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National Nutrition Cluster May 2014

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Nutrition Cluster Contingency Planning

Preparedness And Response Plan 2014

The National Nutrition Cluster Preparedness and Response Plan is a common framework to guide the actions of all partners in the nutrition sector in the event of a disaster. It does not replace the need for planning by individual agencies in relation to their mandate and responsibilities within clusters, but provides focus and coherence to the various levels of planning that are required to respond effectively. It is envisioned that the Preparedness and Response Plan is a flexible and dynamic document that will be updated based on lessons learnt in future emergency responses. Each Provincial Nutrition Cluster will develop a Provincial Nutrition Cluster Preparedness and Response Plan, in cooperation with the Provincial Disaster Management Authority (PDMA) and the Department of Health (DoH). The Provincial Plans are stand-alone documents, however are linked and consistent with the National Plan. 1. Background The 2011 Pakistan National Nutrition Survey confirmed that Pakistan’s population still suffers from high rates of malnutrition and that the situation has not improved for several decades. Two out of every five (44 percent) of children under five are stunted, 32 percent are underweight and 15 percent suffer from acute malnutrition.1 Maternal malnutrition is also a significant problem; 15 percent of women of reproductive age have chronic energy deficiency. Women and children in Pakistan also suffer from some of the world’s highest levels of vitamin and mineral deficiencies. The malnutrition rates are very high by global standards and are much higher than Pakistan’s level of economic development should warrant. Moreover, the rate of decline in malnutrition in Pakistan appears to be slower than in other countries in the region. Based on current trends, Pakistan is not on track to achieve Millennium Development Goal of halving the 1990 level of malnutrition by 2015.

Food insecurity and under nutrition are largely a problem of inequitable access by the poorest and most vulnerable to an adequate and diverse diet. Low nutrition indicators are also an outcome of poor education and low levels of knowledge about infant and young child diet and healthcare. Frequent childhood illness is also a contributing factor, especially illnesses such as diarrhea, measles and pneumonia. Of all the provinces in Pakistan, Sindh and Balochistan are the most vulnerable to food insecurity. Almost three quarters of families in Sindhand two thirds of those in Balochistan are considered food insecure.2

Emergencies exacerbate the underlying nutrition crisis in Pakistan. The 2010, 2011 and 2012 monsoon floods intensified malnutrition for populations that were already suffering from emergency levels of malnutrition before these disasters hit3 and will continue to be a significant factor in the high morbidity and mortality rates of children in Pakistan.

A number of nutritional surveys conducted in Emergency affected areas of KP/FATA and Sindh provinces, and food insecure districts of Balochistan from 2012 – 2014 show malnutrition situation above emergency levels of 15%. The 2013-14 emergency nutritional surveys data in Sindh (Badin district, GAM of 22.1% and SAM of 5.6%, TM Khan district, GAM of 9.4% and SAM of 5.1%, Thatta district, GAM of 18.3% and SAM-6.9%, and Tharparkar district, GAM of 22 % and SAM of 6.9%) showed very high level of

1 All nutrition figures from the draft National Nutrition Survey 2011. 2 Situation Analysis of Children and Women in Pakistan (October 2011) 3 Multi sector needs assessment (Nov 2011)


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acute malnutrition rates. A severe drought has occurred in Thar Desert of the Sindh Arid Zone as a result of the failure of monsoon rains, since Nov-2013, resulted in severe shortage of food, fodder and water in Tharparkar district that aggravated the malnutrition situation in the district.

As per the KP nutritional survey results of 2013, many of the assessed districts documented serious level of acute malnutrition ( DI Khan, GAM of 13% and SAM of 3.2% followed by Tank GAM of 10.4% and SAM of 1.7%, Peshawar GAM of 9.9% and SAM of 2.4%).The IVAP 4[Internally Displaced Persons Vulnerability Assessment & Profiling] exercises continuously conducted over the past three years (capturing all IDPs through door to door survey) revealed that IDPs often develop negative survival strategies, either as a result of pre-existing vulnerabilities or weaken coping mechanisms over time. Many families struggle to afford sufficient food and nutrition supplies, some families are part of an extended family system and often have to share food rations between many family members. 24% of the surveyed families borrowed food or relied on help from friends; 30.1% purchased food on debts; 13.9% of surveyed IDP families decreased their expenditure on health care; 9.2% sold domestic items including jewelry; 7.1% limited their food intake; 3.3% skipped their entire meal; in 2.6% of the families women consumed less food in order to make food available to children. The profiling exercises showed 65 percent of the surveyed IDPs had a poor or border line food consumption score. More than 50 percent of the surveyed individuals reported their children had two or less than two meals eaten per day, significantly lower than the standard for children is four meals per day. The analysis of latest data collected by IVAP showed around 21 percent decrease in frequency of breastfeeding among the IDP women5.

2. Planning Scenario and Assumptions The planning scenario for the Nutrition Cluster Plan is aligned with the agreed approach by the Humanitarian Country Team (HCT) to use benchmarking figures for a non-defined disaster scenario where there between 100,000 to 5 million people affected6, to provide an estimation of the requirements to respond effectively with life-saving nutrition interventions in a timely manner to a disaster in Pakistan. The target caseloads of beneficiaries for the highest threshold of 5 million people affected isoutlined in table 5, page 16. The main disaster scenarios are outlined below. Monsoon

In 2010, the country experienced super-floods, which affected the country on the North-South and East-West axis. Then, in both 2011 and 2012, the impact of the Monsoon was most significant in Sindh and in some areas of Balochistan and Punjab, although all provinces and territory were affected. A number of hydrological threats are possible during the Monsoon season, such as riverine floods, flash floods, glacier melt outflow, glacier lake outflow (GLOF), and irrigation/drainage breaches. Cyclones & Tropical Storms Pakistan is prone to cyclones and tropical storms. This season lasts from May to August, and overlaps the Monsoon season. All coastal districts of Balochistan and Sindh are at risk, with the possibility of impact further inland also. Major port cities of Karachi and Gwador risk being heavily impacted.

Drought

4 http://www.ivap.org.pk/ [2012]

5 http://www.ivap.org.pk/ [2013] 6The five planning assumptions are affected population numbering: 100 000, 500,000, 1 million, 2 million and 5 million people.

http://www.ivap.org.pk/

http://www.ivap.org.pk/


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Traditionally, areas in Pakistan have suffered drought conditions. Extensive canals and irrigation channels throughout the country enable water flow to areas affected. However, lack of maintenance and repairs has rendered many of the smaller systems unusable and prone to overflow, breaching or blockage. In Pakistan a variety of crops (rice, wheat, cotton, vegetables, sun flowers) are grown, which are impacted by drought conditions. The livestock herds also bear an impact in drought conditions.

Earthquakes

Pakistan lies on a number of fault lines. There is a long history of tectonic activity, with the earthquake in Balochistan, 2007, Muzaffarabad, 2005, Balochistan, 2013 the most significant in recent times. There are constant quakes, predominantly in the Balochistan area, which due to the lack of population concentration and depth of the epicentre have limited impact. However, this remains a constant risk.

Conflict

Since July 2008, Pakistan’s north-western areas of KP and FATA have experienced major displacements of populations as a result of insecurity. As the security context has fluctuated across different districts and agencies of KP and FATA respectively, so too have the patterns of displacement and return. Currently it is estimated that there are 1.1 million IDPs residing in communities in the districts of Peshawar, DI Khan, Tank, Hangu, Kohat, Nowshera and Kurram Agency.

Pandemic

Population concentration in Pakistan indicates a risk in public health terms. Vaccine preventable illnesses continue to cause significant impact, with cases of Polio and Measles still prevalent. Dengue and malaria peak seasonally, with areas such as northern Sindh and Punjab at most risk. Lack of sufficient health care services decreases the population’s ability to fight infection, and low vaccine uptake limits immunity. Planning Assumptions There are a number of important planning assumptions, including:

Humanitarian contributions to the response will be determined as a consequence of coordinated planning with government counterparts, and only after the Government’s request for support;

In the most likely scenario, the HCT will plan to support approximately 30 percent of the affected population;

The Government will provide the initial response, and will call on the international community to assist, if needed and as appropriate;

There is limited capacity of the Government to implement management of acute malnutrition services;

Already existing instances of malnutrition, food insecurity and disease, as well as lack of proper basic infrastructure and facilities, will compound the impact of any crisis;

There is often a time-lag for acute malnutrition to increase in a population following a disaster, thus the malnutrition levels must be closely monitored and the response phase may be extended beyond that of other sectors;

Activities that promote the prevention of acute malnutrition must be implemented with treatment of acute malnutrition programs;

Disaster Risk Reduction (DRR) principles underpin the response, by supporting the most vulnerable people within a community, supporting community resilience and coping strategies, and improving capacities through improved nutrition and wellbeing.

Response planning must take into account 2010, 2011 and 2012 flood impact and coping mechanisms utilized by vulnerable populations (especially women);

Insecurity will challenge the response to any crisis;


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Access constraints can hamper humanitarian response such as limited access to affected areas due to standing water, freedom of movement due to No Objection Certificate (NOC) requirements.

3. Nutrition Cluster Goal and Objectives Goal To reduce mortality and morbidity by the timely identification and appropriate management of acutely malnourished children (6-59 months) and pregnant and lactating women (PLW). Objectives

I. To ensure the provision of lifesaving nutrition services for acutely malnourished children (boys and girls 6-59 months of age)

II. To ensure the provision of lifesaving nutrition services for acutely malnourished PLW;

III. To control and prevent micronutrient deficiencies among children aged 6-24 months and PLW;

IV. To protect and promote appropriate infant and young child feeding (IYCF) practices through strengthening caring capacity of family members, and health care providers both at community and facility levels;

V. To protect breastfeeding by prevention of donation and distribution of breast-milk substitutes in emergency affected areas;

VI. To strengthen capacity for effective implementation of nutrition interventions and ensure effective and timely implementation of nutrition interventions through enhanced coordination and information management,and monitoring of trends including the status of malnutrition in the affected population.

The planned preparedness and response actions to achieve the objectives and contribute to the overall goal are outlined in sections 9 and 10.

Guiding principles The Nutrition Cluster is guided by the following principles:

Humanitarian Principles

Principles of Partnership

Sphere Standards

National CMAM guidelines

Global Nutrition Cluster guidelines

4. Nutrition Cluster Members and Structure The National Nutrition Clusteris represented by 29 organizations including the National Disaster Management Authority (NDMA), International and National Non-Government Organizations (I/NGOs), UN Agencies, and donors. The Cluster Lead Agency (CLA) UNICEF chairs the Nutrition Cluster, and the NDMA focal point for nutrition is co-chair during a declared emergency.


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In May 2014 there areactive clusters in KP/FATA. , Balochistan and Sindh Provinces. In Sindh, Balochistan and Punjab, a nutrition coordination mechanism is in placethat cantransform into the Nutrition Cluster in the event of a declared disaster by the NDMA/PDMA. At the Provincial Level, the PDMA and the Department of Health (DoH) remain active members of the Nutrition Clusters. There are a number of challenges relating to disaster management in Pakistan and the structure of the Nutrition Cluster. The National Disaster Management system is largely decentralized from the NDMA to the PDMAs and DDMAs, and there is nascent capacity within the disaster management authorities for nutrition. The DoH in each Provence has established a nutrition cell thatcontributes to the nutrition cluster in a technical capacity. However, there is no line ministry that is directly involved in the Nutrition Cluster at the National Level, since the devolution of the central Government and the abolishment of the MoH in 2011. The result is a nutrition cluster structure that is largely independent in each Provence, working with a number of Government counterparts from the DoH and the PDMA. The National Cluster provides technical oversight and operational support to the Provincial Clusters as required, while leading strategic direction, standards and guidelines development. The full contact list for the Nutrition Cluster is attached in annex 1. Figure 1: Nutrition Cluster Structure in Pakistan

National Nutrition Cluster, Islamabad

Co-chaired by NDMA

Khyber Pakhtunkhwa NC.

Co-chaired by DoH/PDMA

Balochistan NC, Co-chaired by DoH and PDMA

Sindh NC,

Co-chaired by DoH

Punjab Nutrition Coordination,

Co-chaired by DoH


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5. Nutrition Cluster Management and Coordination

5.1. Nutrition Cluster Roles and Responsibilities 5.1.1 Government The NDMA co-chairs the Nutrition Cluster only when there is a declared emergency resulting from a natural disaster, for example during the 2012 floods and for the duration of the Monsoon Humanitarian Operational Plan (MHOP). In the event of a declared disaster in 2014 the NDMA focal point will resume the role of co-chair. 5.1.2 Cluster Coordinators and Information Management Officers

The Nutrition Cluster Coordinators (NCCs) are responsible for leading the Nutrition Cluster in Pakistan, facilitating a timely and effective nutrition response and ensuring that the capacity of Government and other Nutrition Cluster Partners is strengthened. Further, the NCCs must ensure that the specific concerns and challenges that cannot be solved within the Nutrition Cluster are raised and properly discussed at the HCT, and that ensuing strategic decisions are shared and acted upon at the operational level.

Currently, NNC at national level, and 3 provinces are double-hutting as UNICEF programme staff. There is only one dedicated NNC at Sindh province. In the event of an emergency affecting 5 million people, surge support NCCs at the Provincial level with a number of affected districts will be required.

The Information Management Officersare responsible to facilitate and guide the Nutrition Cluster towards a reliable and predictable response through the provision of evidence based strategic and operational information. The IMO compiles inventories of needs and response that lead to a repeatable situational analysis of service gaps. The IMO facilitates coordination, information sharing, and reduces duplication through technical standards.There are cluster IMOs in Sindh, Balochistan and Islamabad. 5.1.3 UN agencies

UNICEF is the Cluster Lead Agency (CLA) for Nutrition at the Global level, and has been designated the CLA by the Humanitarian Coordinator (HC) in Pakistan. UNICEF has the responsibility as the CLA to ensure inclusion of key humanitarian partners, establish and maintain humanitarian coordination, lead planning, strategy development, advocacy and resource mobilization within the nutrition sector. Further, UNICEF is responsible for acting as the provider of last resort (subject to access, security and availability of funding) to meet agreed priority needs. The TOR for the CLA can be accessed from the following site: Cluster Lead TOR

Operationally, UNICEF is responsible for the management of severe acute malnutrition (SAM) in the community through the Outpatient Treatment Program (OTP), Infant and Young Feeding Practices (IYCF) and Micro-nutrient supplementation, and will provide therapeutic nutrition supplies, measuring equipment and essential drugs needed for systematic treatment.

World Food Programme (WFP)is responsible for the management of moderate acute malnutrition (MAM) through the Supplementary Feeding Programme (SFP) component of the CMAM and will provide the supplementary food for the target MAM children and PLW, including transportation and warehousing. Capacity strengthening on MAM management will be ensured. Additionally, where required, General Food Distribution (GFD) in food insecure areas will be undertaken to complement the emergency nutrition interventions. Further, WFP, together with FAO is co-chairing the Food Security Cluster.

http://www.pakresponse.info/LinkClick.aspx?fileticket=jF_cPPKq9p0%3D&tabid=68&mid=475


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World Health Organization (WHO) is responsible for the management of SAM children with complications who require in-patient management in a Stabilization Center (SC). Technical support is provided by WHO to the respective Department of Health of the provinces for the implementation of various activities of nutrition in the Provinces. Nutrition SCs are run by the health departments of the Provinces with the support of WHO. A Health and Nutrition Sentinel Site Surveillance System is also established in the provinces to monitor the trends of malnutrition in the population. Two sentinel sites are selected in the districts based on pre-specified criteria. Surveillance tools are completed by the Lady Health Workers and health care providers and this data is analyzed and report of trend of malnutrition of the districts shared with relevant stakeholders. Food and Agriculture Organization (FAO) is co-lead of the Food Security Cluster. In order to reduce vulnerability, improve food production, income generation, and increase resilience to shocks in rural communities affected by disaster and conflict affected districts of Pakistan, FAO is implementing various food security projects. The main activities include: horticulture (vegetable and fruit production), crop production, livestock support, fishery related activities,capacity building of farmers for crop, vegetable and livestock production and marketing, range land improvement and water harvesting and conservation. 5.1.4 INGOs and NGOs

INGO and NGO Nutrition Cluster partners implement the majority of emergency nutrition interventions in Pakistan. Independently or in partnership with UN Agencies or DoH, I/NGOs will implement the emergency nutrition interventions in areas with response gaps, with particular focus on the thematic areas of OTP, SFP and infant feeding in emergencies. I/NGOs will also manage SC’s where there is a need.

5.2 Intra-Cluster Coordination The Nutrition Cluster meets each month, and more often as required during the emergency phase. The National NCC facilitates the meetings, held at different partner office locations each month. The meeting minutes are circulated to all partners and uploaded to the cluster webpage. 5.2.1. UN agencies The UN agencies responsible for supporting the components of the CMAM are tasked with ensuring that there is regular and effective coordination amongst the three UN partners to ensure that the operational challenges are addressed and that the processes that enable implementation of nutrition services by the implementing partners are both functional and facilitate timely implementation in an emergency situation. Senior nutrition staff from WFP, WHO and UNICEF will meet in Islamabad at minimum on a bi-monthly basis, with facilitation support from the NCC. This coordination meeting outputs will be shared with the nutrition cluster partners. 5.2.2 Nutrition Cluster Joint Actions CMAM working group A small technical group, led by MERLIN is responsible for progressing priority tasks to improve the CMAM program. The priority tasks identified include printing and distributing the 2013 updated National CMAM guideline, supporting CMAM evaluations, and developing standardized tools and work-plans for joint monitoring of CMAM program sites. The CMAM group will meet on a needs-basis. IYCF working group The IYCF working group, led by Save the Children, is tasked with progressing cluster IYCF initiatives. This will include documenting best practices in IYCF in emergencies, integrating agreed IYCF indicators into routine data collection in the NIS. The IYCF group will meet on a needs-basis.


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NIS and IM working group The NIS working group, led by the UNICEF NIS specialist/Nutrition Cluster IMO is responsible for reviewing and improving the NIS, and ensuring that there is a pool of Information Managers from the Nutrition Cluster partners that are skilled in the NIS and can provide technical support to all Implementing Partners. The working group is also tasked with promoting complementarity and alignment amongst the NIS and other sources/databases of nutrition information. The NIS working group will meet on a needs-basis. Project Vetting Committee The project vetting committees are established,as required, at the Provincial level and are composed of the Cluster Government Counterpart, the National and Provincial Nutrition Cluster Coordinators, UNICEF, WFP, WHO and a representative from the NGO, and INGO’s. Organizations submit a concept note and budget to the committee, which are then reviewed and projects are awarded based on merit. A standardized project vetting template is used to assess the project proposals. Further, the NCC’s will be trained by OCHA in applying the gender marker in this process. 5.2.3 Coordination Linkages between the National and Provincial Levels The coordination between the National and the Provincial Level Nutrition Clusters is a primary responsibility of the National NCC. In times of preparedness, the NCC will communicate on a regular basis with the Provincial NCC’s, including monthly Skype/teleconference meetings. When there is an active emergency, the National NCC will be directly supporting the Provincial NCC as required and communicating daily. The coordination of information management is overseen by the National IMO, who is in direct weekly contact with the Provincial IMOs for the collection of Nutrition Cluster data and information that informs the Nutrition Cluster IM products such as situation reports, 4Ws, maps, contact lists etc.

5.3 Inter-Cluster Coordination The Nutrition Clusterparticipates in the Inter-Cluster Coordination Meetings (ICCM) chaired by OCHA Islamabad, the Humanitarian Country Team (HCT), chaired by the HCand relevant cross-cluster meetings such as the Assessment TWG. The Nutrition Cluster will coordinate closely with the Food Security, WASH, Health and Protection Clusters to ensure that there is high complementarity between the Nutrition Cluster and the Clusters most closely related to effective delivery of emergency nutrition interventions. 5.4 Integration of Cross Cutting Issues The Nutrition Cluster aims to integrate cross cutting issues in the emergency response through the timely identification of the most nutritionally at risk groups, based on vulnerability and need. The Cluster strives for effective referral mechanisms for other vulnerable groups not included in the Nutrition Cluster’s response programs, for example education and social services. The Nutrition Cluster will foster partnerships with the Food Security Cluster to strengthen and harmonize nutrition and food security linkages and integrate Disaster Risk Reduction strategies and activities for improved community resilience to disasters. Further, the Nutrition Cluster will seek training on mainstreaming gender into nutrition needs assessment, project design and monitoring and evaluation.


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6. Information Management, Assessment and Reporting 6.1 Information Management To promote timely and effective Information Management (IM) and information sharing in a disaster, the National and Provincial IMO’s are responsible for close coordination with all cluster partners, the NDMA, PDMA, other line ministries, and the IMO TWG. The following table outlines the primary IM products developed and maintained by the IMO. Table 1: Cluster Information Management Products

Product Updated Location/sharing

Contact lists Weekly IMO and website

Meeting minutes Monthly IMO and website

4W’s matrix Monthly IMO and website

Needs gaps analysis Monthly IMO and website

Funding status Monthly IMO and website

Nutrition Cluster Bulletin Bi-monthly Emailed and website

Maps of CMAM sites Monthly Emailed and website

Success stories Quarterly Website

Assessments and surveys As required Emailed and website

6.1.1 Nutrition Information System Nutrition Information System (NIS) is a tool use for the data collection, analysis and reporting of nutrition related activities like CMAM, IYCF, micronutrient supplementation and blanket distribution. This is a cluster tool used by all implementing partners. This system is being used in FATA, KP and Sindh Provinces for nutrition activities and around 700 people have been trained on this system so far in Pakistan. All implementing partners are responsible to update the system on a monthly basis and share with the Provincial cluster IMO. For accurate reporting,the cluster IMO is responsible for supporting the Implementing Partners and Government counterparts to use the NIS. The NIS is being reviewed in the preparedness phase to address inconsistencies and small errors. This review is led by the NIS TWG. The short-term strategy for the NIS is as follows:

The NIS will be a complete data source, inclusive of all relevant nutrition information in Pakistan.

The NIS will be accessible to all partners, and partners can use the NIS data to generate reports at any-time from any location.

The NIS will use the latest tools and technology to deliver a high quality product to the nutrition cluster partners.

The NIS maintenance will be sustainable, led by a group of technical specialists from at least four organizations that are responsible for maintaining, improving and training other partners in its use.


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There will be a schedule for implementation of comprehensive training of the NIS to all Provinces, through a Master Trainer approach, and monitoring of the training implementation and capacity of staff trained in NIS

The NIS will have a flexible format, to cater to a range of capacity levels. For example the ‘NIS simple format’.

The NIS reporting formats will be developed to a very high standard before seeking up-take by the Government counterparts.

The longer term vision is for the NIS to be integrated into the Government health information system. The NIS TWG is meeting regularly, led by UNICEF. 6.2 Assessments

6.2.1 Rapid Assessment

Information in the first 72 hours an emergency is critical to inform the initial response priorities, and enable the Nutrition Cluster Partners to access humanitarian funding. The HCT has endorsed the Multi-Cluster Initial Rapid Assessment (MIRA) methodology, which is designed to identify strategic humanitarian priorities in the initial emergency phase. OCHA, in cooperation with the NDMA and the Clusters will finalize a revised Rapid Assessment Tool in June 2014. The collection of useful nutrition information in rapid assessments is limited due to the difficulty in obtaining potentially sensitive information about infant and young child feeding practices from male key informants. For various reasons, it is not always possible to include MUAC in a rapid assessment, which can provide an indication of the level of acute malnutrition in the affected population. Further, there is often a time-lag between the onset of an emergency and worsening indicators of malnutrition, depending on the pre-emergency nutritional status of the population and the speed and effectiveness of the emergency response to provide/restore essential services. As such, it is of particular importance to the Nutrition Cluster to have reliable and readily accessible secondary data to inform the needs of the affected population in the first phase of the emergency. A map of nutrition assessments that have been conducted from 2000-2014assessment reports are available on the Nutrition Cluster website. Table 2: Secondary Information Sources/Fundamental Operational Datasets

Dataset Status Characteristics Source

Populations statistics Completed, 1998 Area /sex/household size disaggregation

http://www.census.gov.pk

WHO Health and Nutrition Sentinel Site Surveillance System

Monthly reports – vulnerable districts

District level disaggregation

Community level data Available from WHO

National Nutrition Survey, 2011

Survey completed in 2011

Provincial level disaggregation

Soft copy available

CMAM project screening Data

Updated monthly UC level disaggregation Nutrition Information System

SMART Surveys Completed Dependent on survey http://pak.humanitarianresponse.info/clusters/nutrition

Flood Affected Areas Nutrition Survey 2010

Completed in flood affected districts of 2010

Dependent on survey FANS 2010 Report http://pak.humanitarianresponse.info/clusters/nutrition

http://www.census.gov.pk/

http://pak.humanitarianresponse.info/clusters/nutrition





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4Ws Updated monthly UC levels http://pak.humanitarianresponse.info/clusters/nutrition

Districts Profile Updated District levels http://en.wikipedia.org *

Contact list Updated monthly n/a http://pak.humanitarianresponse.info/clusters/nutrition

* In en.wikipedia.org, enter district name in search text field area and the complete profile of the particular district is available. The IMO will be responsible for rapid analysis of the relevant secondary information, and triangulating other initial information from NDMA, PDMA, OCHA and Nutrition Cluster partners present in the affected areas. 6.2.2 Detailed Nutrition Assessment Following a disaster and where more detailed nutrition information in needed to inform the response, the Nutrition Cluster will implement a detailed nutrition assessment based on the Standardized Monitoring and Assessment of Relief and Transitions (SMART) Methodology. The SMART Methodology provides a basic, integrated method for assessing nutritional status and mortality rate in emergency situations, and provides the basis for understanding the magnitude and severity of a humanitarian crisis. The optional food security component provides the context for nutrition and mortality data analysis. A number of Cluster partners have extensive experience in implementing survey using SMART methodology, including UNICEF, Merlin, ACF and Save the Children. Where there is need to conduct a detailed nutrition survey, the Nutrition Cluster forum will provide a forum for coordination of the assessment timing, areas and resources, analysis and reporting. As much as possible, the Nutrition Cluster will coordinate closely with other clusters in the planning and implementation of the detailed assessment to promote resource sharing and reduce assessment overlaps. 6.3 Reporting There is no dedicated reporting officer in the Nutrition Cluster. In the event of a disaster that affects multiple Provinces, the National NCC is responsible for providing information to OCHA on the needs, responses and gaps of the nutrition response for the Humanitarian Situation Report (SITREP). In the event of a disaster that affects one Province only, the Nutrition Cluster inputs for the SITREP will be sent directly from the Provincial NCC to the OCHA field office, with support as required from the National NCC. It is the responsibility of the National NCC and IMO to develop a Nutrition Bulletin for reporting to Nutrition Cluster Partners and the donor community on the activities of the Nutrition Cluster. The Bulletin is released bi-monthly, and summarizes progress against targets, and Nutrition Cluster key activities in the previous months. In a disaster, the bulletin will be compiled and released on a monthly basis. 7. Human Resources

The Nutrition Cluster Partners report the following Human Resources available in Pakistan and available through surge support and other emergency recruitments. Table 3: Human Resources and Capacity Mapping



http://en.wikipedia.org/




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Organization Availability in Pakistan Surge Capacity Additional Resources Needed7

UNICEF 3 NCCs, 2 IMOs 3 Emergency Nutrition Programme Staff ( Nutrition Specialists), 10 Nutrition programme staff ( Nutrition specialists and officers)

Yes – Standby Partner Roster, Regional and HQ staff.

At least 4 additional programme staff to enable the 4 CC’s who are double hatting to become dedicated CC’s. Two additional IMOs.

WFP 8 Nutrition Specialists/ Nutrition

Programme Officers, 10

Programme Assistants (Nutrition), 1

Programme Assistant M & E Database,

30 Field Monitors

Yes-Regional & HQ

emergency roster,

standby partners on roster

Sufficient Capacity in-country and backstopping at RB, HQs

WHO 9 Nutrition Officers, 4 Data Assistants

Yes At least 4 additional staff per each affected province

FAO 1 Nutritionist,1 Agronomist, 2 Training Officers, 1 Information Management Officer, 3 Information Management assistants

No No

Save the

Children

Country Office: Director Health & Nutrition

Nutrition Specialist Nutrition Manager

Field Level: Senior Nutrition Coordinator Nutrition Coordinator

Nutrition Assistant IYCF Officer Nutrition Team

Regional Nutrition Advisor Technical backstopping at RHQs and HQs at UK and US

Sufficient Capacity in-country and backstopping at RHQ, HQs

7 Additional resources needed for a disaster where 5 million people require humanitarian assistance


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Merlin 1 National Nutrition Coordinator, 3 District Nutritionist, 1 NIS coordinator, 4 NIS Assistants, 1 Senior health coordinator, 1 Community Outreach Monitoring officer

Yes 1 roving coordinator is required to cope with emergencies as team lead.

ACF Country Office (Capital):

Head of Department ,Nutrition (01)

Nutrition Coordinator (01)

Nutrition Deputy Coordinator (01)

National Nutrition Information Management officer (01)

Field Level (Bases):

Nutrition Manager (03)

Deputy Nutrition Manager (06)

Nutrition Supervisors Nutrition teams including IYCF officers

Yes, maximum of 2 surge

support from ACF HQs

Technical Director

Senior Nutrition and Health Advisor

ACF can respond to emergencies in the

areas of its presence.

Additional HR will be recruited based on

funding availability.

MSF 1 Project coordinator/team leader, 1 medical team leader, 1 nurse supervisor, 1-2 health educators, 1-2 dispensaries/paramedics, 1 WHS, and 1 LOGs

Yes, there is a roster of medical staff available for training for medical activities during disasters, including nutrition.

Capacity is created as need arises

CDO Pakistan 1 Project Coordinator, 1 Programme Officer, 2 Field Monitors, 1 data entry operator

Yes, from CDO staff in Sindh & KP/FATA

Local staff will be needed for project implementation as per requirement. A new chapter in Gahkuch, District Ghizer will be opened by October 2014

World Vision 1 Integrated Health Specialist, 1 Child Health Advocacy Manager, 3 Health & Nutrition Coordinators , 2 Nutrition Coordinators, 2 Nutritionists, 3 HMIS officers, 8 Health & Nutrition community mobilisers, 1 Food Programme Manager, CTS Coordinator, 1 Food Assistance Officer

Yes- National & International World Vision Global Technical resource network

Funding for Nutrition Coordinator, OTP supervisors, Community Mobilisers and volunteers

Malteser

International

1 programme coordinator, 2 program officer for health and nutrition, 2 medical officers, 3 Lady Health Workers, 8 village health promoters, 1 community liaison training officer

Yes, from regional and HQ offices.

There is the possibility to move staff to affected areas from nearby program activity areas

SHIFA

Foundation

2 CMAM Project Coordinators, 2 Monitoring and Evaluation Officers

Yes in Sindh, KP and Gilgit-Baltistan

Depending on the size of area covered and the location, SF will need to either hire staff locally or if available, mobilize teams from already existing field offices.


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National Rural Support Programme

5 CMAM project coordinators, 2 field monitors, 3 social mobilisers, 1 NIS officer

Yes- NRSP Head Office, Regional and District Offices in all provinces of Pakistan including AJK

New local project staff will be hired during implementation of the project

The Johanniter International Assistance

1 Nutrition Coordinator,2 Provincial Technical Coordinators,3 Nutrition Officers

Yes- Operational coordinators in the Provincial offices

Additional local staff will be hired for implementation of new projects depending on availability of funds.

Relief International/Relief Pakistan

3 Nutrition Project coordinators for four Districts of KP

Yes, 2 staff from regional/HQ level

A Program coordinator depending upon the resource availability

International Rescue Committee (Sindh)

1 District level Nutrition Manager and 1 IMO None Funding for Nutrition Coordinator, OTP supervisors, Community Mobilisers and volunteers

NGO Development Society (Sindh)

2 District level Nutrition Manager and 1 IMO None Funding for Nutrition Coordinator, OTP supervisors, Community Mobilisers and volunteers

HANDS (Sindh) 1 District level Nutrition Manager and 1 IMO Nutrition related staff in HQ Funding for Nutrition Coordinator, OTP supervisors, Community Mobilisers and volunteers

8. Supplies The responsibility for the procurement of nutrition supplies is designated as follows: UNICEF supplies Ready to Use Therapeutic Foods (RUTF), F75 and F100, essential medicines, multi-micronutrient powder for children and MMN tables for PLW and anthropometric equipment. WFP supplies Wheat Soya Blend (WSB), Supplementary Plumpy/ACHA Mum, High Energy Biscuits and Vegetable Oil. WHO and INGOs can procure contingency stocks, if required. The Nutrition Cluster has reported contingency stocks available in May 2014 and calculated quantity of supplies required to respond to the planning scenarios of populations ranging from 100,000 to 5,000,000.


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WFP has a contingency stock levels to respond to the highest planning figure of 5 million people affected. In case of any urgent needs, the available food stocks can be diverted; however, considering the lead time of at least three months, WFP would need the funds well in advance to replenish the diverted stocks to meet its regular programme requirements. The current contingency supplies of UNICEF consisting of RUTF, Micro-nutrients and anthropometric equipment. chloroquine syrup and ferrous sulphate oral solution drops only. However, there is possibility of transfer of program supplies to an emergency response if the need should arise. In the event of a large scale emergency, emergency supplies can be requested from the regional and global stocks. When supplies are ordered, the lead time is up to eight weeks for arrival, plus potential additional clearance time in Pakistan. As a contingency measure, WHO has conducted training to SCs for preparation of F75 and F100 from locally available ingredients. Since 2012 UNICEF has encountered problems in importing several essential medicines. This has adversely affected both the importation of single commodities and whole kits, including kits for Lady Health Workers, Midwifery, Obstetrics, and the standard Inter-Agency Health Emergency Kit. There are three principal issues which have resulted in refusals to grant clearance for UNICEF to import a number of essential medicines and nutritional supplements required for our programme of support to Pakistan:

1. The commodity concerned is not marketed in its country of origin 2. Medicines or kits containing narcotics are banned from importation into Pakistan 3. Medicines manufactured in India are prohibited from importation into Pakistan

The following medicines and kits are currently restricted by the Drug Regulatory Authority (DRA): amoxicillin, ,new formula oral rehydration salts, paracetamol, zinc tablets, 9. Preparedness Activities Due to the frequency and magnitude of disasters in Pakistan, and the highly vulnerable food and nutrition security situation across all areas of country, there is a need for strong focus on both disaster preparedness and disaster mitigation, to lessen the impact of the disaster on the affected community. Table 4 summarizes the activities that have been identified as a priority by the Nutrition Cluster for disaster preparedness in 2014

Preparedness Activities Lead Time line

1. Preparation of the Preparedness and Response Plan

Mapping of partner projects, capacities, human resources, contingency supplies NCC and IMO and all cluster partners

May 2014

Compilation of Fundamental Operational Datasets for the Cluster, including demographic data, malnutrition prevalence disaggregated to the district level and recent nutrition surveyfindings

IMO May 2014


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Consultation on the Plan with Cluster partners and NDMA NCC May 2014

2. Contingency Stocks and Partner Agreements

Contingency stocks are made available All partners May-June

Develop contingency partner agreements UNICEF April-June

3. Capacity Building of Government Counterparts and Cluster Partners

Plan and conduct an Nutrition in Emergencies (NiE) training for NDMA and PDMA nutrition focal points, to raise awareness of nutrition interventions in an emergency and operational aspects of the response.

UNICEF and WFP June-July 2014

Strengthen linkages between nutrition and food security, through the development of an operational guidance for linking food and nutrition implementation.

NCC May-July 2014

Conduct regular trainings on CMAM and IYCF implementation for implementing partners and district Government counterparts

UNICEF, all IPs On-going

Disseminate a joint statement on Breast Milk Substitute distribution/Code in emergencies to all cluster members and DoH to raise awareness of BMS code breaches in an emergency

NCC July 2014

4. Nutrition Assessment and Monitoring

Contribute to the development of the revised 2014MIRA tool and methodology NCC May-June 2014

Develop and submit to NDMA a nutrition detailed assessment tool and methodology NCC May-June 2014

M&E tools that are standardized for the nutrition cluster for monitoring CMAM programs NCC June-July 2014

Continue and advance joint monitoring tools for CMAM activities CMAM working group May 2014

Establish a mechanism for reporting of BMS Code breaches during an emergency through the Nutrition Cluster and the DoH.

NCC July 2014

5. Improve Information Management

Review of different nutrition information management systems modify to match the government’s capacity and requirements and ensure maximum ownership

UNICEF IMO May-June 2014


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Implement expanded NIS trainingto Government and Nutrition Cluster Partners UNICEF May-June 2014

6. Improvement to Operational Guidelines

Develop an operational guideline for IYCF as an substantial element of community mobilization

UNICEF and IYCF working group

June 2014

CMAM guidelinesprinting, and translation to Urdu. CMAM TWG June-July 2014

10. Response Plan

To meet the goal of reducing mortality and morbidity by the timely identification and appropriate management of acutely malnourished children and PLW, the Nutrition Cluster will implement a complement of nutrition interventions under the CMAM programme. The interventions will encompass: community mobilisation (including identification and mobilisation or community networks, community leaders, conducting screening for acute malnutrition and sessions on IYCF, including protection of breast feeding); micronutrient supplementation; management of acute malnutrition through OTPs, SFPs and SC’s; integration and promotion of appropriate infant and young child feeding practices; strengthening the referral linkage between various components of CMAM continuum of care and community mobilization; improving the efficiency of the response information system; establishment of a strong surveillance system, and capacity development of health care providers for all these service areas. The response plan is based on an estimated population of five million affected, and 60 percent coverage by the nutrition cluster. Table 5 outlines the target beneficiaries for a six month response. For the estimated caseload, 250 nutrition sites (OTP/SFP) will be established, and 25 Stabilization Centres. In May 2014, 375 nutrition sites are operational. The additional caseload will be partially absorbed into the existing sites, and new sites established based on the gap analysis. Table 5: Estimated Targets

Population Affected of 5,000,000

60%

3,000,000

Children: %

Basis Prevalenc

e Incidence Target

Screening: # of children 6-59 months of age (14% of total population)

14.0% 420,000 420,000

SFP: # of Moderate Acute Malnourished Children (10% of 6-59 months children)

10.0% 42,000 63,000 73,500

OTP: # of Severe Acute Malnourished Children (5% of 6-59 months children )-80% of SAM for OTP

4.0% 16,800 25,200 29,400

SC: # of SAM Children with Medical Complications (5% of 6-59 months children )-20% of SAM for SC

1.0% 4,200 6,300 7,350

Deworming: # of Children (24-60 months) (12 % of total population)-

8.4% 252,000 252,000


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70% coverage

MM Supplementation: # of Children (6-59 months) (14% of total population)- 70% coverage

9.8% 294,000 294,000

Pregnant/Lactating Women:

Screening: # of Pregnant and lactating women-PLW (8% of target population)

8.0% 240,000 240,000

SFP: # of PLW at risk of malnutrition MUAC < 21 cm (13% of total PLW) 15.0% 36,000 54,000 63,000

Table 6: Response Actions

Actions Lead Timeframe

Coordination and Needs Analysis

Call National Nutrition Cluster meeting and establish coordination within nutrition clusters for quick mapping of the disaster response in terms of needs, capacity, gaps and commitments and report to OCHA and NDMA

NCC and IMOs, with information from NC partners

Day 1

Formulate the initial response plan, in partnership with cluster members and establish strong linkages to other sectors where possible

NCC Days 2-7

Advocate for and mobilize initial funding for the nutrition cluster response NCC, all partners Days 2

Release a joint statement on Breast Milk Substitute distribution/Code to the media and all clusters to try and prevent the influx of BMS

NCC, CLA, DoH Days 1-7

Participate in the MIRA, to identify immediate emergency nutrition requirements

MIRA trained staff Days 3-14

Refine the nutrition sector response strategy for the funding appeal, based on MIRA findings, the pre-crisis information and secondary data.

NCC, all cluster partners

Week 2-4

Vetting and selection of nutrition proposals for inclusion in the revised appeal NCC Weeks 3-8

Contribute in the consolidation and finalization of the operational plan or appeal document

NCC Weeks 3-8

Initiate Nutrition Response

Establish and maintain screening for acute malnutrition outreach and community mobilization

UNICEF, IP’s Week 1 and ongoing

Establish and maintain Supplementary Feeding Program (SFP) sites for the treatment of MAM Children under 5 and acutely malnourished PLW

WFP, IPs Week 1 and ongoing

Establish and maintain Stabilization Centers, to treat SAM children with complications

WHO, IPs Week 1 and ongoing

Establish and maintain Outpatient Treatment Program (OTP) sites, for treatment of SAM children in the community

UNICEF, IPs Week 1 and ongoing

Coordinate with the Food Security Cluster to link GFDs to CMAM interventions NCC, WFP Week 1 and


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as necessary ongoing

Implement comprehensive IYCF interventions, including education sessions and establishment of baby friendly spaces


Provide multiple micronutrient supplement8 to children 6-24 months and PLW combined with adequate counseling


Response Monitoring

Establish and maintain NIS in all CMAM sites UNICEF Week 1 and ongoing

Conduct joint monitoring of CMAM implementation in Sindh, Balochistan and Punjab).

NCC, all partners Week 2 and ongoing

Routinely monitor all CMAM sites, Non-Food Item and food ration distributionto prevent the distribution of breast milk substitutes, bottles, teats and other milk products


Monitor and report on key performance indicators (table 6) NCC, all partners Monthly

11. Cluster Monitoring

Regular monitoring and follow-up of the Nutrition Cluster CMAM activities is essential to ensure the CMAM is being implemented to a satisfactory level of both quality and coverage. Reporting through the existing reporting channels and reporting through NIS to prepare cluster reports needs to be ensured, including strong data analysis and interpretationthat result in adequate actions to adjust the CMAM where and when required. It was identified in the preparedness planning process that an active cluster led CMAM technical working group is required to provide supportive supervisions to improve program quality. To monitor the access and utilization of the CMAM, a coverage assessment using Semi-Quantitative Evaluation of Access and Coverage (SQEAC) will be conducted, and follow up nutritional surveys will be conducted if required. Table 7: Key Programme Indicators

Key Indicators

# Children and PLW screened for acute malnutrition (screening coverage) and % of total need

# Children (boys and girls) treated at OTP, SFP, SC/ % of total identified

% Children cured, defaulted and died (Sphere Standards Reference)

# PLW enrolled in SFP and % of total identified

8 Excluding areas of WFP blanket supplementary food distribution


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# Children (boys and girls) and PLW receiving MMS

# Breast feeding corners established and operational

# CMAM sites/facilities monitored for breast milk substitution and other violations of the code

# Sessions and people reached with IYCF interventions (disaggregated by gender)

# Health care workers trained in facility based management of severe acute malnutrition

# Health care workers and community workers trained in health and nutrition sentinel site surveillance system

# Health care workers and community workers trained in CMAM (disaggregated by gender)

# Health care workers and community workers trained in IYCF (disaggregated by gender)

% CMAM programme coverage

The overall functioning of the cluster and the National Nutrition Cluster will be monitored and evaluated against the core functions of the NCC as specified by the Inter-Agency Standing Committee.

12. Operational Constraints

The following operational constraints have been identified by the Nutrition Cluster:

Delays in the procurement and clearance of essential medicines

Delays in F75/F100 procurement and clearance by the Ministry of Foreign Affairs

Potential delays in the Governmentdeclaring a disaster and requesting assistance

Delays in obtaining Non Objection Certificates (NOC)

Accessibility of the affected areas

Availability of skilled staff

Poor security resulting in reduced access to affected and high risk for project staff

Delays and limitation in rapid resource mobilization

nutrition cluster contingency planning preparedness and ... · national nutrition cluster may 2014...

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