PROGRESS REPORT 2013-2015 STOP STUNTING

PROGRESS REPORT 2013-2015 STOP STUNTING

PROGRESS REPORT 2013-2015 Results for children in Pakistan STOP STUNTING Copyright UNICEF Pakistan Printed in July 2015 Editing Sarah Nam Graphic design Giovanna Burinato Photographs Asad Zaidi For more information contact Daniel Timme Chief of Advocacy and Communication, dtimme@unicef.org

FOREWORD In recent years, the Government of Pakistan has demonstrated increased commitment to social sector development, consequently leading to some notable successes. In particular, the country is celebrating the recent achievement of the Millennium Development Goal (MDG) for sanitation, halving the proportion of the population without sustainable access to basic sanitation. Over the past two decades, the government has also made notable strides in combatting polio, increasing routine immunization and decreasing the number of out-ofschool children. PROGRESS REPORT 2013-2015 Results for children in Pakistan UNICEF, along with its partners, is supporting the Government of Pakistan to achieve the MDGs and will continue to do so in the post-2015 era. More specifically, UNICEF is providing support to achieve the following results in Pakistan: - BIRTH REGISTRATION: Achieve universal birth registration by 2024 - EDUCATE ALL CHILDREN: Provide access to improved education to more than 1.2 million children in Pakistan by 2017 - ERADICATE POLIO: Eliminate the disease by May 2016 - STOP STUNTING: 1.9 million fewer children with stunted growth and development by 2017 - IMPROVE ACCESS TO SANITATION: 10 million fewer people practising open defecation by 2017 - DECREASE CHILD DEATHS: Reduce newborn mortality from 55 to 20 live births per 1,000 by 2017, and have 90 percent fully immunized children (aged 12-23 months) by 2017 These progress reports take a deeper look into these issues, including the latest data and how government interventions have positively impacted children and communities in Pakistan. These reports also present key challenges, recent research, knowledge and evaluations, and strategic direction for the future. Through these reports, we seek to foster productive collaboration, demonstrate the collective contribution of UNICEF and its partners, and reassert our commitment to the Convention on the Rights of the Child. BIRTH REGISTRATION EDUCATE ALL CHILDREN ERADICATE POLIO STOP STUNTING IMPROVE ACCESS TO SANITATION DECREASE CHILD DEATHS Angela Kearney UNICEF Representative in Pakistan

OVERVIEW Stunting and other forms of under-nutrition hinder the optimal health and growth of a child. Stunting is associated with suboptimal brain development, which is likely to have long-lasting harmful consequences for cognitive ability, school performance and future earnings. Globally, about one in four children under 5 years old are stunted 25 percent in 2011. An estimated 80 percent of the world s 165 million stunted children live in just 14 countries 1, including Pakistan. At 44 percent 2, Pakistan s under-5 stunting rates are much higher than the global rate. With a goal to reduce stunting to 34 percent by 2017, UNICEF, in partnership with government and other stakeholders is targeting under-5 children and pregnant and lactating women with key nutrition specific and nutrition sensitive programmes, employing a holistic and multi-sectoral approach. This progress report shows recent statistical data on the national stunting situation and progress on interventions that have been implemented to address stunting. The report details UNICEF s programmatic strategy, key achievements to date and looks forward to the next few years. It also highlights the disparities in the prevalence of stunting that still exist in Pakistan, particularly between children from poorer and richer households.

STOP STUNTING GLOBAL TARGET Reduce the number of under-five children who are stunted by 40 percent by 2025 UNICEF PAKISTAN TARGET Reduce stunting to 34 percent, which means that 1.9 million children will be saved from stunting by 2017 In Pakistan, 44 percent of children are stunted 3. This is the third highest percentage of stunted children in the world and means that more than 9.6 million Pakistani children have experienced chronic nutrition deprivation in utero and/or during early childhood. Every year, stunting is the cause of one million child deaths around the world. For the children who survive, stunting in infancy and early childhood causes lasting damage, including poor cognition and education performance, reduced lean body mass, lower productivity, reduced adult wages and pregnancy complications. It is time the SUN must rise; rays of sunshine should touch lives of millions of children and women suffering from malnutrition who deserve equal dignity, health and economic opportunity. Let the rays of SUN alight the dark spots of malnutrition by developing a well-nourished and healthy society in Pakistan. Professor Dr. Ahsan Iqbal Federal Minister of Planning, reforms and development, Government of Pakistan 6 PROGRESS REPORT 2013-2015 STOP STUNTING PROGRESS REPORT 2013-2015 STOP STUNTING 7

HOW UNICEF WILL HELP ACHIEVE RESULTS Child stunting has become a global development priority. In accordance with the regional approach, UNICEF in Pakistan will continue to focus efforts in the first 1000 days of a child s life, starting from conception. Programmes also emphasise actions that improve the nutritional status of mothers and pregnant/lactating women. Further, the focus is shifting from curativeonly approaches to both curative and preventive approaches and it has been recognized that a reduction in the prevalence of child stunting calls for a multi-sectoral response. This is why UNICEF s programmes are both nutrition specific and nutrition sensitive: DATA PROFILE A snapshot of the child stunting situation in Pakistan According to recent figures 5, stunting increases with age, peaking at 53 percent among children 24 months of age, which illustrates that it is imperative to target nutrition activities towards children 0 to 23 months. Stunting prevalence is slightly higher in male children (48%) than in female children (42%) 6. Stunting disparities among urban and rural population of Pakistan is 37 percent and 46 percent respectively 7. NUTRITION SPECIFIC NUTRITION SENSITIVE Prevalence of stunting in Pakistan supporting the scale up of essential nutrition interventions Improving breastfeeding practices, while continuing to improve the quality of complementary foods for children aged 6-23 months Improving women s nutritional status by focusing on preventing micronutrient deficiencies among pregnant and lactating mothers Improving early detection and treatment of severe wasting in young children Improving women s nutrition, especially for adolescent girls and mothers promoting inter-sectoral programmes Integrating nutrition and WASH behavior messages to improve family and community hygiene practices Ensuring UNICEF multi-sector programmes are aligned to leverage the effects on stunting prevention Recent improvements in Pakistan s improved sanitation figures should also have a positive impact on national stunting figures. This is because poor sanitation can have immediate effects on health, such as diarrhea and other diseases, which can lead to deaths in already malnourished children. There is increasing evidence that it can also cause malnutrition through a gut disorder that leaves the body unable to absorb nutrients 4 6 5 4 3 Punjab Sindh KPK Balochistan Data source: Pakistan National Nutrition Survey 2011. FATA AJK Gilgit 8 PROGRESS REPORT 2013-2015 STOP STUNTING PROGRESS REPORT 2013-2015 STOP STUNTING 9

Stunting a decades old problem The following graph illustrates persistent high levels of stunting in Pakistan since the mid 1960 s. Note that the country has only once dipped below the global critical level of 40 percent in the early 1990 s. Trends in stunting 5 4 NSWP Nutrition Survey of West Pakistan How many children are benefitting from essential nutrition interventions? Early initiation of breastfeeding and exclusive breastfeeding 4 35% 37,1 38 3 28,8 25% 17,6 18 15% 3 NNS National Nutrition Survey MNS Micronutrient Nutrition Survey 5% 8,5 PDHS 1990-91 PDHS 2006-2007 PDHS 2012-2013 Early initiation of breastfeeding Exclusive breastfeeding NSWP:1965 NNS:1985-7 NNS:1990-4 MNS:1997 NNS:2001-02 NNS:2011 Data source: Pakistan Demographic Health Survey, 1990-91, 2006-2207 and 2012-2013. Data source: National Nutrition Surveys 1965, 1985, 1990, 2001, 2011. Minimum weight at birth: Percentage of children who were born with a birth weight > 2500g 8. National Urban PDHS 2006-2007 PDHS 2012-2013 Timely introduction of complementary foods Percentage of infants 6-8 months old who are fed complementary foods. 7 62,3 6 55 51,3 5 49,2 48,6 51,3 Rural Punjab Sindh 4 3 35,7 35,3 KP Balochistan Not available 3 4 5 Sindh FATA GB Punjab Balochistan AJK KP National Data source: Pakistan, National Nutrition Survey 2011. Data source: Pakistan Demographic Health Survey, 1990-91, 2006-2207 and 2012-2013. 10 PROGRESS REPORT 2013-2015 STOP STUNTING PROGRESS REPORT 2013-2015 STOP STUNTING 11

Minimum dietary diversity Percentage of children 6-23 months old who are fed foods from minimum number of food groups. 25% 15% 5% FATA AJK GB Sindh KP Punjab Balochistan National Treatment of Severe Acute Malnutrition 150000 120000 90000 60000 30000 24 6,9 90,3 5,1 133170 134618 3,2 2,7 2,6 2,1 87,4 91% 48591 3 # SAM Children Treated % of SAM children Dischared as Cured ACCELERATING CHANGE IN PAKISTAN IMPORTANT ACTIONS Integrating nutrition into government strategies UNICEF has been working tirelessly to ensure children and women s nutrition is included in the national agenda in Pakistan. UNICEF is currently supporting the development of a National Infant and Young Child Feeding (IYCF) Practices Strategy and guidelines to promote IYCF care practices, and the development of the national IYCF Technical Advisory Group which includes representation from all provinces and areas. Nutrition is part of the Pakistan Vision 2025 Government strategic planning document. The process of integrating nutrition programmes into the health system is currently underway, through formulation of integrated provincial planning commission documents, PC1. The Pakistan Integrated Nutrition Strategy (PINS), supported by UNICEF, was also formulated and used as a strategic framework to guide provinces to define nutrition in their provincial post devolution development agendas. As a result, inter-sectoral nutrition policy guidance notes and strategies were developed by four provinces in Pakistan. 0 2013 2014 2015 Micronutrient supplementation to children and pregnant and lactating women 2000000 1500000 1000000 500000 0 1773724 714621 678097 430435 387202 167948 2013 2014 2015 Micro-nutrient supplementation (6 to 24 m) Micro-nutrient supplementation (PLW) Data source: United Nations Children s Fund Pakistan 2015, programmatic data. 12 PROGRESS REPORT 2013-2015 STOP STUNTING PROGRESS REPORT 2013-2015 STOP STUNTING 13

Driving force behind the SUN movement UNICEF provided crucial technical and logistical support to the National Planning Commission and the Ministry of Health Services, Regulation and Coordination to launch the inaugural Scaling Up Nutrition (SUN) movement in December 2013. The movement was a culmination of years of lobbying to include children and women s nutrition into government strategies and plans. EQUITY Child under-nutrition and maternal education 5 4 3 UNICEF in Pakistan seeks to support essential nutrition interventions, particularly to the most disadvantaged children and women in the country. Equity analyses carried out during the programme planning stage shows that key disparities include urban-rural and socioeconomic differentials. Illiterate 1 to 5 6 to 8 9 to 10 above 10 Urban versus Rural 50 40 30 Rural Urban Stunting Years of education Wasting Socio-economic factors Wealth quintiles In Pakistan, the prevalence of stunting is highest among the lowest wealth quintile, with the same evident in the case of wasting. 20 10 6 0 Stunting Wasting 5 4 Data source: Pakistan National Nutrition Survey 2011. 3 For example, it is evident that the percentage of stunting is much higher among children whose mothers are illiterate versus those whose mothers have completed at least 10 years of education. This has a big impact in Pakistan, where the proportion of illiterate mothers is almost double in rural areas than urban areas (36.6 percent in urban and 69.4 percent in rural respectively 9 ). The graph on the following page shows the connection between under-nutrition and maternal education. Lower wealth quintile Second wealth quintile Middle wealth quintile Fourth wealth quintile Highest wealth quintile Stunting Wasting Data source (both charts): Pakistan National Nutrition Survey 2011. 14 PROGRESS REPORT 2013-2015 STOP STUNTING PROGRESS REPORT 2013-2015 STOP STUNTING 15

Food security Stunting and wasting have been found to be higher in food insecure households with severe hunger. High level of food insecurity is also documented in NNS 2011, where 58 percent of households were found to be food insecure. 60 50 40 30 20 10 Food insecure with hunger-severe Food insecure with hunger-moderate Stunting Data source: Pakistan National Nutrition Survey 2011. Food insecure without hunger Wasting Food secure LOOKING FORWARD In the next few years, continued progress is required to achieve the national target by 2017. Child feeding: Improving the quality of complementary foods for children aged 6-23 months. Improving breastfeeding rates and decreasing the high use of infant formulas. Women s nutrition: Improving women s food intake (quantity and quality) along the lifecycle. Household sanitation: Improving family and community hygiene practices, with a particular emphasis on washing hands with soap after defecation and before child feeding. In pursuit of these aims, UNICEF will work with partners towards: High-level country political commitment to improve nutrition governance and programs. Nutrition-specific and nutrition-sensitive interventions and programmes implemented countrywide. Strengthening of institutional and human capacity to manage nutrition programmes. Improved knowledge-management systems and evidence generation. Renewed focus on food fortification. Developing a multiyear, multi-sectoral strategy for stunting reduction, collaborating with all relevant UNICEF sections and external partners. Developing an evidence-based and multi-sectoral communication strategy in coordination with Pakistan s Planning Commission and the Ministry of National Health Services, Regulation and Coordination. RESEARCH, KNOWLEDGE, EVALUATION Assessing Severe Acute Malnutrition in Pakistan Undertaken by Action against Hunger in February 2014, this Semi-Quantitative Evaluation of Access & Coverage (SQUEAC) assessment of Severe Acute Malnutrition coverage was conducted in Tando Mohammad Khan and Badin districts, Sindh province. See the full report here: <www.humanitarianresponse.info/en/operations/pakistan/document/squeacfinal-report-district-tmk-badin-sindh-acf-pakistan-feb-2014>. Political economy studies In 2013, a series of political economic analyses were undertaken to examine the status of nutrition in Pakistan. The National report is available here: <www.aku.edu/mc-pk/documents/ National%20Synthesis%20PEA%20Pakistan.pdf>. 16 PROGRESS REPORT 2013-2015 STOP STUNTING PROGRESS REPORT 2013-2015 STOP STUNTING 17

Pakistan Food Fortification Scoping Study Provincial reports are also available here: Sindh: <www.aku.edu/mc-pk/documents/political%20economy%20undernutrition%20 Sindh%20Report.pdf>. Balochistan: <www.aku.edu/mc-pk/documents/political%20economy%20under- Nutrition%20Balochistan%20Report.pdf>. Punjab: <www.aku.edu/mc-pk/documents/political%20economy%20undernutrition%20 Punjab%20Report.pdf>. KP: <www.aku.edu/mc-pk/documents/political%20economy%20undernutrition%20kp %20Report.pdf>. Following the studies, Maximizing the quality of scaling up nutrition (MQSUN) also released a briefing note called Action on Under-nutrition in Pakistan: opportunities and barriers: <www.cmamforum.org/pool/resources/action-on-undernutrition-pakistan-mqsun-2013. pdf>. This 2014 Maximizing the quality of scaling up nutrition (MQSUN) report examines the potential to scale up micronutrient fortification in Pakistan in order to reduce micronutrient deficiencies: <www.heart-resources.org/assignment/pakistan-food-fortification-scopingstudy>. Leveraging Agriculture for Nutrition in South Asia (LANSA) LANSA is an international research partnership focused on improving the nutritional status of children in South Asia. They have published a variety of reports and blogs on the topic: A brief review of the agriculture/nutrition policy landscape in Pakistan, April 2014 <http:// lansasouthasia.org/sites/default/files/country%20policy%20landscape%20analysis%20 Pakistan.pdf>. Agriculture and Nutrition in Pakistan - Pathways and Disconnects: LANSA Pakistan Evidence Paper, LANSA and CSSR. May 2013. <www.researchcollective.org/documents/ LANSA_Pakistan_Evidence_Paper_May2013.pdf>. General LANSA reports/blogs: <www.researchcollective.org/projects2.php?id=c_054>. REAL LIVES, REAL CHANGE Good nutrition vital for children s health Playing with his cousins, two-yearold Mehran seems to be just like any other toddler, comfortable with his surroundings at home. He gives a peal of laughter and lunges after a small puppy, the children have been chasing, around the muddy compound. Mehran s family shares the house with his paternal grandparents, two uncles and their families. The children go quiet as they see Shazia, a Lady Health Worker (LHW), enter the house. She is a familiar face here as she visits this family every other week to check on the health of women and children in the family. The household was consuming unsafe drinking water, which caused health and nutrition problems. When I conducted the Mid Upper Arm Circumference with MUAC test, Mehran was under nourished, Shazia explains adding how she convinced the child s parents to visit the health facility. I asked the mother to accompany me to the Basic Health Unit for management of diarrhoea and seek advice from the nutrition assistant. Faryal, the Nutrition Assistant at BHU Mahabbat Abad conducted a thorough check-up and immediately initiated treatment as he was thin and underweight with chances of a stunted growth. When Mehran first came to me three months ago, he was diagnosed with Severe Acute Malnutrition. He weighed only 6.8 kilograms, which is much less than the average weight for children his age. We initiated treatment by providing Ready to Use Therapeutic Food, and other medicines as per standard procedure, says Faryal. With proper treatment provided at the health unit, Mehran started to show signs of improvement. It contributed to his health and growth and his weight increased to 9.6 kilograms within few months. My sisters-in-law noticed how the treatment had aided my child s growth, so they also took their children to the BHU, says Asma, Mehran s mother adding that staff at the BHU are very helpful. Faryal would always listen to us sincerely and treat our children with utmost care. 18 PROGRESS REPORT 2013-2015 STOP STUNTING PROGRESS REPORT 2013-2015 STOP STUNTING 19

Endnotes 1 United Nations Children s Fund 2013, Improving Child Nutrition: The achievable imperative for global progress, <www.unicef.org/gambia/improving_child_nutrition_-_the_achievable_imperative_ for_global_progress.pdf>, accessed June 2015. 2 Islamic Republic of Pakistan 2011, National Nutrition Survey 2011, Ministry of Health and Planning and Development, <www.humanitarianresponse.info/system/files/documents/files/59_national%20 Nutrition%20Survey-2011.pdf>, accessed June 2015. 3 Ibid. 4 Schmidt, C. 2014, Beyond Malnutrition: The Role of Sanitation in Stunted Growth, Environmental Health Prospective, <www.ncbi.nlm.nih.gov/pmc/articles/pmc4216152/>, accessed June 2015. 5 Islamic Republic of Pakistan, Pakistan Demographic & Health Survey 2012-13, National Institute of Populations studies, <www.nips.org.pk/abstract_files/pdhs%20final%20report%20as%20of%20 Jan%2022-2014.pdf >, accessed June 2015. 6 Ibid. 7 Islamic Republic of Pakistan 2011, National Nutrition Survey 2011, Ministry of Health and Planning and Development, <www.humanitarianresponse.info/system/files/documents/files/59_national%20 Nutrition%20Survey-2011.pdf>, accessed June 2015. 8 Islamic Republic of Pakistan, Pakistan Demographic & Health Survey 2012-13, National Institute of Populations studies, <www.nips.org.pk/abstract_files/pdhs%20final%20report%20as%20of%20 Jan%2022-2014.pdf >, accessed June 2015. 9 Islamic Republic of Pakistan 2011, National Nutrition Survey 2011, Ministry of Health and Planning and Development, <www.humanitarianresponse.info/system/files/documents/files/59_national%20 Nutrition%20Survey-2011.pdf>, accessed June 2015. Sources All statistical information has been extracted from the National Nutrition Survey 2011; the Pakistan Demographic Health Survey 2012-13 and UNICEF Pakistan programmatic data. Alderman, H., Bhutta, Z.A., Black, R.E, Gillespie, S., Haddad, L., Horton, S., Lartey, A., Mannar, V., Ruel, M., Victora, C.G., Walker, S.P., Webb, P., 2013, Maternal and child nutrition: building momentum for impact, The Lancet, <www.thelancet.com/series/maternal-and-child-nutrition>, accessed July 2015. Haddad, L., Bhutta, Z.A. and Gazdar, H. 2013, Special Issue: Seeing the unseen: Breaking the logjam of undernutrition in Pakistan, IDS Bulletin, Volume 44, issue 3, page IX, <http://onlinelibrary.wiley.com/ doi/10.1111/idsb.2013.44.issue-3/issuetoc>, accessed June 2015. Balagamwala, M. and Gazdar, H. May 2013, Agriculture and Nutrition in Pakistan Pathways and Disconnects, <www.researchcollective.org/documents/lansa_pakistan_evidence_paper_may2013. pdf>, accessed June 2015. The maps in this publication are stylized and not to scale. They do not reflect a position by UNICEF on the legal status of any country or territory or the delimitation of any frontiers. The dotted line between Jammu and Kashmir represents approximately the Line of Control agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the Parties. UNICEF Pakistan www.unicef.org/pakistan/ www.facebook.com/unicefpakistan twitter.com/unicef_pakistan