PPHI Sindh

A company incorporated under Section 42 of the

Companies Act 2017

NUTRITION WING/SECTION

Tuesday, January 12, 2021

Head Office, Karachi

0
 Outline /Road Map
Projects Introduction
1 Donors, Partners, Districts,
Budget, Consequences of

Staff Introduction
Malnutrition
Human Capital, Economic Loss 5
2 Project Leads and Teams
Solutions / Interventions

Introduction of Malnutrition
Intersectoral Interventions,
6
3 Stunting, wasting, underweight,
Importance of Breastfeeding

Situation Analysis
Cost effective and efficient
intervention 7
4 Findings of NNS 2018
Interventions in PPHI
CMAM Model, OTPs,
Beneficiaries 8
 Projects
CMAM
Handwash
PINS DJ Surge
Umerkot Stations
2 Districts 04 Districts

COVID
PINS RESPONSE
08 Districts 05 District

AAP
13 Districts TSFP
1 Districts
 Financial Portfolio of Nutrition Wing
Surge, 27 Handwash
PINS DJ
Million Stations
234 Million
25 Million
COVID
PINS, 1.1 RESPONSE,
Billion 34 Million

1.742
TSFP, 20
Billion
Total: Million
04 Billion
Projects and Districts
Project Heads

Dr. Zeeshan Noor Shaikh Dr. Sajid Shafique Lakhiar

Project Director-EU PINS Project Coordinator-AAP

PMP-PMI USA, MPH UoM M.B.B.S, MA, (MPH)

Australia,
 AAP TEAM

MEET THE TEAM

Akhtar Ali Dr. Ramzan Samejo Dr. Sajid Shafique Mohsin Hassan Usama Ahmed
Manager NIS Manager Program Project Coordinator Manager Finance Executive Finance

Syed Ali Raza Saddam Suhag Fahad Hussain Muneer Ahmed Abeer Khatri
Communication Officer Compliance Officer Finance Assistant Assistant NIS Assistant NIS
 PINS Team

MEET THE TEAM

Dr. Zeeshan Noor Shaikh

Project DIRECTOR

Syed Faiq Hussain Musvi Ahmed Ali Chandio Kamran Abbasi Irfan Akbar
Manager Finance Manager Technical Program Officer Program Officer

Abdul Waheed Saqib Ali Raza Ali Magsi Naveed Hussain

Compliance Officer Assistant NIS Assistant NIS Assistant NIS
WHY SO MUCH INVESTMENT?
Types of Malnutrition

Acute &
Acute Chronic
Chronic
Malnutrition Malnutrition
Malnutrition
 Types of Malnutrition

Wasting / Stunting/ Underweight/

Acute Chronic Acute & Chronic
Hidden Hunger
Situation of Malnutrition in Pakistan and Sindh
STUNTING
GB

KP
KP

ICT
AJK

KP-NMD
KP-NMD

PUNJAB

BALOCHISTAN

SINDH
STUNTING PUNJAB

36.4%

BALOCHISTAN

SINDH

45.5%
 GB
46.6%
STUNTING KP
KP
40.0%

ICT
AJK
32.6%
39.3%

KP-NMD
KP-NMD
48.3%

PUNJAB

36.4%

BALOCHISTAN
 KP-NMD

WASTING PUNJAB

BALOCHISTAN

SINDH

23.3%
WASTING
GB
9.4%
KP
KP
15.0%
ICT
12.1%
AJK

16.1%

KP-NMD
KP-NMD
23.1%

PUNJAB
15.3%

BALOCHISTAN

18.9%

SINDH

23.3%
 NUTRITION STATUS OF WOMEN IN
PAKISTAN
UNDERWEIGHT
(BMI < 18.5)

NORMAL
14.4% 46.1% 24.0% 37.8% (BMI 18.5 – 24.9)

OVERWEIGHT
(BMI 25.0 – 29.9)

OBESE
(BMI > 30)
 NUTRITION STATUS OF WOMEN IN
PROVINCE WISE
GB 10.10% 62.50% 19.60% 6.90%

AJK 12.90% 52.40% 23.40% 10.30%

KP NMD 5.40% 40.20% 25.10% 23.20%

ICT 10.70% 41.90% 26.70% 19.60%

BALOCHISTAN 14.50% 48.70% 22.10% 12.00%

KP 8.30% 46.70% 28.20% 15.00%

SINDH 22.60% 46.20% 19.80% 10.20%

PUNJAB 12.10% 45.40% 25.40% 15.20%

Underweight (BMI < 18.5) Normal (BMI 18.5-24.9) Overweight (BMI 25.0-29.9) Obese
ANAEMIA

57.40%
42.70%
Anaemia
Among
Women of
Reproductive
age
1%

SEVERE MODERATE NORMAL

DEFICIENCY DEFICIENCY
 Before
WASHING AT FIVE Feeding a child
CRTITCAL TIMES IN PAKISTAN
BY LOCALITY (URBAN/RURAL)
69.4%

70.2%

69.9%

HAND
WASHING PAKISTAN
AT FIVE
RURAL
CRITICAL
TIMES
URBAN
Consequence of Malnutrition
 Undernutrition and Child Mortality 7

Perinatal &
54% of child mortality is associated
Newborn with underweight condition
22%

9.5 million under five deaths in 2006

The single largest common

Pneumonia
20% denominator in global child deaths
Malnutrition is malnutrition
All other
54% causes
29%
Severe wasting is an important
cause of these deaths (it is difficult
Malaria to estimate)
8%

Measles
5% Diarrhea
HIV/AIDS Proportion associated with acute
4%
12% malnutrition often grows
dramatically in emergency contexts
Caulfied, LE, M de Onis, M Blossner, and R Black, 2004
Consequences of Stunting

Mortality 5X greater likelihood of stunted child to die from

Short-term all causes
Consequences

Morbidity
50% of years lived with disability in children
under 4 are attributable to nutritional deficiencies

Increase risk of With faster relative weight gain after age 2

overweight and
(compared to linear growth), There is an 1.5 – fold
raised blood
pressure in increased risk of overweight and 1.07 – fold
adulthood increase in risk of hypertension in adulthood.
Long-term
Consequences Increase risk of A 1 Kg rise in birth weight is associated with a
cardiovascular 12% reduction in cardiovascular mortality for
disease low birthweight babies

Intergenerational Stunted women are 3X more likely to give birth

transfer who are stunted at age 2.
 Sustainable 1

Development Goals
2 3 4 5

6 7 8 9

1 11 1 1
0 2 3

14 15 16 17
 Sustainable 1 NO POVERITY

Development Goals
GENDER
2 ZERO HUNGER 3 GOOD HEALTH
AND WELL-BEING 4 QUALITY
EDUCATION
5 EQUALITY

6 CLEAN WATER AND

SANITAZITION 7 AFFORDABLE AND
CLEAN ENERGY 8 DECENT WORK AND
ECONOMIC GROWTH
9 INDUSTRY INNOVATION
AND INFRASTRUCTURE

1 REDUCED 11 SUSTAINABLE CITIES

AND COMMUNITIES 1 RESPONSIBLE
CONSUMPTION AND 1 CLIMATE
INEQUALITIES PRODUCTION ACTION
0 2 3

14 LIFE BELOW
WATER
15 LIFE ON LAND 16 PEACE JUSTICE AND
STRONG INSTUTIONS
17 PARTNERSHIPS
FOR GOALS
 SDGs and Nutrition
01
Being poor limits the ability of
17 individuals to access adequate food
02
Aid allocated to nutrition has high returns a $1 Agriculture and food security are
investment in nutrition has demonstrated a cornerstones of nutrition
$16 return in economic growth
16 03
War and conflict are major underlying Up to 45% of deaths in children under
factors of nutrition insecurity 5 are caused by under nutrition

04
15
Learning and focusing on school is
Soil degradation threaten our
difficult with out a sufficient diet
ability to grow food

05
13
When women control the family income,
Climate change may reduce food
children's health and nutrition improve at
production and cause water scarity
a greater rate
12 06
Tackling resource use and degradation is Access to safe water and sanitation is an
key for sharing resources and improving absolute prerequisite for nutrition
access to quality food 08
High levels of malnutrition in some
countries may result in 11% loss to GDP
What Should Be Done to Overcome this
Challenge?
 WHY SUCH HUGE BURDEN?
CAUSAL FRAMEWORK OF UNDERNUTRITION
Child
OUTCOME Malnutrition, death and
disability
Immediate
Causes Inadequate
Disease
(Affecting Individuals) dietary intake

Underlying causes Inadequate maternal and

(household/ childcare practices
Insufficient access Poor
Family Level) sanitation/water and
to food inadequate health services

Basic causes at Quantity and quality Inadequate and/or inappropriate

knowledge and discriminatory
Social Level of actual resources—human, attitudes, limited household
economic and organizational—and access to resources

the way they are controlled

Political, cultural, religious,
Potential economic and social systems,
resources: environment, including women’s status, limit
the utilization of potential sources
Technology, people
 Pregnancy Birth 12 Months 24 Months 36 Months 54 Months 72 Months

Counseling on adequate diet Exclusive Complementary feeding Adequate, nutritious and safe diet
during pregnancy
Nutrition breast feeding Therapeutic zinc supplementation for diarrhea
Iron-folic acid for pregnant
mothers Prevention and treatment for acute malnutrition (moderate and severe)
Micronutrients: supplementation and fortification
Antenatal visits
Attended
Immunization
Health Delivery Deworming
Planning for family size and spacing
Access to healthcare
Prevention and treatment parental depression

Access to safe water

Water and
Adequate sanitation
sanitation
Hygiene/Hand washing
Maternal Education
Education
Education about early stimulation, growth, and development
Early childhood and preprimary programs
Birth Continuity to quality
registration primary education
Parental leave and adequate childcare
Social
Child protection services
protection Social assistance transfer program
 1000 Days Window Of Opportunity

Maternal health
Maternal Nutrition Status

Complementary feeding

Embryo-Placenta
development Lactation Diet Diversification

Fetal Development Infancy 2 years

Conception Birth 0-12 months Toddlerhood

Morbidity and
morality in childhood
Nutrition specific
interventions and
programs
• Adolescent health and
preconception nutrition
• Maternal dietary
supplementation
• Micro nutrient
supplementation or
fortification
• Breastfeeding and
complementary feeding
• Dietary supplementation
for children
• Dietary diversification
• Feeding behaviors and
stimulation
• Treatment of severe
acute malnutrition
• Disease prevention and
management
• Nutrition interventions
in emergencies
Cognitive, motor, Adult stature Work capacity
School performance
socioemotional and learning capacity and productivity
Obesity and NCDs
development
Optimum fetal and child nutrition and development
Nutrition sensitive
programs and approaches
• Agriculture and food security
Feeding and
Breastfeeding, • Social safety nets
caregiving practices, Low burden of • Early child development
nutrient-rich foods,
parenting, infectious diseases • Maternal mental health
and eating routine
stimulation • Women's empowerment
• Child protection
• Classroom education
Feeding and • Water and sanitation
Food security, Access to and use of
caregiving resources • Health and family planning
including availability, health services, a
(maternal, household, services
economic access, safe and hygienic
and community
and use of food levels) environment
Building an enabling environment
• Rigorous evaluations
• Advocacy strategies
Knowledge and evidence • Horizontal and vertical
coordination
Politics and governance
• Accountability, incentives
Leadership, capacity, and financial resources
regulation, legislation
Social, economic, political, and environmental context (national and • Leadership programs
global) • Capacity investments
• Domestic resource mobilization
 The evidence: impact of breastfeeding on
mortality
• A non-breastfed child is 16
15.13

14 times more likely to 14

14.4

die in the first 6 months

compared to an 12
10.53
exclusively breastfed 10

child in developing
countries.
8

4
• These risks are
amplified many times in 2
1 1 1

an emergency 0
Diarrhoea mortality Pneumonia All cause mortality
mortality

Exclusive breastfeeding

Not breastfeeding
 Lancet 2013 Nutrition Series: 45% of child deaths
are due to undernutrition; 12% of those deaths or
800,000 deaths, attributable to sub-optimal
breastfeeding
Combined effects 45.4 Combined effects 3,149,000

Stunting 17.0 Underweight 1,180,000

Underweight 17.0 Stunting 1,179,000

Fetal growth restriction 11.8 Fetal growth restriction 817,000

Sub-optimal breastfeeding 11.6 Sub-optimal breastfeeding 804,000

Wasting 11.5 Wasting 800,000

Severe wasting 7.8 Severe wasting 540,000

Vitamin A deficiency 2.3 Vitamin A deficiency 157,000

Zinc deficiency 1.7 Zinc deficiency 116,000

Percentage of deaths 0.0 10.0 20.0 30.0 40.0 50.0
Annual numbers of deaths 0 1,000,000 2,000,000 3,000,000
 Lancet 2013 diarrheal-pneumonia series:
breastfeeding promotion has large impact on child
deaths due to diarrheal and pneumonia
Pneumococcal vaccine
Case management of neonatal infections
Breastfeeding promotion
Case management of pneumonia infections
Improved water source
Zinc supplementation
Hib vaccine
Handwashing with soap
Improved sanitation
ORS
Rotavirus vaccine
Hygienic disposal of children's stools
Vitamin A supplementation
Zinc for treatment of diarrhea
Antibiotics for dysentery

Lives saved - 50,000 100,000 150,000 200,000 250,000 300,000 350,000

 Early initiation of breastfeeding saves
newborn lives
Initiation of breastfeeding within the first hour could prevent up to
20% of neo-natal deaths from all causes

Lancet 2013: initiation within the first 24 hours associated with 45%
reduction in all-cause neo-natal mortality

➢ Newborns are particularly vulnerable in emergencies.

Sources: Singh K, Srivastava P. The effect of colostrum on infant mortality: Urban rural differentials. Health and Population 1992;15(3&4):94–
100.
Edmond, K et al. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics 2006: 117(3):e380-6.
Mullany L. et al. Breastfeeding patterns, time to Initiation and mortality risk among newborns in southern Nepal. The Journal of Nutrition 2008:
138; 599-603.
Lancet 2013, Nutrition Series, Paper2.
'Breastfeeding is a society's collective responsibility,
not only mothers’ issue'
Let Us Save Generations
Lets Take Responsibility and Be A Source of
HOPE!
Expectations from DMS
Establishment and functionality of each OTP site
Visit every OTP site in two months
Ensure you document your OTP visit by filling checklist, writing
comments in observations/comments register
Ensure integration of nutrition service with other services in the
health facility)
Referral from non OTP PPHI HFs
Expenditure Analysis
Do a top and bottom five analysis of all OTPs every month of
following indicators
Screening
Referral (Community, OPD, CHW, LHW)
Admissions
Moved out and Moved in
Deaths and Defaulters NSC (In and out analysis)
RUTF Consumption
 Introduction to CMAM

Community
Services Outreach
and
programs
addressin
Outpatient
care for SAM
Services and/or programs
g MAM without
complications
To prevent under nutrition

Inpatient care
for SAM with
Complication
s
Principles of CMAM

1. Maximum access and coverage

2. Timeliness/ No late arrivals!

3. Appropriate medical and nutrition care

4. Care for as long as needed

Quick Tools for Identification of Acute Malnutrition
Severe Moderate Normal

Bilateral Pitting Oedema MUAC

SAM Present (+, ++, +++) < 11.5 cm

MAM Not Present 11.5 <12.5 cm

CMAM Implementation Model in Sindh

CMAM
Implementation
Model in Sindh

Community
Facility Based
Based
Interventions
Interventions

NSCs in DHQs NGOs in LHW

OTPs in HFs and Tertiary Set- TSFP in Umerkot LHW Uncovered
ups Areas
Major Interventions in OTPs

Nutrition Assessment Treatment of SAM Treatment of Routine

(MUAC, Weight, Height) Children Diseases

Counselling
 Major Interventions in Community

Referral to Follow up
Screening Counselling IFA MNP
OTP sites of Children
 Flow Chart and Referral Mechanism of CMAM
Cured OTP
INPATIENT CARE SC cases are cases are
(STABILISATION rehabilitated in followed up in
CENTRE, one in OTP OTP TSFP
District) (Established in (if operating)
Children 6-59 HFs)
Months: SAM with Children 6-59 TSFP
complications months: (Established in
SAM without HFs)
Infant 1-6 months: complications
acutely A MAM case
malnourished (neonates that deteriorates
are treated in peadiatric An OTP case that
deteriorates is to SAM is
ward) referred as OTP
referred to SC

COMMUNITY
Screening for Malnutrition Using
MUAC by CHWs and LHWs, referral
and
Follow-up
Total Population Covered by the Nutrition Programs

Total Population= 33.34 Million

Summary of Nutrition Programs

Number OTPs in Nutrition Program

Number of District UCs OTP Site

23 920 1,107

Number TSFPs in Nutrition Program

Number of District UCs OTP Site
1 26 29

Number NSCs in Nutrition Program

Number of District NSC
14 16
Current Coverage of Nutrition Programs

AAP OTPs PINS OTPs

OTP
OTP # District UCs
# District UCs Site
Site
1 Thatta 30 30
1 Badin - A&B 45 49
2 Sujawal 25 25
2 Ghotki 34 56
3 Tando M Khan 16 16
3 Hyderabad 30 40
4 Tando Allahyar 22 22
4 Jacobabad 38 46 5 Matiari 30 30
5 Kashmore 35 42 6 Kamber 40 40
6 Khairpur - A&B 76 105 7 Larkana 47 47
7 Mirpurkhas-A&B 37 61 8 Shikarpur 53 52
Nasuhehro 9 Dadu 66 52
8 49 63
Feroze 10 Jamshoro 30 41
Shaheed Total 359 355
9 46 50
Benazirabad
10 Sanghar - A&B 48 70
11 Sukkur 46 69
TSFP
12 Tharparkar 51 72 TSFP
# District UCs
Site
13 Umerkot 26 29
1 Umerkot 26 29
Total 561 752
 Current Coverage of Nutrition Programs
AAP NSCs
# District NSC

1 Badin 1 PINS NSCs

2 Ghotki 1
# District OTP Site
3 Hyderabad 2
4 Kashmore 1 1 Dadu 1
5 Khairpur 1 2 Jamshoro 1
6 Mirpurkhas 1
Total 2
7 Nasuhehro Feroze 1
8 Shaheed Benazirabad 1
9 Sanghar 1
10 Sukkur 1
11 Tharparkar 2
12 Umerkot 1
Total 14
 Main activities at the OTP sites

Nutritional Screening (MUAC & Edema)

Management of SAM children as per OTP protocols (Including RUTF,
Medicine & Other services)
Delivery of Health Education Sessions
NSC referral for complicated SAM children
Provision of MNP & Zinc (Only diarrhea cases) to under 5 children
Provision of IFA Tablets to PLW
Linkage development / Coordination with all outreach stake holders
(Monthly meetings at OTP etc)
Reporting & Recording
 Main Corners at the OTP sites
1. Safe Drinking Water

2. Waiting Area

3. Screening Area

4. OTP Corner

5. Breast Feeding/IYCF Corner

6. Hand Washing Corner

7. Appetite Test Corner

8. Supplies Corner
 Linkage with other Stakeholders
CHWs
LHWs
CSGs

OTP

FSGs

NSC

MSGs Nutrition Sensitive

Interventions
 Integration of Service Delivery at PPHI Managed HFs

Family
Planning
Vaccination
ANC

OTP

PNC & New- Medical

born Care Care

KMC
Ambulance
Health Service
Education
 Nutrition Program Achievement

Indicators No. of Children

Children <5 Assessed 4,875,735
Enrolled in OTP 400,061
Cured Discharge from OTP 306,450
 Program Achievements since Start

Indicator Achievement %
0.2% 1.9% 1.2%
Under 5 years children 1.3%
4,750,484 5.8%
Assessment for Malnutrition
4.9%
No. of SAM Children
400,262
Registered

Cured 306,450 90.6 %

Default 16,548 4.9 %

Death 591 0.2 % 90.6%

Non Cured 4,281 1.3 %

Cured
Medical Transfer 6,282 1.9 % Default
Transfer to Inpatient (NSC) 3,932 1.2 % Death
Non-Cured
Moved Out / Others 20,923 5.8 % Medical Transfer
Total No. of Exit 359,007 Transfer to Inpatient (NSC)
Moved Out
Remaining on Treatment 41,255
Sphere Standards: The proportion of discharges from therapeutic care who have died is <3per cent, recovered is >75per cent and defaulted is <15per cent
 Nutrition Stabilization Center Progress Since Start

Indicator Achievements %
1.5% 9.3%
0.3%
Enrolment of SAM Children
3,623
with Medical Complication 6.2%

Cured 2,974 92 %

Default 200 6.2 %

92%
Death 49 1.5 %

Non Cured 11 0.3 %

Transfer Out 332 9.3 %

Total No. of Exit 3,566 ~

Remaining on Treatment 57 ~ Cured Default Death

Non-Cured Transfer Out
 Successful Case Study

Badal 16 months old baby boy at

the admission time his weight
4.5kg & MUAC 6.5cm, 77 days in
the program and nutrition team
providing therapeutic treatment
and continues monitor the
growth of baby, now successfully
cured from the OTP program at
the exit day of program having
weight 7.1kg & MUAC 12cm
 Successful Case Study

Before After

Saeedan 36 months old baby girl at the admission time her weight 6.7kg & MUAC 8.5cm, 73 days in the
program and nutrition team providing therapeutic treatment and continues monitor the growth of baby, now
successfully cured from the OTP program at the exit day of program having weight 7.9kg & MUAC 12.3cm