Country: Pakistan (Sindh Province) Date: 23 July IPC for Acute Malnutrition Map Current Classification 04/2017 to 06/2017

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1 IPC Acute Malnutrition Analysis Key Findings All three districts (Jamshoro, Umerkot and Tharparkar) included in the IPC Acute Malnutrition have been classified as in Phase 4, which is considered a Critical situation requiring urgent attention. Overall, more than 88,000 children are affected by acute malnutrition in all 3 districts and require urgent treatment. The major factors contributing to acute malnutrition include very poor quality of food, high prevalence of diseases, poor sanitation system and poor feeding practices. While the immediate response must focus on treating children with acute malnutrition, it is also vital to address the major contributing factors in order to address acute malnutrition. Country: Pakistan (Sindh Province) Date: 23 July 2017 GAM Prevalence and Caseload for Acute Malnutrition District GAM (%) # of GAM # of MAM # of SAM Jamshoro ,393 23,938 3,455 Umerkot ,996 19,379 5,617 Tharparkar ,015 30,400 5,615 Total N/A 88,404 73,717 14,687 GAM: Global Acute Malnutrition MAM: Moderate Acute Malnutrition SAM: Severe Acute Malnutrition IPC for Acute Malnutrition Map Current Classification 04/2017 to 06/2017 IPC for Acute Malnutrition Map Projected Classification 07/2017 to 09/2017 JAMSHORO * UMERKOT * THARPARKAR * JAMSHORO UMERKOT THARPARKAR IPC Acute Malnutrition Area Classification Map legend Assessment of evidence reliability ** Reliability Score High * Reliability Score Low Projected Changes within Phases Areas with Inadequate Evidence Areas not analysed + Based on historical data [Indicates changes within a specified Phase i.e. overall situation may deteriorate or improve without a Phase change]

2 SUMMARY OF FINDINGS, METHODS, AND NEXT STEPS Findings and Key Issues All three districts (Jamshoro, Umerkot and Tharparkar) of Sindh Province included in the IPC Acute Malnutrition (IPC AMN) analysis have been classified as being in phase 4, (Critical phase) according to the IPC AMN scale during April June 2017, which is lean/post-harvest period in majority of the areas of these districts. As per the findings of the IPC AMN analysis, Jamshoro and Tharparkar districts are on borderline with the phase 5 of IPC AMN, which is the Extreme Critical Phase, where nearly 1 in 5 children is acutely malnourished. According to the IPC AMN projection analysis, which was based on some assumptions, the situation is likely to remain the same in Jamshoro and Umerkot districts while some improvements are expected in Tharparkar District during the monsoon season (July-September 2017). However, the improvement expected is at a small scale which will unlikely change the phase classification for the district i.e. the district will likely continue to remain in the same Critical phase. Major contributing factors to acute malnutrition identified are (1) very poor quality of food intake by children (most likely resulting from very high acute food insecurity in the areas), (2) relatively high prevalence of diseases (particularly diarrhoea), (3) poor sanitation system; and (4) poor feeding practices (e.g. very low level of exclusive breastfeeding). Several structural issues especially human, physical, and financial capital were also identified as major factors contributing to acute malnutrition in these areas. Methods & Processes Experts and analysts on nutrition, health, food security and statistician from Pakistan with the support from IPC Global (Rome) and Regional (Bangkok) team carried out the analysis process using the standard IPC methodology. The analysis was conducted from 10 to 15 July, Availability of recent data, representative at the district level, was a major limitation for some indicators. In these, inference was made based on available data. The data on outcome indicator GAM (MUAC) was taken from the recently conducted Livelihood and Food Security Assessment (LFSA) conducted in April/May 2017 under Food Security Working Group Sindh. However, it is noted that quality of MUAC data only narrowly meets the IPC minimum quality criteria. For other indicators on contributing factors SMART nutrition surveys conducted by UNICEF and partners in the targeted districts were used as the main sources of information in the analysis. Where necessary and relevant, results from the LFSA, MICS, and other national surveys were also used in the analysis. Seasonality and Monitoring Implications The acute malnutrition situation is likely to remain in the same IPC AMN phase in Jamshoro and Umerkot districts (phase 4) but expected to improve in Tharparkar district in the upcoming season. Despite the small improvement in the situation in Tharparkar district, the critical levels of acute malnutrition warrant emergency response in all districts. It is important to monitor the seasonal diseases (particularly diarrhoea but also ARI) as they are expected to increase in the coming season and ensure treatment is available and accessible. Given the very high prevalence of acute malnutrition and since the quality of the MAUC data used only narrowly meets the IPC minimum quality criteria, it may be useful to carry out SMART surveys that meet the IPC quality criteria to estimate the prevalence of acute malnutrition in these areas in the coming season. 2

3 Recommendations and Next Steps for Analysis and Decision Making Treatment of all acutely malnourished children, identified across the district, is very high priority. For this, availability and access to treatment programmes should be ensured while the ongoing treatment programmes should also be scaled up. While immediate attention must focus on the treatment of exiting of acute malnutrition, attention should also be focussed on addressing other factors identified as major contributing factors to acute malnutrition as a way to prevent acute malnutrition in the future. The prevention efforts should focus on improving of quality of food consumed by children, treatment and prevention of childhood illness, addressing poor sanitation situation, and promoting appropriate feeding practices. It is recommended to review the results of the recently conducted Situation and Response Analysis Framework (SRAF) exercise by Food Security Working Group and tailor the interventions based on the major contributing factors. Furthermore, it would also be highly useful to carry out similar analyses in the other districts of Sindh province, where acute malnutrition levels are high. This analysis will not only be helpful in determining the extent of the acute malnutrition problem in these districts but also will help identify the major contributing factors to acute malnutrition so that appropriate response to tackle acute malnutrition can be planned. Contact for Further Information Ajmal Jahangeer, FAO Pakistan, Raja.Jahangeer@fao.org Analysis Partners & Supporting Organizations 3

4 Annex I: Expected number of Area Expected number of of acute malnutrition [ caseload for 12 months (taking into account an incident rate of 1.5] Total population 6-59 Months Children Population GAM % no. of GAM no. of MAM no. of SAM Jamshoro 877, , ,393 23,938 3,455 Umerkot 998, , ,996 19,379 5,617 Tharparkar 1,376, , ,015 30,400 5,615 Total 3,317, ,682 N/A 88,404 73,717 14,687 Caseload for MAM and SAM 23,938 19,379 30,400 3,455 5,617 5,615 Jamshoro Umerkot Tharparkar caseload for SAM caseload for MAM 4

5 Annex II: Major contributing factors to acute malnutrition by district SUMMARY CONTRIBUTING FACTORS MAJOR CONTRIBUTING FACTOR MINOR CONTRIBUTING FACTOR NOT A CONTRIBUTING FACTOR NO DATA Inadequate dietary intake Diseases Inadequate access to food Inadequate care for children Insufficient health services & unhealthy environment Minimum Dietary Diversity (MDD) Minimum Meal Frequency (MMF) Minimum Acceptable Diet (MAD) Minimum Dietary Diversity Women (MDD-W) Diarrhoea Dysentery Malaria HIV/AIDS prevalence Acute Respiratory Infection Disease outbreak Outcome of the IPC for Acute Food Insecurity analysis Exclusive breastfeeding under 6 months Continued breastfeeding at 1 year Continued breastfeeding at 2 years Introduction of solid, semi-solid or soft foods Measles vaccination Polio vaccination Vitamin A supplementation Skilled birth attendance Health seeking behaviour Coverage of outreach programmes CMAM programme coverage (SAM, MAM, or both) Access to a sufficient quantity of water JAMSHORO THARPARKAR UMERKOT

6 Basic causes Other nutrition issues Access to sanitation facilities Access to an improved source of drinking water Human capital Physical capital Financial capital Natural capital Social capital Policies, Institutions and Processes Usual/Normal Shocks Recurrent Crises due to Unusual Shocks Other basic causes Anaemia among children 6-59 months Anaemia among pregnant women Anaemia among non-pregnant women Vitamin A deficiency among children 6-59 months Low birth weight Fertility rate 6