PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB5672 Project Name

Transcription

1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB5672 Project Name Pakistan - Enhanced Nutrition for Mothers and Children Project Region SOUTH ASIA Sector Health (90%); Other social services (10%) Project ID P Borrower(s) ISLAMIC REPUBLIC OF PAKISTAN Implementing Agency National Nutrition Program, Ministry of Health, Government of Pakistan 10 D West, Taimur Chambers, Blue Area Islamabad Pakistan Tel: (92-51) , Fax: (92-51) Contact Person Dr Baseer Achakzai, National Program Manager achakzaibk@gmail.com Environment Category [ ] A [ ] B [X] C [ ] FI [ ] TBD (to be determined) Date PID Prepared May 28, 2010 Estimated Date of October 1, 2010 Appraisal Authorization Estimated Date of Board December 21, 2010 Approval 1. Key development issues and rationale for Bank involvement Slow progress towards health and nutrition related Millennium Development Goals (MDGs). Pakistan is not performing well in improving health and nutrition outcomes or services, especially for the poor. The present rate of improvement is much lower than for its South Asian neighbors. In fact, Pakistan it is not on track to achieve health and nutrition related MDG targets. It needs to significantly improve its performance in these areas, otherwise poor health and nutrition outcomes remain an obstacle to economic growth, especially during times of macroeconomic challenges, political and security related instability and external shocks with a disproportionately negative impact on the poor. Maternal and child health indicators have improved, but large challenges remain. The under-5 mortality rate has fallen by 24% since 1990 but there has been no change in the poorest income quintile since Maternal mortality seems to be declining but women in Pakistan still run a 1 in 80 chance of dying of maternal causes during their reproductive life. The total fertility rate has declined from 5.8 children per woman in 1990 to 4.1 in 2005 with improving coverage during 2003/07 in antenatal care (35% to 61%), skilled attendance at birth (24% to 36%), and proportion of fully immunized children (53% to 76%). Despite these improvements there is still a lot to be done - about one fourth of children are not immunized, two thirds of women are delivering without skilled attendance and there is a large unmet need for family planning. 1

2 Pakistan has made minimal progress in improving nutritional outcomes of children and mothers over the last two decades. Pakistan suffers from high rates of childhood malnutrition with 38% of children under 5 being underweight (<-2SD weight for age) and 12.3% severely underweight (<-3 SD) and 37% of children being stunted (<-2SD height for age) and 18% severely stunted (<-3SD). Thirteen percent (13%) of Pakistani children under 5 are wasted (<-3 SD weight for height) and 3% suffer from severe acute malnutrition (<-3 SD). One in four children (26%) is born with low birth weight (less than 2.5kg). In addition, micronutrient deficiencies are widespread with high rates of iron-deficiency anemia, zinc, iodine folic acid and vitamin A deficiencies having a particularly damaging impact on the survival, growth, development and productivity of pre-school children and pregnant women. Half (51%) of children 0-5 years and two in every five (39%) pregnant women suffer from anemia. Malnutrition is also prevalent among women of reproductive age with 13.6% being underweight, and 2.5% severely thin. Inequity in health and nutrition services is also a major concern, with access to services being significantly better for wealthier and urban Pakistanis. For example, while 82% of children born in households in the highest income quintile receive colostrum, less than half (46%) of the poorest children do so. Based on current trends Pakistan is unlikely to achieve MDG 1C, i.e., halving the 1990 level of malnutrition by Most existing nutrition programs are small in scale with very low coverage. The current global increase in food prices and economic crisis are other threats to the nutrition of young children and women of child-bearing age. Previous attempts to develop a national nutrition program. The Government of Pakistan (GOP) has been aware of the problem of malnutrition for many years. To address the above challenges, the Ministry of Health has developed National Nutrition and Micronutrient Strategies outlining its commitment. The Ministry of Health (MOH) requested the Bank for technical assistance (TA) to help them plan a new program that would be evidence-based and focused only on what the health sector could either deliver directly or influence other Ministries to deliver. The Bank in collaboration with UNICEF and Micronutrient Initiative provided TA to support the development of the program including development of a concept paper. Based on this paper, the GOP requested the Bank s assistance for the development and financing of the program proposed in this PCN. Government s proposed program: an evidence-based approach. With the Bank s and other partners technical assistance, MOH is in the process of translating the existing strategies into a focused nutrition program. The proposed program s technical design is ready and costing is being carried out. The program will be two-tiered and focus on: (i) scaling-up those interventions that are proven to work at scale in a country such as Pakistan, and (ii) supporting operations research for interventions which we know work at small scale but for which delivery models at large scale need to be developed in the Pakistan environment. The Bank has so far assisted in helping translate the concept into a program including technical workshops to prioritize interventions based on available evidence and clarifying issues relating to interventions to improve maternal nutrition and infant and young child feeding (IYCF) practices. 2

3 The proposed operation is in line with the Country Partnership Strategy being developed for FY10-13 and is in line with the Pakistan Poverty Reduction Strategy II which in turn is aligned with MDGs. The proposed operation is linked with the second pillar which envisages support to improve human development and social protection. The country strategy envisages seeking opportunities to address malnutrition in a multi-sectoral way by adding nutrition components to programs in various sectors which can contribute to the response. While a multi-sectoral approach to addressing nutrition is ultimately what is required, most countries tend to start with strong nutrition programming in the health sector and this has yet to be achieved in Pakistan. The proposed project will thus support evidence-based nutrition interventions to be delivered by the health sector and will build the capacity of MOH to engage with other sectors (e.g. agriculture, education) on nutrition issues. The proposed project is also in line with the priority accorded to nutrition within the Bank, in recognition of the magnitude of the problem in South Asia and of the critical role which good nutrition plays in national development. 2. Proposed objective(s) The development objective of the project is to assist GOP in improving the nutritional status of children under two years old and that of pregnant and lactating women by improving the coverage of effective nutrition interventions with a focus on the poor and marginalized within these groups. Project components: The project will have three components: a) Addressing general malnutrition in women and children; b) Addressing micronutrient malnutrition; and c) Strengthening institutional arrangements. Component 1: Addressing general malnutrition in women and children. This component will address general malnutrition in pregnant and lactating women and children less than two years of age, with the exception of community management of acute malnutrition (CMAM) which will cover children under five as per the national protocol. Targeting children from conception to 24 months is the recommended age group for providing nutrition inputs/interventions and the age at which nutrition interventions are most effective for the physical and intellectual development of children. This component will include: (i) set of infant and young child feeding (IYCF) interventions implemented through Lady Health Workers (LHWs) in a phased results-based manner at community level that will target a few key behaviors to improve nutritional outcomes and use of micronutrient powders to improve the quality of complementary 1 food; (ii) CMAM with phased expansion in the same geographical areas as IYCF which as per international guidelines will be primarily community-based, with complications referred to referral facilities. It will support the use of prepared/packaged foods 2 to treat children with severe acute malnutrition at community level and explore the feasibility of producing a similar product in Pakistan; (iii) support scale-up of key maternal nutrition interventions (de-worming and weekly iron folic acid (IFA) supplementation for women of child-bearing age and improving the nutrition quality of antenatal visits and provision of daily IFA supplementation during pregnancy) as well as operations research on program models for delivering a package of key interventions to 1 introduction of semi-solid foods in addition to breastfeeding 2 ready-to-use therapeutic food (RUTF) 3

4 address maternal malnutrition in first two years of the project in Islamabad Capital Territory (ICT) and Sindh, to be later scaled up based on results of rigorous evaluation; (iv) mass media for behavior change focusing on nutritional practices in line with expected project outcomes; and (v) in order to reach the population not covered by the LHW program and in urban areas, the project will contract with NGOs to promote appropriate infant and young child feeding practices (including micronutrient powders) and CMAM initially in one district in each province, with an in-built independent rigorous impact evaluation with a view to outlining policy options for expansion. Component 2: Addressing micronutrient malnutrition. This component will support micronutrient interventions which will be expanded and sustained across Pakistan. As development partners are actively supporting the scale-up of micronutrient interventions (except zinc supplementation), the project will complement these investments on building the capacity of the government to carry out its stewardship role including: (i) improving the quality of monitoring data for vitamin A supplementation through annual coverage assessment surveys which will help target program improvement efforts; (ii) for salt iodization and wheat flour fortification as the production side is being be supported by partners (Micronutrient Initiative, GAIN), the project will focus on enabling the development of legislation, building enforcement capacity and mechanisms, developing a sustainable model for access to fortificant for processors, and building consumer demand for fortified foods; and (iii) zinc supplementation for treatment of diarrhea: scaling-up efforts to expand use of zinc supplementation with oral rehydration solution (ORS) in management of diarrhea in children through public sector channels only. Component 3: Strengthening institutional arrangements in the health sector. The existing institutional capacity for nutrition within the health sector at the federal, provincial and district levels are inadequate. The Nutrition units at federal and provincial levels are weak in their ability to plan programs (as evident in project preparation which has taken longer than expected), to use evidence for decision making and to advocate outside of the health sector for nutrition interventions. The project will support strengthening and building capacity to provide leadership for nutrition programs in the health sector with a focus on strengthening nutrition units at federal and provincial and at the district level. The project will support organizational strengthening including supporting technical and management staff including staff training; provision of technical assistance for effective implementation including long and short-term nutrition experts, firm(s) for monitoring and evaluation including undertaking periodic surveys and program evaluations; and strengthening procurement and financial management capacities. In addition, the project will support operational research to test new interventions/approaches for infant and young child feeding (e.g. models of social marketing of micronutrient powders and soap, delivery of vitamin A to children within 2 days of delivery by LHWs) and maternal nutrition (e.g. models for working with religious and other leaders to address early marriage and pregnancy and birth spacing). 4

5 Implementation arrangements: The proposed project will be implemented through the federal MOH and provincial DOH. The Nutrition Wing at the federal level will provide the overall leadership with Nutrition Units in each of the provinces will manage the program. The federal role with be limited to policy, technical guidelines and oversight. The program management will be a district and provincial responsibility. All of the units will require strengthening of capacity in terms of program management, procurement, financial management and coordination to ensure effective implementation through the public system and through NGOs and other partners. The monitoring and evaluation framework for the project will include special surveys conducted by a third party on behalf of GOP. The project is not expected to trigger any safeguard policies. 3. Safeguard policies that might apply The project is not expected to have any negative social impacts, and does not trigger Bank policies on involuntary resettlement, indigenous people and environmental safeguards. However it will trigger Projects in Disputed Areas (OP/BP/GP 7.60) as it will support interventions in Azad Jammu and Kashmir. By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties claims on the disputed areas. 4. Tentative financing Source: ($m.) Government of Pakistan (BORROWER) 5 International Development Association (IDA) 55 Total Contact point Contact: Inaam Haq Title: Senior Health Spec. Tel: Fax: ihaq@worldbank.org Location: Islamabad, Pakistan (IBRD) 6. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C Telephone: (202) Fax: (202) pic@worldbank.org Web: 5

6 6