1. 1 | P a g e
Punjab Policy Environment Analysis
A Brief Review of Health and Nutrition Policy Landscape in Punjab
7 September 2015
By:Laila Rubab Jaskani
Punjab Pakistan
Empowerment, Voice and Accountability for Better Health and
Nutrition Project Pakistan

2. 2 | P a g e
Table of Contents
1. Health Policies and Strategies in Punjab....................................................................................3
1.1 Background ..........................................................................................................................3
1.2 Most recent Developments in this context in Punjab ..........................................................3
2. Nutrition Policies and Strategies in Punjab ...............................................................................4
2.1 Background ..........................................................................................................................4
2.2 Most recent Developments in this context in Punjab .........................................................4
3. A Critical Gap Analysis of Policies in Punjab contexts .................................................................

3. 3 | P a g e
Acronym:
MI Micronutrients Initiative
SUN Scaling up Nutrition Movement in Pakistan (Pakistan is signatory of SUN)
MSNA
IRMNCH Integrated Reproductive Maternal Newborns and Child Health
GAIN Global Alliance for Integrated Nutrition
BHN Better Health and Nutrition
EVA Empowerment, Voice and Accountability
PHC Punjab Health Care Commission
EPHS Essential Package for Health Services
MSDS Minimum Service Delivery Standards
PHSS Punjab Health Sector Strategy
CMIT Chief Minister Inspection Team
PITB Punjab Information Technology Board
WB World Bank
NNS National Nutrition Strategy
PINS Pakistan Integrated Nutrition Strategy
SUN Scaling Up Nutrition
NWG Nutrition Working Group
MNCH Maternal Newborn Child Health
MTDF Medium Term Development Framework
NNSP National Nutrition Strategic Plan
TWG Technical Working Group
SC Steering Committee
P&D Planning and Development Department Punjab

4. 4 | P a g e
Health Policies and Strategies in Punjab
General Objective:
To describe the overall health and Nutrition policy environment in Punjab health sector.
Specific Objective:
1) To review the health and nutrition policies environment and new developments in Health
sector Punjab
Background:
Health and particularly reproductive maternal newborns and child health is top priority PML-N
government in Punjab. Therefore, Muhammad Shahbaz Sharif, Chief Minister Punjab is monitoring
the efforts and the steps being taken for the Road Map project and PHSS. Top priority of the Chief
Minister Muhammad Shahbaz Sharif is to provide best health services and facilities to the citizens of
the province and prevention of diseases. For this purpose a new policy is being prepared to remove
the gaps in the Health sector, strengthening of primary healthcare system and more focus on
prevention of diseases.
The National Programs, Lady Health Workers’ Program (LHWP), National Maternal, Newborn and
Child Health (MNCH) Program and Nutrition Program, are included in the Ten-Year Perspective
Development Plan 2001-11 and Medium Term Development Framework 2005-10.1
Pakistan’s Expanded Program on Immunization (EPI) has aimed to significantly improve child and
maternal health through immunization against tuberculosis (TB), measles, tetanus, diphtheria,
pertussis, hepatitis B, and poliomyelitis. The report released named “Pakistan’s Polio programme is
a disaster”. We analyse that this report highlighted the most crucial gaps in the achieving the EPI and
routine immunization targets in Pakistan.2As per the report, 80% of the polio cases emerged
worldwide in 2014 are from Pakistan.
1
IRMNCH PC1
2
Pakistan's polio program a 'disaster': Report retrieved on 04 December,2014

5. 5 | P a g e
Lady Health Workers and the Primary Health Care National Program; 3LHWs can provide preventive,
curative and rehabilitative services to the community. Lady health workers work also aimed at to
educate and provide Family Planning methods and MCH services. We EVA-BHN project analysed that
LHWs program plays pivotal role in reaching the vulnerable and marginalised communities as they
have to go door-to-door for the provision of community outreach activities. Lady health workers have
their catchment population within the union council level. LHWs can work under the specified and
allocated catchment population named at “LHWs covered areas” while at the same time they cannot
reach at the uncovered population. Now it is serious concerns and a question mark for us regarding
the uncovered population for the provision and access to services being provided by LHWs. Chief
Minister’s Health Attainment Program towards Reproductive Maternal (CHARM) is also one of the
health initiatives by the government of Punjab.
Family Welfare Program through department of family planning;4The Population Welfare
Programme is a social development activity aimed at reducing population growth rate which is a
necessity for developing countries like Pakistan(The Population Welfare Program Pakistan).
Women Health Project was funded by DFID department of health of government of Punjab in 2005;
safe motherhood and newborns babies care. The project was good initiative contribution towards
MDGs 4 and 5.It is noteworthy that DFID the UKAID is largely potential donor regarding RMNCH and
Nutrition in Punjab
Most Recent Developments in this Context in Punjab:
The Integrated Reproductive Maternal Newborns and Child health program which is funded by
Government of Punjab, UNICEF and WFP. Nutrition activities are undertaken by LHWs, CMWs It is
somehow addressing nutrition sector needs and undertaking activities. Nutrition Officers are
appointed in all 36 districts of Punjab but they are not utilizing for undertaking nutrition activities at
the facility level.
3
Lady Health Worker Program-Punjab;data retrieved on 04 December,2014
4
The Population Welfare Programme; retrieved on 04 December,2014

6. 6 | P a g e
It is noteworthy that Punjab Health sector strategy is key to health sector reforms in department of
health government of Punjab. The PHSS 2012-2020 was developed under the guideness and direct
supervision of Punjab Health Sector Reforms Program. Currently the PHSRP is shifted or converted
into Policy Strategic and Planning Unit (PSPU).
5The Punjab strategy emphasizes RMNCH and Nutrition by proposing a number of initiatives
including:
I. Integrate MNCH, family planning and nutrition activities in the Essential Primary Health
Services Package Ensure availability of 24/7 EmONC services, strengthen linkages between
outreach workers (LHWs, CMWs etc.) and primary health units
II. Upgrade BHUs, RHCs, THQs, and DHQs to provide 24/7 Comprehensive EmONC services
III. Integrate nutritional services in pregnancy and child care in both health facilities and outreach
workers
This is in the light of consultations with different stakeholders; we now analyse the followings
important developments in Punjab health sector regarding achieving the MDGs 4 and 5.Followings
are the key health sector developments in Punjab Health sector so far;
Integrated Reproductive Maternal Newborns and Child Health Program (IRMNCH) is started by
government of Punjab; in 2013.The project aimed at addressing the reproductive maternal and
newborns child health and nutrition in the province of Punjab for contributing towards meeting the
MDGs targets towards reducing maternal and infant and child death rates.
Health department of Punjab has notified the Essential Package of Health Services for Primary Health
Care in Punjab. This is under the Essential Package of Health Services (EPHS); government of Punjab
has committed and commissioned for the provision of EPHS to the citizens of Punjab. EPHS contains
all the basic and necessary provisions of services. This is important policy strategic action towards
achieving MDGs targets 4 and 5. Minimum Health Services Delivery Standards (MHSD) are also
5
Punjab Health Sector Strategy 2012-2020

7. 7 | P a g e
important initiative by the government of Punjab. It is liability at each health facility BHU/RHCs to
implement the MHSD for the health wellbeing of citizen of Punjab.
Establishment of Punjab Health Care Commission has been established with respect to ensuring
health regularities within the Punjab health care facilities.6PHCC aimed at improving the quality,
safety and efficiency of healthcare service delivery for all Public and Private Healthcare
Establishments (HCEs) including Allopath, Homeopaths and Tibbs in the province of Punjab. Punjab
Health Care commission take actions on grievances redress mechanisms in Punjab.
Establishment of Policy Strategic and Planning Unit (PSPU) at Lahore. The purpose of PSPU is to give
strategic directions to department of health for policy formulations. Secondly, to harmonize
coordination among development partners and government for joint venture of improving health
services.
Donors funding for health and nutrition;7among the multilateral donors, the World Bank and the
Asian Development Bank are the two largest donors to the health sector, with other smaller
multilateral donors providing additional funding. In terms of bilateral donors, DFID has been and
continues to be the most important donor by a large margin. DFID has supported to the Government
of Punjab through dozen of projects on RMNCH.
Provincial Health and Nutrition Program is the biggest one which is supported by DFID in two
provinces Punjab and KPK of Pakistan. It is relevant with PHNP that DFID has supported to TR+ and
EVA-BHN for facilitating to government of Punjab in perspectives of supply side technical support and
demand creation through the grass rout level. PHNP aimed at contributing towards achievement of
MDGs targets 4 and 5 particularly reducing maternal and infant death rates, improving malnutrition,
reducing and unwanted pregnancies.
Nutrition Policies and Strategies in Punjab
6
Punjab Health Care Commission; retrieved at 04 December,2014
7
A JPMA Research Study Report: Public Sector health financing in Pakistan: A retrospective study

8. 8 | P a g e
Background:
Punjab has faced high floods in Aug, 2010.The poor and marginalised communities faced destructions
of their assets and lives. Since that time; Sector based clusters emerged for addressing the unmet
needs of flood affectees. Nutrition cluster is also one of the important platform which highlighted
malnutrition and under nutrition issues from district to provincial and then national to global level.
According to UNDP report on progress to Millennium Development Goals; Punjab is off track in
achieving the targets MDGs 4 and 5.In MDG 4, targets related to mortality rates, immunization
against measles and lady health workers’ coverage of target population are likely not to be achieved.
In MDG 5, with the current progress, targets for the maternal mortality ratio, proportion of births
attended by skilled birth attendants, contraceptive prevalence rate and total fertility rate are unlikely
to be met. International donor community and United Nations is also focusing on “Post 2015 MDGs
agenda “if in case Pakistan is unable to meeting the MDGs target 4 and 5 than what will be the
strategic guidelines and directions and dimensions for meeting MDGs targets. These are all questions
In 2002, the Ministry of Health established a Nutrition Wing in 2002, but the wing had no direct
presence at the districts level for implementing and monitoring health-related nutrition activities. A
National Nutrition Strategic Plan was approved that same year but was never implemented. The
Ministry of Health also initiated a development programme proposal called the “Enhanced Nutrition
Programme” but its approval by the Planning Commission was stalled by constitutional changes in
2009. Nutrition has thus received little attention from policymakers and it has historically been dealt
with through a “project-based approach under Planning Commissions documents”.
It is important to understand that nutrition is not a standalone subject and needs to be addressed
through multi-sectoral approach. Inter-sectoral coordination committee was formed under the
umbrella of planning & development department that assisted the Punjab government in developing
multi-sectoral policy notes for addressing malnutrition.18th amendment gave provinces a big
opportunity and provinces started work on their nutrition guiding notes and strategies.
Most Recent Developments in this Context in Punjab:

9. 9 | P a g e
The department of health of the government of Punjab started to pay attention to nutrition. This is
due to pressure from international community/donors agencies specifically World Bank and DFID and
ECHO/EU and as mentioned earlier this is due to the impacts of disasters on poor populations.
Resultantly; Coordination is slowly improving and Donors funding are now available to develop
various, coordinated inter-sectoral interventions.
In Punjab, “Inter-Sectoral Nutrition Committees and Technical Working Groups” have been set up,
with support and lobbying from UNICEF and the World Bank and UN agencies .However, the
ownership and capacity of Punjab government to tackle malnutrition yet remain to be
comprehended.
In September 2011, the federal government presented the results of the National Nutrition Survey
(NNS), the largest nutrition survey in the history of the country. This NNS survey reported alarming
issues of malnutrition, under nutrition, wasting, stunting and acute malnutrition in Punjab. After the
2010-2011 monsoon floods, a “Nutrition Working Group” was established to coordinate nutrition-
related programmes and establish the way for inter-sectoral action by the government in order to
eliminate malnutrition.
The Nutrition Working Group has proposed a “Pakistan Inter-sectoral Nutrition Strategy (PINS)”,
which frames malnutrition as a multi-dimensional issue that encompasses many faces, such as the
consumption of food, childcare practices, household food insecurity, income, water and sanitation,
high fertility rate, low levels of literacy and natural disasters and emergencies.
It is come to know during the consultation meetings with key health experts and practitioners within
the department of health that PINS after passing the review stages from technical working group and
sectoral technical working groups now it is currently in the preliminary stages of approvals of steering
committee in Planning and development department Punjab. Currently only Technical working group
for nutrition is headed by secretary health Punjab for reviewing the overall progress in nutrition
sector Punjab.
Planning & Development Department Punjab, while realizing its role in tackling the grave issue of
malnutrition in Punjab, constituted a Steering Committee (SC) with representation of relevant sectors

10. 10 | P a g e
including government departments and international development partners. This committee was
given the mandate to develop Nutrition Policy Guiding Notes (NPGN), Punjab. The Steering
Committee constituted a Technical Working Group (TWG) in August 2012 and the TWG subsequently
notified six sectoral technical groups namely Agriculture Sector, Food Sector, Health Sector,
Education Sector, Social Protection Sector and WASH Sector.8
The sectoral groups were comprised of representatives of relevant Government departments,
development partners, academia and civil society. These sectoral groups, through meetings and
consultative process, developed their respective nutrition policy guidance notes. These notes were
refined through a series of meetings at the provincial and national level and were then approved by
Steering Committee in its meeting held on 07 Feb, 2014.
It is on 6th January, 2015 that Planning and Development Department Punjab has approved Multi-
sectoral Nutrition Strategy for implementation at all levels.
In April 2013, Pakistan joined the Scaling up Nutrition (SUN) a global initiative. SUN is an opportunity
for the national and provincial governments to draw on the support of international donors, UN
agencies, and civil society to make progress against malnutrition. Developments partners meetings
helds in Islamabad where all NGOs, INGOs, UN Agencies, Planning and Development department,
Donor agencies participate for discussing Nutrition issues in Pakistan with the technical and financial
support of Work Bank.
A Critical Gaps Analysis of Policies in Punjab Contexts:
There is no health and nutrition policy in Punjab although drafting of various health and nutrition
strategies have been developed. Ad-hoc plans are available which are time to time executed based
on different circumstances and emergency. National plans and program are there. Most of these are
donors driven and mainly dependent on external resources both financial and technical.
8
Nutrition Policy Guidance Notes;29th
December,2012

11. 11 | P a g e
18th amendments understanding is not understood in the light of constitutions shift. Although; 18th
constitutional amendment does not provide recipe for provincial autonomy for health sector. Largely,
the devolved functions of some of the national programs are partially shifted to the provinces and to
division and districts. No-one accepted and understood in the true letter and spirit to this
constitutional shift to provinces, divisions and districts. Within the country policies and frameworks
and provincial strategies are formulated for addressing the citizen’s needs but in the true sense.
All the prevailing laws on health are mostly national in nature but now the provinces has started
developing their own laws rules and regulations. Without realising to the national laws and policies
the provincial laws might contravene to the federal laws.
Multi-sector nutrition guiding notes and then Multi-sector nutrition strategy is in place meeting the
processes of necessary approvals from planning and development department Punjab; inter-sectoral
plans are in place but their implementation is like a fantasy. It is noteworthy, that all the outreach
interventions including in the Nutrition interventions are undertaken through LHWs and CMWs. Now
there is question mark of “capacity building” of LHWs and CMWs for undertaking the quality of
outreach interventions of nutrition is interrogative in sense.
As we have already mentioned that all the programs and initiatives in the department of health
Punjab are separated into segmentations which is losting the integration of interventions for meeting
the citizens driven needs and addressing the grievances launched by the citizens is again
interrogatives.
It is for the implementation of policy to be needed to technical man-power/human resources,
realistic budgeting and funds transfer flow from provinces to districts is largely needs to be advocated
and focused for the true implementation of programs in department of health government of Punjab.
Laws, rules and regulations and policies are necessary to develop in the citizens’ needs of health
perspectives. There is too much compartmentization within the department of health. Policy is the
dimension which provide systematic approach to address the issues and challenges in the cadre
of needs in the best interest of citizens.

12. 12 | P a g e
Policies are normally approved by nontechnical bureaucrats. Unfortunately the political systems is
neither well equipped and nor knowledgeable on policies development process broadly in Pakistan
and specifically in Punjab Provinces which is the reason of poor, non-democratic and gender biased
programs have been formulated for addressing the citizens’ needs.