Providing district-level coverage for nutrition programming in Balochistan, Pakistan province

Hassan Hasrat is the Chief Executive Officer of the Society for Community Action Process (SCAP-Balochistan), a local NGO. He has ten years’ experience in health, nutrition and community development.

Shah Mohammad is SCAP-Balochistan’s Programme and Operations’ Manager, with 15 years’ experience in community development. 

Introduction

Balochistan is the most under-developed of Pakistan’s four provinces, with a high proportion of children under five years of age (CU5) who are stunted (52 per cent)¹ and 16 per cent of CU5 who are wasted. Moreover, the prevalence of anaemia among children in this age group is 57 per cent and nearly 49 per cent among women of childbearing age. Numerous factors are thought to contribute to child undernutrition in Balochistan, including: sub-optimal infant and young child feeding (IYCF) practices; frequent child infections (especially diarrhoeal diseases and measles); maternal nutritional deficiencies and/or illness and death; absence/inadequacy of micronutrient supplementation; and household food insecurity and gender inequity².

A district-level focus on nutrition

In response to the challenging nutrition situation in the province, the Balochistan Department of Health (DoH) launched the Nutrition Programme for Mothers and Children (BNPMC) in 2016 through the new provincial-level Nutrition Cell located in the DoH. The BNPMC implements proven nutrition activities (see list below) among the rural and urban population of seven selected districts, with a focus on economically and socially disadvantaged populations. The total population of these districts is 1,654,613, of which estimated target populations include 132,369 pregnant and lactating women (PLW) and 254,615 CU5. The process for developing the BNPMC involved consultation to agree roles and responsibilities with all stakeholders. These included the DoH, district government, Peoples Primary Health Initiative (PPHI) (the Government’s public-private partnership programme providing health services at Basic Health Units in the districts) and local NGOs.

The Nutrition Cell’s main role is to set policy at both national and provincial level (the latter is used for implementation). It also provides oversight and leadership for effective programming at both the provincial and district level, establishes standards and technical guidelines (including how to reach the target population), provides technical assistance, carries out monitoring and evaluation, oversees operations research, and plays an advocacy role with other sectors, such as agriculture and livestock.

Programme implementation, especially service delivery, remains in the domain of the districts, where activities are carried out through partnerships with other public and private sectors. The major partnerships are with the National Programme for Family Planning and Primary Health Care (via the Lady Health Worker Programme, a cadre of community-level health workers providing primary healthcare services), the PPHI and NGOs and community-based organisations (CBOs).

The BNPMC has five components:

1. Addressing undernutrition among children via increased access and availability of IYCF support and Community Management of Acute Malnutrition (CMAM) services across the targeted districts and pregnant and lactating women, via behaviour change communication sessions on nutrition, health and hygiene;

2. Addressing micronutrient malnutrition, including vitamin A supplementation of children aged 6 to 59 months and expansion of salt iodisation and wheat flour fortification, etc.;

3. Behaviour change communication – coordinating with communication channels for behaviour changes in nutrition and socio-cultural practices that can lead to undernutrition via advocacy such as development and dissemination of materials, radio programmes, community theatre, etc.;

4. Strengthening institutional arrangements – the BNPMC plans to identify roles and responsibilities, build capacity and strengthen institutional mechanisms since there are currently no clearly defined mechanisms for coordinating sectors (while the public sector does support one position of Deputy Director of Nutrition at the provincial level, district-level activities are supported entirely through positions funded by development partners); and

5. Strengthening monitoring and evaluation systems – an M&E unit has been established within the Nutrition Cell in the DoH to coordinate monitoring activities throughout the province.

The total cost of the BNPMC is 1,492.62 million PKR (US$14.21 million), of which 80 per cent has been provided by the World Bank (through the Partnership for Improved Nutrition Trust Fund) and 20 per cent by the Government of Balochistan. The majority of the funding has been allocated to strengthening institutional arrangements (41.3 per cent), which includes programme staffing, technical assistance for capacity building, strengthening coordination mechanisms, etc., addressing malnutrition among children and PLW (37 per cent) and addressing micronutrient malnutrition (13.6 per cent). SCAP Balochistan has received 48 million PKR (US$0.45 million) of funding for the programme, via the DoH.

Partnering with a local NGO

A DoH mapping exercise identified that more than half of the areas in each district were not being covered by the BNPMC. A local NGO, the Society for Community Action Process (SCAP-Balochistan), was selected as a partner to implement nutritional services in two poorly serviced districts, Nushki and Kharan, from January 2017 to June 2018. SCAP trained a new cadre of 70 community service providers, including Community Nutrition Workers and project staff, on BNPMC objectives and activities in both districts.

As well as CMAM and supplementary feeding for PLW, the programme focuses on prevention activities. For example, 31,928 women of child-bearing age are being supported on improved IYCF practices, health and hygiene, and the importance of female education and health interventions, such as immunisation. To prevent anaemia, iron and folic acid (IFA) tablets will be provided to 2,554 women in non-covered areas, along with other strategies such as deworming and promoting food diversity and quality. A total of 250 community support groups (Mothers and Fathers Support Groups) have been formed and mobilised, with each group consisting of approximately 20 households. The groups have identified their community resource person, who has undergone capacity-building training in order to conduct group sessions as directed by SCAP using information, education and communication (IEC) materials.

The nutritional services being implemented by SCAP Balochistan will monitor a number of targets. These include: exclusive breastfeeding among infants aged 0-6 months (increase from 40 per cent to 50 per cent); minimum acceptable diet in children aged 6-24 months (increase by 15 per cent from baseline); and an increase by 50 per cent of pregnant women who receive and show compliance in consuming IFA tablets, among other targets. The programme has already achieved 89 per cent coverage of targeted beneficiaries with its first round of community screening and outreach services, including a total of 238,468 CU5 and 120,778 PLW reached/screened.

A number of aspects of the programme are working well in districts:

• NGO has trained human resources with logistics services to ensure nutritional services at fixed OTP sites;
• District Coordination Council (DCC) meetings are being held regularly to ensure the involvement of other stakeholders/departments and policymakers; and
• Few challenges are being experienced with coordination at district level, mainly because the District Health Department is fully involved in programme implementation and providing support for nutritional services.

Challenges and lessons learned

There are always numerous challenges in working in rural areas where services are poor and health facilities are ill-equipped and difficult to access. About 65 per cent of the districts covered by SCAP lacked any kind of services. Other barriers to be overcome include community misconceptions about different interventions, especially the provision of IFA supplementation and ready-to-use therapeutic food for children with SAM due to lack of education and awareness.

SCAP has engaged in extensive community empowerment to increase people’s involvement and participation, although this is hampered by the lack of services. Team building within SCAP has been another crucial factor in ensuring successful programme implementation. The NGO has involved different cadres in this and trained its own staff to ensure quality of services by following global guidelines while working at the district level. SCAP plans to do extensive advocacy for the wider replication of this model and scale-up to reach vulnerable populations in other parts of Balochistan.