Integration of essential nutrition interventions into primary healthcare in Pakistan to prevent and treat wasting: A story of change

This is a summary of a Field Exchange field article that was included in issue 63 – a special edition on child wasting in South Asia. The original article was authored by Dr Baseer Khan Achakzai, Eric Alain Ategbo, James Wachihi Kingori, Saba Shuja, Wisal M Khan and Yasir Ihtesham.

Dr Baseer Khan Achakzai is Nutrition Director for the Ministry of National Health, Service, Regulation and Coordination, Pakistan.

Eric Alain Ategbo is Chief of Nutrition for UNICEF Pakistan.

James Wachihi Kingori is a Regional Nutrition Officer for the World Food Programme (WFP) Asia and Pacific.

Saba Shuja is a Nutrition Officer for UNICEF Pakistan.

Wisal M Khan is a Nutrition Specialist for UNICEF Pakistan.

Yasir Ihtesham is acting Head of Nutrition for WFP Pakistan.

Background

Child undernutrition remains a public health problem in Pakistan – contributing to high rates of child mortality (currently 74 deaths per 1,000 live births) and impeding socioeconomic development. Rates of wasting (acute malnutrition) and stunting (chronic malnutrition) in children under five years are high (17.7% and 40.2% respectively). While a slow downward trend is observed in the prevalence of stunting, wasting prevalence has shown a steady upward trend, increasing from 12.5% in 1990 to the current 17.7%. The prevalence of severe wasting, or severe acute malnutrition (SAM), also increased from 5.8% in 2011 to 8.0% in 2018.

Child undernutrition in Pakistan has many complex causes. At the individual level, maternal undernutrition is a cause of high rates of low birth weight (LBW) (around 20%). Uptake of iron and folic acid (IFA) supplementation during pregnancy in Pakistan is low (32.9%) and early marriage and low maternal education are common. Infant and young child feeding (IYCF) practices in Pakistan are sub-optimal with only half of infants under six months being exclusively breastfed and 3.5% of infants over six months receiving complementary foods that meet the requirements of a minimum acceptable diet.

To increase the coverage of child wasting treatment, the Government of Pakistan (GoP) began implementing community-based management of acute malnutrition (CMAM)¹ from 2005. This was initially implemented as a stand-alone emergency nutrition intervention and later evolved into a government-owned intervention that is being integrated into primary healthcare for countrywide rollout.

Evolution of the approach to wasting treatment in Pakistan

CMAM as a donor-funded, stand-alone emergency response

Over the last 15 years, Pakistan has endured several natural and manmade disasters that have had devastating impacts on food and health systems. To tackle the resulting high levels of wasting, the first CMAM programme was implemented in Pakistan in 2005. The primary aim was a rapid increase in the coverage of wasting treatment services through a vertical, stand-alone, emergency response in high prevalence areas implemented from 2005 to 2011. Core elements of the programme included community screening, inpatient care for complicated SAM cases and outpatient management of uncomplicated SAM and moderate acute malnutrition (MAM). The Nutrition Cluster was established at provincial and district levels to coordinate the response in affected areas and CMAM implementation mainly depended on external donor funding and humanitarian agencies.

The success of the nutrition emergency response in averting deaths spotlighted the CMAM approach in Pakistan. To avoid suspension of nutrition services post-emergency, and to continue building on the gains made, national CMAM guidelines were developed by the GoP with support from UNICEF, the World Food Programme (WFP), the World Health Organization (WHO) and NGOs (non-governmental organisations) in 2010 (updated in 2015).

CMAM as a government-funded vertical programme

In 2012, the GoP initiated CMAM in selected emergency and non-emergency districts. CMAM was implemented in 36 districts in Punjab, nine districts in Sindh, seven districts in Balochistan and several districts in Khyber Pakhtunkhwa in the Provincial Nutrition Projects (PC1) from 2016 to 2019 and has since been extended further in Punjab, Sindh, Khyber Pakhtunkhwa and Balochistan.

In this system, CMAM continued to be implemented as a vertical programme. Thus, while it was located ‘under the same roof’ as health services within each province, the programme had separate staff, supply chains and information management systems rather than being integrated within existing government structures. Fragmented information systems, weak supply and logistics management structures and reliance on short-term funding grants have limited the sustainability and coverage of the programme. In 2019, overall coverage was around 5% with 65,000 children treated for SAM and 157,000 children treated for MAM countrywide.

Opportunity to mainstream nutrition-specific interventions into Pakistan’s routine package of primary healthcare services

In October 2018, the GoP endorsed the Astana Declaration on public healthcare revitalisation and revisited the primary healthcare approach to universal health coverage. Nutrition partners, including the World Bank, UNICEF, WHO and WFP, seized this opportunity to advocate for the mainstreaming of wasting treatment and prevention services. As a result, it was agreed that a ‘minimum essential nutrition package’ (including wasting treatment services as well as key prevention and promotion services such as IYCF counselling, vitamin A supplementation, deworming and multiple micronutrient supplementation (MMS) for children and pregnant and lactating women) would become part of the Universal Health Benefits Package. This package would be delivered routinely through the government health system by the existing health workforce. Additionally, nutrition supplies would be integrated into the health commodities logistics management system, nutrition indicators would be incorporated in the Health Management Information System (HMIS) and oversight of nutrition services would be enhanced to enable programme sustainability.

Process of integration

This process of integration is being guided by the Disease Control Priority approach (DCP3) with support from a Technical Group led by the GoP Ministry of Health with input from UNICEF. Pakistan is the first country to adopt the DCP3 and is being supported with technical assistance from Liverpool University, UK.  

Costing and resource allocation  

A cost-effectiveness analysis for the proposed package was carried out by the Ministry of National Health Services, Regulation and Coordination (MoNHSR&C). To support the process, the Nutrition Section of the MoNHSR&C, with technical support from UNICEF, is facilitating the development of a nutrition investment case for each of the four provinces of Pakistan. This will inform advocacy for the allocation of resources to implement the programme.

Development of workforce capacities

Currently, nutrition services are largely delivered by nutrition assistants at health facility level. These staff are recruited and maintained in projects only when resources allow, making for an unsustainable workforce. Pakistan’s army of community lady health workers (LHWs) is in the process of being engaged to increase the nutrition workforce. This approach has been integrated into the federal PC-1 which is currently being finalised and is set to boost the coverage of nutrition services from 60% to 80%.

To enable this approach, in-service training will be required for LHWs and other facility-level health staff including health service managers. Training will be cascaded from district-level managers to nutrition assistants to LHWs who will receive a simplified version of the training. As a result of the COVID-19 pandemic, GoP and UNICEF are currently exploring options to deliver this training online. Sufficient graduate and postgraduate human resources will also be required to coordinate and manage nutrition-service implementation; this will require advocacy for the inclusion of nutrition in the curricula of medical schools and tertiary institutions.

Integration into government supply chain and information systems

Local production of lipid-based nutrient supplements (ready-to-use therapeutic food (RUTF) and ready-to-use supplementary food (RUSF)) for the treatment of MAM and SAM are at advanced stages of production for use in CMAM programming. The GoP has passed a bill for tax exemption on the imported raw materials used in RUSF production in order to sustain local production. Efforts are also being made to obtain similar exemption for RUTF production. This will increase the cost-effectiveness of the CMAM programme and pipeline sustainability. Inclusion of imported multiple MMS tablets and sachets in the essential drugs list is also being explored. Finally, nutrition indicators are currently being integrated within the existing District Health Information System (DHIS) which will streamline nutrition information and reporting within the government health information system.

Institutional arrangements

In recent years, there has been greater political commitment to tackle widespread undernutrition in Pakistan. This has led to the development of the Pakistan Multi-Sectoral Nutrition Strategy (PMNS) 2018-2025 which aims to link and coordinate sector nutrition strategies and optimise federal support for nutrition-specific and nutrition-sensitive programming. The PMNS target, in line with the Sustainable Development Goals, is to reduce and maintain childhood wasting to <5% in Pakistan by 2025, or at least to achieve a reduction in child wasting of 0.5% per year between 2018 and 2025. Ongoing efforts to mainstream nutrition into primary healthcare would provide an opportunity to scale up nutrition programming and achieve wasting reduction targets.

However, programme coverage remains low and less than 10% of children with SAM currently have access to treatment. A huge effort is required to increase coverage, starting with a focus on areas of the country at high risk of polio. Attention will then be given to districts with high burdens of SAM before expanding the programme across the whole country. Opportunities to integrate these efforts with ongoing social protection schemes and wasting prevention programmes in Pakistan are being explored and leveraged.

Conclusions

For several years, efforts have been made to transition from emergency-driven, vertical nutrition programming in Pakistan to a systematic, developmental approach which addresses malnutrition through the primary healthcare system. Continuous advocacy and sensitisation of policymakers have driven change towards the full, nationwide integration of nutrition services into the primary healthcare system. While this has been effective at policy level, these changes are yet to be rolled out. The immediate next step is to add wasting management to the health function of the GoP’s Five-Year Plan (2018-23) and National Action Plan (2019-23) and to advocate for the allocation of financial resources to implement the minimum essential package of nutrition services. This government-led approach is key to enabling full coverage of wasting prevention and treatment services to meet national wasting reduction targets.

For more information, please contact Eric Alain Ategbo at eaategbo@unicef.org