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STOPSTUNTING

PROGRESS REPORT 2013-2015

Copyright © UNICEF PakistanPrinted in July 2015

Editing Sarah NamGraphic design Giovanna BurinatoPhotographs Asad Zaidi

For more information contact Daniel TimmeChief of Advocacy and Communication, [email protected]

PROGRESS REPORT 2013-2015Results for children in Pakistan

STOP STUNTING

BIRTH REGISTRATION EDUCATE ALL CHILDRENERADICATE POLIO

STOP STUNTINGIMPROVE ACCESS TO SANITATIONDECREASE CHILD DEATHS

PROGRESS REPORT 2013-2015Results for children

in Pakistan

FOREWORDIn recent years, the Government of Pakistan has demonstrated increased commitment to social sector development, consequently leading to some notable successes. In particular, the country is celebrating the recent achievement of the Millennium Development Goal (MDG) for sanitation, halving the proportion of the population without sustainable access to basic sanitation. Over the past two decades, the government has also made notable strides in combatting polio, increasing routine immunization and decreasing the number of out-of-school children.

UNICEF, along with its partners, is supporting the Government of Pakistan to achieve the MDGs and will continue to do so in the post-2015 era. More specifi cally, UNICEF is providing support to achieve the following results in Pakistan:

- BIRTH REGISTRATION: Achieve universal birth registration by 2024

- EDUCATE ALL CHILDREN: Provide access to improved education to more than 1.2 million children in Pakistan by 2017

- ERADICATE POLIO: Eliminate the disease by May 2016

- STOP STUNTING: 1.9 million fewer children with stunted growth and development by 2017

- IMPROVE ACCESS TO SANITATION: 10 million fewer people practising open defecation by 2017

- DECREASE CHILD DEATHS: Reduce newborn mortality from 55 to 20 live births per 1,000 by 2017, and have 90 percent fully immunized children (aged 12-23 months) by 2017

These progress reports take a deeper look into these issues, including the latest data and how government interventions have positively impacted children and communities in Pakistan. These reports also present key challenges, recent research, knowledge and evaluations, and strategic direction for the future.

Through these reports, we seek to foster productive collaboration, demonstrate the collective contribution of UNICEF and its partners, and reassert our commitment to the Convention on the Rights of the Child.

Angela Kearney UNICEF Representative in Pakistan

OVERVIEWStunting and other forms of under-nutrition hinder the optimal health and growth of a child. Stunting is associated with suboptimal brain development, which is likely to have long-lasting harmful consequences for cognitive ability, school performance and future earnings.

Globally, about one in four children under 5 years old are stunted – 25 percent in 2011. An estimated 80 percent of the world’s 165 million stunted children live in just 14 countries1, including Pakistan.

At 44 percent2, Pakistan’s under-5 stunting rates are much higher than the global rate. With a goal to reduce stunting to 34 percent by 2017, UNICEF, in partnership with government and other stakeholders is targeting under-5 children and pregnant and lactating women with key nutrition specifi c and nutrition sensitive programmes, employing a holistic and multi-sectoral approach.

This progress report shows recent statistical data on the national stunting situation and progress on interventions that have been implemented to address stunting. The report details UNICEF’s programmatic strategy, key achievements to date and looks forward to the next few years.

It also highlights the disparities in the prevalence of stunting that still exist in Pakistan, particularly between children from poorer and richer households.

6 7PROGRESS REPORT 2013-2015 STOP STUNTING PROGRESS REPORT 2013-2015 STOP STUNTING

In Pakistan, 44 percent of children are stunted3. This is the third highest percentage of stunted children in the world and means that more than 9.6 million Pakistani children have experienced chronic nutrition deprivation in utero and/or during early childhood. Every year, stunting is the cause of one million child deaths around the world. For the children who survive, stunting in infancy and early childhood causes lasting damage, including poor cognition and education performance, reduced lean body mass, lower productivity, reduced adult wages and pregnancy complications.

STOPSTUNTING

UNICEF PAKISTANTARGETReduce stunting to 34 percent, which means that 1.9 million children will be saved from stunting by 2017

GLOBAL TARGETReduce the number of under-fi ve children who are stunted by 40 percent by 2025

It is time the SUN must rise; rays of sunshine should touch lives of

millions of children and women suffering from malnutrition who deserve equal dignity, health and economic opportunity. Let the rays of SUN alight the dark spots of malnutrition by developing a well-nourished and healthy society in Pakistan.”

Professor Dr. Ahsan IqbalFederal Minister of Planning, reforms and development, Government of Pakistan


HOW UNICEF WILL HELP ACHIEVE RESULTS

Child stunting has become a global development priority. In accordance with the regional approach, UNICEF in Pakistan will continue to focus efforts in the fi rst 1000 days of a child’s life, starting from conception. Programmes also emphasise actions that improve the nutritional status of mothers and pregnant/lactating women. Further, the focus is shifting from curative-only approaches to both curative and preventive approaches and it has been recognized that a reduction in the prevalence of child stunting calls for a multi-sectoral response.

This is why UNICEF’s programmes are both nutrition specifi c and nutrition sensitive:

DATA PROFILE

Data source: Pakistan National Nutrition Survey 2011.

A snapshot of the child stunting situation in Pakistan According to recent fi gures5, stunting increases with age, peaking at 53 percent among children 24 months of age, which illustrates that it is imperative to target nutrition activities towards children 0 to 23 months.

Stunting prevalence is slightly higher in male children (48%) than in female children (42%)6.

Stunting disparities among urban and rural population of Pakistan is 37 percent and 46 percent respectively7.

Prevalence of stunting in Pakistan

Improving breastfeeding practices, while continuing to improve the quality of complementary foods for children aged 6-23 months

Improving women’s nutritional status by focusing on preventing micronutrient defi ciencies among pregnant and lactating mothers

Improving early detection and treatment of severe wasting in young children

Improving women’s nutrition, especially for adolescent girls and mothers

NUTRITION SPECIFIC

supporting the scale up of essential nutrition interventions

NUTRITION SENSITIVE

promoting inter-sectoral programmes

Integrating nutrition and WASH behavior messages to improve family and community hygiene practices

Ensuring UNICEF multi-sector programmes are aligned to leverage the effects on stunting prevention

Recent improvements in Pakistan’s improved sanitation fi gures should also have a positive impact on national stunting fi gures. This is because poor sanitation can have immediate effects on health, such as diarrhea and other diseases, which can lead to deaths in already malnourished children. There is increasing evidence that it can also cause malnutrition through a gut disorder that leaves the body unable to absorb nutrients4

Gilgit

PunjabSin

dhKPK

Balochista

nFATA AJK

0%

10%

20%

30%

40%

50%

60%


Stunting – a decades old problem The following graph illustrates persistent high levels of stunting in Pakistan since the mid 1960’s. Note that the country has only once dipped below the global critical level of 40 percent in the early 1990’s.

Trends in stunting

Minimum weight at birth: Percentage of children who were born with a birth weight > 2500g 8.

Data source: Pakistan Demographic Health Survey, 1990-91, 2006-2207 and 2012-2013.

How many children are benefi tting from essential nutrition interventions?

Early initiation of breastfeeding and exclusive breastfeeding

Data source: Pakistan Demographic Health Survey, 1990-91, 2006-2207 and 2012-2013.

Timely introduction of complementary foodsPercentage of infants 6-8 months old who are fed complementary foods.

Data source: Pakistan, National Nutrition Survey 2011.

Data source: National Nutrition Surveys 1965, 1985, 1990, 2001, 2011.

0%

10%

20%

30%

40%

50%

NSWP:1965 NNS:1985-7 NNS:1990-4 MNS:1997 NNS:2001-02 NNS:2011

NSWPNutrition Surveyof West Pakistan

NNSNational Nutrition Survey

MNSMicronutrient Nutrition Survey

0% 10% 20% 30% 40% 50%

National

Urban

Rural

Punjab

Sindh

KP

Balochistan

PDHS 2006- 2007PDHS 2012- 2013

Not available

8,5

17,6

28,8

37,1

18

38

0%

10%

20%

30%

40%

50%

60%

70%

Sindh FATA GB Punjab Balochistan AJK KP National

62,3

5551,3 49,2 48,6

35,7 35,3

51,3

PDHS 1990-91 PDHS 2006-2007 PDHS 2012-2013

0%

5%

10%

15%

20%

25%

30%

35%

40%

Early initiation of breastfeeding Exclusive breastfeeding


Integrating nutrition into government strategies

UNICEF has been working tirelessly to ensure children and women’s nutrition is included in the national agenda in Pakistan.

UNICEF is currently supporting the development of a National Infant and Young Child Feeding (IYCF) Practices Strategy and guidelines to promote IYCF care practices, and the development of the national IYCF Technical Advisory Group which includes representation from all provinces and areas.

Nutrition is part of the Pakistan Vision 2025 Government strategic planning document. The process of integrating nutrition programmes into the health system is currently underway, through formulation of integrated provincial planning commission documents, PC1.

The Pakistan Integrated Nutrition Strategy (PINS), supported by UNICEF, was also formulated and used as a strategic framework to guide provinces to defi ne nutrition in their provincial post devolution development agendas. As a result, inter-sectoral nutrition policy guidance notes and strategies were developed by four provinces in Pakistan.

ACCELERATING CHANGE IN PAKISTAN

IMPORTANT ACTIONS

Minimum dietary diversityPercentage of children 6-23 months old who are fed foods from minimum number of food groups.

Treatment of Severe Acute Malnutrition

Micronutrient supplementation to children and pregnant and lactating women

Data source: United Nations Children’s Fund Pakistan 2015, programmatic data.

0%

5%

10%

15%

20%

25%

FATA AJK GB Sindh KP Punjab Balochistan National

0

30000

60000

90000

120000

150000

2013 2014 2015

91%90,30%

87,40%

# SAM Children Treated

% of SAM children Dischared as Cured

0

500000

1000000

1500000

2000000Micro-nutrient supplementation (6 to 24 m)

Micro-nutrient supplementation (PLW)

2013 2014 2015

6,95,1

3,2 2,7 2,6 2,1

24

3

133170 134618

48591

1773724

678097

387202430435

167948

714621


Driving force behind the SUN movement

UNICEF provided crucial technical and logistical support to the National Planning Commission and the Ministry of Health Services, Regulation and Coordination to launch the inaugural Scaling Up Nutrition (SUN) movement in December 2013. The movement was a culmination of years of lobbying to include children and women’s nutrition into government strategies and plans.

EQUITY

UNICEF in Pakistan seeks to support essential nutrition interventions, particularly to the most disadvantaged children and women in the country. Equity analyses carried out during the programme planning stage shows that key disparities include urban-rural and socio-economic differentials.

Urban versus Rural

For example, it is evident that the percentage of stunting is much higher among children whose mothers are illiterate versus those whose mothers have completed at least 10 years of education. This has a big impact in Pakistan, where the proportion of illiterate mothers is almost double in rural areas than urban areas (36.6 percent in urban and 69.4 percent in rural respectively9).The graph on the following page shows the connection between under-nutrition and maternal education.

Socio-economic factors – Wealth quintilesIn Pakistan, the prevalence of stunting is highest among the lowest wealth quintile, with the same evident in the case of wasting.

0

10

20

30

40

50

RuralUrban

Stunting Wasting


Illiterate 1 to 5 6 to 8 9 to 10 above 10

Stunting Wasting

Lowerwealth quintile

Secondwealth quintile

Middlewealth

quintile

Fourthwealth quintile

Highestwealth

quintile

Stunting Wasting

Child under-nutrition and maternal education

Data source (both charts): Pakistan National Nutrition Survey 2011.

50%

40%

30%

20%

10%

0%

Years of education

60%

50%

40%

30%

20%

10%

0%


In the next few years, continued progress is required to achieve the national target by 2017.

• Child feeding: Improving the quality of complementary foods for children aged 6-23 months.

• Improving breastfeeding rates and decreasing the high use of infant formulas.

• Women’s nutrition: Improving women’s food intake (quantity and quality) along the lifecycle.

• Household sanitation: Improving family and community hygiene practices, with a particular emphasis on washing hands with soap after defecation and before child feeding.

In pursuit of these aims, UNICEF will work with partners towards:

• High-level country political commitment to improve nutrition governance and programs.

• Nutrition-specifi c and nutrition-sensitive interventions and programmes implemented countrywide.

• Strengthening of institutional and human capacity to manage nutrition programmes.

• Improved knowledge-management systems and evidence generation.

• Renewed focus on food fortifi cation.

• Developing a multiyear, multi-sectoral strategy for stunting reduction, collaborating with all relevant UNICEF sections and external partners.

• Developing an evidence-based and multi-sectoral communication strategy in coordination with Pakistan’s Planning Commission and the Ministry of National Health Services, Regulation and Coordination.

LOOKING FORWARDFood securityStunting and wasting have been found to be higher in food insecure households with severe hunger. High level of food insecurity is also documented in NNS 2011, where 58 percent of households were found to be food insecure.

RESEARCH, KNOWLEDGE, EVALUATION

Assessing Severe Acute Malnutrition in PakistanUndertaken by Action against Hunger in February 2014, this Semi-Quantitative Evaluation of Access & Coverage (SQUEAC) assessment of Severe Acute Malnutrition coverage was conducted in Tando Mohammad Khan and Badin districts, Sindh province. See the full report here: <www.humanitarianresponse.info/en/operations/pakistan/document/squeac-fi nal-report-district-tmk-badin-sindh-acf-pakistan-feb-2014>.

Political economy studiesIn 2013, a series of political economic analyses were undertaken to examine the status of nutrition in Pakistan. The National report is available here: <www.aku.edu/mc-pk/Documents/National%20Synthesis%20PEA%20Pakistan.pdf>.

10

20

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Food insecure with hunger-severe

Food insecure with hunger-moderate

Food insecure without hunger

Food secure

Stunting Wasting



Playing with his cousins, two-year-old Mehran seems to be just like any other toddler, comfortable with his surroundings at home. He gives a peal of laughter and lunges after a small puppy, the children have been chasing, around the muddy compound. Mehran’s family shares the house with his paternal grandparents, two uncles and their families.

The children go quiet as they see Shazia, a Lady Health Worker (LHW), enter the house. She is a familiar face here as she visits this family every other week to check on the health of women and children in the family.

“The household was consuming unsafe drinking water, which caused health and nutrition problems. When I conducted the Mid Upper Arm Circumference with MUAC test, Mehran was under nourished,” Shazia explains adding how she convinced the child’s parents to visit the health facility. “I asked the mother to accompany me to the Basic Health Unit for management of diarrhoea and seek advice from the nutrition assistant.”

Faryal, the Nutrition Assistant at BHU Mahabbat Abad conducted a thorough check-up and immediately initiated treatment as he was thin and underweight with chances of a stunted growth.

“When Mehran fi rst came to me three months ago, he was diagnosed with Severe Acute Malnutrition. He weighed only 6.8 kilograms, which is much less than the average weight for children his age. We initiated treatment by providing Ready to Use Therapeutic Food, and other medicines as per standard procedure,” says Faryal.

With proper treatment provided at the health unit, Mehran started to show signs of improvement. It contributed to his health and growth and his weight increased to 9.6 kilograms within few months.

“My sisters-in-law noticed how the treatment had aided my child’s growth, so they also took their children to the BHU,” says Asma, Mehran’s mother adding that staff at the BHU are very helpful. “Faryal would always listen to us sincerely and treat our children with utmost care.”

REAL LIVES, REAL CHANGEGood nutrition vital for children’s health

Provincial reports are also available here:

• Sindh: <www.aku.edu/mc-pk/Documents/Political%20Economy%20UnderNutrition%20Sindh%20Report.pdf>.

• Balochistan: <www.aku.edu/mc-pk/Documents/Political%20Economy%20Under-Nutrition%20Balochistan%20Report.pdf>.

• Punjab: <www.aku.edu/mc-pk/Documents/Political%20Economy%20UnderNutrition%20Punjab%20Report.pdf>.

• KP: <www.aku.edu/mc-pk/Documents/Political%20Economy%20UnderNutrition%20KP%20Report.pdf>.

Following the studies, Maximizing the quality of scaling up nutrition (MQSUN) also released a briefi ng note called Action on Under-nutrition in Pakistan: opportunities and barriers: <www.cmamforum.org/Pool/Resources/Action-on-undernutrition-Pakistan-MQSUN-2013.pdf>.

Pakistan Food Fortifi cation Scoping StudyThis 2014 Maximizing the quality of scaling up nutrition (MQSUN) report examines the potential to scale up micronutrient fortifi cation in Pakistan in order to reduce micronutrient defi ciencies: <www.heart-resources.org/assignment/pakistan-food-fortifi cation-scoping-study>.

Leveraging Agriculture for Nutrition in South Asia (LANSA)LANSA is an international research partnership focused on improving the nutritional status of children in South Asia. They have published a variety of reports and blogs on the topic:

• A brief review of the agriculture/nutrition policy landscape in Pakistan, April 2014 <http://lansasouthasia.org/sites/default/fi les/Country%20Policy%20Landscape%20Analysis%20Pakistan.pdf>.

• Agriculture and Nutrition in Pakistan - Pathways and Disconnects: LANSA Pakistan Evidence Paper, LANSA and CSSR. May 2013. <www.researchcollective.org/Documents/LANSA_Pakistan_Evidence_Paper_May2013.pdf>.

• General LANSA reports/blogs: <www.researchcollective.org/projects2.php?id=C_054>.

Endnotes

1 United Nations Children’s Fund 2013, “Improving Child Nutrition: The achievable imperative for global progress”, <www.unicef.org/gambia/Improving_Child_Nutrition_-_the_achievable_imperative_for_global_progress.pdf>, accessed June 2015.

2 Islamic Republic of Pakistan 2011, “National Nutrition Survey 2011”, Ministry of Health and Planning and Development, <www.humanitarianresponse.info/system/fi les/documents/fi les/59_National%20Nutrition%20Survey-2011.pdf>, accessed June 2015.

3 Ibid.4 Schmidt, C. 2014, “Beyond Malnutrition: The Role of Sanitation in Stunted Growth”, Environmental

Health Prospective, <www.ncbi.nlm.nih.gov/pmc/articles/PMC4216152/>, accessed June 2015.5 Islamic Republic of Pakistan, “Pakistan Demographic & Health Survey 2012-13”, National Institute of

Populations studies, <www.nips.org.pk/abstract_fi les/PDHS%20Final%20Report%20as%20of%20Jan%2022-2014.pdf >, accessed June 2015.

6 Ibid.7 Islamic Republic of Pakistan 2011, “National Nutrition Survey 2011”, Ministry of Health and Planning

and Development, <www.humanitarianresponse.info/system/fi les/documents/fi les/59_National%20Nutrition%20Survey-2011.pdf>, accessed June 2015.

8 Islamic Republic of Pakistan, “Pakistan Demographic & Health Survey 2012-13”, National Institute of Populations studies, <www.nips.org.pk/abstract_fi les/PDHS%20Final%20Report%20as%20of%20Jan%2022-2014.pdf >, accessed June 2015.

9 Islamic Republic of Pakistan 2011, “National Nutrition Survey 2011”, Ministry of Health and Planning and Development, <www.humanitarianresponse.info/system/fi les/documents/fi les/59_National%20Nutrition%20Survey-2011.pdf>, accessed June 2015.

Sources

All statistical information has been extracted from the National Nutrition Survey 2011; the Pakistan Demographic Health Survey 2012-13 and UNICEF Pakistan programmatic data.

Alderman, H., Bhutta, Z.A., Black, R.E, Gillespie, S., Haddad, L., Horton, S., Lartey, A., Mannar, V., Ruel, M., Victora, C.G., Walker, S.P., Webb, P., 2013, “Maternal and child nutrition: building momentum for impact”, The Lancet, <www.thelancet.com/series/maternal-and-child-nutrition>, accessed July 2015.

Haddad, L., Bhutta, Z.A. and Gazdar, H. 2013, “Special Issue: Seeing the unseen: Breaking the logjam of undernutrition in Pakistan”, IDS Bulletin, Volume 44, issue 3, page IX, <http://onlinelibrary.wiley.com/doi/10.1111/idsb.2013.44.issue-3/issuetoc>, accessed June 2015.

Balagamwala, M. and Gazdar, H. May 2013, “Agriculture and Nutrition in Pakistan – Pathways and Disconnects”, <www.researchcollective.org/Documents/LANSA_Pakistan_Evidence_Paper_May2013.pdf>, accessed June 2015.

The maps in this publication are stylized and not to scale. They do not refl ect a position by UNICEF on the legal status of any country or territory or the delimitation of any frontiers. The dotted line between Jammu and Kashmir represents approximately the Line of Control agreed upon by India and Pakistan. The fi nal status of Jammu and Kashmir has not yet been agreed upon by the Parties.

UNICEF Pakistan www.unicef.org/pakistan/www.facebook.com/unicefpakistantwitter.com/UNICEF_Pakistan