Provincial Inception Meeting Report- Sindh
DISCLAIMER
This document is an output from a project funded by the UK Department for International Development (DFID) and Australian Agency for International Development (AusAID) for the benefit of developing countries. The views expressed and information contained in it are not necessarily those of or endorsed by DFID, AusAID or the Maternal and Newborn Health Programme Research and Advocacy Fund(RAF), which can accept no responsibility or liability for such views, completeness or accuracy of the information or for any reliance placed on them.
ACKNOWLEDGEMENT
‘Studying the knowledge, beliefs and practices of unmarried and married adolescent girls with respect to nutrition and on the sources of nutrition information the adolescents have access to and use’ is a project funded by the Maternal and Newborn Health Programme Research and Advocacy Fund (RAF) and is implemented by Fatima Memorial Hospital, in collaboration with its implementing partner Nur Center for Research and Policy (NCRP).
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CONTENTS
Disclaimer............................................................................................................................................................... 2 Acknowledgement .................................................................................................................................................. 3 Contents ................................................................................................................................................................. 4 Introduction ............................................................................................................................................................ 6 Objective of meetingS in provinces ................................................................................................................... 7 Specific Objectives of thE seminar held in SINDH ........................................................................................... 7 Scope .................................................................................................................................................................. 7 Participant Profile ................................................................................................................................................... 8 Meeting Methodology ............................................................................................................................................ 8 Proceedings ........................................................................................................................................................ 8 Situation Analysis: Nutrition related issues in sindh Dr Asif Aslam, UNICEF, Sindh office) ................... 8 Nutritional Status of Adolescent Girls & its implications for MNH Outcomes – An Overview of the RAF-funded Research Study (Dr. ShabnUm Sarfraz, Chief Operating Officer, NCRP-FMS) .................. 9 Discussion ........................................................................................................................................................ 13 Closing comments by the PRINCIPAL INVESTIGATOR .................................................................................. 14 RecommendationS of Participants ........................................................................................................................ 14 Annex 1- Introduction to FMH ................................................................................................................... A Annex 2- Background of Meeting .............................................................................................................. B Annex 3- Agenda ........................................................................................................................................ C Annex 4- Participants’ Registration and Attendance (1 of 7) .....................................................................D Annex 4- Participants’ Registration and Attendance (2 of 7) ..................................................................... E Annex 4- Participants’ Registration and Attendance (4 of 7) ..................................................................... F Annex 4- Participants’ Registration and Attendance (5 of 7) .................................................................... G
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Annex 4- Participants’ Registration and Attendance (6 of 7) .....................................................................H Annex 4- Participants’ Registration and Attendance (7 of 7) ...................................................................... I Annex 5- Feedback Form ............................................................................................................................ J Annex 6- Pictures from the Provincial Inception Meeting, Punjab ............................................................ K
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INTRODUCTION Nur Center for Research and Policy (NCRP) and the Sindh government organized a joint seminar for the dual purpose of initiating dialogue with relevant stakeholders for the development of strategy as a follow up to the recently formulated Inter-Sectoral Nutrition Policy Guidance and Strategy Sindh (INSS), and to place in this context the multicenter national adolescent nutrition study led by NCRP. Recognizing the implications of high levels of malnutrition and efforts to achieve Millennium Development Goals (MDGs), the Government of Sindh (GoP) and its partners decided to develop an Inter-Sectoral nutrition Policy Guidance and Strategy involving representatives of key development sectors which, collectively, have considerable potential for reducing malnutrition significantly in the province. The seminar brought together members of the Department of Health, academia, researchers and development professionals who have been playing an active role in the field of Nutrition (participants’ list attached as Annex I). The seminar proceedings started with a situation analysis of nutrition indicators and nutrition related issues in Pakistan particularly the Sindh province, via a presentation made by Dr. Dur e Shahwar, Provincial Nutrition Focal Person, Nutrition Cell, Health Department, Government of Sindh. Representatives from international organizations and key government institutions shared their perspectives with participants. This was followed by a participatory discussion. Participants endorsed the areas of focus of the Sindh guidance document which outlines the vision for investment in nutrition as well as need for intersectoral partnerships in this regard. The discussion also added additional actions and recommendations which could further enrich Nutrition policy in Sindh as well as the rest of the country. Some participants also identified areas for improvement in the current version of the INSS, and suggested recommendations for improvement. The closing remarks were made by Dr. Shabnum Sarfraz Chief Operating Officer, Nur Center for Research and Policy, implementing partner of Fatima Memorial Hospital, and Principal Investigator, FMH-RAF Nutrition Research Project. She expressed her organization’s commitment to partner with stakeholders, development partners and government institutions to address the issue of malnutrition in relation to various sociodemographic factors, and particularly to address the nutritional needs of poor and marginalized adolescent girls. Nur Center for Research and Policy (NCRP) is a technical arm of the Fatima Memorial Hospital (FMH) and is currently implementing a nutrition research project, supported by the Research & Advocacy Fund (RAF). The evidence-generated is expected to make a compelling case for prioritizing and strengthening nutritional aspects of health and other programs. The project hereby has policy implications and is being undertaken at an opportune time when the provinces are working on developing their nutritional strategies. It aims to document the knowledge, beliefs and practices of unmarried and married adolescent girls with respect to nutrition; and record different sources of nutrition information. It also sought to determine the role and practices of stakeholders including school teachers in promoting adequate nutrition among students. Stakeholders also included health policy-makers and managers so that their views and knowledge contributes to better future interventions. The study findings are expected to contextualize an array of possible factors influencing nutritional status of marginalized girls as well as adolescent mothers, with the purpose of
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informing MNCH policies and strategies to accelerate progress towards achievement of Millennium Development Goals (MDGs) 4 & 5. The provincial inception meeting is a part of project titled ‘Studying the knowledge, beliefs and practices of unmarried and married adolescent girls with respect to nutrition and on the sources of nutrition information the adolescents have access to and use’, funded by the Maternal and New born Health Programme Research and Advocacy Fund (RAF) and is implemented by Fatima Memorial Hospital. The technical assistance for the project is being provided by the Principal Investigator, the four provincial coordinators, technical experts in the field of gender, M&E, research, statistics and epidemiology. The project further has support of an entire panel of nutritional experts on board of Fatima Memorial Hospital and Nur Center for Research and Policy. This provincial inception meeting is a joint collaborative project of FMH and its implementing as well partner, Nur Center for Research and Policy.
OBJECTIVE OF MEETINGS IN PROVINCES i. ii. iii. iv.
To develop an understanding of the project To understand the need of the study keeping MDG 4 and 5 in perspective To understand the need to study adolescent girls due to lack of evidence in this age group, particularly after the National Nutrition Survey 2011 To bring about a consensus on the purpose of the study and possible outcomes
SPECIFIC OBJECTIVES OF THE SEMINAR HELD IN SINDH The Seminar was organized to provide a forum to review issues and challenges facing Sindh in improving the nutritional status of its people and to take further the dialogue on the development of the proposed multisectoral nutrition strategy (also known as Inter-Sectoral Nutrition Policy) i. ii.
iii.
To facilitate direct interaction between policy-makers; development partners and members of the Technical Working Group on formulation of multi-sectoral nutrition strategy To share an overview of the RAF-funded research with participants and advocate for the utilisation of the evidence generated in the Sindh government nutrition strategy and other relevant health and nutrition related actions. To make recommendations to strengthen the Sindh Health strategies for addressing nutrition issues and combating malnutrition.
SCOPE The Meeting focused on five areas:
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Theme 1: MDGs 4 and 5 Theme 2: Adolescents in Pakistan Theme 3: Role of early marriages Theme 4: Role of nutrition Theme 5: Outcome of research study
PARTICIPANT PROFILE Participants included Senior Health Professionals from MNCH and PGHS, UNICEF Nutrition, Micronutrient Initiative, RAF Office, other Provincial Program representatives, policymakers, activists, healthcare workers, educators, community leaders, UN Agencies representatives, senior level staff of local, national, regional and international NGOs and CSOs working for nutrition. For more information, please refer to Annexure
MEETING METHODOLOGY
Power Point Presentation on the project, the research problem and background of the grantee i.e. Fatima Memorial Hospital. Presentations lasted between 15-30 minutes and provided opportunity for questions and discussion. Discussion during which participants discussed the role of various stakeholders in the nutrition of adolescent girls, particularly that of LHWs, LHVs, TBAs and CMWs. The discussion also revolved around the steps that can be taken by institutions like KMU and FMH, in covering nutrition in the curricula at undergrad, grad and post-grad levels.
PROCEEDINGS The welcome note to the audience was given by the Principal Investigator Dr Shabnum Sarfraz. The seminar proceedings comprised of five presentations and a group discussion SITUATION ANALYSIS: NUTRITION RELATED ISSUES IN SINDH (DR ASIF ASLAM, UNICEF, SINDH OFFICE) •
The session presented a statistical overview of malnutrition as a global as well as a regional problem involving developing countries. According to UN report 2008, 51% of the population in Pakistan is food insecure. UNICEF data estimates that there are more than 150 million malnourished children under the age of 5 years. In addition, up to 35% of the 9.2 million annual deaths globally are attributable to malnutrition. While recognizing under-nutrition as a major health problem in which contributes to country’s high maternal/child mortality and morbidity, it ranks Pakistan 57th on the Global Hunger Index. The prevalence of anaemia is alarmingly high among children under 5 years of age. This was identified as leading to vulnerability to disease and higher child mortality rates particularly when there exists no organized system of nutrition counselling and early screening.
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While underweight prevalence has declined in urban areas of Pakistan (from 29% to 27%) between 2001 and 2011 (according to National Nutrition Survey 2001 amd 2011), there has been no improvement in rural areas of Pakistan, with the underweight prevalence remaining static at 33%. Incidence of Wasting has increased in rural areas from 45% (in 2001) to 46% (in 2011), and in urban areas from 36% (in 2001) to 37% (in 2011). Incidence of stunting in urban areas increased rural areas from 14% (in 2001) to 16% (in 2011), and in urban areas it has declined from 15% (in 2001) to 13% (in 2011). There is a direct correlation of Maternal Literacy with Stunting, Wasting & Underweight prevalence in Pakistan; the higher the maternal literacy rates the lower the incidences of stunting, wasting and underweight prevalence. Anthropometric deficits are systematically higher in rural areas. In the Pakistani diet cereals remain the main staple food providing 62% of total energy. Milk consumption is significant in Pakistan while the consumption of fish, meat, vegetables and fruits remains very low
The presentation touched upon the need to identify gaps in legislations in order to ensure adequate nutrition for high-risk population. It also called for exploring an integrated or multisectoral approach involving different departments and organizations. It further emphasized on improving research quality by gathering reliable data that contributes to institutionalize policies directed at eradication of malnutrition.
NUTRITIONAL STATUS OF ADOLESCENT GIRLS & ITS IMPLICATIONS FOR MNH OUTCOMES – AN OVERVIEW OF THE RAF-FUNDED RESEARCH STUDY (DR. SHABNUM SARFRAZ, CHIEF OPERATING OFFICER, NCRP-FMS) It included review of the ongoing project at NCRP, regarding knowledge, beliefs and practices of unmarried and married adolescent girls with respect to nutrition at NCRP. The study involves evaluation of nutritional status of adolescent girls in Pakistan. It also aims at socio-cultural factors which serve as barriers to comprehensively address the issue of malnutrition. The issue of unsafe abortions and pregnancy at earlier age were discussed in context of gender inequalities. It also identified school-going children particularly girls as most vulnerable to nutritional deficiencies which has contributed to constant rise in maternal and child mortality. The Principal Investigator summarized the research objectives, project scope and expected output after completion of data collection phase. She called for participants’ support for collaborative advocacy in order to ensure the utilization of the evidence generated by the study.
INTER-SECTORAL NUTRITION POLICY GUIDANCE AND STRATEGY SINDH (INSS) (DR. DUR E SHAHWAR, PROVINCIAL NUTRITION FOCAL PERSON, NUTRITION CELL, HEALTH DEPARTMENT, GOVERNMENT OF SINDH) The presentation addressed the following: •
The Malnutrition Challenge for Pakistan:
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National Nutrition Survey 2011 indicates that Sindh is the most food deprived province of Pakistan with only 28% of food secure households. 16.8% food insecure with severe hunger.
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Prevalence of “Hidden Hunger” or micronutrient deficiency as a major challenge presently constrains the development of a healthy population.
Comparison of Standing of Pakistan in terms of IMR and MMR: •
Pakistan has the highest IMR (87) in the region as compared to India, Bangladesh, Sri Lanka, Iran, Maldives and Nepal.
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Pakistan has the highest MMR (314) in the region as compared to India, Bangladesh, Sri Lanka, Iran, Maldives and Nepal.
Malnutrition Indicators of Pakistan and Sindh: •
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There is a high incidence of Chronic Malnutrition in Pakistan, as well as a very high incidence of Anaemia. These are compounded by Micro-nutrient deficiencies (Vitamin A and D, as well as Zinc deficiency.
Scale up Nutrition (SUN) Approach and relation of INSS with it: •
Unique global movement to address malnutrition globally
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Within the SUN Movement, national leaders are prioritizing efforts to address malnutrition
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Currently, 41 countries are members of this approach including Pakistan
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SUN recommends nutrition specific and nutrition sensitive interventions such as
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Promoting good nutritional practices:
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Breastfeeding
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complementary feeding for infants after the age of six months
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improved hygiene practices including hand washing
Provision of micronutrients for young children and their mothers: •
Periodic Vitamin A supplements
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Therapeutic zinc supplements for diarrhoea management
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Multiple micronutrient powders
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De-worming drugs for children (to reduce losses of nutrients)
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Iron-folic acid supplements for pregnant women to prevent and treat anaemia
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Iodized oil capsules where iodized salt is unavailable
Provision of micronutrients through food fortification for all: •
Salt iodization
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Iron fortification of staple foods
Therapeutic feeding for malnourished children with special foods: •
Prevention or treatment for moderate under nutrition
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Treatment of severe under nutrition (“severe acute malnutrition”) with ready-touse therapeutic foods (RUTF).
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MDG Goals and Nutrition
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Causal Framework of malnutrition: •
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The framework shows that the underlying causes of malnutrition are multifaceted which can be addressed by inter-sectoral approached, health alone has important but limited roll in preventing malnutrition. The main reason why previous intervention did not work is that one dimensional approach is taken.
Process of development of INSS and its details •
Group of D10 meeting in September, 2011 in Islamabad
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Policy Guidance Notes Development
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Establishment of Provincial Steering Committee
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To provide strategic planning, coordination, oversight for implementation, and monitoring across multi-sectoral partners, development of a strategy and the development of a monitoring and evaluation framework.
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Technical Working Group Meetings
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Recommendation of INSS in second Steering Committee meeting and recommendation to CM for final th approval on 7 August, 13
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Objectives and guiding principles of INSS
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By the end of 2016, the Inter-sectoral Nutrition Strategy for Sindh seeks to:
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Reduce chronic malnutrition in children aged 0-24 months by 10 percentage points (from an estimated 49.8% to 39.8% by the end of 2016.)
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Iron deficiency anaemia in children from 73% to 62%
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Maternal anaemia from 59% to 49 through sustainable, effective and inter-sectoral interventions.
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Recognition of Right to food
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Evidence based interventions
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Geographical convergence
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Gender empowerment
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Intersectoral intervention
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Encourage involvement of the civil society
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Plan multi-sectorally, implement sectorally, review inter-sectorally
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Common targets and indicators
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Target Group and departments involved in INSS
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Health and Population Welfare
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Education and Literacy Department
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WASH
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Public Health Engineering Department
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Local Government Department
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Social Net
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Women Development Department
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Social Welfare Department
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Civil Society Organizations
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Benazir Income Support Program
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Civil Society Organizations
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Food Security
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Agriculture Department
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Food Department
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Food and Livestock Department
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Fisheries Department
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Employment and Financial Security
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Planning and Development Department
Recommendations proposed in INSS and Way Forward •
A Nutrition Cell would be established in the province in Planning and Development Department that will provide guidance, support, coordination and processing of nutrition sensitive intervention across all the sectors.
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Inter-sectoral strategy will be the central tool and will have the monitoring indicators to see progress on the nutrition status.
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Concerned departments will make their plans which are nutrition sensitive preferably using policy notes.
After the presentations, the forum was declared open for discussion.
DISCUSSION •
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It was noted that Nutrition related challenges and issues have not changed over decades, and strategy after strategy is implemented by the government, muiti-lateral and bi-lateral donors, but the approach is top down and not community based. This leads to failure in implementation. Current policies need to be changed from the top; landless poor are amongst the most food insecure, Feudals need to give up part of their land otherwise food insecurity can never truly be addressed. Participants noted lack of robust monitoring and evaluation mechanism and accountability mechanisms as well as research capacity which are considered pre-requisite for achieving milestones. This is exacerbated by poor governance. While malnutrition is a critical issue, obesity is also a concern. A study by the Pakistan Medical Research Council shows that the incidence of malnutrition is 20% in women under 30, whereas 40% of women over the age of 45 years who live in urban Pakistan suffer from obesity. Intrauterine Malnutrition increases incidences of Stunting which increases chances of morbid diseases. Breastfeeding in urban areas is affected by power of milk formula industry which promotes alternatives harmful to baby and readily available. Hopefully legislation will have an impact. In rural areas, 18.7% women give water with breast milk causing infections. A single behavioural change can have a significant impact that they do not need to add water. Lauded the role of private sector institutions like NCRP in promoting the research and collaboration to address malnutrition related issues in Pakistan, particularly from a Knowledge, Attitude and Practices (KAP) perspective.
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CLOSING COMMENTS BY THE PRINCIPAL INVESTIGATOR • • • •
This was an important and productive forum. A note of thanks was given to all the participants. Shields were presented to the Guests of Honour by Ms. Maha Rehman, founding member of NCRP and Co-investigator, Sindh This group of participants can together act as a think tank, towards generating more information and evidence for policy makers.
RECOMMENDATIONS OF PARTICIPANTS The following recommendations emerged from the deliberations of the seminar: I.
Explore multi-sectoral approach and its potential to address the issue of malnutrition in Sindh through community participation and collaborations, and also involve Civil Society Organizations
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Review the relevant PC 1 and assess: a. What should be the staffing level? b. What role existing staff can play? c. What capacities need to be built to exploit them? d. Is there a need for new cadre?
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It is imperative to have stronger mechanism for accountability, monitoring and evaluation of all programmes in order to ensure successful implementation
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Build in a sustainability focus. Interventions can only be sustainable if: a. Local communities are involved: i. social Mobilizers/other community based service providers are from the same communities. ii. Engage male mobilise to work with men in communities. iii. Communities are encouraged to employ their indigenous resources. iv. Locally prepared, indigenous food products which are affordable, healthy and nutritious are promoted and communities are educated on their benefits, and are also involved in preparing them. b. Separate budgets are earmarked for evaluation and periodic monitoring c. Lessons learnt from M&E are incorporated and implementation strategies revised accordingly d. Nutrition Experts with educational background in public health with focus on Nutrition must be involved in nutrition programs e. PC1 should include training of LHW to help mothers with breastfeeding, and how to address problems encountered during breastfeeding, instead of simply counselling them to “breastfeed for 2 years” or referring them to a doctor to address problems encountered during breastfeeding
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Nutrition Assistants should be placed at the BHU Level and have ongoing liaison with LHWs and LHS g. Nutrition Assistants should work with non-pregnant women towards improving their nutritional knowledge, practices etc. Initiate evidence-based advocacy and promotional campaigns through partnering with media, particularly to: o a) to enhance awareness about importance of healthy nutrition o b) demonstrate ways in which families can have (low cost) healthy nutrition practices such as radio and TV shows on low cost kitchen gardening, etc o c) Use mobiles for text messaging/audio messaging to convey messages stressing importance of healthy nutrition and way in which families can have (low cost) healthy nutrition practices
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ANNEX 1- INTRODUCTION TO FMH
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ANNEX 2- BACKGROUND OF MEETING
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ANNEX 3- AGENDA
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ANNEX 4- PARTICIPANTS’ REGISTRATION AND ATTENDANCE (1 OF 6)
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ANNEX 4- PARTICIPANTS’ REGISTRATION AND ATTENDANCE (2 OF 6)
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ANNEX 4- PARTICIPANTS’ REGISTRATION AND ATTENDANCE (3 OF 6)
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ANNEX 4- PARTICIPANTS’ REGISTRATION AND ATTENDANCE (4 OF 6)
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ANNEX 4- PARTICIPANTS’ REGISTRATION AND ATTENDANCE (5 OF 6)
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ANNEX 4- PARTICIPANTS’ REGISTRATION AND ATTENDANCE (6 OF 6)
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ANNEX 5- FEEDBACK FORM
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ANNEX 6- PICTURES FROM THE PROVINCIAL INCEPTION MEETING, SINDH
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Group Photograph- End of Seminar
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A REPORT FROM THE RAF PROJECT OFFICE AT FATIMA MEMORIAL HOSPITAL IMPLEMENTING PARTNER : NUR CENTER FOR RESEARCH AND POLICY 2013