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Field Article
• An increased burden of disease and mortality,
in particular due to communicable
diseases.
• An increased burden of acute malnutrition:
Global Acute Malnutrition (GAM) was
found to be 15% in Punjab and 23.1% in
Northern Sindh, compared to 2.9 and 6.1%
in the same regions prior to the floods
(WHO Growth Standard 2006). 9
The GoP launched a major response to the
flood with support from the international
community. UNICEF as the Nutrition Cluster
Lead Agency (CLA) staffed the coordination
positions (including Information Managers) at
national and sub-national levels to assist the
MoH with coordination. The emergency phase
of the response to the floods was concluded by
February 2010. However 8 million people,
including 1.4 million children under 5 years
and another 1.4 million women still needed
urgent access to health care. Following consultation
with provincial health authorities,
regional offices and health sector implementing
partners, the WHO supported the health sector
to develop a comprehensive early recovery plan
for health that focused on 29 priority districts
across Pakistan. Nutrition-related priorities for
the ‘early recovery phase’ included provision of
nutritional support and treatment for acutely
malnourished under-five children and pregnant
and lactating women.
CMAM roll-out during the 2010 floods
The scale of the problem
It was well understood by all that malnutrition
was a serious problem in Pakistan before the
floods. The health information system in
Pakistan collects no routine data at all, thus
baseline nutrition data were missing. The scale
of the flooding and the resulting loss of homes
and livelihoods created an urgent need for upto-date
nutrition information to assess the
extent of malnutrition amongst the affected
communities.
A Flood Affected Nutrition Survey (FANS)
was duly undertaken (with the support of
UNICEF and other partners) during October
and November 2010. Data were collected in 19
worst affected districts. The FANS survey estimated
the GAM prevalence to be 23.1% in
northern Sindh and 21.2% in southern Sindh.
These results were considerably higher than the
WHO emergency threshold. Furthermore,
records from Northern Sindh revealed a prevalence
of SAM of 6.1%. The Sindh government
estimated that about 90,000 children aged 6 to
59 months were malnourished. 10 The nutrition
situation was also identified as ‘serious’ in
Punjab (see Table 2) and ‘poor’ in KPK and
Balochistan (data not shown).
The CMAM response
Since 2003, small community-based nutrition
programmes had been implemented in
Table 3: Numbers of SAM treatment sites and children
screened/admitted (March 2011)
Province
No. of
sites
(OTP/SC)
No. of
children
screened
No. of children
admitted in
OTP/SC
Sindh 163 374,646 22,741
Punjab 191 386,575 19,460
KPK 212 468,087 6,759
Balochistan 59 62,929 4,828
Total 625 1,292,237 53,788
Table 2: Acute malnutrition rates according to MUAC in Punjab, Northern and Southern Sindh (FANS preliminary
results)
Survey Punjab survey 2 Punjab survey 2 Northern Sindh Southern Sindh
Survey period 1-7 November, 2010 8-14 November,
2010
Balochistan for Afghan migrants and host
communities. In 2007, UNICEF commenced
comprehensive nutrition interventions including
the promotion of infant and young child
feeding practices, CMAM programmes and
micronutrient supplementation in the flood
prone areas of Balochistan and Sindh. In
2008/09, these interventions were expanded to
earthquake-affected districts in Balochistan,
flood-affected districts in Punjab, conflictaffected
areas in the NWFP (as it was known
then), and food insecure areas in other
provinces. These programmes were effective in
terms of high coverage, high cure rate, low
death and low defaulter rates. 11 This experience
is described below.
As a response to the 2010 floods, CMAM was
rapidly expanded to the worst affected districts.
More than 30 partnerships were established.
Memoranda of Understanding were developed
to clarify roles and responsibilities. Capacity
development was undertaken and a network of
CMAM/IYCN (Infant and Young Child
Nutrition) services were established and linked
to health services. A total of 1.3 million children
under 5 years had been screened by March
2011. Tables 3 and 4 outline the numbers treated
overall (from August 2010 to March 2011).
The feeding centres are serving a total of
55,921 out of 89,832 severely malnourished children,
155,000 out of 301,000 moderately
malnourished children and 95,131 out of
180,000 pregnant and lactating women. 12
Differing modalities of CMAM
implementation
CMAM in Pakistan has mostly been piloted
during crises and emergencies. With a weak
health care system, poor access and low coverage
of services, there has been a dependence on
donor support for human resource, training
and supplies. There are a number of stakeholders
with sometimes overlapping and different
mandates. As a result of poor coordination, the
referral and treatment networks have remained
fragmented. Pakistan received technical
support for the formulation of National CMAM
Guidelines from UNICEF, Valid International
and Save the Children. However these guidelines
have yet to be properly disseminated.
Table 4: Numbers of MAM treatment sites and
beneficiaries screened/admitted (March 2011)
29th October to 3rd
November, 2010
29th October to 4th
November, 2010
Indicator % (n) (C.I.) % (n) (C.I.) % (n) (C.I.) % (n)
MUAC