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Punjab Policy Environment Analysis

A Brief Review of Health and Nutrition Policy Landscape in Punjab

7 September 2015

By:Laila Rubab Jaskani

Punjab Pakistan

Empowerment, Voice and Accountability for Better Health and

Nutrition Project Pakistan

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Table of Contents

1. Health Policies and Strategies in Punjab.................................................................................... 3

1.1 Background .......................................................................................................................... 3

1.2 Most recent Developments in this context in Punjab .......................................................... 3

2. Nutrition Policies and Strategies in Punjab ............................................................................... 4

2.1 Background .......................................................................................................................... 4

2.2 Most recent Developments in this context in Punjab ......................................................... 4

3. A Critical Gap Analysis of Policies in Punjab contexts .................................................................

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Acronym: MI Micronutrients Initiative

SUN Scaling up Nutrition Movement in Pakistan (Pakistan is signatory of SUN)

MSNA

IRMNCH Integrated Reproductive Maternal Newborns and Child Health

GAIN Global Alliance for Integrated Nutrition

BHN Better Health and Nutrition

EVA Empowerment, Voice and Accountability

PHC Punjab Health Care Commission

EPHS Essential Package for Health Services

MSDS Minimum Service Delivery Standards

PHSS Punjab Health Sector Strategy

CMIT Chief Minister Inspection Team

PITB Punjab Information Technology Board

WB World Bank

NNS National Nutrition Strategy

PINS Pakistan Integrated Nutrition Strategy

SUN Scaling Up Nutrition

NWG Nutrition Working Group

MNCH Maternal Newborn Child Health

MTDF Medium Term Development Framework

NNSP National Nutrition Strategic Plan

TWG Technical Working Group

SC Steering Committee

P&D Planning and Development Department Punjab

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Health Policies and Strategies in Punjab

General Objective: To describe the overall health and Nutrition policy environment in Punjab health sector.

Specific Objective: 1) To review the health and nutrition policies environment and new developments in Health

sector Punjab

Background: Health and particularly reproductive maternal newborns and child health is top priority PML-N

government in Punjab. Therefore, Muhammad Shahbaz Sharif, Chief Minister Punjab is monitoring

the efforts and the steps being taken for the Road Map project and PHSS. Top priority of the Chief

Minister Muhammad Shahbaz Sharif is to provide best health services and facilities to the citizens of

the province and prevention of diseases. For this purpose a new policy is being prepared to remove

the gaps in the Health sector, strengthening of primary healthcare system and more focus on

prevention of diseases.

The National Programs, Lady Health Workers’ Program (LHWP), National Maternal, Newborn and

Child Health (MNCH) Program and Nutrition Program, are included in the Ten-Year Perspective

Development Plan 2001-11 and Medium Term Development Framework 2005-10.1

Pakistan’s Expanded Program on Immunization (EPI) has aimed to significantly improve child and

maternal health through immunization against tuberculosis (TB), measles, tetanus, diphtheria,

pertussis, hepatitis B, and poliomyelitis. The report released named “Pakistan’s Polio programme is

a disaster”. We analyse that this report highlighted the most crucial gaps in the achieving the EPI and

routine immunization targets in Pakistan.2As per the report, 80% of the polio cases emerged

worldwide in 2014 are from Pakistan.

1 IRMNCH PC1 2 Pakistan's polio program a 'disaster': Report retrieved on 04 December,2014

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Lady Health Workers and the Primary Health Care National Program; 3LHWs can provide preventive,

curative and rehabilitative services to the community. Lady health workers work also aimed at to

educate and provide Family Planning methods and MCH services. We EVA-BHN project analysed that

LHWs program plays pivotal role in reaching the vulnerable and marginalised communities as they

have to go door-to-door for the provision of community outreach activities. Lady health workers have

their catchment population within the union council level. LHWs can work under the specified and

allocated catchment population named at “LHWs covered areas” while at the same time they cannot

reach at the uncovered population. Now it is serious concerns and a question mark for us regarding

the uncovered population for the provision and access to services being provided by LHWs. Chief

Minister’s Health Attainment Program towards Reproductive Maternal (CHARM) is also one of the

health initiatives by the government of Punjab.

Family Welfare Program through department of family planning;4The Population Welfare

Programme is a social development activity aimed at reducing population growth rate which is a

necessity for developing countries like Pakistan(The Population Welfare Program Pakistan).

Women Health Project was funded by DFID department of health of government of Punjab in 2005;

safe motherhood and newborns babies care. The project was good initiative contribution towards

MDGs 4 and 5.It is noteworthy that DFID the UKAID is largely potential donor regarding RMNCH and

Nutrition in Punjab

Most Recent Developments in this Context in Punjab: The Integrated Reproductive Maternal Newborns and Child health program which is funded by

Government of Punjab, UNICEF and WFP. Nutrition activities are undertaken by LHWs, CMWs It is

somehow addressing nutrition sector needs and undertaking activities. Nutrition Officers are

appointed in all 36 districts of Punjab but they are not utilizing for undertaking nutrition activities at

the facility level.

3 Lady Health Worker Program-Punjab;data retrieved on 04 December,2014 4 The Population Welfare Programme; retrieved on 04 December,2014

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It is noteworthy that Punjab Health sector strategy is key to health sector reforms in department of

health government of Punjab. The PHSS 2012-2020 was developed under the guideness and direct

supervision of Punjab Health Sector Reforms Program. Currently the PHSRP is shifted or converted

into Policy Strategic and Planning Unit (PSPU).

5The Punjab strategy emphasizes RMNCH and Nutrition by proposing a number of initiatives

including:

I. Integrate MNCH, family planning and nutrition activities in the Essential Primary Health

Services Package Ensure availability of 24/7 EmONC services, strengthen linkages between

outreach workers (LHWs, CMWs etc.) and primary health units

II. Upgrade BHUs, RHCs, THQs, and DHQs to provide 24/7 Comprehensive EmONC services

III. Integrate nutritional services in pregnancy and child care in both health facilities and outreach

workers

This is in the light of consultations with different stakeholders; we now analyse the followings

important developments in Punjab health sector regarding achieving the MDGs 4 and 5.Followings

are the key health sector developments in Punjab Health sector so far;

Integrated Reproductive Maternal Newborns and Child Health Program (IRMNCH) is started by

government of Punjab; in 2013.The project aimed at addressing the reproductive maternal and

newborns child health and nutrition in the province of Punjab for contributing towards meeting the

MDGs targets towards reducing maternal and infant and child death rates.

Health department of Punjab has notified the Essential Package of Health Services for Primary Health

Care in Punjab. This is under the Essential Package of Health Services (EPHS); government of Punjab

has committed and commissioned for the provision of EPHS to the citizens of Punjab. EPHS contains

all the basic and necessary provisions of services. This is important policy strategic action towards

achieving MDGs targets 4 and 5. Minimum Health Services Delivery Standards (MHSD) are also

5 Punjab Health Sector Strategy 2012-2020

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important initiative by the government of Punjab. It is liability at each health facility BHU/RHCs to

implement the MHSD for the health wellbeing of citizen of Punjab.

Establishment of Punjab Health Care Commission has been established with respect to ensuring

health regularities within the Punjab health care facilities.6PHCC aimed at improving the quality,

safety and efficiency of healthcare service delivery for all Public and Private Healthcare

Establishments (HCEs) including Allopath, Homeopaths and Tibbs in the province of Punjab. Punjab

Health Care commission take actions on grievances redress mechanisms in Punjab.

Establishment of Policy Strategic and Planning Unit (PSPU) at Lahore. The purpose of PSPU is to give

strategic directions to department of health for policy formulations. Secondly, to harmonize

coordination among development partners and government for joint venture of improving health

services.

Donors funding for health and nutrition;7among the multilateral donors, the World Bank and the

Asian Development Bank are the two largest donors to the health sector, with other smaller

multilateral donors providing additional funding. In terms of bilateral donors, DFID has been and

continues to be the most important donor by a large margin. DFID has supported to the Government

of Punjab through dozen of projects on RMNCH.

Provincial Health and Nutrition Program is the biggest one which is supported by DFID in two

provinces Punjab and KPK of Pakistan. It is relevant with PHNP that DFID has supported to TR+ and

EVA-BHN for facilitating to government of Punjab in perspectives of supply side technical support and

demand creation through the grass rout level. PHNP aimed at contributing towards achievement of

MDGs targets 4 and 5 particularly reducing maternal and infant death rates, improving malnutrition,

reducing and unwanted pregnancies.

Nutrition Policies and Strategies in Punjab

6 Punjab Health Care Commission; retrieved at 04 December,2014 7 A JPMA Research Study Report: Public Sector health financing in Pakistan: A retrospective study

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Background: Punjab has faced high floods in Aug, 2010.The poor and marginalised communities faced destructions

of their assets and lives. Since that time; Sector based clusters emerged for addressing the unmet

needs of flood affectees. Nutrition cluster is also one of the important platform which highlighted

malnutrition and under nutrition issues from district to provincial and then national to global level.

According to UNDP report on progress to Millennium Development Goals; Punjab is off track in

achieving the targets MDGs 4 and 5.In MDG 4, targets related to mortality rates, immunization

against measles and lady health workers’ coverage of target population are likely not to be achieved.

In MDG 5, with the current progress, targets for the maternal mortality ratio, proportion of births

attended by skilled birth attendants, contraceptive prevalence rate and total fertility rate are unlikely

to be met. International donor community and United Nations is also focusing on “Post 2015 MDGs

agenda “if in case Pakistan is unable to meeting the MDGs target 4 and 5 than what will be the

strategic guidelines and directions and dimensions for meeting MDGs targets. These are all questions

In 2002, the Ministry of Health established a Nutrition Wing in 2002, but the wing had no direct

presence at the districts level for implementing and monitoring health-related nutrition activities. A

National Nutrition Strategic Plan was approved that same year but was never implemented. The

Ministry of Health also initiated a development programme proposal called the “Enhanced Nutrition

Programme” but its approval by the Planning Commission was stalled by constitutional changes in

2009. Nutrition has thus received little attention from policymakers and it has historically been dealt

with through a “project-based approach under Planning Commissions documents”.

It is important to understand that nutrition is not a standalone subject and needs to be addressed

through multi-sectoral approach. Inter-sectoral coordination committee was formed under the

umbrella of planning & development department that assisted the Punjab government in developing

multi-sectoral policy notes for addressing malnutrition.18th amendment gave provinces a big

opportunity and provinces started work on their nutrition guiding notes and strategies.

Most Recent Developments in this Context in Punjab:

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The department of health of the government of Punjab started to pay attention to nutrition. This is

due to pressure from international community/donors agencies specifically World Bank and DFID and

ECHO/EU and as mentioned earlier this is due to the impacts of disasters on poor populations.

Resultantly; Coordination is slowly improving and Donors funding are now available to develop

various, coordinated inter-sectoral interventions.

In Punjab, “Inter-Sectoral Nutrition Committees and Technical Working Groups” have been set up,

with support and lobbying from UNICEF and the World Bank and UN agencies .However, the

ownership and capacity of Punjab government to tackle malnutrition yet remain to be

comprehended.

In September 2011, the federal government presented the results of the National Nutrition Survey

(NNS), the largest nutrition survey in the history of the country. This NNS survey reported alarming

issues of malnutrition, under nutrition, wasting, stunting and acute malnutrition in Punjab. After the

2010-2011 monsoon floods, a “Nutrition Working Group” was established to coordinate nutrition-

related programmes and establish the way for inter-sectoral action by the government in order to

eliminate malnutrition.

The Nutrition Working Group has proposed a “Pakistan Inter-sectoral Nutrition Strategy (PINS)”,

which frames malnutrition as a multi-dimensional issue that encompasses many faces, such as the

consumption of food, childcare practices, household food insecurity, income, water and sanitation,

high fertility rate, low levels of literacy and natural disasters and emergencies.

It is come to know during the consultation meetings with key health experts and practitioners within

the department of health that PINS after passing the review stages from technical working group and

sectoral technical working groups now it is currently in the preliminary stages of approvals of steering

committee in Planning and development department Punjab. Currently only Technical working group

for nutrition is headed by secretary health Punjab for reviewing the overall progress in nutrition

sector Punjab.

Planning & Development Department Punjab, while realizing its role in tackling the grave issue of

malnutrition in Punjab, constituted a Steering Committee (SC) with representation of relevant sectors

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including government departments and international development partners. This committee was

given the mandate to develop Nutrition Policy Guiding Notes (NPGN), Punjab. The Steering

Committee constituted a Technical Working Group (TWG) in August 2012 and the TWG subsequently

notified six sectoral technical groups namely Agriculture Sector, Food Sector, Health Sector,

Education Sector, Social Protection Sector and WASH Sector.8

The sectoral groups were comprised of representatives of relevant Government departments,

development partners, academia and civil society. These sectoral groups, through meetings and

consultative process, developed their respective nutrition policy guidance notes. These notes were

refined through a series of meetings at the provincial and national level and were then approved by

Steering Committee in its meeting held on 07 Feb, 2014.

It is on 6th January, 2015 that Planning and Development Department Punjab has approved Multi-

sectoral Nutrition Strategy for implementation at all levels.

In April 2013, Pakistan joined the Scaling up Nutrition (SUN) a global initiative. SUN is an opportunity

for the national and provincial governments to draw on the support of international donors, UN

agencies, and civil society to make progress against malnutrition. Developments partners meetings

helds in Islamabad where all NGOs, INGOs, UN Agencies, Planning and Development department,

Donor agencies participate for discussing Nutrition issues in Pakistan with the technical and financial

support of Work Bank.

A Critical Gaps Analysis of Policies in Punjab Contexts: There is no health and nutrition policy in Punjab although drafting of various health and nutrition

strategies have been developed. Ad-hoc plans are available which are time to time executed based

on different circumstances and emergency. National plans and program are there. Most of these are

donors driven and mainly dependent on external resources both financial and technical.

8 Nutrition Policy Guidance Notes;29th December,2012

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18th amendments understanding is not understood in the light of constitutions shift. Although; 18th

constitutional amendment does not provide recipe for provincial autonomy for health sector. Largely,

the devolved functions of some of the national programs are partially shifted to the provinces and to

division and districts. No-one accepted and understood in the true letter and spirit to this

constitutional shift to provinces, divisions and districts. Within the country policies and frameworks

and provincial strategies are formulated for addressing the citizen’s needs but in the true sense.

All the prevailing laws on health are mostly national in nature but now the provinces has started

developing their own laws rules and regulations. Without realising to the national laws and policies

the provincial laws might contravene to the federal laws.

Multi-sector nutrition guiding notes and then Multi-sector nutrition strategy is in place meeting the

processes of necessary approvals from planning and development department Punjab; inter-sectoral

plans are in place but their implementation is like a fantasy. It is noteworthy, that all the outreach

interventions including in the Nutrition interventions are undertaken through LHWs and CMWs. Now

there is question mark of “capacity building” of LHWs and CMWs for undertaking the quality of

outreach interventions of nutrition is interrogative in sense.

As we have already mentioned that all the programs and initiatives in the department of health

Punjab are separated into segmentations which is losting the integration of interventions for meeting

the citizens driven needs and addressing the grievances launched by the citizens is again

interrogatives.

It is for the implementation of policy to be needed to technical man-power/human resources,

realistic budgeting and funds transfer flow from provinces to districts is largely needs to be advocated

and focused for the true implementation of programs in department of health government of Punjab.

Laws, rules and regulations and policies are necessary to develop in the citizens’ needs of health

perspectives. There is too much compartmentization within the department of health. Policy is the

dimension which provide systematic approach to address the issues and challenges in the cadre

of needs in the best interest of citizens.

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Policies are normally approved by nontechnical bureaucrats. Unfortunately the political systems is

neither well equipped and nor knowledgeable on policies development process broadly in Pakistan

and specifically in Punjab Provinces which is the reason of poor, non-democratic and gender biased

programs have been formulated for addressing the citizens’ needs.