Scaling up CMAM in the wake of 2010 floods in Pakistan

By Dr. M. Suleman Qazi

Dr. Qazi was engaged by the ENN to capture the lessons from Pakistan on CMAM scale up. Dr Qazi is a medical graduate with a post graduate degree in Health Policy and Management. He has worked as a nutrition consultant for the past few years with the government and non-governmental organisations. His expertise and areas of interest range from policy to practice with a special focus on research, training and policy advocacy.

The author is grateful to Dr. Baseer Khan Achakzai, National Nutrition Focal Person, National Institute of Health, Islamabad, Pakistan, (Presently Director, National Disaster Management Authority, Ministry of Climate Change, Government of Pakistan) for his overall guidance and support in identifying and accessing the information rich sources and organising the field visit for the interviews. Thanks are due to the respondents for generously giving valuable time for in-depth interviews despite their busy schedules in the holy month of Ramadan (a list of interviewees is included at the end of this article). My special thanks to Ms. Emily Mates and other colleagues at ENN, for their follow up and enthusiasm in developing this case study.

 

Acronyms:
BCC	Behaviour Change Communication
BHU	Basic Health Unit
CBO	Community Based Organisation
CMAM	Community-based Management of Acute Malnutrition
CMW	Community Midwife
DEWS	Disease Early Warning System
DoH	Department of Health
DHIS	District Health Information System
EDO	Executive District Officer
ENN	Emergency Nutrition Network
EPI	Expanded Program on Immunization
FATA	Federally Administered Tribal Areas
FLCF	First Level Care Facility
FP	Family Planning
GAM	Global Acute Malnutrition
GDP	Gross Domestic Product
GOP	Government of Pakistan
HMIS	Health Management Information System
IASC	Inter Agency Standing Committee
IDP	Internally Displaced Person
IEC	Information Education Communication
IMR	Infant Mortality Rate
INGO	International Non Governmental Organization
IP	Implementing Partner
IYCF	Infant and Young Child Feeding
KP	Khyber Pakhtunkhwa
LHW	Lady Health Worker
MDGs	Millennium Development Goals
MICS	Multiple Indicator Cluster Survey
MoH	Ministry of Health
NDMA	National Disaster Management Authority
NGO	Non-Government Organisation
NNS	National Nutrition Survey
NWFP	North Western Frontier Province
OTP	Outpatient Therapeutic Programme
PC1	Planning Commission Performa 1
PDHS	Pakistan Demographic and Health Survey
PDMA	Provincial Disaster Management Authority
PHC	Primary Health Care
PPHI	People’s Primary Healthcare Initiative
PPP	Public Private Partnerships
RHC	Rural Health Centre
RUTF	Ready to Use Therapeutic Food
SAM	Severe Acute Malnutrition
SC	Stabilization Centre
TFC	Therapeutic Feeding Centre
UN	United Nations
UNICEF	United Nations International Children’s Emergency Fund
WB	World Bank
WFP	World Food Programme
WHO	World Health Organisation

 

The Islamic Republic of Pakistan is the sixth most populous country in the world (>180 million in 2011), the second largest Muslim population after Indonesia and has wide diversity in terms of culture, ethnicity, language, geography and climate. Pakistan is a federal parliamentary republic consisting of four provinces and four federal territories.

Malnutrition in Pakistan

Pakistan has some of the worst health and nutrition indicators in the Asia region. The prevalence of child malnutrition is higher than in Sub-Saharan Africa and the rate of decline of the prevalence rate is significantly slower than in the rest of South Asia. The National Nutrition Survey (NNS) 2010- 2011 revealed that indicators of stunting and wasting had worsened during the last 10 years, where 43.6% of children were stunted compared to 41.6% in NNS 2001 (see Table 1). Similar trends were observed for wasting, 15.1% of children in Pakistan were suffering from wasting in NNS 2011 as compared to 14.3% in NNS 2001. Underweight rates have at least remained constant during the last decade (31.5%).

AJK: Azad Jammu and Kashmir

Inadequate infant feeding practices are acknowledged to be a major contributing factor to child malnutrition in Pakistan. In 2001, the Pakistan Demographic and Health Survey (PDHS) found exclusive breastfeeding to be 25%. Some years later, the PDHS 2006/7 indicated an improvement of only 12%, with exclusive breastfeeding estimated at 37%. Complementary feeding¹ improved even less, from 32% (1991) to 36.3% (2006/7)².

Factors that have an impact on the nutritional status of the overall population include inadequate food consumption, morbidity, poor health infrastructure and socio-economic factors. Since Pakistan's independence, the pro- vision of health infrastructures has improved but remains inadequate, particularly in rural areas. The burden of infectious diseases such as respiratory and intestinal infections remains high. These are estimated to be responsible for up to 50% of deaths of children under five. Malnutrition is a major aggravating factor, especially in the most populated areas.³

Over the past few years, food prices have increased by almost 30%, while salary scales and labour rates have not increased at the same rate. Pakistan is listed among 40 countries that are facing food crises⁴. Based on current trends, Pakistan is not on track to achieve health and nutrition related Millennium Development Goals (MDGs).

High coverage has been achieved for some nutrition interventions (e.g. vitamin A supplementation and salt iodisation). Coverage of essential services that improve the nutritional status of women and children within the health sector can, however, suffer from poor performance. The Government of Pakistan (GoP) is aware of the problems in implementing a few successful interventions aimed at addressing the consistently high rates of under nutrition in Pakistan. The lack of progress in reducing the high prevalence of malnutrition is partly a reflection of:

• A lack of substantial investment in nutrition activities
• Absence of clarity on the roles of the different sections of government
• The need for political commitment, including a strong and sustained leadership to address malnutrition systematically
• A lack of a critical mass of people to work full time on nutrition activities, and
• The absence of routine information systems to capture nutrition status, behaviours, and service coverage.⁵

Institutional arrangements for nutrition

Prior to 2002, nutrition was not institutionalised within the GoP. This resulted in weak nutrition structures within all levels of government (federal, province and district). Recognising this, a number of structures were put in place by the Ministry of Health (MoH):

• In 2002, a Nutrition Wing was established, responsible for implementing and monitoring health-related nutrition activities at federal level. However, the Nutrition Wing had no direct role in the provinces or districts for the implementation of nutrition activities.
• In 2002-03, four Nutrition Cells were established with provincial support. The Nutrition Wing extended technical support to these cells, however they still have very limited capacity and government support at provincial level. At present, no provincial nutrition policy exists, compromising the role of Nutrition Cells.
• In 2003-04, a high level inter-ministerial body, the Federal Nutrition Syndicate, was established. It comprised representatives from line ministries, non-governmental organisations (NGOs) and international agencies and was chaired by the Deputy Chairman, Planning Commission. It had responsibility for overall planning and policy guidance, and inter-agency and interprovincial collaboration. However the Syndicate failed to operationalise.

At Federal MoH, the Nutrition Wing has had both the coordination role between different development partners, and the implementation role for various nutrition activities within the four provinces. The Nutrition Wing has proven successful in launching and coordinating nutrition- related activities in the provinces, through playing a pivotal role in ensuring resources for implementation from international partners. The successful completion of the National Nutrition Survey in 2011, which has taken almost a decade to achieve, is another major achievement for the Nutrition Wing.

On the 1st July 2011, the 18th Constitutional Amendment was passed which involved devolution of the MoH in Pakistan. This development has brought a number of possibilities and concerns. On the plus side, it may empower lower levels of government by giving them more autonomy and enhance responsiveness and efficiency through a closer feedback loop (i.e. action can be taken more quickly when problems have been identified). The devolution may also ensure greater equity within provinces. Concerns, mainly stemming from the lack of information about how it will work, include:

• Capacity issues: Many of the provincial, regional and district authorities do not have sufficient technical, human and financial resource to manage the services well.
• Emergency situations: Given the federal level had difficulty coordinating a huge response, there are questions regarding how the provinces would cope.
• Inter-provincial problems: For example, around managing outbreaks or epidemics. This is a concern especially considering the lack of routine health information collection. Coordination of responses and accountability issues are also challenges.
• Provincial funding mechanism: It is not yet established how the donors will manage to fund the provinces, e.g. through a federal system of distribution or a series of province/regional specific agreements.

At present (August 2011), the Nutrition Wing has survived elimination, unlike other vertical programmes, and has been moved to the National Institute of Health of The Cabinet Division.

Pakistan’s Public Healthcare System

The healthcare system in Pakistan is threetiered with primary, secondary and tertiary levels of care (see Figure 1).

The 2010 Pakistan floods

Pakistan has faced repeated natural and manmade emergencies. These emergencies have included cycles of droughts, earthquakes, major floods and armed conflict, leading to the largest internally displaced population (IDPs) in the country’s history⁶. These humanitarian crises have resulted in major damage to infrastructure and livelihoods, leading to increased food insecurity and malnutrition among the affected populations.

The enormous floods seen in Pakistan during 2010 were rated by the United Nations as the greatest humanitarian crisis in recent history⁷. The floods affected more than 50% of the districts in the country (78/141 districts) and at least 20 million people (one-tenth of Pakistan’s population). Close to 2,000 people died, with villages and livelihoods devastated from the Himalayas to the Arabian Sea. The World Health Organisation (WHO) reported that ten million people were forced to drink unsafe water. The Pakistani economy was extensively disrupted by the damage to infrastructure and crops. Damage to structures was estimated to exceed 4 billion USD, with wheat crop losses estimated at more than 500 million USD. Total economic impact may have been as much as 43 billion USD.⁸

In terms of the impact of the flood on health infrastructure, Khyber Pakhtunkhwa (KPK) and Sindh provinces fared the worst - approximately 11% of total health facilities in the affected districts were damaged or destroyed. The effects of the floods provided considerable challenges for the health system in service delivery, notably:

• Interruption of health care provision due to damaged facilities and displacement of the health workforce.
• An increased burden on secondary health facilities, often used as a first contact facility due to extensive damage and disruption of primary health care facilities.
• An increased burden of disease and mortality, in particular due to communicable diseases.
• An increased burden of acute malnutrition: Global Acute Malnutrition (GAM) was found to be 15% in Punjab and 23.1% in Northern Sindh, compared to 2.9 and 6.1% in the same regions prior to the floods (WHO Growth Standard 2006).⁹

The GoP launched a major response to the flood with support from the international community. UNICEF as the Nutrition Cluster Lead Agency (CLA) staffed the coordination positions (including Information Managers) at national and sub-national levels to assist the MoH with coordination. The emergency phase of the response to the floods was concluded by February 2010. However 8 million people, including 1.4 million children under 5 years and another 1.4 million women still needed urgent access to health care. Following consultation with provincial health authorities, regional offices and health sector implementing partners, the WHO supported the health sector to develop a comprehensive early recovery plan for health that focused on 29 priority districts across Pakistan. Nutrition-related priorities for the ‘early recovery phase’ included provision of nutritional support and treatment for acutely malnourished under-five children and pregnant and lactating women.

CMAM roll-out during the 2010 floods

The scale of the problem

It was well understood by all that malnutrition was a serious problem in Pakistan before the floods. The health information system in Pakistan collects no routine data at all, thus baseline nutrition data were missing. The scale of the flooding and the resulting loss of homes and livelihoods created an urgent need for upto- date nutrition information to assess the extent of malnutrition amongst the affected communities.

A Flood Affected Nutrition Survey (FANS) was duly undertaken (with the support of UNICEF and other partners) during October and November 2010. Data were collected in 19 worst affected districts. The FANS survey estimated the GAM prevalence to be 23.1% in northern Sindh and 21.2% in southern Sindh. These results were considerably higher than the WHO emergency threshold. Furthermore, records from Northern Sindh revealed a prevalence of SAM of 6.1%. The Sindh government estimated that about 90,000 children aged 6 to 59 months were malnourished.¹⁰ The nutrition situation was also identified as ‘serious’ in Punjab (see Table 2) and ‘poor’ in KPK and Balochistan (data not shown).

Table 2: Acute malnutrition rates according to MUAC in Punjab, Northern and Southern Sindh (FANS preliminary results)
Survey	Punjab survey 2	Punjab survey 2	Northern Sindh	Southern Sindh
Survey period	1-7 November, 2010	8-14 November, 2010	29th October to 3rd November, 2010	29th October to 4th November, 2010
Indicator	% (n) (C.I.)	% (n) (C.I.)	% (n) (C.I.)	% (n)
MUAC <125mm and/or oedema	13.9% (82) (9.6-18.7)	7.3% (37) (4.6-10.3)	18.8% (74) (14.4 -24.2)	12.6% (49)
MUAC <115mm and/or oedema	4.9% (29) (3.0- 7.5)	2.6% (13) (1.4- 4.3)	7.6% (30) (5.0 -11.5)	2.8% (11)
MUAC =115 mm and <125 mm	9.0% (53) (6.1-12.3)	4.7% (24) (2.7- 7.4)	11.2% (44) (8.6 -14.5)	9.7% (38)

 

Table 3: Numbers of SAM treatment sites and children screened/admitted (March 2011)
Province	No. of sites (OTP/SC)	No. of children screened	No. of children admitted in OTP/SC
Sindh	163	374,646	22,741
Punjab	191	386,575	19,460
KPK	212	468,087	6,759
Balochistan	59	62,929	4,828
Total	625	1,292,237	53,788

 

Table 4: Numbers of MAM treatment sites and beneficiaries screened/admitted (March 2011)
Province	No. of SFP sites	No. of children screened	No. of PLW screened	No. of PLW admitted
Sindh	152	50,764	127,164	33,872
Punjab	170	50,829	119,813	29,510
KPK	202	28,903	218,913	20,745
Balochistan	53	13,292	26,648	11,004
Total	577	143,788	492,538	95,131

 

The CMAM response

Since 2003, small community-based nutrition programmes had been implemented in Balochistan for Afghan migrants and host communities. In 2007, UNICEF commenced comprehensive nutrition interventions including the promotion of infant and young child feeding practices, CMAM programmes and micronutrient supplementation in the flood prone areas of Balochistan and Sindh. In 2008/09, these interventions were expanded to earthquake-affected districts in Balochistan, flood-affected districts in Punjab, conflictaffected areas in the NWFP (as it was known then), and food insecure areas in other provinces. These programmes were effective in terms of high coverage, high cure rate, low death and low defaulter rates.¹¹ This experience is described below.

As a response to the 2010 floods, CMAM was rapidly expanded to the worst affected districts. More than 30 partnerships were established. Memoranda of Understanding were developed to clarify roles and responsibilities. Capacity development was undertaken and a network of CMAM/IYCN (Infant and Young Child Nutrition) services were established and linked to health services. A total of 1.3 million children under 5 years had been screened by March 2011. Tables 3 and 4 outline the numbers treated overall (from August 2010 to March 2011).

The feeding centres are serving a total of 55,921 out of 89,832 severely malnourished children, 155,000 out of 301,000 moderately malnourished children and 95,131 out of 180,000 pregnant and lactating women.¹²

Differing modalities of CMAM implementation

CMAM in Pakistan has mostly been piloted during crises and emergencies. With a weak health care system, poor access and low coverage of services, there has been a dependence on donor support for human resource, training and supplies. There are a number of stakeholders with sometimes overlapping and different mandates. As a result of poor coordination, the referral and treatment networks have remained fragmented. Pakistan received technical support for the formulation of National CMAM Guidelines from UNICEF, Valid International and Save the Children. However these guidelines have yet to be properly disseminated.

Three different modalities of CMAM programs have been adopted with differences in experience of implementation.¹³ These are summarised in Table 5.

Table 5: Experience from different modalities of CMAM implementation
Implementation Modality	Experience
Implementation by the local and national level NGOs	High coverage and high performance indicators (cure rate, death rate, and default rate).
Joint implementation by NGOs in collaboration with the district government	Relatively low coverage and medium performance indicators.
Implemented only by the government	Frequent interruptions in implementation in both NGO and Government supported projects encountered due to non-availability of supplies and cash (to run the programme) on time.

 

A mapping of district implementation of CMAM activities found that the donor-dependent programmes aimed at addressing SAM are diverse in terms of presence/absence of ‘management’, ‘community base’ and type of malnutrition¹⁴. Thus under the title of CMAM, the support offered ranged from only provision of the product, e.g. ready to use supplementary food (RUSF) to community specific interventions without the support of health institutions.¹⁵ The experience also indicated a project-based approach: no funding = no activities.

Common issues during implementation

The role of the People’s Primary Health Care Initiative (PPHI) in ensuring support for CMAM

PPHI is the largest primary health care contracting arrangement in the world. It has taken over the majority of Basic health units from the health department all over Pakistan. Up until 2005, Pakistan was facing major challenges in delivering primary health care in rural areas. The government faced problems appointing and retaining medical officers, managing supplies of drugs and equipment, and supervising the performance and functioning of these 5,000 mainly rural facilities. Following a successful pilot in Punjab, the federal government launched the PPHI contracting model in mid-2005.

Under the PPHI model, district governments can contract out primary health care facilities to provincial entities known as Rural Support Programmes (RSP). RSPs are private development organisations specialising in social work. Most of their funding comes from the government. Under contracts between the RSPs and the district governments, the PPHI receives the same funds that the district government would have transferred to the district department of health. By using the budget flexibly and by strengthening managerial practices and supervision, PPHI is expected to fill rural staff vacancies by providing additional staff incentives and allowances, particularly to medical officers and Lady Health Visitors. The federal government gives additional financial support to cover management and the cost of rehabilitating health facilities.¹⁶

Evaluations have shown that PPHI proved its worth in terms of ensuring availability of doctor, medicines and equipments at the health facilities. However due to initial contracting out, their role in preventive medicine was not adequately defined.

The district managers of PPHI are usually managers from civil service backgrounds. They have considerable liberty in terms of taking decisions on the involvement or not of PPHI in any health initiative beyond their mandate. In the case of CMAM, some districts received extensive support while others did not. A key lesson for implementing at scale is that PPHI is an important entity that must be brought on board to ensure the success of this type of initiative.

The variable involvement of Lady Health Workers with community outreach activities

The National Programme for Family Planning and Primary Health Care, also known as the Lady Health Workers Programme (LHWP), was launched in 1994 by the Government of Pakistan. The objective of the LHWP was to reduce poverty through providing essential primary health care services to communities and improving national health indicators. The Programme objectives contribute to the overall health sector goals of improvement in maternal, newborn and child health, provision of family planning services and integration of other vertical health promotion programmes. This national initiative constitutes the main driving force for the extension of outreach health services to the rural population and urban slum communities. It involves the deployment of over 100,000 Lady Health Workers (LHWs) and covers more than 65% of the target population. The Government of Pakistan funds the National Programme for Family Planning and Primary Health Care. International partners have been offering support in selected domains in the form of technical assistance, training and emergency relief.¹⁷

While nutrition is one of the major services the LHW is supposed to provide, CMAM has not been institutionalised as yet. The programme was being controlled federally before the 18th Amendment, however, it is now in the control of provincial health departments.

The experience of involving LHWs in CMAM (community component and screening) was mixed. Some provinces were quite open to adopt this modified role of LHWs whilst others were reluctant and awaited a federal level concurrence.

Supply of Ready to Use Therapeutic Food (RUTF) and RUSF: local production, a common problem

In general, all the provinces were concerned about the supply of the RUTF and/or RUSF. There was a general consensus that the high cost of importing such supplements (PKR 1100- 1400 per kilogram) might be a significant constraint to the implementation of CMAM, particularly considering the burden of acute malnutrition. Although there is a general agreement that these should be produced locally, there is much debate but little consensus on the way this could be done.

The consequent lack of availability of locally produced RUTF is clearly a concern for many stakeholders in Pakistan. HELP, an NGO, devised and piloted a local brand of High Density Diet.¹⁸ The World Bank supported project is compiling evidence about this product. There are local food manufacturers that have the capacity and interest in preparing RUTF in particular. However, there seems to be little market for their product until international agencies start to purchase from them instead of importing.

There are also sensitivities about local production of RUTF. King Edward Medical University has, for instance, shown reservations on the caloric value and nutritional quality (in terms of absence of vitamins and minerals) of locally produced fortified blended food (FBF). Essentially, local production of RUTF is of vital concern for programme sustainability.

Experiences of rolling-out CMAM: findings

To capture the variety of experiences of implementing CMAM in Pakistan, a series of interviews were conducted with stakeholders from four provinces (Balochistan, Khyber Pakhtunkhwa, Sindh and Punjab). The unique experiences and managerial outlook of each province are presented here.

Balochistan: Banking upon excellence in coordination

Balochistan is the largest province geographically but has the lowest population density. It is the least developed province and offers a great challenge to the population in terms of access to health and nutrition interventions.

Adding to the difficulty of geographical access is the dearth of trained and skilled personnel. Balochistan has 30 districts, out of which only 6 or 7 have medical doctors, concentrated in urban or peri-urban areas. The auxiliary workers are by and large providing basic health amenities to the population, although they lack the skills to render quality health services.

In Balochistan, the management of acute malnutrition as a humanitarian response started during the 2006 floods with the support of UNICEF, Valid International and MSF. Eight food insecure districts set up CMAM programmes. The programmes focused at the community level where LHWs were available. The LHWs were given two days training on both practical and theoretical aspects of CMAM. The LHW’s Health House was used as a screening centre. In areas where no LHW was available, volunteers and civil society organizations were involved. TFCs were established by strengthening existing public sector health facilities.

The implementers encountered a host of challenges that included:

• Poor health services coverage and lack of skilled personnel
• Lack of strong mechanisms in place to monitor health interventions. Any progress was therefore difficult to measure
• Ownership by the government: time taken for government staff to understand the need to prioritise nutrition-related activities.
• Guidelines: There were conflicting guidelines on the management of acute malnutrition from UNICEF and WHO that confused practitioners.
• The Health Management Information System (HMIS) was providing data and generating unclear reports from districts to provincial level. Evidence-based decision making is still not the norm culturally.
• Frequent shortages of supplies (RUTF, therapeutic milk), especially following the end of the declared emergency. Many challenges with logistics. There is a need to include therapeutic products into essential drugs/ supplies list. Practitioners increasingly expressed the need for home made recipes for treating malnutrition, rather than expensive imported products.
• There is a lack of knowledge at communitylevel that malnutrition is a medical problem. There is a strong culture of seeking help from faith healers for wasted children. This societal perspective as a backdrop proved another hurdle for those who had access to CMAM.
• Sharing of food among the household: general food insecurity resulting in use of RUTF as a ration for all family members.

Response to the 2010 floods

In order to scale up services in Balochistan, a team (comprising of UN and other NGOs under the auspice of a Nutrition Cell) took proactive measures of engaging with the district authorities, including the department of health at district level, from the outset of the programme.

"The MoH quickly understood the problem of malnutrition in their districts, especially among pregnant and lactating women and children. We shared with them the evidence of effective strategies and what we will be offering and expecting.. and we asked them if they will own the project?" Provincial Nutrition Focal Person of Health Department

Bringing the district health officials on board and engaging them frequently from provincial level resulted in a strong ownership by the MoH at district level. Previously, when there was a lack of supplies, the therapeutic feeding centres (TFCs) were closed, giving the impression that the project had closed. However, despite similar supply issues, the Stabilisation Centres (SCs) remained open so that the community understood that the service would be provided once the supplies had arrived.

At health system level, the nutrition initiative also made a positive contribution:

"The best thing is that nutrition became mainstreamed in district health system of the affected districts. Trainings on CMAM of community level workers, LHWs and community based organisations (CBOs), health care providers in the facilities and involvement of district health managers, it all resulted in a continuum of raising awareness about nutrition, of which no-one knew about previously".
NGO Representative

Another positive aspect of the response was that all the partners had a similar understanding of roles and responsibilities.

"Everyone knew who will do what. What would each one get in terms of training, finances and logistics and who will ensure transportation of supplies till the end distribution point. Previously it had emerged as a big challenge to ensure supplies at the district level, with very limited means of distribution. This time the donor was well aware that the delivery of supplies till the last point will require additional assistance. Previously the supplies were just delivered at the district warehouse."
Provincial Level Respondent from Health Department

Although payments were usually paid to government staff to monitor the programme,

"The district coordinators of National Programme for FP and PHC and the EDO were given a fixed per diem for the visits conducted against the approved monitoring plan previously submitted".
Provincial Level Respondent from Health Department

During the initiation of training, each LHW was provided with a mat and utensils etc. for the strengthening of their health houses so that they could conduct activities and demonstrate good practices, such as hand washing. The LHWs also received a per diem for their work, which reportedly enhanced motivation.

Challenges for CMAM in Balochistan

The aforementioned shortage of doctors in rural areas was a major constraint in effective implementation of activities. Additionally LHWs are not present in many rural areas and there are some concerns about possible politicisation in this province, because of the importance of relationships with local tribal leaders.

A high turnover of government staff necessitated frequent re-training. It was common to find untrained staff providing CMAM services. Frequent stock-outs of RUTF and other products to treat acute malnutrition were experienced due to difficulties maintaining an uninterrupted supply chain.

The deteriorating security situation posed a great challenge both to programme implementation and monitoring. Some programmes had to close down due to escalating security concerns.

Another hurdle was engaging the medical officers of the PPHI. These medical doctors, despite invitations from the DoH, did not join the training on facility-based CMAM. It was assumed by the department of health that being a non-state provider, the PPHI thought itself to be a competitor. PPHI on the other hand had basically no mandate for CMAM. Hence the Basic Health Units (BHUs) could not be engaged.

By virtue of their presence and roots in the community, as well as their access to donor resources, the local NGOs have an advantage. They often understand local power structures well and are able to manage the potential political pressure from local power brokers. Their ability to network can generate increasing community demand for CMAM services.

"We found significant number of people coming from villages, demanding for the ‘chocolate’ (RUSF) for their kids."
NGO Representative

While NGO programmes are vital, particularly during disasters, sustainability issues prevail at all levels of programme implementation.

Lessons learned

The CMAM response in Balochistan has shown that a timely emergency response is crucial in order to contain rapidly deteriorating situations. Ownership within the health department, especially at district level, make a visible difference for programme success, although it must be recognised that payments for government staff to provide services might compromise longer-term programming, in terms of expectations (implementation of CMAM programmes resulted in additional per diem payments).

Involvement of the community in the screening process resulted in better acceptance and understanding of the programme. Local NGOs were particularly successful in breaking the substantial gender barriers in rural areas during the disaster, engaging with the affected people, especially pregnant and lactating women.

NGO staff tend to stay in positions longer, probably due to the better remuneration packages that NGOs are able to offer. Questions of sustainability are repeatedly raised.

The structural factors and underlying socioeconomic conditions will influence whether a child is likely to relapse into acute malnutrition, as remarked by a representative from a NGO that implemented SCs but not OTP.

"We witnessed that kids referred from poor socioeconomic households recovered from SAM in the SC after admission and treatment and went to their community but later returned with the same set of complaints again for which they were admitted earlier."
NGO Representative

The future for CMAM in Balochistan

At present, the provincial team is concerned that the post-18th amendment scenario will be characterised by an immediate vacuum in policy and technical assistance that formerly came from federal level.

Additionally, the approach to date has been highly donor dependent. While these strategies provide short-term solutions for nutrition problems, longer-term financial support from donors is required to sustain programmes and to develop a provincespecific nutrition policy.

Khyber Pakhtunkhwa (KPK): Scaling Up at Home, Rolling out Elsewhere

Khyber Pakhtunkhwa (KPK) was in a relatively better position to respond to the flood emergency, due to prior experience of large-scale emergencies and previous work on CMAM. At the time of the 2010 floods, the DoH was able to scale up existing operations rapidly. It is clear that the previous capacity built in nutrition response proved effective in facilitating scaleup. Despite KPK being the worst affected province, it performed better in terms of reduction in SAM and GAM prevalence in subsequent surveys, when compared with other provinces, such as Sindh.

Although there was a disaster contingency plan in place, it was not entirely successful due to extensive damage to nutrition-related commodities stored in a warehouse located on the bank of the river Kabul, which was washed away by the floods. The floods badly damaged the health facilities, most of which were submerged partly or wholly by the floodwater. It was a considerable challenge to establish SCs, the CMAM model was therefore modified. Mobile teams were introduced and provided services directly to villages.

"In Nuashehra Noushera and Charsadda the population settled along motorway, roadsides, schools and scattered pockets. Health facilities became non functional and inaccessible. Therefore six mobile teams were mobilised. Each vehicle visited a village once a week and followed up the same on next week... The mobile team included a group of people who offered services of WASH, PHC and nutrition jointly at the spot. Screening was done there and then. EPI, ANC, safe drinking water, de-worming etc. all services were made available at the door step... We requested to with hold wheat and soya bean combination (FBF) to WFP because that needs water for preparation, which was not readily available. Instead newly introduced supplementary plumpy was distributed. High energy biscuits were distributed uniformly to all families with children under five."
Manager of an INGO

2010 floods: the challenges

There were a number of challenges to the scaleup. One problem was that the UN agencies had limited communication between each other and at times appeared to be in competition. Pressure from the DoH highlighted and encouraged the need for better coordination. Coordination was made more difficult because of the complications experienced by partners having to sign separate MoUs with UNICEF, WHO and WFP (who were responsible for training and supplies of OTP, SC and SFP, respectively). Linkages between the three components of CMAM were often sub-optimal, as described below:

"What happened is that, say one agency started OTP but the other didn’t establish an SC as a referral facility or vice versa. It could result in the child being referred to SC and not receiving treatment, or a child treated at SC when returned to community could not be taken care of by SFP. The missing components of CMAM were compromising the quality of care."
Provincial level manager from Department of Health

The DoH also became frustrated with programming that they were not informed or aware of:

"The donors were awarding contracts for service delivery to the local NGOs without even informing the health authorities. We had no idea who is doing what and where and for how long the local NGO is intending to serve and what is its exit strategy".
Provincial level manager from Department of Health

CMAM successes in KPK

Particular successes were noted for the programme in KPK:
KPK had a functional nutrition cluster in place, which had already sensitised the provincial government for the urgent need for nutrition activities. Importantly, agencies and government staff working in KPK were able to share their skills and experience with other provinces, enabling a more rapid response in other provinces. Although, as mentioned above, there were still challenges to coordination arising from inter-agency mandates.

The response was better in KPK due to good collaboration from the start between the PPHI, DoH and NGOs. A tripartite agreement between the three partners paved the way for coordinated efforts, which were noticeably lacking in other provinces (especially in terms of coordination with the PPHI).

Much higher acceptability for the nutrition programme was seen when compared to EPI. This is likely due to the fact that the programme provided treatment, rather than being a preventative programme. The community can often be more willing to seek out treatment options for their sick children.

The SCs function well in KPK. They are well equipped, have trained staff and reports indicate that high quality services are being provided.

Winter supplies were planned and a 2- month stock of blanket food for the targeted population was pre-positioned. This helped to ensure uninterrupted supplies during the winter months in the inaccessible mountainous areas.

The future for CMAM in KPK

The 18th constitutional amendment continues to confuse health managers. There is a lack of clarity regarding new roles and the nutrition programme. At present, nutrition does not enjoy the status of a fully-fledged entity but is being run on an ad-hoc arrangement. Additionally, the future of the Nutrition Cell in the DoH KPK is not clear as the provincial authorities are occupied with internalising and responding to the challenges of the 18th amendment. There is little understanding about IYCF and CMAM as programmatic measures at provincial level. Meanwhile, the longer-term nutrition program (the World Bank supported PC1) to support the nutrition in KPK is awaiting approval from provincial authorities.

Sindh: A Late Wakeup Call

While Sindh province had some well-established vertical programmes such as EPI, there were no institutional nutrition programmes, and there seemed to be little commitment within the health department for nutrition when the floods arrived. The provincial nutrition focal person, a dedicated female doctor, had limited influence over the Executive District Officers (EDOs), partly because nutrition was not particularly embedded within the health department and partly because she was a woman.

The response to the 2010 floods

The massive floods came as a surprise to Sindh. Out of 16 districts, nine were severely hit. Some districts were not directly affected, but received large numbers of displaced people. There was no experience to draw upon for the response to a major emergency. There was very limited capacity for nutrition-related programming within the government and NGOs

A couple of CMAM pilot projects had been implemented in food insecure areas during 2009 that were not flood affected. While support was provided from these districts, and other expertise was brought in from KPK province (as they had previous experience in CMAM), it still was not sufficient for the scale of response required. No contingency plan was available in Sindh. Initial planning was undertaken on the basis of NNS 2001, the most recently available data at the time.

"All assumptions for planning were made on the basis of 2001 survey [NNS]. The resultant response was therefore wholly insufficient. While operations had to start immediately, problems with planning and the delays in supplies resulted in a worryingly slow response"
Provincial level programme manager of health department

Involvement of LHWs and PPHI

In Sindh province, the LHWs were not permitted to engage in the CMAM programme, until direction was given from the Federal level. The PPHI programme was able to offer some space at their facilities for CMAM activities (e.g. OTP and/or SFP). However, the staff at the BHUs were not involved in programme implementation, which was undertaken by NGO staff,

Pitfalls and challenges

At the start of CMAM, the government faced a range of challenges. For example, the concept of ‘nutrition’ was regularly confused with food aid. This misunderstanding stretched also to civil society.

"We received an overwhelming response from the civil society. A number of NGOs approached us and showed interest in working on nutrition. But the moment they came to know that the nutrition is not about food distribution, that interest vanished" Provincial Programme Manager

These misunderstandings were compounded when blanket food support arrived causing a change in focus of the programme. Community perception was shifted from CMAM as a treatment programme to that of food distribution. There was a great deal of demand for edible oil and biscuits, but not for medicine. The change to blanket distributions caused a great deal of problems in the community. Once the situation was stabilised, blanket feeding was replaced by targeted interventions. Despite conducting social mobilisation, there were serious misunderstandings regarding the targeting, with community members preferring the blanket distributions. Security was compromised at some of the distribution sites.

"When the community saw the vehicles of nutrition staff, they emerged as a mob, armed with canes. They were angry because the previous staff had distributed goods to much of the vulnerable population, including their kith and kin. They thought that the nutrition people were there for the same kinds of distributions."
INGO Representative

Mobile teams were introduced to cover remote rural areas, however they proved quite costly.

As described above, capacity challenges were the biggest hurdle to the scale-up of CMAM provision in Sindh province. Positions were not adequately filled and the high turnover of project staff compounded the problem. There were generally very limited handover processes amongst government staff when turnover occurred, affecting the continuity of programming.

The government faces a lack of capacity for many reasons, with the humanitarian community sometimes contributing to the shortage of skilled manpower:

"Donors can help to incapacitate the government. In order to make their projects successful, they identify, attract and lure the government personnel with attractive package. This further incapacitates the government system"
Provincial Manager from Health Department

Punjab: Slow and Steady, and with a Vision

The Government of the Punjab had already been proactively developing and implementing an agenda for better health, even before the advent of 18th amendment. To improve quality of health care delivery, setting up standards and institutional development the province rigorously followed the Punjab Healthcare Commission.

The 2010 flood response

The floods also came as a surprise to Punjab province. Neither government nor civil society expected such a massive disaster. Punjab’s previous experience in CMAM was limited to two small pilot projects in Rajan Pur and Kot Addu districts during the floods in 2008.

As the floods emerged, NGOs from KPK came forward with assistance, but their scale of operations was diluted due to the lack of skilled force to run operations of this size. Programme sustainability and ownership were the prime concerns from the outset of the Punjab Government’s response. The government was in the driving seat and showed authority in addressing the issues. It held the NGOs accountable for their work. It started with the setting of ground rules, for instance:

"Before initiating new hiring, government defined the minimum structural requirements for CMAM. It was decided to avoid unnecessary and overstaffing on one hand and to ensure that the government employees perform their duties" (and not shift the task to the contracted employees). "The most critical element in the effectiveness of the response was the strong commitment of the then able leadership in department of health."
Provincial Manager, Health Department

A distinguishing feature of the response in Punjab was that, unlike the other provinces, the government only involved public sector health facilities (BHUs and RHCs). No non-governmental facilities were involved in the response.

Strong government commitment and leadership at provincial level helped to ‘sell’ the idea of CMAM as an appropriate emergency response. An example of this was that the provincial health secretary personally took an interest in the performance monitoring reports and questioned district managers on any poor results.

In summary, although the (government’s) response could be viewed as slow in Punjab, the strong foundation of CMAM will likely have a long term impact on nutrition in emergencies in Punjab.

Coordination and use of the LHWs for CMAM

During the initial phase of the response, there was confusion about the roles and responsibilities of various partners. The cluster approach partly addressed the issue, but this was finally resolved after the signing of MoUs between UN agencies.

A Technical Advisory Group (TAG) was established by the government, which managed the various stakeholders and their different mandates and priorities well. The National Programme for Family Planning and Primary Health Care (FP and PHC) in Punjab was given a lead role in responding to flood disaster. This decision was based on the facts that:

• There was limited field level visibility/say of the provincial Nutrition Cell.
• The National Programme for FP and PHC had effective implementation and monitoring mechanisms in place.
• The ‘community-based management’ aspect of CMAM could only be addressed through community-based workers, i.e. LHWs.

This bold decision caused a stir in the federal programme implementation unit at national level because they were not comfortable with the involvement of LHWs in the nutritional aspects of disaster response. Nevertheless the provincial government’s strong determination ensured that their decisions were not undermined by the federal office.

The quality and content of training of LHWs has been questioned in the past. The province has addressed these concerns through a number of measures, for instance: Previously there were multiple, fragmented and weak trainings on nutrition. However a new training manual of LHWs comprising of vitamin A, IDD infant and young child feeding (IYCF) and CMAM was drafted, with the training given in a single 5-6 day package. This plan is awaiting approval by the TAG.

Prior to the 18th amendment, the federal programme office had been following a trickle down training approach, i.e. the federal office developed the training material and gave training to national level trainers, who trained provincial trainers, who trained district health facility staff, who trained the LHWs. This tiered approach often diluted the quality of training. The new approach of direct nutrition training for LHWs is expected to improve their skills and knowledge on nutrition.

In Punjab, CMAM experience illustrated that the LHW can quickly become overburdened managing large numbers of beneficiaries, taking anthropometric measurements, etc, which can compromise the quality of her work. To address this, the chowkidar (guards) were instructed to provide support for managing queues at the facility, and assistants were asked to help with measurements and records. This nutrition assistant (graduate level) preferably has a diploma in nutrition (compared to LHW who are minimum 8th grade standard).

The future for CMAM in Punjab

Implementation through NGOs is a costly business and poses serious challenges for sustainability. The government has planned to gradually acquire NGO-operated projects through the LHW programme, with no new signings of PCAs. However, the NGOs are encouraging a period of transition:

"The role of NGOs should not be undermined. Some of these organizations have demonstrated strength in social mobilisation and they have engaged the population through economic opportunities, such as microcredit, which can be employed to improve nutrition. Hence the role of NGOs should be considered as complementary and the transition should be gradually phased out."
INGO Representative

At present, the government is developing an ‘Integrated Module on Prevention and Treatment of Malnutrition’ that contains both IYCF and CMAM. It will include all three anthropometric measurements, i.e. weight-forage (WFA), height-for-age (HFA) and MUAC, to capture both chronic and acute malnutrition.

While the initial focus of the government and NGOs was purely on CMAM and not on underlying factors associated with SAM, the importance of IYCF in relation to CMAM has since been realised.

"Gradually the focus has shifted and now more and more is being enquired about the progress on IYCF. We now say that if a CMAM site is without a breast feeding corner and counselling services, it should not be claimed as a CMAM site."
INGO Representative

However, the effective integration of IYCF and CMAM still requires a great deal of advocacy, particularly to increase community awareness and knowledge.

Conclusions and the way forward

"The programme is doing self advocacy. Unlike Polio where the prevention doesn’t show any visible effect, the community has a chance to witness real positive change among malnourished children. They found that once bed ridden, a child gets up and starts playing and taking interest in life after induction in CMAM programme. This resulted in self advocacy and people from the uncovered areas started visiting the facilities".
Provincial Manager

The positive outcome of the 2010 floods is that a country-level response established nutrition as an important area of intervention in the eyes of government, partners and the community. Despite all the hurdles, setbacks and concerns of inefficiencies, the country now has substantial local experience in the public and private sectors for implementing CMAM. This wealth and variety of experience needs to be employed in the policy and planning decisions.

Under the post-18th amendment scenario, the sole responsibility of health and nutrition policy and planning now rests with the provinces. The weak capacity of some provinces might require technical coordination and support from the existing arrangement at the federal level. The provinces need to define a nutrition policy in order to mainstream nutrition in the public health system. This would require an evidence base, which can be solicited from the other provinces. However, a central, federal-level venue could provide inter-provincial coordination and promotion of evidence-based practices. At present, the Nutrition Wing of the Cabinet Division could undertake this function.

The institutionalisation would require longterm vision and investments. This includes the introduction and embedding of relevant topics in the curricula and training courses of community based, auxiliary and the clinical care providers. The cost effectiveness would logically be achieved through strengthening nutrition services within the existing PHC system instead of introducing a vertical programme.

The trickle down of provincial nutrition policy and strategies depends on the district level leadership, capacity and commitment. This might require training of district management, including sensitisation on nutrition issues, building capacity in needs assessment, and planning and management of nutrition in emergencies and non-emergency contexts. At the district level, nutrition should be made part of ‘a package’ because a child with multiple problems cannot be treated and managed by different programmes, coming from different donors, with time lags, through the same team at district level.

The policy and practice would be governed by evidence on the effectiveness and cost effectiveness of the modalities of community level implementation. For example, by defining the role of Public Private Partnerships (PPP), through contracting in/out, and determining how the services of public sector community level workers would be made available and how the non-government organisations would be enabled to serve in areas that are not covered and in emergency situations. It would be a primary responsibility of the health department to ensure transparency through strong monitoring of the nutrition initiatives.

The experience of CMAM scale up also dictates the need