CMAM Review Report · Web viewAs the CMAM program seeks to shift from an emergency intervention to...

VALID INTERNATIONALSEPTEMBER 2013

ACKNOWLEDGEMENTS

First and foremost, Valid International would like to thank UNICEF and WFP not only for funding the review, but also for the excellent briefings and the continued technical and logistical support provided throughout the visit.

This review would not have been possible without the support of UN staff, government staff and NGO partners at the provincial level in Sindh, Punjab and Balochistan. It was an honor to work with such dedicated individuals.

Last, but not least, thanks to the numerous government health and community workers, CMAM program staff, beneficiaries and community members who so willingly gave up their time to participate in interviews, discussions and focal groups.

Valid International Valid Team

35 Leopold Street Caroline Grobler-TannerOxford, OX4 1TV Anne [email protected] Theresa Banda

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mailto:[email protected]

TABLE OF CONTENTS

Summary vi1. INTRODUCTION1.1 Background and purpose…………………………………………………………………………………….. 11.2 Objectives and methods………………………………………………………………………………….….. 2

2. KEY FINDINGS2.1 Modalities…………………………………………………………………………………………………………... 42.2 Mapping and program data……………………………………………………………………………...... 72.3 Quality of programming………………………………………………………………………………………. 102.4 Criteria and exclusion/inclusion……………………………………………………………………..…... 142.5 Infant and young child feeding……………………………………………………………………………. 152.6 Prevention………………………………………………………………………………………………………….. 162.7 Monitoring and reporting…………………………………………………………………………………... 172.8 Policy and coordination………………………………………………………………………………………. 18

3. ACTIONABLE RECOMMENDATIONS3.1 Sustainable foundation for CMAM in policy and practice 193.2 Program 203.3 Monitoring and Reporting 22

ANNEXESAnnex 1: Team itinerary……………………………………………………………………………………………… 24Annex 2: Key contacts met…………………………………………………………………………………………. 26Annex 3: Documents reviewed…………………………………………………………………………………… 28Annex 4: Review methodology…………………………………………………………………………………… 29Annex 5: Program data (NIS: January 2011 – June 2013)……………………………………………. 32Annex 6: IYCF suggested indicators ……………………………………………………………………… 33Annex 7: Prevention package……………………………………………………………………………………… 34Annex 8: Illustrative simplified OTP card…………………………………………………………………….. 35Annex 9: Illustrative template for reporting and collating Information………………………. 37

List of TablesTable 1: Sites visited during the reviewTable 2: Standard rations and routine medical treatments in the CMAM program Table 3: Actual and targeted OTP and SFP sites by 2017 by provinceTable 4: Current OTP, SFP and SC sites reported by NIS, July 2013Table 5:Training conducted January 2011- June 2013

List of FiguresFigure 1: Punjab: Evolution of OTP sites Figure 2: NIS mapping data: July 2013Figure 3: Punjab: OTP outcome data: January 2010- June 2013 Figure 4: OTP Outcomes by province: January to June 2013

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FREQUENTLY USED ACRONYMS

ANC Ante Natal CareARI Acute Respiratory Infection BCC Behavioral Change CommunicationBHU Basic Health UnitC4D Communication for DevelopmentCHARM Chief Minister’s Attainment and Realization of MDGs (FP and PHC Punjab)C-IMNCI Community based– Integrated Management of Newborn and Childhood IllnessesCMAM Community based Management of Acute MalnutritionCMW Community MidwifeCPR Community Resource PersonsDCO District Coordinating OfficerDHIS District Health Information SystemDHQ District Headquarter HospitalDoH Department of HealthEDO (H) Executive District Officer (Health)EHH Extended Health HouseEPI Expanded Program on ImmunizationFANS Flood Affected SurveysFLA Field Level Agreement (WFP)FP Family PlanningHANDS Health & Nutrition Development SocietyHEB High Energy BiscuitsHH Health House ( of Lady Health Worker)HMIS Health Management Information SystemIEC Information, Education and CommunicationIP Implementing PartnerIYCF Infant and Young Child FeedingKAP Knowledge Attitudes and PracticeLBW Low Birth WeightLHS Lady Health SupervisorLHV Lady Health VisitorLHW Lady Health WorkerLNS Lipid-based Nutrient SupplementLUMHS Liaquat University of Medical and Health SciencesMAM Moderate Acute MalnutritionMICS Multi Indicator Cluster SurveyMIS Management Information SystemMMS Multi Micronutrient Supplements MNCH Maternal, Newborn and Child HealthMRP Minimum Reporting PackageMUAC Mid Upper Arm CircumferenceNPPHC-FP National Program for Primary Health Care and Family Planning.NGO Non-Government OrganizationNIS Nutrition Information SystemNNS National Nutrition SurveyNSP-Sindh Nutrition Support Program – SindhNTT Newborn Tetanus ToxoidOPD Out Patient DepartmentORS Oral Rehydration SaltOTP Out Patient Therapeutic ProgramP and D Planning and Development Department

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PC-1 Planning Commission – Performa 1PCA Project Cooperation Agreement (UNICEF)PDHS Pakistan Demographic Household Survey (2012/13)PHC Primary Health Care PINS Pakistan Integrated Nutrition StrategyPLW Pregnant and Lactating WomenPMU Provincial Program Management UnitPRRO Protracted Relief and Recovery OrganizationPRSP Pakistan Rural Support ProgramPPHI Peoples Primary Healthcare InitiativeRAM Rapid Assessment MethodRHC Rural Health CenterRMNCH Reproductive Maternal Newborn Child Health and Nutrition Program- PunjabRUSF Ready to Use Supplementary FoodRUTF Ready to Use Therapeutic FoodSAM Severe Acute MalnutritionSC Stabilization Center SMS Short Message ServiceS3M Simple Spatial Survey MethodSLEAC Simplified Lot Quality Assurance Sampling Evaluation of Access and CoverageSRSP Sindh Rural Support ProgramSQUEAC Semi-quantitative Evaluation of Access and CoverageSUN Scaling Up NutritionTT Tetanus Toxoid (vaccine)UC Union Council WINS Women and Children/Infants Improved Nutrition-SindhWSB Wheat Soy Blend

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SUMMARY

For many years Pakistan has had persistently high rates of acute malnutrition exceeding emergency thresholds. Rates of severe acute malnutrition (SAM) are particularly high with a national average of 5.8%. Pakistan is second only to India in contributing to the global burden of SAM. Thus addressing this burden is critical in meeting MDG 4 (reduction of mortality). The community-based management of acute malnutrition (CMAM) was initially piloted in Pakistan in 2008/9 and draft guidelines developed. The widespread floods of 2010/11 resulted in an influx of NGOs and significant scale-up of CMAM in the affected provinces of Sindh, Punjab and Balochistan. Concurrently political changes led to devolution of power from federal to provincial level. CMAM in Pakistan is implemented by the Provincial Department of Health (DoH) and NGO partners with support from by UNICEF, WFP and WHO.

As the CMAM program seeks to shift from an emergency intervention to a program fully integrated into ongoing health services, questions have arisen as to how this can be done effectively. An independent review was conducted by a team from Valid International in July 2013 in Sindh, Punjab and Balochistan. The specific objective was to uncover what is working well and what is not working and to make to make evidence based recommendations. The scope of the review was determined by a committee comprising of UNICEF, WFP, WHO and the Federal Planning Commission. The team focused on the operational aspects of CMAM with regard to effectiveness, relevance and sustainability, and sought to expose barriers to effective integration. The team visited 14 sites in five districts of Sindh and 11 sites in three districts of Punjab. For security reasons, it was not possible to visit any sites in Balochistan. Selection of stabilization centers (SC’s), Outpatient therapeutic program (OTP) and supplementary feeding program (SFP) sites was based on various criteria including; differing operational modalities, cultural and geographical factors and security. Quantitative and qualitative methods were used to collect and collate data and information. In addition, the team conducted informant interviews and semi-structured focus group discussions with program managers, health and community workers, community members and beneficiaries in order to assess program quality and perceptions. The team reviewed an extensive range of reports, strategies, guidelines and operational plans at national and provincial level.

Key findings

The CMAM program in Pakistan aims to provide the complete package of components including OTP for SAM without complications, inpatient care for SAM with complications at a stabilization center (SC), supplementary feeding for MAM cases and community outreach. The full package also includes the provision of a food ration for acutely malnourished pregnant and lactating women (PLW) and a ration for the siblings of children admitted to OTP/SFP. In addition, most programs have an infant and young child feeding (IYCF) component. While, the CMAM package is standard, implementation modalities vary considerably. The exception is the SC which follows is integrated into the public sector model at the DHQ hospital. This is standard in all three provinces.

In Sindh, CMAM is largely implemented by NGO’s with little integration into the existing health system. Reportedly, a key constraint to integration is the failure to incorporate nutrition programming into the DoH contract with the People’s Primary Health Care Initiative (PPHI) which operates the Basic Health Units (BHUs). However, successful integration of OTP/SFP at government dispensaries was observed. This integration, albeit limited, was found to markedly improve uptake of other health services. Large scale donor funding to NGO’s in Sindh presents an opportunity to pilot test innovative and sustainable interventions, and build capacity at the provincial level. However,

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this opportunity is not currently being taken. Without effective government leadership, a successful handover to government led programming seems doubtful. By contrast, Punjab has recently transitioned from a predominantly NGO implmeted emergency intervention to government implementation of OTP under the National Program for Primary Health Care and Family Planning. The factors contributing to this successful transition include; strong government leadership, effective coordination and a well articulated handover strategy. Integration of OTP into the health system has resulted in good quality programming and an evident increase in demand and uptake of other services such as EPI and family planning.

In Balochistan, lack of access to health facilities due to distance requires an adaptation of the conventional CMAM model. The Health House (HH) of the Lady Health Worker (LHW) is used as the main site for treatment of children with MAM and PLW supported by WFP. However, there are currently only 8 OTPs in eight districts of Balochistan. This has resulted in large numbers of untreated SAM cases. A trained LHW is capable of treating SAM cases without complications at the Health House as part of her ongoing work. Restricting the treatment of SAM to health facilities is severely hampering coverage and scale up in Balochistan.

The team found difficulties in accessing data on the CMAM program. There were discrepancies in both the data and mapping which has implications for the accuracy of reporting, effective analysis and program management. Impact of treatment programs as determined by available data against sphere minimum standards was very good. Cure rates were high and death rates extremely low in OTP and SFP in all three provinces. Default rates for OTP are low in Sindh and higher in Punjab and Balochistan reflecting a government led program with less intensive outreach. In Sindh point coverage within selected program areas was found to meet sphere standards. However geographical coverage is limited in all provinces. Insufficient coverage of LHW’s is the key reason cited for limited scale up of government led programs. Quality of programming as assessed by safe treatment practice, appropriate referral and wait times exceeded minimum standards at all SC, OTP and SFP sites. In Sindh, average MUAC on admission was 11.2cm for SAM cases. This is indicative of early case finding. However, average length of stay (LOS) was much longer and rates of weight gain much lower than expected. Confused messages regarding the use of RUTF and issues with discharge criteria were key reasons. In Punjab, rates of weight gain were much higher due to a more focused program and better messaging. The sibling ration was found to neither deter sharing nor affect the LOS or weight gain. Community perceptions of the program are favorable, the exception being discontent regarding the inclusion/exclusion criteria for PLW. Acutely malnourished infants less than 6 months are particularly likely to be excluded from the program and lost to follow up. Screening and admission against targets is unnecessary and inappropriate in an integrated program. The team found no difference in quality between NGO and government implemented programs, but significant differences in cost.

An IYCF component is included in all CMAM programs with the intended aim of addressing the underlying causes of acute malnutrition in children less than 24 months. The criterion for who receives counseling at the sites is not systematic. Counseling that was observed varies from a lecture style to an effective practical approach. The content and quality of IYCF counseling also varies. Most counseling sessions addressed early initiation of breastfeeding, positioning and feeding on demand. Messaging on complementary feeding was frequently found to be inappropriate and impractical. The most effective counselors were experienced LHW’s with strong inter-personal skills and a highly practical approach. There is no standard set of indicators to measure the impact of IYCF. Findings of focus group discussions suggest a shift in breastfeeding practice has taken place in program areas of Sindh. Early initiation of breastfeeding and exclusive breastfeeding for 2-3 months was common practice. Appropriate introduction of complementary foods was much less common. All sites visited

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had an IYCF component at the site; however, opportunities to extend IYCF to the community are very under-exploited.

Given the high prevalence of both wasting and stunting, a standard practical prevention package is essential. Prevention programming tends to become far more complicated than necessary. The key causes of malnutrition are known. The issue is determining a simple package which is can be implemented across the board and effectively measured at the community level to determine impact.

The review uncovered issues with monitoring and reporting. Numerous examples of duplicative paperwork were found. The Nutrition Information System (NIS) is too complex, and at the same time ineffective in determining impact and analysis is poor. It is also resource intensive. In looking towards a sustainable integrated program, it is clear that the NIS will need to be simplified and indictors revised in order to feed into health information systems.

Coherence to national and global strategies was found to be strong in all provinces at least in rhetoric. Coordination mechanisms are particularly effective in Punjab. In Sindh, the Nutrition Cell is not as prominent in leadership and coordination, perhaps in part because the cluster is still functioning. In Balochistan, a formal coordination mechanism exists but is not currently active.

Actionable Recommendations

1. In order to ensure effective successful integration and scale up of CMAM, a sustainable foundation must first be established. Thus the following key actions are recommended:

A coordinated effort by donors, WFP and UNICEF to provide human resource and technical support to the DoH/Nutrition Cell. This will allow the DoH to take a leadership and coordination role and to develop clear strategic priorities, policies and plans for integration, scale up and emergency.

Allocate funding to the recruitment and deployment of LHW’s and advocate for the removal of current barriers that limit increasing their numbers.

Develop clear roles and responsibilities of core staff (LHW, LHV and Community midwife) in the management of SAM, MAM and PLW.

Promote inter-provincial exchange visits by a DoH led delegation. NGO’s can play can support government priorities by building capacity particularly at the

community level; assisting government to pilot test sustainable strategies such as in-country production of RUTF and programming in high burden but low coverage areas.

2. In order to promote sustainable CMAM programming, the following should be investigated, implemented and tested:

Efficacy and cost effectiveness of in-country production of RUTF. Sustainable modes of implementation such as the Health House model. Innovative and cost-effective ways of managing MAM and reducing incidence of acute

malnutrition. Testing of the ready to use food which is currently under production for PLW.

3. Integrated programming results in increased demand and uptake of other health services. Parallel programming should be avoided. In seeking to improve program quality and coverage the following key actions are recommended:

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Immediately address the lack of treatment coverage for SAM cases in Balochistan through programming at the existing 345 SFP sites at the Health House.

Develop and test a pack of simplified standard protocols in Urdu in line with the revised National Guideline.

Remove the sibling ration from OTP/SFP programs. Revise messaging to ensure clear communication on the use of RUTF. Ensure availability of routine drugs. Follow up and track infants less than 6 months in OTP. PLW should be managed by the LHV and the CMW at the health facility or LHW at the

Health House and linked to ANC.

4. In order to strengthen implementation practice and broaden the reach and impact of IYCF interventions, the following actions are suggested:

IYCF counseling should be managed by the LHW or CMW. All PLW should receive IYCF counseling linked to ANC at the facility and/or through the

Health House at the community level. Develop and test a standard package of tools for IYCF in Urdu and local languages. Extend IYCF to the community through effective mobilization and training of peer

counselors. Revise process and impact indicators for IYCF. Assess the impact of IYCF at the community level though simple assessment methods

against key baseline indicators.

5. A standard package for prevention is suggested and a focus on simple affordable, feasible appropriate and practical (AFAP) messaging. The prevention package should be linked to a set of process and impact indicators and fed into health management information systems (HMIS). As with IYCF, impact at the community level should be determined through simplified rapid assessments against key baseline indicators.

6. Current tracking, monitoring and reporting systems require streamlining and simplification to improve accurate reporting, ease of access to data and improved analysis. Specifically, a simple format is required that encompasses key data from SC, OTP and SFP in a readily accessible format in soft and hard copy. Data on PLW should be reported separately. Indicators selected should include a combination of process indicators for program management and impact indicators. The minimal package of impact indicators should be incorporated into the DHIS/MIS.

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CMAM Review Report 2013

1. INTRODUCTION

1.1 Background and purpose

For many years Pakistan has had persistently high rates of acute malnutrition exceeding emergency thresholds. 1 Rates of severe acute malnutrition (SAM) are particularly high with a national average of 5.8%. Pakistan is second only to India in contributing to the global burden of SAM. 2 The majority of SAM cases are under 24 months with a notably high burden in infants. 3 Addressing the persistently high burden of SAM through treatment and prevention programs is critical in meeting the MDG 4 (reduction of mortality). It requires an integrated approach that is sustainable. The links between food insecurity and acute malnutrition have been well documented.4 In addition, inadequate child care and feeding practices are a direct cause of acute malnutrition in Pakistan.

The community-based management of acute malnutrition (CMAM) was initially piloted in Pakistan in 2008/9 and draft guidelines developed. 5 The widespread floods of 2010/11 resulted in an influx of NGOs and significant scale-up of CMAM in the affected provinces of Sindh, Punjab and Balochistan as a result of high levels of acute malnutrition found in the Flood Affected Surveys (FANS). 6 Concurrently political changes led to devolution of power from federal to provincial level. CMAM in Pakistan is implemented by the Provincial Department of Health (DoH) and NGO partners, with support from by UNICEF, WFP and WHO.

The scale up of CMAM over the last three years has occurred rapidly. This was achieved with little capacity on the ground. As the CMAM program seeks to shift from an emergency intervention to a program fully integrated into ongoing health services, questions have arisen as to how this can be done effectively. Internal evaluations of CMAM have been conducted including a recent case study in Khyber Pakhtunkhwa (KP).7 However, a more systematic and objective review was felt to be needed in the three provinces of Sindh, Punjab and Balochistan. The review was timely as there is considerable attention to the scaling up nutrition in the global policy arena. Pakistan has recently become a member of the global initiative - Scale Up Nutrition (SUN). Provincial governments are finalizing three year plans for health and nutrition and the Planning Commission-Perfoma 1 (PC-1) documents are at the pre-implementation stage. Supply of Ready to Use Therapeutic Food (RUTF) is secured by UNICEF for three years. WFP expects to have funding under the Protracted Relief and Rehabilitation Operation (PRRO) unitl 2015 for the continuation of supplementary feeding programs (SFP) in many areas. In addition, donors have provided significant funding to NGO’s for nutrition in Sindh in three districts. This funding platform affords the opportunity for long-term planning and sustainable programming.

1 National Nutrition Survey (NNS). Planning Commission/UNICEF/Aga Khan University, 2011. Draft.2 Based on a SAM rate of 5.8% and an under five population of approximately 21.4 million (180m pop), Pakistan has an estimated 1.5million SAM cases3 26% of SAM cases are in infants less than 12 months. In Sindh and Punjab, the proportion of acutely malnourished infants less than 12 months is approximately 40% of caseload (NNS Data and caseload data). 4 Balagamwala ,M., Gazdar H., Breaking the Logjam of Undernutrition in Pakistan IDS Bulletin Volume 44 Number 3 May 2013.5 National Guidelines for the Community Based Management of Acute Malnutrition. DRAFT. Ministry of Health, 2009. 6 FANS, Sindh. UNICEF/ACF, November 2010; FANS, Punjab. UNICEF ACF/Government of Punjab. January 2011.7 Evaluation of CMAM, Pakistan Country Case Study of KhyberPakhtunkhwa (KP) Province. UNICEF. September 2012.

1 Valid International




An independent review of CMAM was conducted by a team from Valid International in July 2013 in Sindh, Punjab and Balochistan. The overall aim of the review was to uncover what is working well and what is not working and to make to make evidence based recommendations. The Itinerary can be found in Annex 1. Key contacts and people met during the review can be found in Annex 2.

This report presents the key findings of the review and actionable recommendations. Case studies and success stories from the three provinces which capture lessons learned and examples of good practice are available as a separate document. The team was also asked to provide input to the review of the National Guidelines for CMAM. This is also a separate document. The scope and time limits of the review did not permit analysis of the costs of CMAM or supply chain management.

It is anticipated that the review findings will be used by provincial and national governments, UN agencies and implementing partners to strengthen existing programs and move towards an integrated and sustainable model of CMAM programming.

1.2 Objectives and methods

Objectives

As a review and not an evaluation, the team was asked to focus on the on the operational and practical aspects of CMAM with regard to effectiveness, relevance and sustainability. The policy climate was also taken into account. The review did not focus on any particular organization or institution. The scope of the review was agreed by a Review Committee comprising of UNICEF, WFP and the Federal Planning Commission.8 Specifically the team explored the following key areas:

The strength and weaknesses of different program modalities at provincial level. Quality and consistency of data and information. Program relevance and appropriateness and potential for sustainability. Adherence to national and provincial policy and guidelines. Provincial coordination and leadership. Critical gaps and/or issues that prevent integration and scale-up.

Due to security issues, only one team member visited Balochistan. It was not possible to visit any CMAM sites in Balochistan. Thus the collection of data and information at field level was compromised and the team had to rely on secondary reports and interviews with practitioners.

The review was conducted during Ramadan. This occasionally affected opening hours of health facilities and CMAM sites.

8 Terms of Reference. UNICEF/WFP Review of CMAM in Sindh, Punjab and Balochistan). May, 2013.



Methods

The team used quantitative and qualitative methods to collect and collate data and information. The essential principles for determining effective and quality CMAM programming were assessed according to the OECD/DAC criteria.9 In addition to site visits, the team conducted informant interviews and semi-structured focus group discussions with program managers, health and community workers, community members (both male and female) and beneficiaries in order to assess program quality and perceptions. The team also explored issues of inclusion/exclusion in programming. The team collected and reviewed a range of reports, strategies, guidelines and operational plans at national and provincial level. A list of documents reviewed can be found in Annex 3. The methodology used during the review can be found in Annex 4.

The selection of stabilization centers (SC’s), outpatient therapeutic program (OTP) and supplementary feeding program (SFP) sites was chosen in discussion with the Review Committee and implementing partners. Sites were selected based on various criteria including differing modalities, cultural and geographical factors, security constraints and access. The team visited some sites without pre-arrangement. Sites visited by the team are noted in Table 1.

Table 1: Sites visited during the review

Province Districts SCs OTP/SFP OTP only Implementing partner (s) at sites visited

Sindh UmerkotTMK HyderbadS. BenazirabadThatta

5 8 1 SC at DHQ hopsitalGovernment and some NGO’s. Operated by doctors and nursesSupported by WHO

OTP/SFP at community centers, schools and government dispensaries Shifa, Save the Children, HANDS, ACF, Merlin.Operated by NGO recruited staffSupported by UNICEF/WFP

Punjab LahoreMultanRajanpur Muzuffargarh Layyah

4 2 5 SC at DHQ HospitalGovernment (DoH) supported by WHO or UNICEFOperated by nurses and LHV’s

OTP at BHU (and in some cases RHC and Health House)Government (DoH) supported by UNICEFOperated by LHV’s (in some cases also CMWs)

SFP at BHUGovernment (DoH) supported by WFPOperated - same as OTP

Balochistan Noshki* N/A SFP at health House of LHWGovernment (DoH) supported by WFPOperated by LHW

*Lady Health Workers, Lady Health Supervisor and district staff met with the team. Sites were not visited.

9 Organization for Economic Cooperation and Development/ Development Assistance Committee. Principles for Evaluation of Development Assistance, 1991.



2. KEY FINDINGS

2.1 Modalities

The CMAM program in Pakistan seeks to provide the complete package of components as per the traditional emergency model. This includes OTP for SAM without complications, inpatient care for SAM with complications, supplementary feeding for MAM cases and community outreach. The full package also includes the provision of a food ration for acutely malnourished pregnant and lactating women (PLW) and a ration for the siblings of children admitted to OTP/SFP. In addition, most programs have an IYCF component. Ration levels and routine drug protocols are standardized. However, the availability of drugs for the routine medical treatment in OTP is erratic. The complete ration for PLW is not always available.

Table 2: Standard rations and routine medical treatments in the CMAM program

Component SC OTP SFP PLW

Target group 0-59 months SAM with complications

6-59 monthsSAM without complicationsMUAC < 11.5cm

6-59 monthsMAM

MUAC <12.5cm

Pregnant (2nd trimester) women and lactating with infant < 6 m with MUAC <21cm

Nutritional treatment

Standard according to WHO protocol

StandardRUTF by weight according to National Guideline

Sibling ration1.2kg/15 packs HEB’s every 15 days

Acha Mum1.50 kg/15 sachets

Sibling rationSame as OTP

WSB 5kg/monthOil 2.25kg/month

Medical treatment Standard according to WHO protocol

Use and availability of routine drugs erratic

Not systematic Mostly absent

Iron /folate erraticMulti micronutrient tabs erratic

Operating 24/7 Weekly and sometimes every 15 days

Every 15 days Every month

Supply and logistics WHO UNICEFWFP sibling ration

WFP WFPUNICEF medical treatment

Technical support WHO andUNICEF in Punjab

UNICEF WFP WFP

While, the CMAM package is standard, the implementation modality varies considerably. In all three provinces, SCs are integrated into government run health facilities at the district level. SC’s are supported by WHO and in some cases UNICEF. WHO aims to support one SC per district.

The review team found significant differences in the modalities in the community based management of SAM without complications and MAM.

In Sindh, nearly all sites have the ‘full CMAM package’ of services as described above in Table 2. In rare instances where SFP is not operating, it is due to pipeline breaks or administrative issues with Field Level Agreements (FLA’s). CMAM is largely led by NGO’s with PCA/FLA’s with UNICEF/WFP. There is little integration into the existing health system. The program has very



good outcomes (see quality of programming) but operates in emergency mode and implementation is resource intensive.

The lack of integration is largely due to a failure to incorporate nutrition programming into the DoH contract with the People’s Primary Health Care Initiative (PPHI) which operates the Basic Health Units (BHUs). However, the team found examples of successful integration where these obstacles had been circumvented at the district level. In Thatta district for instance OTP/SFP had been successfully integrated into government dispensaries. The team found some evidence that this integration improved uptake of other health services. In Thatta district, 87% of mothers of children in the OTP/SFP reported also using family planning services.

The PC- 1 for Sindh suggests a government implemented pilot OTP program in 7 districts operated by Lady Health Visitors (LHV’s) at health facilities and Lady Health Workers (LHWs) at Health Houses. WFP will continue to provide the ration for MAM and PLW’s. There is, as yet, no plan for how this would be implemented and no scale up plan with details on the number and location of sites. In addition, The European Union (EU) is supporting NGO implemented CMAM programming in three districts under the Women and Children/Infants Improved Nutrition in Sindh (WINS) program.10

The team found the absence of a strong leadership and clear vision were issues in hampering transition to a government led implementation. Parallel programming has resulted in overly complicated monitoring and reporting systems and varying policies regarding implementation and staffing. Large scale donor funding to NGO’s in Sindh presents an opportunity to pilot test innovative and sustainable interventions, and specifically to build capacity at the provincial level. However, this opportunity is not currently being taken. 11

In contrast, Punjab has recently transitioned from a predominantly NGO led emergency intervention to government implementation of OTP under the National Program for Primary Health Care and Family Planning. Factors contributing to this successful transition include; strong government leadership, effective coordination and a well articulated hand-over strategy. Importantly, the DoH contract with the Pakistan Rural Support Project (PRSP) included nutrition. Thus the incorporation of OTP into primary health care activities at the BHU has not been an issue.

The Punjab Government PC-1 is a fully integrated document. OTP is fully integrated into the primary health care system with functional links to the National Maternal Newborn and Child Health (MNCH) program and the Chief Minister’s Health Initiative for Attainment and Realization of MDGs (CHARM). The PC-1 includes a clear phased scale-up plan to integrate OTP into 931 BHUs and regional health centers (RHCs) (30% of all health facilities) in 30 of 36 districts by 2017 (Figure 1). Punjab has recognized the issue of urban malnutrition and the scale- up plan includes the treatment of SAM in nine mega cities. LHW’s will be trained to manage SAM as well as other health activities through and Extended Health House (EHH). The EHH will be pilot tested prior to scale up.

10 The WINS project (€30million over four years) supports ACF, Merlin and Save the Children CMAM programming in Dadu, Thatta and Shikarapur and aims to treat 284,593 children and 507,675 PLW). 11 Nigel Nicholson. European Commission Nutrition Advisory Service ( EC-NAS). Mission Report Pakistan. 10 to 21 June 2013



Figure 1: Punjab: Evolution of OTP sites WFP had SFP programs in seven districts until the end of 2012. Currently WFP is operational in two districts. Thus SFP is not a core component of the package. It is important to note that this is due to a prioritization on the part of WFP and is indicative of the erratic nature of SFP implementation which occurs only when funding and food supplies are available. It is thus viewed as not sustainable by the DoH. A prevention package will be fully implemented at facility and community level

through the LHWs. The review found that integration into the primary health system has resulted in an in demand and uptake of other services such as EPI and family planning.

Balochistan is the largest province and the least densely populated. The distance and access to health facilities requires adaptation to the conventional CMAM model. The Health House of the LHW is used as the main site for treatment of children with MAM and PLW. Currently there are 354 SFP sites at the Health Houses (HH) supported by WFP. This program provides the standard WFP ration from at the HH. Reportedly the program is working well with good weight gains but this could not be verified by the team and there is no evidence suggesting that the current program has reduced incidence of SAM or MAM.

Geographical coverage of SFP is good in the target districts. However, coverage of treatment for SAM is extremely low. There are currently only eight OTPs in health facilities in Balochistan. This has resulted in large numbers of untreated SAM cases. The review team interviewed LHVs and LHWs as well as District Health staff who reported that they are indentifying SAM cases and making appropriate referrals to SC and OTP. However, due to distance and access, most of these cases are lost to follow up. A trained LHW is capable of treating SAM cases without complications at the Health House as part of her ongoing work. 12 Restricting the treatment of SAM to health facilities is severely hampering coverage and scale up in Balochistan.

Several key points emerge from the three provinces regarding modalities:

The impact of the large scale treatment program for children with MAM and PLW has not been determined and thus there is no evidence that the current program modality is cost effective means of reducing incidence of acute malnutrition.

All three provinces cited insufficient coverage (and absolute numbers of) government Lady Health Visitors at health facilities and particularly Lady Health Workers in the community as

12 Kate Sadler, et al. Community Case Management of Severe Acute Malnutrition in Southern Bangladesh. Save the Children/Feinstein Famine Center, June 2011. http://sites.tufts.edu/feinstein/2011/community-case-management-of-severe-acute-malnutrition-in-southern-bangladesh


http://sites.tufts.edu/feinstein/2011/community-case-management-of-severe-acute-malnutrition-in-southern-bangladesh

http://sites.tufts.edu/feinstein/2011/community-case-management-of-severe-acute-malnutrition-in-southern-bangladesh


the main reason for limiting scale up and integration. This human resource constraint limits integration, coverage, impact and implementation of the prevention package.

Effective coordination and leadership of the DoH are the hallmarks to successful integration. The DoH has a critical function in setting priorities for programming and strategic direction.

Current CMAM sites and the planned target number of sites as noted in PC-1 plans can be found in Table 3. In the pre implementation stage, considerable focus must be given to developing these plans and ensuring a strategic framework and implementation plan is put in place.

Table 3: Actual and targeted OTP and SFP sites by 2017 by province

Province District No.

Rates %NNS Baseline

Goal key performance Indicator

Current sites and planned targets to meet goalSCCurrent

SCTarget

OTP Current

OTP Target SFPCurrent

SFPTarget

Sindh 23 SAM 6.6MAM10.9

30% reduction in SAM cases

22 23 221

15 districts

Unclear

10 districtsNGOs: 4 districtsDoH: 6 districts

221

15 districtsNGOs

Unclear

10 districtsNGOs: 4 districtsDoH :6 districts

Punjab 36 SAM 4.8MAM 8.9

-OTP sites at 30% of all BHU/ RHCs

By -80% indentified enti SAM cases treated

25 36 1447 districts

93130 districts

582 districts

Unclear

Balochistan 32 SAM 7MAM 9.1

30% reduction in SAM cases

9 20 8 8 districtsDoH/Doctor

Unclear7 districtsUnclear

3457 districtsDoH/LHW

Unclear

Data sources: SC data (WHO and UNICEF); OTP/SFP Provincial Nutrition Cell: Targets: PC1 documentsSindh: PC1 2013-16 Nutrition Support Program (NSP): ($43m)Punjab: PC1 2013-16 Integrated Reproductive Maternal and Child Health (RMNCH) and Nutrition Program:( $98m)Balochistan: PC-1 2013-16 Balochistan Nutrition Program for Mothers and Children (BNPMC): ($16 m)

2.1 Mapping and program data

Mapping

Current mapping is done in conjunction with the Nutrition Information System (NIS). During the review the team found it challenging to get a grasp on the number of sites past, current and planned. For example the PC- 1 for Sindh reports 463 OTP sites and 463 SFP sites in 20 districts. At some point this changed and the current number is reported by the NIS in Sindh is 221 OTP/SFP sites (as of July 2013). WFP reported functional OTP/SFPs in Sindh as 252, an additional 30 sites compared to the NIS. In Balochistan, the number of SFP sites reported by the NIS is 289 as shown in Table 4. According to WFP and the DoH Nutrition Cell, there are currently 345 SFP sites in Health Houses. There is also discrepancy regarding the current number of SC’s in Sindh. While the most recent NIS report at time of review showed 16 SC’s, WHO reported to the team that there were 22 SC’s. Similarly in Punjab, the NIS reports 15 SC’s while WHO and UNICEF data reports show 25 SC’s currently functioning. This disparity in Punjab is in part due the fact that UNICEF is supporting some SC’s which are not reported in the total by WHO.



The number of planned OTP and SFP sites for Sindh and Balochistan is unclear and could not be obtained from the PC-1 or the NIS. Thus the basic information required for supply planning and human resource projections is not readily available.

Figure 2: NIS mapping data: July 2013

Mapping is useful in determining geographical coverage. Thus it is important to specify and color code the type of site. The current mapping used in the NIS as shown in Figure 2 does not differentiate between SFP and OTP sites and OTP only sites. This is important. In Balochistan for example there are currently only 8 OTP sites but 345 SFP sites. They are not the same sites or in the same locations.

It should be immediately evident when looking at a map that coverage of treatment of SAM in Balochistan is extremely low and action is urgently needed. Coverage of LHW’s and LHV’s should also be mapped. This would aid considerably in planning scale up.

Program data

The team found it very difficult to access basic data on programming outcomes and key indicators. The NIS is the main source for data. In addition NGO partners, UN agencies have their own systems. WHO reports separately on Stabilization Centers through the Health Management Information System (HMIS). Importantly there is very little analysis of NIS data particularly regarding data trends so that comparisons over time cannot easily be made. The exception is Punjab where the NIS is not used. In Punjab, data analysis for the last three years was readily available as shown in Figure 3. The accuracy of data is questionable largely because recording data at the base (at health facilities) is in accurate.


Table 4: Current OTP, SFP and SC sites reported by NIS, July 2013

Province #Districts#Tehsil

s#UC

Areas #SFPs #OTPs #SCsPunjab

12 43 219 58 144 15 Sindh

7 24 111 190 219 16Balochistan

10 17 43 289 8 10


Figure 3: Punjab: OTP outcome data: January 2010- June 2013

Data outcomes by province for the last six months from the NIS are shown in Figure 4. Data for all program components can be found in Annex 5. Coverage surveys to determine point prevalence have been conducted in six districts of Sindh using SQUEAC methodology. Findings reveal average point coverage of 40-65%. 13

Figure 4: OTP Outcomes by province: January to June 2013

Coverage is reported as geographical coverage only in the NIS and is very inaccurate.

Data source: NIS

A considerable amount of training has been conducted for health workers and community workers. This is reported in the NIS. Current training is mainly CMAM specific. Only the number of those trained is reported. The team looked at the total trainings provided in the last two and half years. The type of community worker is not specified so it is not possible to find the number of LHV’s or LHWs trained in identification and treatment of SAM and MAM or IYCF. In addition, many ‘master trainers’ have been trained but the quality and impact of this training is not known. It is clear that considerable capacity has been built in the last few years as shown in Table 5. However, much of the training has been conducted in an ad hoc manner and not part of a coherent scale-up plan. 13 Coverage Monitoring Network/ACF. SQUEAC Report. TMK District, Sindh Pakistan, February 2013. ACF SQUEAC Report, Dadu District, Sindh, April 2013.


From the start of the program in 2010, 123,223 children have been admitted to OTP.

With handover of the program at the end of 2012, outcomes have remained constant. Lower admission rates are attributed to fewer sites, less community screening and a reduction in caseload.

Data Source: UNICEF Punjab

Sindh: Admissions: 19,611. Cured 96%, default 4%, deaths < 1%

Punjab: Admissions: 4,245: Cured 82%, default 17 %, deaths 1%

Balochistan: Admissions: 6,550 Cured 85%, default 14%, death 1%


Table 5: Training conducted January 2011- June 2013

Province Sindh Punjab Balochistan

Trainings for health workers 31 740 Not available

Trainings of community based workers 1465 740 Not available

Staff/Counselors trained in IYCF 448 18485 6380

Data source: NIS

2.3 Quality of programming

Quality of CMAM programming as determined by outcomes is very good as shown above in Figure 4.14 In all three provinces cure rates for SAM and MAM exceed SPHERE minimum standards. Default rates are low for OTP in Sindh and higher in Punjab and Balochistan which is likely a reflection of distance and less intense community outreach. Default rates for MAM are within SPHERE standards. The mortality rates for OTP and SFP are very low reflecting extremely good and early case finding and effective treatment. However, deaths occurring in the stabilization centers are not recorded separately through the government health information system. Thus it is not possible to determine the impact of the overall SAM treatment program. Accurate SC data was very difficult to access. Where it was available, the team attempted to find an approximate mortality rate. Given the available data, the rate appeared to be very low at less than 2% (data WHO Sindh, Punjab and Balochistan). Many cases of SAM are lost to follow-up in Balochistan due to the lack of access to OTP treatment.

Coverage of treatment for SAM and MAM is difficult to determine since surveys have only been conducted in select areas of Sindh. Geographical coverage by province does not yet meet SPHERE standards of >50%. In addressing coverage, it will be essential to reach marginalized communities, urban areas and far flung areas where rates of SAM are high.

Large numbers of children screened and referred for treatment during ongoing active case finding and mass screening during campaigns and child health days. In some cases Community Resource Persons (CPRs) and other volunteers are engaged in screening and outreach activities. In Sindh, NGO recruited and paid nutrition assistants play a key role in community outreach. This accounts for the early case finding and low default rate in Sindh. In Punjab and Balochistan, the LHW has the primary responsibility for case finding.

The team found little difference in overall program quality between international and local NGOs and government led programs. However, there was a considerable difference in costs according to PCA budgets. A local NGO was approximately five times cheaper than an international NGO. The DoH in Punjab reported that government costs for SAM were considerably less than an NGO. This does not account for support from UNICEF and WFP in supplies and logistics but reflects transport costs, overheads and staffing. 15 These findings are

14 Sphere Minimum Standards (2011). SAM (cure >75%, default < 15%, deaths < 10%). MAM (cure rates >75%, default <15%, deaths <3%) www.sphereproject.org.15 RUTF accounts for 33% of the overall cost in OTP programs.


http://www.sphereproject.org/


indicative. A detailed analysis is required to look at the cost effectiveness of programming factoring in economies of scale.

Treatment of SAM (OTP)

In the last two (January 11- June 2013) over 32, 000 cases of SAM have been treated in the three provinces. In Sindh, The average MUAC on admission in Sindh and Punjab is 11.2cm.16 Given this early presentation and the low rates of oedema (less than 1%), most cases should recover within 60 days (to current discharge criteria). However, length of stay (LOS) of 81 days is much longer than expected in Sindh. This has significant cost implications. The long LOS is in part due to frequent absences and sharing. However, recording errors were also a factor. Many cases were found when the child had met the discharge criteria several weeks before. Some OTP staff had been instructed by their agency to keep children in the program longer as a policy or because of pipeline breaks in the SFP. Weights were not always recorded accurately, thus calculating average weight gain was challenging. The team found that the messages regarding the use of RUTF were not accurately conveyed or understood and other foods are often given. There was a high correlation between sites giving confused messages on the use of RUTF and low weight gains in both Sindh and Punjab. The converse was also true. In sites with good messaging and accurate recording in Punjab, weight gains were 400-600 g/week. Therefore clear messaging on the use of RUTF and community follow up is critical. It is clear that the sibling ration does little to impact weight gain or LOS.

The RUTF pipeline is stable and reliable. Interviews with community members suggest default is primarily due to distance in Balochistan and workload of the mother in Sindh and a combination of both factors in Punjab. The low default rate in Sindh, as noted above is primarily due to strong community outreach and relatively short distances to the OTP. In some cases where OTP is operating every two weeks, there is confusion regarding the definition of default. Supply of routine drugs is however erratic. At the time of the review there was very ad hoc availability of amoxicillin due to issues in the supply chain. This is important to rectify but is likely not a major factor in LOS.

OTP operates weekly and in some cases every two weeks. Static sites may be open 6 days a week, satellite sites are operated 2-3 days a week. Caseload is variable depending on how long the site had been open. Caseload ranged from 6-80 a day in Sindh and from 10-100 a day in Punjab. Experience in Punjab suggests that a caseload of 10 cases per day is manageable by the LHV as part of primary health care. In Balochistan, LHW’s estimate that average caseload would be 3-6 SAM cases/week in the Health House. The number of staff required to manage the quality treatment of SAM was found to be:

1 LHV at the health facility or 1 LHW at the HH. 1 CMW or nutrition assistant trained in IYCF counseling and prevention. As part of the government system a cleaner, store keeper and pharmacist are found at

the facility level.

Most OTP’s had reasonable wait times with the exception of one agency in Sindh that turned beneficiaries away due to very restricted opening times. Efficiency was variable with the best

16 Calculation based on 200 OTP cards from six sites in Sindh and 7 sites in Punjab.



examples, managing new admissions of SAM first. Most sites managed SAM and MAM cases together successfully. In some cases the PLW component added confusion and crowding making it challenging to effectively provide clinical treatment. Quality of care and patient interaction varied from excellent to reasonable. For the most part the admission parts of the OTP card are correctly filled out. However the clinical assessment is rarely conducted fully and the boxes checked without assessment. Weight is also not always taken or recorded correctly and thus weight gain numbers are random. Workload requirements were found to impact on the accuracy of recording on the individual OTP cards making the data unreliable.

Competency in use of the Action Protocol to determine referral of SAM with complications was good. Referrals were made appropriately. In Sindh, IP’s frequently provided transport and funds were also provided to caretakers to offset the opportunity cost of staying in the SC. No transport or funding assistance was provided in Punjab. In all sites visited referrals to SC were less than 5% of the caseload.

Treatment of MAM (SFP)

The treatment of MAM cases is managed in the following way:

At the same site and by the same staff at OTP in Sindh and two districts of Punjab At the HH managed by the LHW in Balochistan.

Program outcomes are generally good. While SFP has reportedly treated over 380,000 MAM cases over the last two years in the three provinces, there is no means of gauging impact.17 Whilst anecdotal evidence suggests weight gain and improved outcomes in communities, it is unclear if the large-scale and costly investment in treatment of MAM has reduced incidence of MAM or SAM.

The program operates every two weeks and occasionally monthly in remote locations. The pipeline of Acha Mum is reliable, but the short shelf life (6 months) means transport and storage in far flung places is challenging and results in waste. WFP is seeking means to extend the shelf life. Programs with clear and transparent criteria and good messages can effectively handle both SAM and MAM cases. In Punjab, sites with both OTP and SFP were busier than OTP only sites. This affected workload and the accuracy of recording, but it did not affect outcomes.

Treatment of PLW (SFP)

The SFP also includes the treatment of acutely malnourished PLW (MUAC < 21cm). The ration of WSB and oil is widely shared among women and children in the household. The program is popular and the food ration well-liked. The team found frequent complaints regarding the erratic availability of oil. As a high value commodity the oil is a particular draw. During the review, the WFP ration was doubled for same beneficiaries as shelf life of commodities was expiring. This caused confusion among staff and beneficiaries and increased resentment among those receiving nothing.

17 Data provided by the NIS (2011-13) indicates over 600,000 admissions in the three provinces and approximately 350,000 treated with approximately 29,000 defaults and 44 deaths.



The WSB ration is packed in 2.5kg or 5kg bags aids in distribution. The ration acts as a draw to health facilities. This has both advantages and disadvantages. In those few districts in Sindh where CMAM is implemented in a health facility, there is evidence of uptake of ANC services and family planning, and TT vaccination. It also provides an opportunity for IYCF counseling. However, the large amount of food and crowding at the site detracts from clinical management of SAM and MAM cases. The team found the distribution of iron/folate and/or micronutrient supplements to be erratic and mostly absent from sites visited. The impact of the program is impossible to gauge. Most reach a MUAC of 21cm but stay in the program a long time. Anecdotal reports suggested improved weight gains among PLW and indirect benefits gained from the opportunity to conduct IYCF counseling. The team believe that micronutrient fortified a ready to use product would be a more appropriate ration for PLW. This should be distributed through ANC or at the Health House with clarity on the purpose of the program and target group. WFP are currently developing a locally produced lipid-based nutrient supplement (LNS) PLW.

Stabilization Centers

Stabilization Centers are working well in terms of efficiency and effectiveness and safe treatment.

The pipeline of supplies (F75, F100) was good and when not available for a short period, staff was able to successfully use the local recipes in the National Guideline. Staff has been well trained in the management of SAM with complications. In some cases the SC was too over-medicalized with far too many doctors. In one SC in Sindh, the team found five doctors for 2 patients and no nursing staff. Reports of frequent staff absence and difficulties in communication between partners operating OTP and SC hospital staff in Sindh could not be verified by the team. In Punjab, SC was operated by an LHV or nurse with a doctor on rotation. Referrals to and from the SC were problematic in some cases. This is less of a problem when an LHW specifically followed the case. WHO is currently piloting an SMS referral system to attempt to make referrals more efficient.

The vast majority of cases at the SC do not come from OTP, but come via the outpatient department at the hospital (OPD). The average SC caseload was found to be on average 7-15month. On the whole, SC staff understands the purpose of the SC is to follow WHO steps 1-7 until a child is stabilized. However, some staff are using the old TFC protocols and keep children until they reach WFH <1Z. Most SC’s had a functional OTP attached to the SC ward or in a different part of the hospital. This helped considerably in follow up. A few cases from remote areas where follow- up at the hospital OTP was difficult were provided with RUTF rations for up to a month.

Most SC’s claimed to be able to manage infants effectively. This was observed in two cases where supplemental suckling technique (SST) was used successfully. The quality of IYCF counseling was variable and for the most not highly practical. Two excellent examples of SC good practice stood out. In Lahore, the SC at the Ganga Ram Hospital is led by LHVs who also work in the community. The SC is linked to the breastfeeding counseling center next door. Attention is given to addressing the underlying causes of SAM with complications including psycho-social support and bonding. The SC at Thatta DHQ Sindh had a high caseload of infants 14 Valid International


under 6 months and provided SST very successfully. SC staff led a mother-mother support group to address the key reasons for malnutrition in their infants. As a result staff had successfully reduced the re-admission rate among infants.

The amount of paper work for SC staff is extremely cumbersome and impacts on staff time for quality clinical care and support. In several sites, five cards and patient reports were being completed when one card would be sufficient.

During the review, several NGOs discussed their intention to open additional SC’s in Sindh. Given the small number of cases, the opening of additional SC’s by NGO partners beyond WHO’s planned scale up should be avoided. This is not an effective use of resources and is not sustainable. Efforts are much better focused on early identification of SAM.

2.4 Criteria and exclusion/inclusion

The team found good adherence to the National Guideline. Understanding and application of discharge criteria varied with some IPs in Sindh keeping children in the program after they had met discharge criteria (15% weight gain and MUAC >11.5cm) and some sites in Punjab discharging children at 6 weeks irrespective of whether they had met the discharge criteria.

MUAC was used for indentifying SAM and MAM cases and PLW and for admission to OTP and SFP. In a few cases weight for height was also used at the OTP site. This creates error and is labor intensive and unnecessary. Weight for height should not be used in any community based program. There is also no need for weight for height at the SC. The use of MUAC only would create harmonization between program components. The use MUAC only does not exclude SAM cases in need of treatment. 18

The use of MUAC for PLW is problematic in that it is not clearly understood by beneficiaries. Several cases of manipulation of the MUAC tape were observed in Sindh. An immediate solution is to use a color coded tape for PLW to increase transparency. However, the large food ration given to some PLW and not others in the same community was raised as an issue by community leaders, community groups and by pregnant and lactating women not in the program. In part, this confusion regarding the target criteria stems from the long-time inclusive blanket feeding programs for PLW in Sindh and Punjab. In Balochistan, where the PLW program is managed at the Health House with beneficiaries individually known to the LHW, this is somewhat less of an issue.

Infants less than 6 months are particularly likely to be excluded in OTP. Whilst some cases are referred to SC as per current protocol, many do not go or drop out. Infants less than 6 months are currently not followed in the OTP/community outreach if they refuse SC or if they default from the SC. As a result, they are lost to follow up

18 Save the Children, ENN, ACF and UNHCR. Mid Upper Arm Circumference and Weight for Height as indicators for severe acute malnutrition. A consultation of operational agencies and academic specialists to understand the evidence, identify knowledge gaps and inform operational guidance. Final Review Paper. December 2012. www.ennonline.net


http://www.ennonline.net/


The allocation of rations is linked to targets as is the renewal of a PCA/FLA. The allocation of rations is determined according to targets. In several cases the targets for SAM had been exceeded in new sites. One IP had stopped screening and referring children for fear of running out of supplies. Others had not met targets due to a low caseload. Over time the incidence of SAM and MAM should reduce assuming a program is effective. It should be clear to IPs that supply is based on admissions and they will not be penalized for exceeding or not meeting targets. Screening against targets is unnecessary. Screening, or rather active case finding should be role of the LHW. MUAC should be routinely recorded in the LHW register. The use of screening sheets is not necessary.

2.5 Infant and young child feeding

An IYCF component is included in all CMAM programs with the intended aim of addressing the underlying causes of acute malnutrition in children less than 24 months through improved feeding and care practices. High rates of acute malnutrition in infants are correlated with very low rates of exclusive breastfeeding, early introduction of other foods and liquids such as tea and inadequate feeding frequency and lack of diet diversity after 6 months. The high rates of low birth weight (LBW) babies are also important to note as these babies are more prone to becoming acutely malnourished as well as stunted.19 These causal factors are well documented. However, addressing these causes in the context of a CMAM program has proven challenging.

Most programs have a dedicated staff member for IYCF. In Sindh this is either a recruited paid staff member or less often an LHW (given a top up incentive). In Punjab, IYCF counseling is carried out by the CMW running ANC and/or the LHV/LHW operating the OTP. In Balochistan, the LHW provides IYCF counseling as part of her ongoing work. The implementation of the IYCF component is extremely variable. IYCF counseling takes place at the OTP/SFP site in a designated corner. In some sites the standard hospital curtain rail and label of ‘breastfeeding corner ‘existed only as a function. The criterion for who receives counseling at the sites is not systematic. At some sites all PLW and mothers of children in the program who are breastfeeding are referred for counseling. At other sites, only those thought to have issues were referred. At two sites visited, only those who volunteered themselves were counseled. The counseling itself varies from a dictatorial approach to an inter-personal practical approach.

The content of the IYCF counseling also varied. Some implementing partners use a rapid assessment tool to determine IYCF issues. Most counseling sessions addressed early initiation of breastfeeding, positioning and feeding on demand. Very few attempted re-lactation or could deal effectively with complicated issues. Messaging on complementary feeding was frequently found to be inappropriate and impractical. Several staff advised mothers to use Cerelac, eggs and meat when at home there was only bread, potato, curdled milk and chili peppers. The most effective counselors were experienced LHW’s who know the community well. Several LHWs gave very practical advice to mothers using food readily available in the house and how to barter and exchange items to increase diet diversity. The IYCF component for the most part does not include the care of PLW in terms of nutritional counseling and micronutrient supplementation.

19 LBW (< 2.5kg) rates: Punjab: 27.8, Sindh, 14.5 Balochistan: 24.8, NNS data 2011.



While there are many IEC materials in circulation, much of this is not useful. In Sindh, the team heard about an IYCF training box including tools for counselors, but what was in it was a mystery since we were not able to find it. There is no standard package of IYCF tools in Urdu. All sites visited had an IYCF component at the site. However, opportunities to extend IYCF to the community are very under-exploited. Several IPs had breastfeeding support groups at the site but not at the community level. IP’s in Sindh were implementing a ‘bottles for cups’ exchange. Bottle feeding is pervasive so the idea is a good one. The bottle which is highly valued was replaced with a cup without a lid. The team found many mothers who stood out as natural leaders and would make good peer counselors in the community. This would help change practice and build sustainable capacity at the community level Other innovative ideas were suggested by the Village Development Committees (VDC’s). When asked how the community could better support women to feed and care for their babies while at work in the fields, they suggested crèches and breast feeding shelters. Both ideas were accepted as feasible by the landlords interviewed in Sindh.

In urban areas, IYCF is critical, yet there are few examples of CMAM/IYCF in the mega cities. The team found an excellent model of at the Ganga Ram Hopsital in Lahore The center is a drop in and caters for all women in the nearby urban slum areas. Counseling is personal and extremely effective. The center is linked to the SC/OTP and also emphasizes psycho-social aspects of bonding and mother/baby well being.

The team attempted to gauge the impact of the IYCF component. In talking to mothers and grandmothers, it emerged that that a significant shift in breastfeeding practice has taken place in program areas of Sindh. Early initiation of breastfeeding and exclusive breastfeeding for 2- 3 months were common practice. Exclusive breastfeeding to 6 months and appropriate introduction of complementary foods was much less common.

There are currently no simple indicators to measure the impact of IYCF. The only indicator used in the NIS is ‘the number of IYCF counseling sessions.’20 This indicator revels little about the quality or impact of the IYCF counseling and is thus by itself quite meaningless. Indicators used must be simple and in line with the goals of PC-1 and integrated into the HMIS. No KAP surveys were reported at the time of the review and/or findings were not yet available. At the time of the review and IYCF consultant made recommendations for IYCF indicators. These have been revised by the team and can be found in Annex 6.

2.6 Prevention

Given a focus on treatment and IYCF, other activities such as health, hygiene and micronutrient deficiency prevention have taken a back seat. Currently, prevention interventions range in both content and style. The team found a lecture style dictatorial approach on the virtues of hand-washing at one site, while at another site an inter-active group discussion included practice of hand washing and the distribution of soap. The use of micronutrient sachets (sprinkles) is another example of variance. The use of sprinkles in practice is extremely erratic. The target

20 Total IYCF counseling sessions (Jan 11- June 13 Sindh = 29,784, Balochistan: = 1326 Punjab: = 928. NIS data July 2013.



group was unclear with IP’s providing them variously to children under five, to children less than 24 months and to PLW who were not enrolled in the CMAM program. Some provided them for 7 days and some for 15 days and many did not provide them at all. The use of sprinkles for 15 days is not effective. It requires at least 2- 3 months to treat or prevent micronutrient deficiencies. The sachets were given more as compensation than a prevention strategy.

There is no standard prevention package. Given the high prevalence of both wasting and stunting, a standard prevention package is essential. The team was unable to gauge the impact of current prevention activities. Thus there is a need both for a standard prevention package and a set of impact indicators. A suggested standard treatment and prevention package and impact indicators can be found in Annex 7.

The team did observe linkages to food security and livelihood programs in practice. Implementing partners in Sindh reported that their programs under WINS included (or planned to include) one or more of the following prevention activities aimed to reduce wasting and stunting:

Home gardens for to increase diet diversity at household level. Cash transfers for households in the poorest quintile with children 6-18 months social safety net program for PLW and/or infants of 6-24 months whose access to food

currently depends on gifts/donations

2.7 Monitoring and reporting

Monitoring

The team found numerous examples of multiple form filling and redundancy. The issue with paperwork overload can be partly resolved by removing redundant forms and streamlining paperwork. For example there is no need for an OTP or SFP card and a register. There is no need for a ration card, screening forms, or charts registering the numbers of children attending. In addition several agencies had their own forms. At the SC, multiple forms where being filled out when one SC monitoring card would suffice.

Workload has resulted in OTP cards being completed inaccurately. Therefore a simplified OTP card is required that is short enough to be filled out accurately to give better quality monitoring and more reliable data. This will simplify recording at the site and thus increase the accuracy of reporting from the base to the district level. A simplified OTP card can be found in Annex 8.Reporting requirements across all the MCH activities also need to be streamlined to give health workers more time with patients.

In Punjab, the LHW monitors MUAC of all children in the register book, this allows for effective tracking and early intervention.

Reporting



The Nutrition Information System (NIS) is complex, difficult to access to those not specifically trained to use it and resource intensive. In looking towards a sustainable integrated approach for CMAM, it is clear that the NIS will need to be simplified. An NIS ‘lite” has been developed and this is a good basis for a simplified reporting system that can be used in all provinces for harmonization.

The NIS currently records individual children. There is no need for individual child monitoring outside of a research program. In Punjab, the NIS is not used. Instead, a simple hard and soft copy format is used for reporting is used which makes data much more readily accessible and easier to understand and analyze.

SC data is reported separately through the HMIS since SC’s are based in government hospitals. In an integrated program, the harmonization of data becomes a government concern and not a cluster issue. There is a need for a simple template for data to be collated in one place. The format for collating data must include SC data. A minimal package of indicators is also needed. This package can be informed by the Minimum Reporting Package (MPR), but only one report format is essential. The indicators used should feed into the HMIS at district and provincial level. An example of a template for collating/presenting data can be found in Annex 9.

Effective monthly coordination led by the DoH in an integrated manner can help avoid these data issues. A simplified system should ensure a common monitoring and reporting tool used by all programs whether government or NGO. It should also aid in analysis.

2.8 Policy and coordination

Coherence to national and global strategies was found to be strong in all provinces at least in theory. National and global strategies such as the Pakistan Integrated Nutrition Strategy (PINS) have been adapted to provincial level. All three provinces plan to increase ‘nutrition sensitive’ programming. In practice, this policy framework is unlikely to have direct impact on CMAM outcomes. The focus for CMAM must be on integration in the health system and a clear strategic plan for scale up.

Coordination mechanisms are effective in Punjab. In Sindh, the Nutrition Cell is not as prominent in leadership and coordination, perhaps in part because the cluster is still functioning. In Balochistan, a formal coordination mechanism exists but is not currently active. Leadership and coordination by the provincial DoH is essential for the integration and scale up of CMAM and is now more appropriate than the cluster coordination mechanisms which is being phased out.

There is currently no evidence that feasible plans are in place to provide surge capacity to assist with an increased caseload of SAM in the event of an epidemic and/or natural disaster. The model for surge capacity will need to change over time as CMAM is scaled up. Government should be in a position to redeploy already trained staff to affected areas and to work with UNICEF, WFP and NGOs for additional human resources, RUTF, supplementary food, and logistical support to be able to respond to acute emergencies. For example, in the 2011 the Ethiopian emergency, although weak in several sectors, health was able to respond to increases



in acute malnutrition by supporting the government with additional supplies, logistics, and M&E to enable frontline health workers to treat more children within existing services and facilities. (see: DEC Ethiopia Real time Evaluation Report:www.alnap.org/pool/files/1381.pdf)

At the central level, the Planning Commission is the focal point for coordinating the nutrition agenda. The Nutrition Development Partners Group has taken forward the nutrition agenda including the formulation of steering committees, the technical working groups and policy guidance notes at provincial level. Inter-sectoral nutrition strategies have been developed as a basis for scaling up nutrition (SUN) membership. It is important to note, that any policy regarding CMAM must have must have buy-in at the provincial level. Thus the revision of the National Guideline for example should be informed by the significant practical experience of integrated programming at the provincial level.



3. ACTIONABLE RECOMMENDATIONS

3.1 Sustainable foundation for CMAM in policy and practice

In order to ensure effective successful integration and scale up of CMAM, a sustainable foundation must first be established. Thus the following key actions are recommended:

Human resource and technical support to the DoH/ Nutrition Cell

A coordinated effort by donors, WFP and UNICEF to provide human resource and technical support to the DoH/Nutrition Cell. This will allow the DoH to: [A] Take a leadership and coordination role. [B] Develop clear strategic priorities and policies including the essential incorporation of nutrition into contracts with partners operating BHU’s. [C] Develop clear phased plans for integration and scale up including human resource and training needs. [D] Develop emergency contingency plans for surge capacity.

Promote inter-provincial exchange visits by a DoH led delegation. This should include those directly responsible for decision making as well as technical staff responsible for programming. Specifically the exchange visits could benefit from: Successful integration of OTP into primary health care (Punjab) and government dispensaries (Sindh) ; Effective NGO handover, coordination and leadership (Punjab) and sustainable program modalities that potentially provide good coverage at the community level in rural and urban areas such as the Health House (Balochistan) and Extended Health House model (Punjab).

NGO’s should avoid parallel programming including opening of SC’s outside the government structure. NGO’s can support government priorities by: building capacity particularly at the community level; assisting government to pilot test sustainable strategies and programming in high burden but low coverage areas including urban areas.

CMAM policy is largely determined at the provincial level. The revision of the National CMAM Guidelines should be informed by the significant practical experience of integrated programming at the provincial level. The Guideline should be a standard national document. However, the protocols and tools will likely be taken and adopted and if necessary adapted and translated to suit the local context.

Capacity building

Allocate funding to the recruitment and deployment of LHW’s and advocate for the removal of current barriers that limit increasing their numbers.

Develop clear roles and responsibilities of core staff (LHW, LHV and CMW) in the management of SAM, MAM and PLW.

Pre-service and in-service training of these core staff should include the management of SAM, IYCF and the prevention package. Master trainers responsible for the training of practitioners in CMAM must have practical experience themselves.



Pre-service training for nurses includes a practical rotation at the SC. This training should also extend to OTP to give nurses a better practical experience of the management of SAM at community level and referral mechanisms.

Pilot testing effective models

In order to promote sustainable CMAM programming, the following should be pilot tested as an immediate priority:

Efficacy and cost effectiveness of in-country production of RUTF. The experience of local production of RUSF should prove a good basis from which to begin investigations, but any lower cost RUTF recipes a will require effectiveness trials in order to ensure efficacy in reatment of SAM.

Sustainable modes of implementation that potentially provide good coverage such as the Health House model.

Innovative and cost-effective ways of managing MAM and reducing incidence of acute malnutrition. The use of one product (RUTF) for SAM and MAM could be explored. Specifically, the use of short- term RUTF when MUAC is 12– 12.5cm for 7 days could be tested and analyzed to determine the impact and potential cost savings in reducing incidence over time.

Innovative means of promoting diet diversity at the household level such as home gardens small scale animal husbandry and systems of barter and exchange.

The use of a ready to use food for PLW. The LNS product under development by WFP for PLW should be tested and linked to use at ANC and the Health House.

The use of an Action Protocol specifically for acutely malnourished infants less than 6 months to determine which infants need referral to SC and those that can be managed in the community.

3.2 Programming

Quality

Integrated programming results in increased demand and uptake of other health services. Parallel programming should be avoided. In seeking to improve program quality and coverage the following key actions are recommended:

Immediately address the lack of treatment coverage for SAM cases in Balochistan through programming at the Health House.



Focus on integrated programming at the BHU/dispensary in Sindh and Punjab in the immediate term and pilot test the Health House model to promote further coverage.

Develop and test a pack of simplified standard protocols, monitoring and reporting tools in Urdu in line with the revised National Guideline.

Weight for height should not be used in CMAM programming or in community based surveillance. MUAC should be used for identification and admission to treatment. MUAC should also be used in all surveys. Use of MUAC only at the SC is simple and preferable. MUAC and weight should be used for individual child monitoring.

Remove the sibling ration from OTP/SFP programs.

Revise messaging to ensure clear communication on the use of RUTF. RUTF only should be consumed for the first three weeks of treatment. Thereafter, other family foods may be added AFTER RUTF and breastfeeding.

Ensure availability of routine drugs.

Follow up and track infants less than 6 months in OTP (see testing of an Action Protocol).

The nutritional and preventative care of PLW should be managed by the LHV and the CMW at the health facility or LHW at the Health House and linked to ANC.

IYCF

In order to strengthen implementation practice and broaden the reach and impact of IYCF interventions, the following actions are suggested:

IYCF counseling should be managed by the LHW or CMW.

All PLW should receive IYCF counseling linked to ANC at the facility and/or through the Health House at the community level.

Develop and test a standard package of tools for IYCF in Urdu. Core content should include: Breastfeeding counseling aids; suggested ideas for establishing mother to mother groups; key messages for complementary feeding with ideas for adapting these messages to the local context in order to ensure they are, appropriate, feasible, affordable and practical (AFAP); simple report form, ANC referral slip, routine prevention treatments for PLW.

Extend IYCF to the community through effective mobilization and training of peer counselors. Specifically this should include; a) Mobilizing a cadre of mothers to become peer counselors and leaders of mother to mother support groups; and b) Mobilizing Village Development Committees and landlords to support interventions that support breastfeeding mothers while working.



Revise process and impact indicators for IYCF (Annex 6).

Assess the impact of IYCF at the community level though rapid assessment methods and KAP ‘lite’ against key baseline indicators. Coverage methodology such as SLEAC and 3SM can effectively be used to collect information on behavioral change.

Prevention

Develop a standard treatment and prevention package linked to a set impact indicators. The content of the package should be in line with the prevention activities outlined in the PC-1’s and address the key causal factors of malnutrition and child illness (Annex 8 ).

Prevention messages should be feasible and practical. No more than five core messages should be given related to IYCF and health and hygiene specifically hand-washing with soap and use of ORS. These messages must be repeated often at facility, community level and practiced. Content can be informed through positive deviance investigation, focus groups and community based surveys and surveillance.

The LHW is responsible for the health and nutrition prevention in the community. In this role, she can be assisted by the various health and development committees at the local level. NGOs can assist in the development and implementation of creative approaches including; the promotion of family health action groups, the training of peer counselors and promotion of dietary diversity.

The widespread availability of mobile phones, satellite TV and radio provide ample opportunity for prevention messages via the media. Messaging should be simple and practical with a focus on breastfeeding and complementary feeding.

A baseline is required against which to determine impact. This may exist already without the need for laborious and complex baseline surveys. Impact assessment of behavior change can be conducted through KAP ‘lite’ surveys and rapid assessment methods as well as through ongoing sentinel/nutritional surveillance sites.

3.3 Monitoring and reporting

Monitoring

Current tracking, monitoring and reporting systems require streamlining and simplification to improve accurate reporting, ease of access to data and improved analysis.

Simplify the OTP card so that it can be filled out accurately to give better quality monitoring and more reliable data (Annex 8). The simplified card should be field tested.

Reporting requirements across all the MCH activities also need to be streamlined to give health workers more time with patients.



Revise LHW registers to include the tracking of MUAC. This routine monitoring allows for early identification of acute malnutrition

Streamline and remove redundant paperwork at the OTP/SFP site. The following are unnecessary: registers, attendance sheets, ration cards and screening forms.

At the SC, one card can be used to monitor inpatients. There is no need for a register.

Reporting

Simplify reporting tools for LHV at the health facility and LHW at the community level to ensure accurate reporting from the base.

Develop a simple report format that encompasses key data from SC, OTP and SFP in a readily accessible format in soft and hard copy (Annex 9). PLW data should be reported separately.

As the DOH/Nutrition Cell takes the lead in coordination (rather than the cluster), monthly report summaries should be compiled by the DOH.

Indicators used for monitoring will include a combination of process indicators for program management and impact indicators which will be a minimal package of indicators incorporated into the DHIS/MIS. The MRP can be used to inform the minimal package of indicators but the focus must be on simplification not the addition of further reporting mechanisms.

Effective methodology such as S3M should be used to map coverage on a large scale as well

as collect information on behavioral change to measure impact of IYCF and prevention interventions.

Mapping of sites must include analysis of trends past, current and planned. This is critical for planning and accurate supply management. Mapping of sites will be color coded to clearly designate OTP only sites from OTP/SFP sites and SFP only sites. This will assist in determining geographical coverage (current and planned). Mapping should also include LHW coverage overlaid with site coverage since this is essential foundation to the scale up of CMAM.



ANNEX 1: Valid International Review Team ItineraryDATE TRAVEL ACTIVITY LOCATION TEAMJuly 7 Travel to Islamabad Meeting with UNICEF Islamabad Tanner/WalshJuly 8 Discussions with UNICEF/WFP Review Team Team

Meeting with IYCF ConsultantMeetings with ACF, Save the Children and Merlin

July 9 Meeting with CMAM Task ForceMeeting with Nutrition Cluster

July 10 Meeting with Planning CommissionMeeting with National Disaster Management Authority

SINDHJuly 11 Travel to Karachi Meetings with UNICEF staff Karachi TeamJuly 12 Meetings with Nutrition CellJuly 13 Field visit preparations July 14 Travel to Umerkot Meetings with Shifa Umerkot Team

Night visit to Umerkot DHQ SC Walsh/BandaJuly 15 Umerkot DHQ SC Walsh

Umerkot DHQ OTP/SFP Shifa Banda/TannerInterviews with outreach workers WalshInterviews with mothers Banda/TannerShifa OTP/SFP site at Kunri Memon Banda/TannerBreastfeeding support group at site TannerFocal group with Landlords and VDC BandaFocal group in community Banda/TannerSave the Children OPT/SFP site at Bostan WalshObserved OTP/SFP/Screeningand EPI WalshCommunity visits of beneficiaries in programme Walsh

July 16 Travel to TMK TMK DHQ SC TMK WalshACF supported OTP/SFP at DHQ Banda/TannerIYCF counseling TannerObservation of SFP and screening BandaACF OTP/SFP site at Mazar Pur Tanner/WalshFocus group discussions with PLW BandaOTP review WalshACF OTP/SFP at Jansan Sombro Banda/WalshInterviews with mothers and grandmothers TannerACF Field Office meeting TeamSC 1 at LUMHS TeamSC 2 at LUHMS Team

July 17 Travel to Benazir Abad HANDS OTP sites Benazir AbadIYCF interviews TannerOTP review TannerFocus groups discussions with caregivers BandaHANDS OTP site at Sakrand Walsh OTP review WalshObserved breastfeeding lecture WalshInterviews with mothers and CPRs WalshBriefing and field office meeting Hands Team

July 18 Travel to Thatta Meeting with Merlin at Field office Thatta TeamMerlin OTP/SFP site at Sher Ali Shah TannerDiscussions with staff at dispensary TannerFocus group with beneficiaries in the community TannerMerlin OPT/SFP site at Var Walsh/BandaObservation and review of OTP/SFP WalshDiscussions and interviews in the community Banda

Travel to Karachi TeamJuly 19 Debrief presentation Karachi Tanner

Discussion with Nutrition Cell, UNICEF, WFP Team



Meeting with HELP staff/DS Akram Team

PUNJABJuly 20 Travel to Lahore Meeting with UNICEF and WFP Lahore TeamJuly 21 Document review and field trip planningJuly 22 Meetings with Director General Health Services, Provincial

Director National ProgramSC and Breastfeeding Centre/Sir Ghanga Ram Hospital

July 23 Meeting with CMAM implementing partnersTravel to Multan Multan Walsh/Banda

July 24 Travel to Quetta SEE BELOW TannerJuly 24 Travel to Rajanpur OTP at BHU Saleem abad Rajanpur Walsh/Banda

OTP at BHU BukhraBHU/RHC at Kot MittanMeeting with EDO Health and Nutrition Focal Point

July 25 Travel Muzuffargrah OTP at BHU Jadday Wala MuzuffargraOTP at BHU JaggatpurSC at Kot AdduMeeting with EX-PD of Health Sector Reformt and DCO Meeting with EDO Health, DCNP MuzuffargarhSC at Children’s Hospital Multan

July 26 Travel Layyah OTP at BHU 36/TDA LayyahOTP at BHU Jharkil SC DHQ LayyahMeetings with EDO Health and Nutrition Focal PointDebriefing Multan Walsh/Banda

July 27 Travel Lahore/Islamabad

Walsh Banda

BALOCHISTANJuly 24 Travel to Quetta Meetings with UNICEF and WFP Quetta TannerJuly 25 Meetings with district level staff from Noshki (LHS, LHWs,

LHV District Coordinator, Medical Officer)Meeting with implementing partners

July 26 Meetings with Nutrition Cell Meetings with Director General - HealthMeeting with Provincial Coordinator National Programme

Travel to Islamabad TannerISLAMABADJuly 28 Presentation preparation Islamabad TeamJuly 29 Debrief with key stakeholders

Guideline review and recommendations/CMAM Task ForceDebrief with UNICEF and next steps

July 30 Meeting with NIS Task Force TannerFollow up on Guidelines

July 31 Depart Islamabad Team



ANNEX 2: Key ContactsISLAMABADGovernment- FederalMohammed Yahoob Nutrition Advisor Planning CommissionAli Ahmad Khan Federal Nutrition Officer Planning CommissionDr Aslam Shaheen Chief Nutrition Planning CommissionDr. Sabrina Durrani Deputy Director DRR II/ Nutrition Cluster Co-Chair National Disaster Management Authority (NDMA)UN AgenciesSilvia Kaufmann Chief Nutrition UNICEFSayed Saed Qadir Nutrition Officer UNICEF Qutab Alam NIS Officer UNICEFMegan Gayford National Nutrition Coordinator UNICEFTeshome Feleke Nutrition Officer UNICEFKim Blechynden Consultant IYCF/CMAM UNICEF Mona Shaikh Nutrition Officer WFPGhulam Abbas Abass Nutrition Officer WFPTahir Namwaj Nutrition Officer WFPMamoona Ghaffar Nutrition Officer WFPMargarita Lovon Consultant Stunting Prevention Study WFPNatiq Kazhi Information Officer WFP/NIS Working GroupHadia Nusrat Gender Equity Advisor UN WomenImplementing PartnersDr. Ibrahim Feyissa Country Nutrition Coordinator Johanniter InternationalErin Rae Hutchinson Country Director ACF Shahid Faizal Nutrition Coordinator ACFDr. Asif Iqbal Nutrition Manager Save the ChildrenOnno van Manen Director Program Development Save the ChildrenDr. Qudsia Uzma Director Health and Nutrition Save the ChildrenAsma Badar IYCF Advisor Save the Children/Lead IYCF Task ForceDr. Farhat Munir Senior Program Officer National Rural Support Program (NRSP)Aliya Taylor Program Coordinator Community Development Organization PakistanDr. Wisal Mohammad Khan Nutrition Coordinator/ CMAM Task Force MerlinOther OrganizationsAbdul Reham National FFP Officer USAID/FFPClemantine Catoni Technical Advisor ECHOSINDHGovernmentDr. Dureshehwar Khan Provincial Nutrition Focal Point Nutrition Cell (Dept Health)Dr.Zaineb Parvez Nutrition Program Officer Nutrition Cell (Dept Health)Dr. Abdul Sattar Nutrition Focal Point Umerkot District UN AgenciesDr. Mohammed Najeeb Cluster Coordinator UNICEF Eleonora Genovese Child Survival and Development Specialist UNICEF Dr. Mazhar Alam Nutrition Officer UNICEFAsim Younis Nutrition Information System UNICEF Dr. Nisar Ahmed Memon Provincial Nutrition Officer WHO Sub Office Dr. Leesham Noor Shaikh Provincial Nutrition Officer WHO Sub Office Dr Yasit Ihtesham Nutrition Officer WFPImplementing partnersDr. Hanif Memon Field Director Merlin Thatta Shiaster Jaabeed Nutrition Coordinator Shifa FoundationSayeed Jawd Iqbal District Program Coordinator HANDSGaetan Pietquin Field Coordinator ACF SindhOther OrganizationsDr. Yasmeen Shakeel Program Manager Health and Education Literacy Program HELPDr. Amara Shakeel Project Coordinator HELPProfessor Salmah Shaikh Dean of Faculty LUHMS HyderbadPUNJABGovernment Dr Tanwir Ahmad Shaiq Director General Health Services Department of HealthDr. Akhtar Rasheed Provincial Coordinator National Program for FP and PHCDr. Amara Khan Nutrition Officer National Program for FP and PHCDr. Mohammed Ahmed Program Manager Food and Nutrition /DOHSadia Shauket Lady Health Visitor Breastfeeding Counsellor Sir Ganga Ram Hospital/Breastfeeding Support Centre



UN AgenciesDr. Ketsamay Rajpinthon Head of Provincial Office UNICEFDr. Qurrat-ul Ain Nutrition Officer UNICEFUzma Khurram Bukhari Nutrition Officer UNICEF Salma Yaqub Nutrition Officer WFP Shahzada Rashid Mehmood Chief Provincial Officer WFP Dr. Sadia Azam Nutrition Officer WHOOther OrganizationsDr. Munir Akhtar Saleemi Professor Dept Social /Preventive Paediatrics, Sir Ganga Ram Dr. Farhat Munir Senior Programme Officer National Rural Support Program (NRSP)Abdul Nauman Programme Coordinator Johanniter InternationalKalim Kirmani Programme Coordinator Muslim AidBALOCHISTANGovernmentDr. Masood Nousherwani Director General Health ServicesDr. Noor Qazi Provincial Coordinator National Program for FP and PHCDr. Ali Nassar Bugti Deputy Director Nutrition CellHabibur Rahman Provincial Coordinator Nutrition CellMohammed Sheraz Information Management Nutrition CellZaheer Khan Data Analyst Nutrition CellSidra Khusid Social Mobisation Expert Nutrition CellDr. Zafarullah Medical Superintendent District NushkiDr. Fareed Ahmed Coordinator National Program, NushkiZahoor Ahmed District Nutrition Coordinator District NoshkiMeena Kumari Lady Health Worker District NoshkiSahira Younas Lady Health Worker Supervisor District NoshkiMs. Irum Lady Health Visitor District NoshkiUNDr. Mohammed Amjan Ansari Health and Nutrition Specialist UNICEFDr. Mohammed Faisal Nutrition Officer UNICEFKulsoom Bugti Provincial Nutrition Officer WHOZoheb Qasim Program Officer WFPNicole Carn Nutrition Officer WFPIPsSharaf Ud-Din Program Coordinator Poverty Alleviation OrganisationSheraz Ali Baloch Program Manager Poverty Alleviation OrganisationHassan Hasrat Director Society for Communication Action ProcessQari Khan Nutrition Officer Society for Communication Action ProcessMahir Ali Program Manager Global Movement of Children and Women



ANNEX 3: Documents Reviewed

Food Insecurity in Pakistan. Sustainable Policy Institute/SDC/WFP. 2009.National Rural Support Program Review and Update. April 2013.National Nutrition Survey. Planning Commission/UNICEF/Aga Khan University, 2011.Pakistan Integrated Nutrition Strategy (PINS) 2011.Sindh Intersectoral Nutrition Strategy (2012).Punjab Integrated Nutrition Strategy (2012.)Nutrition Cell, UNICF/WFP/WHO. Nutrition Highlights, 2012.Nutrition Cell Balochistan. Brief of Nutrition Program, 2013Strengthening Comprehensive Nutrition Intervention for Women and Children of Balochistan. AusAID/UNICEF 2012.Punjab Tehsil Based Multiple Indicator Cluster Survey (MICS), UNICEF 2007-8.Punjab Multiple Indicator Cluster Survey (MICS) Bureau of statistics, Planning and development Department, UNICEF 2011,Punjab Nutrition Response Plan. Department of Health, Government of Punjab, 2012Punjab Nutrition Guidance Policy Note. December, 2012Pakistan Demographic and Health Survey (PDHS) Preliminary Findings 2012-13. Department of Health, Government of Punjab. Integrated Reproductive Maternal Newborn & Child Health (RMNCH) and Nutrition Program. Planning Commission – Performa 1: 2013-16Government of Sindh, Department of Health. Nutrition Support Programme for Sindh (NSP), Planning Commission Performa 1: 2013-16Department of Health, Government of Balochistan. Balochistan Nutrition Programme for Mothers and Children. Planning Commission Performa 1: 2013-16Flood Affected Surveys (FANS), Sindh. UNICEF/ACF, November 2010Flood Affected Surveys (FANS), Punjab. UNICEF ACF/Government of Punjab. January 2011.Nutrition Cluster Evaluation Pakistan Flood Response. September, 2011.Evaluation of CMAM, Pakistan Country Case Study of KhyberPakhtunkhwa (KP) Province. UNICEF. September, 2012.Department of Health, Punjab. Chief Minister’s Health Initiative for Attainment and Realization of MDGs (CHARM). Provision of 24/7 EmONC Services at Selected Health Facilities. National Program for FP and PHC. Annual Reports 2011, 2012.World Food Programme Nutrition Bulletins 2012, 2013.World Food Programme. Protocol for MAM and PLW, 2013.National Guidelines for the Management of Acute Malnutrition (Draft Form), 2009.Punjab Nutrition Programme Brief September 2010- June 2013. UNICEF and WFP. July, 2013.World Health Organization. Draft Recommendations for the Outpatient Management of SAM, 2012.Nigel Nicholson. European Commission Nutrition Advisory Service ( EC-NAS). Mission Report Pakistan. June, 2013.Nutrition Cluster Evaluation Pakistan Flood Response. September, 2011.Evaluation of CMAM, Pakistan Country Case Study of KhyberPakhtunkhwa (KP) Province. UNICEF. September, 2012.Department of Health, Punjab. Chief Minister’s Health Initiative for Attainment and Realization of MDGs (CHARM). Provision of 24/7 EmONC Services at Selected Health Facilities. National Program for FP and PHC. Annual Reports 2011, 2012.World Food Programme Nutrition Bulletins 2012, 2013.Coverage Monitoring Network/ACF. SQUEAC Reports. TMK District, Sindh Pakistan, February 2013 ACF SQUEAC, Dadu District, Sindh, Pakistan April 2013



ANNEX 4: Methodology

Quantitative data:

The team compiled and reviewed quantitative data from secondary sources including current and previous survey reports to determine trends. The Nutritional Information System (NIS) was used to attempt to assess incidence, current caseload, seasonal variation caseload and trends over time. Other data information systems in current use such as the WHO SC reporting system, the Minimum Reporting Package (MRP) for CMAM), Management Information System (MIS), and Distinct Information Systems (DIS) were also assessed for validity, appropriateness and possible duplicity. Coverage survey reports were reviewed to determine quality and program effectiveness. To date one report from two districts in Sindh is finalized. Another survey has recently been completed in three further districts in Sindh and findings are pending. Data on the number of trainings conducted for health workers and community staff such as LHWs was also be collated.

Qualitative data and information:

The team conducted semi- structured interviews with the key stakeholders at national and provincial level and at the program implementation level. This included meetings, discussions and interviews with the Planning Commission, Ministry of Health Services, National Disaster Management Authority and Department of Health at provincial level, bilateral donors, international and national NGO implementing partners, CMAM Task Force, Nutrition Cluster, UNICEF and WFP. Field level informant interviews and semi-structured focus group discussions will be held with program managers, health and community workers, community members (both male and female), mother support groups and beneficiaries in order to assess quality of the program The team explored community perceptions regarding CMAM and issues of inclusion/exclusion in programming. Qualitative data found in the SQUEAC coverage surveys will be analysed and verified to determine barriers to access and uptake of services. Knowledge Attitude and Practice (KAP) surveys or equivalent were looked at (where they existed) in order to determine behavioral changes at community level.

Informative and contextual information:

The team looked at existing strategic frameworks and operational plans such as the Inter-sectoral Nutrition Strategy (2012) and the Pakistan Integrated Strategy (2012), and current Planning Commission 1 (PC-1) operational plans at the Provincial level. The team will also investigate and assess the appropriateness and relevance of current and proposed operational research. The team reviewed the current National Guideline and existing protocols as well as the proposed d integration of a chapter on IYCF in the National Guideline.

Triangulation:

The combined multiple sources of quantitative and qualitative data and information to circumvent bias that comes from single informant, data source or concept. The extent to which donor requirements and priorities are harmonious or conflict with national and provincial priorities was also appraised by exploring multiple viewpoints. In order to avoid bias and ensure key issues were addressed, the team used quick assessment checklists at the program site and community level. Where access was and for gender or language reasons, the list was given to a local staff member travelling with the team and later cross-checked with a team member to derive the critical information



Data and Information collection methods

Objective Source of data/information Purpose Nature of data

Program relevance and appropriateness

Strategies, policies, proposals and reports at national and provincial level

Appropriate and relevant response to needs and priorities and possible redundancy/duplicity of strategies and operational plans

Informative/ contextual

Observation of intervention modalities and activities

Informant interviews with program staff, beneficiaries and community

Appropriate response to need as determined by high levels of acute malnutrition in specific target groups

Relevance to local authorities and communities, caregivers (perceived need)

Qualitative

Program effectiveness and coverage

NIS data and reportsSQUEAC survey reportsTarget and screening figures (NIS)

Caseload data

Training sessions for health workers, LHW’s and community workers

KAP surveys, causal analysis

Determine program effectiveness by outcome and coverage dataDetermine referral between componentsAccuracy and use of targets and screening

Incidence rates for SAM and MAM

Contribution of program to capacity building of health system

Extent to which IYCF, IEC and prevention components have impacted on caring and feeding practices

Quantitative

Observation of treatment at SC/OTP/SFP sites/attitude of staff

SQUEAC survey analysis

Interviews and focus group discussions at community level

Effectiveness of training and mentoring applied in practice

Barriers to access and uptake of services and reasons for default

Cross check extent to which IYCF, IEC and prevention components have impacted on caring and feeding practices and identify gaps and cultural constraints

Qualitative

Program efficiency and quality of services

NIS supply data

Track NIS reporting mechanism from site to provincial and national level

Review of SC/OTP/SFP admission and discharge cards

Reliable supply pipeline management

Suitability of current monitoring and reporting mechanisms, identification of gaps and need for streamlining

Cross check on reliability of data, reasons for default

Quantitative

Observation and key informant interviews on regularity of OTP servicesObservation of supply pipeline and storage of RUTF/RUSF/WSB/HEB and F75/100/Essential drugs and equipment such as MUAC tapes

Observation of use of nutritional products/medications at household level and key informant interviews

Focus groups on community understanding of services (wait times, criteria, access, rations)

Verification of reliable supply pipeline, storage, quality of nutritional treatment

Utilization and effectiveness of nutritional treatment, sibling ration, key messages and impact on breastfeeding/complementary feeding

Analysis of demand driven service and quality of components from user view and possible reasons for default

Possible reasons for absence and default/use and misuse of treatment/rations

Qualitative



Observation and key informant interviews regarding innovations to improves efficiency or quality

Seek out best practice and lesson learned and factors contributing (or not) to quality standards

Informative/contextual

Sustainability and scale up

Tracking of NIS data from site to provincial level

Tracking supply chain and long term commitments to procurement/local or in-country production

indentify gaps and assess the need for streamlining of monitoring and reporting

Feasibility of scale up

Quantitative

Observation and interviews on of RUTF/essential drugs use and availability

Observation at SC/OTP/SFP sites at health facility

Observation and interview with community health workers and community key informants

Interviews with provincial and national government

Reliable and sustainable supply pipeline and channels

Feasibility of CMAM integration into health services such as BHU in given context

Determination of capacity at community level for potential scale up

Determination of capacity gaps at government level

Qualitative

Analysis of funding cycles (NGO, WFP/UNICEF PCA/FLA and provincial PC1

Analysis of funding allocation by district and program component

Determine availability of government/donor to assess financial feasibility of scale up

Determine feasibility ad appropriateness of funding prioritization of components, target groups and districts

Informative/contextual

Program Impact (actual and potential in raising nutrition profile)

Observation and key informant interviews in the community

Historical trends and interviews with program staff

Semi- structured interviews with key stakeholders at national and provincial and district level

Program contribution to raising awareness of acute malnutrition in the communities and health sector

Extent to which CMAM program has placed nutrition on the policy and development agenda and uncovering of gaps potentially hindering sustainability and scale up.

Commitment to national and global scale up initiatives (e.g. SUN)

Qualitative/Informative

Cross cutting issues Observation of and participation in coordination mechanisms

Observation at sites and in the community

Analysis of available causal analysis information

Frequency and effectiveness of vertical and horizontal coordination and involvement of other sectors in planning and implementation and coordinated response to demonstrated needs.

Equity issues in service delivery, participation/access and staffing

Assessment of principle causes of acute malnutrition (food insecurity/care/health)

Policy issues Observation and cross check on use of national protocols at site

Adherence or adaptation to national guidelines and identification of need for adaption to the national guidelines



ANNEX 5: Program Data (NIS January 2011 – June 2013)

SINDH BALOCHISTAN PUNJAB

YEAR 11 12 13 Total 11 12 13 Total 11 12 13 Total

OTP sites 223 170 224 617 13 85 08 106 135 240 144 519

Admissions 32,992 51,942 19,611 10,4545 4,624 9,578 6,550 20,752 76,096 33,439 4,245 76,096

Cure 12,273 20,474 7,419 40,166 3,722 8,271 5,135 17,128 25,296 20,643 5,202 25,296

Default 962 2029 243 3,234 677 1,270 843 2,790 6,749 4,044 1134 6,749

Death 26 85 32 143 38 49 35 122 23 24 74 23

SFP sites 223 170 190 583 N/A 215 345 560 135 240 58 519

Admissions 91,538 148,793 36,972 277,303 Not available

37,053 28,116 65,169 248,504 97,255 25,869 248,504

Cure 40,515 62673 12,805 115,993 Not available

26,678 10,483 37,161 80,608 61,539 5753 80,608

Default 1,579 2,878 124 4,581 Not available

5,372 2,271 7,643 11,707 6,914 229 11,707

Death 20 6 6 32 Not available

0 0 0 12 9 0 12

PLW 0 N/A

Admissions 44,518 76,722 17,973 139,213 Not available

18,515 20,102 3,8617 137,503 61,078 13,090 13,7503

Cure 15,228 19,460 5,341 40,029 Not available

14071 6,518 20,589 40,904 40,768 1915 40,904

Default 317 742 18 1,077 Not available

2221 1,099 3320 5,948 4,533 225 5,948


0 0 0 4 2 0 4

SC sites 9 16 16 41 N/A 07 10 10

Admissions 879 1,251 956 3,086 Not available

3,542 888 1,795 Not available

Not available

Not available

Not available

Discharges 623 1,092 797 2,512 Not available

3,195 706 1,496 Not available

Not available

Not available

Not available

Default 4 108 55 167 Not available

277 39 114 Not available

Not available

Not available

Not available


49 2 2 Not available

Not available

Not available

Not available

Data extracted from the NIS (July 2013)



ANNEX 6: IYCF Indicators

Recommended by IYCF Consultant Suggested by review team

Health facility: maternal nutrition & IYCF interventions MCHN registers at health facilities / OTP/ MAM card % relevant health staff trained on counseling

% health facilities with HR assigned for IYCF counseling

% of caretakers of under two children who received IYCF counseling

% of mothers attending ANC who received iron – folic acid supplementation

Mother counseled on exclusive breast feeding Mother counseled for appropriate complementary feeding

ANC register (Pregnant women)

Received iron/folate Counseled in early initiation of BF and exclusive breastfeeding

Community IYCF counseling LHW register % targeted pregnant women in last trimester counseled for early initiation and exclusive BF

% targeted mothers with child <6months counseled for exclusive breast feeding

% targeted mothers with child 6-23month counseled for appropriate complementary feeding

Mother counseled on exclusive breast feeding Mother counseled for appropriate complementary feeding PLW Counseled in early initiation of BF

Communication Report format % of Health committees (out of the total) in the targeted area which provided messages on IYCF %of PLW and Mothers of children <2 in the targeted area reached with IYCF message.

Process indicators

#% Mothers counseled on exclusive breast feeding

#%Mothers/caretakers counseled for appropriate complementary feeding

#/% PLW counseled in early initiation of BF and exclusive breastfeeding

Impact indicators ( HMIS)

% mothers initiating breastfeeding within one hour of birth

% mothers exclusive breastfeeding until 6 months

% Children 6-23 months fed in accordance with three practices (food diversity, feeding frequency, consumption of breast milk or animal milk)

#/% PLW receiving iron/folate

Note: ANC data on PLW is reported separately in an integrated system. The following indicators should be reported through ANC:

# % of pregnant women attending ANC who received iron – folic acid supplementation#/%#/% PLW counseled in early initiation of BF and exclusive breastfeeding



Annex 7: Treatment and Prevention Package

What Where Suggested Impact indicators (HMIS)

Treatment

Treatment of SAM without complications

BHU/RHCHealth House

% cured

% death

% coverageTreatment of SAM with complications

Stabilization CenterDHQ Hospital

IYCF

Breastfeeding promotion, support and counseling

BHU/RHCHealth HouseCommunity though peer counselors and support groups

% mothers initiating breastfeeding within one hour of birth

%mothers exclusive breastfeeding to 6 months

Complementary feeding from 6 months

% of children 6-23 months fed in accordance with 3 practices (food diversity, feeding frequency, consumption f breast or animal milk

Deficiency Prevention

Micronutrient sachets (sprinkles) 6-24 months for 2-3 months (All children not enrolled in OTP/SFP)

BHU/RHC (ANC)Health House

% reduction in anemia (against baseline) 6-24 months

Iron/folate, to all Pregnant women (all married women in Punjab)

% reduction in anemia (against baseline) PLW - married women

Vitamin A to post partum women and children 6-59 months

Campaigns/health days % vitamin A coverage (against baseline)

Deworming all children 12-59 months

% children dewormed (against baseline)Health and Hygiene

Hand-washing and soap distribution

BHUHealth HouseCommunity groups

% reduction in watery diarrhea against baseline

Water purification

ORS and Zinc to children < 5 with diarrhea

Measles vaccination all children above 6 months BHU/RHC

Campaigns/ health days% vaccination coverage against baseline



ANNEX 8: Suggestion for Simplified OTP Card (front)

ADMISSION DETAILS: OUTPATIENT THERAPEUTIC PROGRAM

Name Reg. No

Address

Age (months) Sex M F Date of Admission

Admission Direct from Community From SFP From

SC From OPD SC Refusal

Admission Anthropometry

Weight (kg) MUAC (cm)

Oedema 0 + ++ +++

Other reason for admission (specify)

History

Diarrhoea Yes No Stools / Day 1-3 .4-5 >5

Cough Yes No

Appetite Good Poor None Breastfeeding Yes No

Mother counseled on breastfeeding Yes No Mother/caretaker counseled on

complementary feedingYes No

Any relevant history

Physical Examination on ADMISSION

Respiration Rate (# min) <30 30 -

39 40 - 49 50+ Chest Retractions Yes No

Temperature (0C)

Routine Medication

Drug Date Dosage Drug Date Dosage

Vitamin A Amoxicillin

Mebendazole Anti malarial



ANNEX 8: Simplified OTP Card (Back)

FOLLOW UP: OUTPATIENT THERAPEUTIC PROGRAM

Name Registration Number

Week ADM 2 3 4 5 6 7 8 9 10 11 12

Date Anthropometry

Weight (kg) Weight loss * (Y/N) * * MUAC (cm) Oedema (+ ++ +++)

* Weight changes: Marasmic : if below admission weight on week 3 refer for home visit. If no weight gain by week 5 refer to SC.

Clinical Exam and Action

Is child clinically well? Yes/No? If not note date, problem, and

action taken

Transfer to SC (write T SC and date of transfer)

RUTF and IYCF

RUTF Test Good/Poor/Refused RUTF (# sachets) Mother counseled on breastfeeding (Y/N)Mother/caretaker counseled on comp. feeding (Y/N)Name of Examiner OUTCOME ***

*** A= absent D= defaulter (3 consecutive absences) T SC= transfer to SC X= died SFP= discharged cured RT= refused transfer HV= home visit NC= discharged non-cured

** Additional notes



ANNEX 9: Illustrative Template for Reporting and Collating Information

OTP REPORT

Month

Total in program at beginning of month

IN

Returning from SCOUT

Transferred to SC

NEW

Oedema

MUAC <11..5cm

Infant < 6 months

Other

TOTAL ADMISSIONS

EXITS Discharge cured

Death

Default

Non-responder

TOTAL EXITS

TOTAL IN OTP AT END OF MONTH

SFP REPORT

Month


NE W

MUAC 11.5-12.4 cm

Other

TOTAL ADMISSIONS

EXITS Discharged curedDeath



Default

Non Responder

TOTAL EXITS

TOTAL IN SFP AT END OF MONTH

SC REPORT

Month


Transfers from OTP

Transfers back to OTP

NEW Oedema ++/+++

MUAC< 11.5cm

Infants < 6 months

TOTAL ADMISSIONS

Transfers from OTP

EXITS

Discharged

Death

DefaultReferred out of SC for medical care or non response

TOTAL EXITS

TOTAL IN SC AT END OF MONTH

Suggested additional information for report formats

OTP (circle) Weekly Every 15 days

Other

SFP (circle)) Every 15 days Every month Other

Number of OTP sites Current Planned

Number of SFP sites Current Planned

IYCF

Number of mothers counseled on exclusive breast feeding

Number of mothers/caretakers counseled for appropriate complementary feedingPrevention

Number of children 6-24 months receiving micronutrient sachets for 2 monthsNumber of children receiving ORS/Zinc for diarrhea



Training

Number LHWs trained in management of SAM and active

Number of LHWs trained in IYCF counseling

Number LHW’s provided IYCF tool kit

Number CMWs trained in IYCF

Number LHV’s trained in management of SAM and active

Notes

This is illustrative. A final format will need to be developed and tested

Data and information on PLW and associated impact indicators should be reported separately

Report data does not need to be segregated by gender. This has proven to be redundant information and is time consuming to collate.

Rates of weight gain and length of stay should not be included in a simple report format. Where weight gain is investigated and reported during monitoring/supervisory visits, it should be by g/week not by day.


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