commission (NPC), when it was considered a subject rather than a
sector. To consider nutrition as a sector, required multi-sectoral ownership and close linkages
with other sectors like Agriculture, Education, Health, Social Protection, Water and Sanitation,
and Women’s Development.
From 1970s through 2000, there were hardly any holistic initiative that focused at addressing
the issue of malnourishment. Prior to 2011, Pakistan even lacked national nutrition policy,
however had a National Nutrition Strategic Plan 2002 which was, unfortunately, never
implemented.
The Planning Commission (PC) had a mandate to mainstream nutrition across different
sectors but its operations were housed in the nutrition wing of the Ministry of Health in 2005.
This arrangement was reflective of the understanding that nutrition was a sub-set of health
and thus it remained confined to the Health Sector [10].
A number of events in the recent past have highlighted the nutrition on the policy agenda. The
flash floods of 2010 and 2011 provoked a coordinated response by the development partners
across provinces. In affected areas, mother and child under-nutrition was highlighted to
stakeholders during recovery efforts that fostered the development of Pakistan Integrated

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FINAL REPORT 19
Nutrition Strategy (PINS) at the federal level with support from UNICEF. PINS envisage linking
of all social sectors (agriculture, health, social welfare, public health engineering and
education) and having inter-sectoral planning and implementation with strong coordination,
monitoring and evaluation.
The findings of the last National Nutrition Survey 2011, supported with unusual media publicity,
further brought under-nutrition into policy prominence. It generated a lot of deliberations
among researchers, media, and development partners. Finally, the provincial devolution of
2011 gave development partners an opportunity to have direct and easier engagement with
implementers, avoiding the centralized and slower planning processes.
However, the devolution also witnessed a transition state with vague role of federal and
provincial actors. After devolution, a Nutrition Wing was established in the Planning
Commission (PC), which faced issues since PC was not an implementing agency. Moreover,
there was still no nutrition policy to guide in addressing the issue within the regular working of
ministries. Nutrition is still dealt with through the development budget of the PC rather than as
an integrated part of the recurrent budget of the Ministry of Finance [7].
Globally, the realization to prioritize the nutrition sector has led to the Scaling Up Nutrition
(SUN) Movement. SUN is a unique movement founded on the principle that all people have a
right to food and good nutrition. It unites people from governments, civil society, the UN
agencies, donors, businesses, and researchers in a collective effort to improve nutrition.
Pakistan became signatory to the SUN movement in 2013.
This multi-stakeholder platform, developed as a result of joining the Scale Up Nutrition (SUN)
movement, shows a high-level of commitment for nutrition at the national and provincial levels
with all partners on board. The provincial Nutrition Policy Guidance Notes and Strategy and
SUN roadmaps have been developed and approved within the scope of Vision 2025. The
multi-sectoral nutrition strategy is in a development stage through a consultative process,
which is based on the provincial policy guidance notes, inter-sectoral nutrition strategies, and
national and global commitments.
The SUN Units at national and provincial levels are being established at the respective
planning and development departments. This arrangement intends to enhance coordination
and collaboration at implementation levels for multi-sectoral strategy and also to develop
linkages among all public-sector departments, provinces, SUN Networks, and the Global SUN
Movement Secretariat. In Pakistan, government, donors, UN, Civil Society Alliance (CSA) are
functioning, whereas business, and research and academia networks have been established
recently to streamline SUN Movement innovative approaches [19].
Protection and Promotion of Breastfeeding laws have been enacted by federal and all
provincial governments. These legal frameworks are meant to ensure safe and adequate
nutrition for infants and young children. It has framed laws to regulate marketing and promotion
of certain designated products. The implementation of these laws can only be ensured by the
active participation and persistence of all the stakeholders especially the civil society. Other
legislative measures are limited to food regulations which deal with the adulteration and food
safety related to food supply or some others related to the consumer protection as does for
consumers of any other commodity [20].
In an event of disaster, to guide the actions of all partners in the nutrition sector, another policy
level response is reflected in the form of “National Nutrition Cluster Preparedness and

FINDINGS
FINAL REPORT 20
Response Plan”. It provides focus and coherence to the various levels of planning that are
required to respond effectively but does not replace the need for planning by individual
agencies in relation to their mandate and responsibilities within clusters [20].
The Annual Plan (2016-17) of the Planning Commission envisage to develop a national plan
of action on food and nutrition/Pakistan’s Multi-Sectoral Strategic plan with an emphasis on
national nutrition priorities [1].
2.4 Financial Commitment at Federal and Provincial Level
Prior to 2011, Pakistan lacked a national nutrition policy and National Nutrition Strategic Plan
2002 was never implemented. The Pakistan Integrated Nutrition Strategy (PINS) 2011,
however, sets out an incremental plan for the implementation of nutrition-related interventions.
Each of the four provinces and three regions of Pakistan have begun drafting inter-sectoral
nutrition strategies.
Global Nutrition Report, 2016 reports that in 2013 Pakistan spent 1.06 percent of the general
government expenditure on nutrition-specific and nutrition-sensitive interventions and stood at
15th position among 24 countries. Whereas among the South Asian countries Pakistan ranked
last as Nepal spent 3.59 percent and Bangladesh’s spending was at 3.31 percent. In Pakistan,
around 35 percent of the nutrition budget was nutrition specific, while the remaining 65 percent
was nutrition sensitive, and among 24 countries, Pakistan was better than only 4 countries.
Whereas amongst South Asian countries Pakistan was at the bottom. Furthermore, a
comparison of the budget allocations to nutrition-relevant sectors were compared for 16
countries, including Nepal, Bangladesh and Pakistan from South Asia, where Pakistan had
allocated only 5 percent of general government expenditure to nutrition-relevant sectors,
compared to 41 percent by Nepal and 37% by Bangladesh [21].
Nutrition is still managed through the development budget of the PC rather than as an
integrated part of the recurrent budget. Donors view good nutrition as a means to achieving
growth, the PC frames nutrition as a social outcome of economic growth, whereas the
legislature is focused on food security.
The scarce funding has resulted in compromised capacities at federal and provincial levels.
The overall capacity of provincial departments is limited both in terms of availability of nutrition
staff as well as their capacity to deliver.
2.4.1 Provincial overview
Historically, provinces lacked consistent planning for nutrition and therefore followed tailored
initiatives designed by development partners and the federally supported Lady Health Worker
(LHW) Programme. However, the post devolution scenario provides more fiscal and strategic
space to provinces to prioritize nutrition.
2.4.1.1 Punjab
Punjab has surplus food production, lower poverty levels, and better access to water,
sanitation, and preventive health. However, Southern Punjab districts have inequitable land
distribution, greater poverty, and less access to social services, so they are the main source
of under-nutrition and call for district-focused strategies. Punjab has a supportive executive
bureaucracy, strong administrative control over implementation, and has integrated nutrition
within health, hence enhanced sustainability.

FINDINGS
FINAL REPORT 21
2.4.1.2 KP
In Khyber Pakhtunkhwa (KP), low outreach access in certain districts, social exclusion of
women, and conflict are the largest contextual issues. However, it is not food-insecure
because of a more equitable land distribution and greater crop diversification. Therefore, KP
has lower levels of under-nutrition than Sindh and Balochistan. Moreover, it has reorganized
the health department around nutrition-related issues, and sustainability and reforms are high
on the provincial development agenda. The nutrition improvement is following a slow but
deliberative process, being carefully tied to the provinces’ post-devolution development vision.
In the Punjab and Khyber Pakhtunkhwa (KP), integrated health reforms programmes with
strong nutrition component, have started implementation and are going to be further
strengthened.
2.4.1.3 Sindh
Despite being the second most food-producing province, Sindh faces considerable under-
nutrition and the highest level of food insecurity. They result from contextual issues of
inequitable land ownership, poverty, patriarchy, and poor delivery of social-sector services.
Weak cross-sectoral coalition, low district accountability, and weak governance in Sindh is
likely to undermine both the horizontal coordination and implementation of nutrition. Sindh also
has the most promising non-state sector, but there is lack of cooperation by the state.
2.4.1.4 Balochistan
Balochistan is the most vulnerable, faces high food insecurity, chronic water shortage,
vulnerable to both drought and flooding, inadequate outreach of social-sector services, and a
has patriarchal and tribal power structure. This is reflected in high level of under-nutrition. It is
also constrained by weak political leadership and low district capacities for implementation.
However, Balochistan is better positioned than Sindh due to stronger coalition building
amongst key sectors and cohesive working led by P&DD [22].
2.4.1.5 Planning Commission
Planning Commission has planned various nutrition specific and nutrition sensitive projects
under Annual Plan 2016-17, which include:
 An amount of Rs100 million in PSDP 2015-16 has been allocated for a project titled
‘National Initiative for SDGs/ Nutrition’ [23]. Nutrition Specific Interventions will be launched
in each province through approved projects under National Initiative for SDGs.
 Nutrition Support Programme for Sindh (NSP), costing Rs 4,118 million, has been
approved and will be implemented during this year. The overall goal of the project is to
improve the nutritional status of male and female children under five years and that of
pregnant and lactating women in nine selected districts.
 The Balochistan Nutrition Programme for Mothers and Children (BNPMC), costing Rs
1,493 million, has also been approved and it will be implemented this year. The overall
goal of the project is to improve the nutritional status of male and female children under
five years of age, including women of reproductive age, by improving the coverage of
effective nutrition interventions in the selected seven district.
 Universal Salt Iodization (USI) Programme is being implemented with the assistance of
the development partners like Micronutrient Initiative (MI), WFP, UNICEF and Global

FINDINGS
FINAL REPORT 22
Alliance for Improved Nutrition (GAIN). This will continue in 110 districts to benefit almost
174 million population of the country. A technical and financial review of the programme
will be conducted.
 The National Food Fortification Alliance has been re-established at the Ministry of National
Health Services, Regulation and Coordination to restart fortification programme which was
abandoned due to devolution. Hence wheat flour fortification with iron and folic acid is
being revitalized to overcome micronutrient deficiency disorders with the support of the
UN agencies and Nutrition Development Partners.
 Nutrition Sensitive Agriculture Project: This is a three-year project, approved in 2016 to
improve nutrition status in three districts of Sindh, i.e., Umerkot, Jacobabad and Sanghar.
The project will follow the community development approach and will establish fund to
support nutrition related agriculture activities. The cost of the project is Rs 582 million of
which 85 per cent will be funded by the DFID.
 The Khud Kafalat Scheme will generate economic activities through provision of interest
free loans and Islamic Microfinance Facility. Moreover, the Insaaf Agricultural Loans are
aimed at provision of affordable loans to small farmers. Protection of infant and child
nutrition through provincial and district level regulatory committees has also been initiated
to improve nutritional outcomes. The Sehat Ka Etihad scheme is aimed at eradication of
polio from the province. Moreover, subsidized healthcare assistance will be provided to
over one million patients and grant of Rs 2,700 as cash grant to 50,000 mothers.
 The Balochistan government has allocated ample resources to socially uplift the province.
Given its budget constraints, the federal government is providing Rs10 billion per annum
since 2010-11 under the Aghaz-e-Huqooq-e-Balochistan for its contribution to develop
Balochistan. Additionally, 142 development projects are being supported through the
Federal Development Programme in the province. The provincial government has
increased subsidies on tube-wells to Rs 8 billion for promotion of the agriculture sector,
but the province needs subsidies directly targeted to the vulnerable. The government has
allocated Rs 10 billion for education and Rs 8 billion for the health sector. However, no
direct allocation for Nutrition specific programme is planned.
Nutrition sensitive approaches are:
 Benazir Income Support Programme (BISP) will continue as an effective social safety Net
Measure by providing cash to the poor segments of population throughout the country.
 National Zero Hunger Programme, a joint collaboration between public sector and UN
agencies, is being devised to address hunger and malnutrition.
 Various Scaling Up Nutrition (SUN) Movement Networks (government, UN, donors, CSA,
business and research and academia) will be streamlined. The SUN secretariat and units
at all levels will start functioning to deliver the desired results.
 All four provinces in Pakistan have promulgated laws on breastfeeding. During 2015-16,
it will be carrying out follow up activities for the implementation of the laws on
breastfeeding in all provinces and at the federal level.
2.5 Mechanisms to Monitor Policy and Financial Commitment
The devolution has brought major actors responsible for nutrition specific and nutrition
sensitive intervention such as health, education, food, agriculture, women development and

FINDINGS
FINAL REPORT 23
social welfare departments, under provincial control. At the same time, there were significant
changes in funding modalities with a shift of funding responsibilities to the provinces. This
scenario has limited the role of federal ministries, such as Ministry of Planning, Development
and Reforms and Federal Ministry of Health Services Regulation to only coordination,
conducting surveys and providing technical assistance.
The provinces have formulated their respective integrated nutrition strategies. Some steps
have been taken by provinces to improve the oversight of nutrition projects and develop inter-
departmental coordination mechanisms.
Punjab and Sindh Provinces have institutionalized the roles of provincial oversight committees
under their policy framework. These committees have the representation from relevant
departments and P&DD under the overall supervision of top offices in the provinces. In Punjab,
Provincial Steering Committee is established under leadership of Chief Minister, while in Sindh
and KP, provincial P&DD and offices of ACS are leading these mechanisms, respectively.
Government of Sindh has also institutionalized inter-district nutrition group to increase
coordination and monitoring of nutrition interventions.
These frameworks though promise continued oversight and ownership by major governmental
offices, the efficacy of these mechanisms is dependent on multiple factors. These include
prioritization of nutrition as major developmental need, political will and commitment, and
capacities of relevant departments to develop nutrition sensitive interventions. Most
importantly, these mechanisms are intrinsic to the respective provincial governments and the
ability to attain financial commitment remains subjective to provincial priorities.
Punjab and Sindh provinces have approved nutrition PC-1s and have made financial
commitments for nutrition specific and sensitive interventions. However, the decision on actual
financial allocation to these projects is dependent on the commitment of provinces to these
projects and real term progress made by each project.
2.6 Awareness and Capacity of Opinion Makers, Media & Civil Society
Civil Society Organizations (CSO) and opinion makers can play an important role in educating
the communities and building consensus to bring forth nutrition on development agenda. The
understanding of cross functional role of nutrition demands continued political and financial
commitments for nutritional interventions.
Over the last one and a half decade, CSOs have been more active in promoting community
participation on various development issues, and increasing outreach of various services to
marginalized segments. These CSOs occupy a strategic space through mediating the gaps
between perceived needs and governmental priorities. Although, many organizations have
been advocating on sociopolitical issues including gender, health, family spacing, education
and rights, however, due to a limited understanding of nutritional issues, it is generally
perceived as a sub-sector of health.
The Constitution of Pakistan already recognizes the right of food under the article 38: “The
State shall provide basic necessities of life, such as food, clothing, housing, education and
medical relief”. The right to food is recognized in the 1948 Universal Declaration of
Human Rights as part of the right to an adequate standard of living, and is enshrined in the
1966 International Covenant on Economic, Social and Cultural Rights.
Adoption of Sustainable Development Goals (SDG) provides a new phase of global

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FINAL REPORT 24
development framework. SDGs emphasize on Improved Nutrition as the outcomes. SDG Goal
2 (End Hunger, Achieve Food Security, Improved Nutrition, and Sustainable Agriculture)
directly targets the issue of the hunger and malnutrition while SDGs 1, 3, 4, 5, 6, 12 & 17
address interacting processes linking health care, education, sanitation and hygiene, access
to resources, and women empowerment.
The provincial integrated nutrition strategies, agriculture and food security policies, and the
legislations around breastfeeding shows increased government commitment to nutrition and
would further pave way for CSOs to strongly advocate for financial commitments.
However, in order to achieve optimal results through this opportunity, it is essential to build the
capacity of CSOs and opinion makers (including print, electronic and social media) on issues
related to nutrition, policy and legislative framework, social beliefs and challenges that
contribute to malnutrition, etc.
In recent years, electronic and social media has emerged as powerful tools for raising issues
and generating awareness, facilitating policy debates and shaping public opinion in Pakistan.
The audience of electronic and social media has drastically increased due to wide spread
proliferation of TV channels and internet connectivity in both the urban and rural areas. There
were some attempts to raise public awareness on use of micronutrients such as iodine and
vitamin A & D. Private sector has also successfully use electronic media for advertisement of
fortified edible products. However, there is still a lot of potential for using these mediums for
advocacy on nutritional issues.
Opinion makers in print and electronic media can significantly promote involvement to protect
the right to adequate food and nutrition. These mediums have the potential to reach out to the
communities and establish the food security and nutrition as priority areas in developmental
arena. The challenges of nutrition have been effectively addressed by promoting effective
political and social leadership in countries like Peru, Brazil, Thailand, and India.
CSOs and media can potentially increase the demands for nutrition specific and sensitive
interventions in Pakistan by engaging with parliamentarians at national and specifically
provincial level.
2.7 Findings from In-depth Interviews (IDIs)
The in-depth interviews, conducted with various federal stakeholders, UN agencies and media
representatives, revealed that the realization of nutrition issues in Pakistan has greatly
increased after dissemination of findings of National Nutritional Survey in 2011. Various actors,
including government planning agencies, are more inclined to address the underlying causes
of malnutrition, and the nutrition sensitive programming is being focused as development
agenda.
2.7.1 Key actors working on nutrition issues in Pakistan
The participants identified a variety of actors working for nutrition related issues in Pakistan.
Planning commission is primarily the federal body that is responsible for allocations of public
sector development projects through PSDP. Within planning commission, three sections deal
with nutrition specific programing: population, nutrition and food security. The nutrition section
of planning commission is also the focal point for SUN movement in Pakistan. P&DDs are
mainly responsible for planning and making financial commitments for nutrition specific and
nutrition sensitive development projects in the provinces.

FINDINGS
FINAL REPORT 25
Ministry of National Health Services, Coordination and Regulation and provincial health
departments are the main stakeholders in nutrition specific interventions. MoNHSCR is mainly
responsible for coordination of PHC and nutrition activities. Nutrition section in MoNHSCR is
directly involved with nutrition projects including National Fortification Alliance. At the provincial
levels, National Programme for Family Planning and Primary Healthcare has been providing
extensive outreach to the communities especially for health education on nutrition.
The new provincial nutrition strategies demand Agriculture, Food, Public Health Engineering,
Education and Social Welfare and Women Development departments to design nutrition
sensitive projects in their respective domains.
National Agriculture Research Center, University of Agriculture Faisalabad and University of
Arid Agriculture are among leading academic and research institutions that provide technical
assistance in agriculture, food security and nutrition to conduct pilot projects.
WFP, FAO, WHO and UNICEF were identified as main UN agencies working on nutrition and
food security. World Bank, DFID, AUSAID and JICA were among main bilateral donors which
fund nutrition interventions.
There are various INGOs that are funding nutrition intervention in Pakistan. These include
Micronutrient Initiative, ACF, Merlin, GAIN, Save the Children, Concern Worldwide,
Johanniter, Shifa Foundation, Amman Foundation, CDO and HANDS. In addition, SUN Civil
Society Alliance has registered 108 civil society organizations which have adopted Civil
Society Declaration on Nutrition and Food Security.
Private sector is also contributing to the cause of nutrition in Pakistan especially in fortification
of food products. Small and large scale salt producers in private sector have adopted iodization
practices. Punjab Floor Mills association is promoting wheat fortified with iron and folic acid in
Punjab under GAIN project. SUN business network includes fast moving consumer groups,
pharmaceuticals, salt, confectionary, rice, flour, food commodities, plastics, packaging,
agriculture, consumer services, logistics, mill owners, etc. Engro foods have started some
school based nutrition projects in Sindh.
2.7.2 Perceptions around nutrition policy and food security
Mostly the participants mentioned that there was currently no nutrition policy at national or
provincial level. Nutrition guidance notes and Vision 2025 provides some policy guidance
regarding nutrition. The Planning Commission is in process of developing Pakistan Multi-
Sectoral Strategic Plan that intends to bridge the gaps in the national and provincial Integrated
Nutrition Strategies.
In lieu of SDGs, a dire need was recognized to prepare the framework for nutrition planning,
emphasized on SDG 2 and including vulnerable groups with respect to gender and age.
The participants also highlighted that the indicators for measuring hunger were collected at
household level in Pakistan Social and Living Standard Measurement survey, and suggested
that they should be measured for individuals living in the household.
There was a mixed reaction on food security issues. It was emphasized that there was
abundant production of wheat and government was taking adequate measures to subsidize
the supply chain of wheat. However, the issue of scarcity of appropriate storage facilities was
a big concern. It was also highlighted that government’s subsidy on wheat procurement was
inequitable and small farmers were unable to avail these benefits. Benazir Income Support

FINDINGS
FINAL REPORT 26
Program was identified as a single significant intervention providing relief to the poor
households.
2.7.3 Legislations to translate national policies into action
Most of the study participants were unaware of the legislations with respect to nutrition. Only
a few participants made a brief mention of breast feeding laws, iodized salt and food safety
laws.
2.7.4 Financial commitment for nutrition at federal and provincial level
The participants unanimously agreed that considering the extent of nutritional issue, the
available funding for nutrition projects is inadequate, and there were huge gaps in available
and required resources.
Federal Government has not allocated budget in recent years for nutrition but there is strong
political will to start advocacy interventions for nutrition. Some participants identified that
nutrition projects were only driven by donor funding and were governed by the donor agenda.
These donor-funded programs benefit only a segment of population.
In addition to the financial gaps, the capacities of institutions working for nutrition also need
strengthening in terms of trained human resources, improved governance, and monitoring and
supervisory mechanisms. The components of research, knowledge management, and
communication systems also need further strengthening.
2.7.5 Monitoring mechanisms at federal and provincial level
It was informed that there was no organized mechanism that could monitor and follow up a
policy implementation or financial commitment. The provincial nutrition cell within P&DD, is the
key to monitor nutrition interventions and policy implementation in the provinces. But no
mechanism is evident in the province to monitor financial commitment.
However, it was pointed out that there was a strong need to monitor policy interventions within
the federal and provincial structures.
2.7.6 Role of legislators, opinion makers, media and CSOs
The participants stated that media could play strong role in creating awareness on nutritional
issues. The media coupled with nutritional experts can effectively raise awareness among
policy makers and the political leadership. The school nutrition messages can improve the
dietary patterns among students and general population if adequately communicated.
Advocacy with legislators and opinion makers needs special attention and can potentially
increase political commitment to nutrition. The opinion makers, researchers, media personnel
and civil society have been engaged in SUN networks and need to have continued capacity
building support.
The participants also identified the need to roll out capacity building opportunities for CSOs for
advocacy, nutrition implementation, and conducting research.
***********

CONCLUSIONS
FINAL REPORT 27
3 CONCLUSIONS
1. In Pakistan, multi-sectoral approach is recently adopted to address the nutrition issues
after Pakistan became signatory to Global SUN Movement.
2. After devolution, at the federal level, nutrition section is established in the Ministry of
Planning, Development and Reforms however its role is limited to only coordination
between provinces, sharing updates and experiences with provinces, and providing
technical support. At the provincial levels, the multi-sectoral approach is led by P&DD
instead of health departments. The federal level has no role in monitoring of either policy
or financial commitments.
3. In Punjab, Provincial Steering Committee under leadership of Chief Minister, while in
Sindh and KP, provincial P&DD and offices of ACS constitute the monitoring
mechanisms, respectively. Government of Sindh has also institutionalized inter-district
nutrition group for monitoring of nutrition interventions.
4. Although, at the provincial level, this has resulted into improved coordination but the
partnerships with donors have not grown enough to pool required funds. Moreover,
limited staff dedicated to nutrition and a lack of direct programmatic experience, limit the
capacity of P&DDs.
5. In the provinces, although the governments have gradually increased funding through
health sector related nutrition-specific interventions, development partners still contribute
a major share through specific projects. This poses risks to sustainability of these
initiatives beyond the projects duration.
6. Under support from DFID, the governments of Punjab and KP, have developed
Minimum/Essential Health Service Package and nutrition specific interventions are part
of the overall package. It is more likely that being part of the government system, these
interventions would better sustain in these two provinces.
7. At provincial levels, the efforts to plan for multi-sectoral interventions around nutrition are
evident through preparation of relevant PC-1s. However, within the P&DDs, the
acceptance level is low to take primary responsibility for nutrition.
8. There are issues in understanding when separately interpreting health and nutrition,
because in half of the provinces the multi-sectoral approach for nutrition is being
interpreted as multi-sectoral coordination for health activities.
9. The politicians, media personnel, and Civil Society Networks are generally not much
aware of the complexity of nutritional issues in Pakistan. Moreover, the elected
representatives commonly follow the visible approach of food distribution.
10. The SUN Movement is seen as a lead agency in providing guidance in nutrition
interventions. It is well supported by the government and the development partners, and
has established a successful alliance with large number of civil society organizations.
11. The SUN Units at national and provincial levels are established at the respective P&DD.
This arrangement would enhance coordination and collaboration at implementation
levels, and linkages among partners. The government, donors, UN, and CSA
collaborations are functioning, whereas business, research and academia networks are
established recently.

CONCLUSIONS
FINAL REPORT 28
12. After the devolution, the provinces have developed education sector plans and strategies
for the period 2013-17 however they lack nutrition sensitive interventions. Therefore,
nutrition is not amongst the targeted outcomes of education sector strategies. Moreover,
provinces lack expertise in designing nutrition-sensitive interventions.
13. The role of the food department is critical in ensuring nutritional standards of foods. So
far only Punjab has set up a Food Regulation Authority for quality assurance functions.
14. Nutrition is an outcome of complex processes and agriculture has a direct impact on
household food security through food availability and income distribution. After the
devolution, agricultural policymaking has been shifted to the provinces. Agricultural
policy, however, has not paid much attention to nutrition or food consumption.
15. The facts, that prior to 2011 Pakistan lacked a national nutrition policy and the National
Nutrition Strategic Plan 2002 was also not implemented, clearly reflect that the
respective governments in Pakistan never committed any nutrition specific funds. In
2013, government spending (only spent 5% of general government expenditures) on
nutrition was much less (6 to 8 times) than the spending of its neighboring countries.
***********

RECOMMENDATIONS
FINAL REPORT 29
4 RECOMMENDATIONS
1. There is need to advocate political and administrative authorities, to further convince
them to add nutrition among the top priorities of the governments, translate policies into
actions and ensure allocation of funds for nutrition interventions. If they are not convinced
enough they would never prioritize nutrition on their agenda and hence will not allocate
financial resources.
2. With the adoption of sustainable development goals, efforts should be directed to
develop multi-sectoral nutrition specific and nutrition sensitive development programs
with the involvement of Health, Social Welfare, Education, Food, Agriculture, and Public
Health Engineering departments.
3. The government, donors and development partners should focus at building capacities
of respective departments in provision of trained staff and of personnel in understanding,
planning and implementation of nutrition related interventions, at federal, provincial and
district levels.
4. The governments should establish mechanisms to monitor policy interventions and
financial commitments. Technical and financial assistance should be provided to federal
and provincial governments in establishing such mechanisms.
5. Structured and well planned efforts should be directed to raise understanding regarding
nutritional issues among the legislators, policy makers, media and implementers.
6. SUN SCA should advocate Federal and Provincial Governments for nutrition sensitive
and nutrition specific projects and improving the financial commitments.
7. Scaling Up Nutrition Civil Society Alliance at federal level has the potential to influence
the monitoring mechanisms of policies and financial mechanisms. This should be
achieved through taking concrete steps to influence the financial commitments at
provincial level through continued advocacy for financial allocation.
8. The capacity of CSOs should be enhanced for developing and implementing effective
advocacy programs and nutrition sensitive interventions.
9. The beneficial outcomes of BISP on nutrition outcomes should be enhanced through
sensitizing the beneficiary households on rational spending and benefits of prioritizing
spending on nutritious food.
***********

REFERENCES
FINAL REPORT 30
REFERENCES
1. Annual Plan, Planning Commission of Pakistan, 2016-17
2. Asian Development Bank, Food Security in Asia and Pacific, 2013
3. Global Food Security Index, 2016
4. The Political Economy of Undernutrition National Report: Pakistan, March 2013
5. Essential Package of Health Services for Primary Health care, Punjab, 2013
6. Minimum Health Service Delivery Package for Primary Health Care, KPK, 2012
7. Preventing Undernutrition Through Multi-Sectoral Initiatives in Pakistan - A Landscape
Analysis, July 2015
8. The Political Economy of Undernutrition National Report: Pakistan, March 2013
9. Multi-sectoral Integrated Nutrition Strategy, Khyber Pakhtunkhwa, Dec 2014
10. Zaidi et al. Nutrition Policy in the Post-Devolution Context in Pakistan: An Analysis of
Provincial Opportunities and Barriers, May 2013
11. http://www.nih.org.pk/Nutrition.asp
12. http://pc.gov.pk/organization/sections/nutrition.pdf
13. http://scalingupnutrition.org/news/the-sun-civil-society-alliance-launches-in-pakistan-
and-adopts-a-declaration-to-mark-the-occasion-2#.VfZ6qNKqqko
14. http://nhsrc.gov.pk/news_details.php?news_id=197
15. Baluchistan Province Report: Nutrition Political Economy, Pakistan
16. Khyber Pakhtunkhwa Province Report: Nutrition Political Economy, Pakistan
17. Agriculture and Nutrition in Pakistan: Pathways and Disconnects, IDS Bulletin Volume
44 Number 3 May 2013
18. Benazir Income Support Program; First follow-up impact evaluation report, Oxford Policy
Management, April 2014
19. Strategic Plan, Scale Up Nutrition-Civil Society Alliance 2016 -2020
20. Pakistan National Nutrition Cluster Preparedness and Response Plan 2013
21. Global Nutrition Report, 2016
22. Pakistan National Synthesis – PEA
23. Strategic Plan - SUN CSA 2018-2020
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MI - FINAL REPORT - SITUATIONAL ANALYSIS FOR ADVOCACY PROJECT

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