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Field Article
six mobile teams were mobilised. Each vehicle
visited a village once a week and followed up the
same on next week... The mobile team included a
group of people who offered services of WASH,
PHC and nutrition jointly at the spot. Screening
was done there and then. EPI, ANC, safe drinking
water, de-worming etc. all services were made
available at the door step... We requested to with
hold wheat and soya bean combination (FBF) to
WFP because that needs water for preparation,
which was not readily available. Instead newly
introduced supplementary plumpy was distributed.
High energy biscuits were distributed
uniformly to all families with children under five.”
Manager of an INGO
2010 floods: the challenges
There were a number of challenges to the scaleup.
One problem was that the UN agencies had
limited communication between each other and
at times appeared to be in competition.
Pressure from the DoH highlighted and encouraged
the need for better coordination.
Coordination was made more difficult because
of the complications experienced by partners
having to sign separate MoUs with UNICEF,
WHO and WFP (who were responsible for
training and supplies of OTP, SC and SFP,
respectively). Linkages between the three
components of CMAM were often sub-optimal,
as described below:
“What happened is that, say one agency started
OTP but the other didn’t establish an SC as a
referral facility or vice versa. It could result in
the child being referred to SC and not receiving
treatment, or a child treated at SC when returned
to community could not be taken care of by SFP.
The missing components of CMAM were compromising
the quality of care.”
Provincial level manager from Department of
Health
The DoH also became frustrated with programming
that they were not informed or aware of:
“The donors were awarding contracts for service
delivery to the local NGOs without even informing
the health authorities. We had no idea who is
doing what and where and for how long the local
NGO is intending to serve and what is its exit
strategy”.
Provincial level manager from Department of
Health
CMAM successes in KPK
Particular successes were noted for the
programme in KPK:
KPK had a functional nutrition cluster in place,
which had already sensitised the provincial
government for the urgent need for nutrition
activities. Importantly, agencies and government
staff working in KPK were able to share
their skills and experience with other
provinces, enabling a more rapid response in
other provinces. Although, as mentioned
above, there were still challenges to coordination
arising from inter-agency mandates.
The response was better in KPK due to good
collaboration from the start between the PPHI,
DoH and NGOs. A tripartite agreement
between the three partners paved the way for
coordinated efforts, which were noticeably
lacking in other provinces (especially in terms
of coordination with the PPHI).
Much higher acceptability for the nutrition
programme was seen when compared to EPI.
This is likely due to the fact that the programme
provided treatment, rather than being a preventative
programme. The community can often be
more willing to seek out treatment options for
their sick children.
The SCs function well in KPK. They are well
equipped, have trained staff and reports indicate
that high quality services are being
provided.
Winter supplies were planned and a 2-
month stock of blanket food for the targeted
population was pre-positioned. This helped to
ensure uninterrupted supplies during the
winter months in the inaccessible mountainous
areas.
The future for CMAM in KPK
The 18th constitutional amendment continues
to confuse health managers. There is a lack of
clarity regarding new roles and the nutrition
programme. At present, nutrition does not
enjoy the status of a fully-fledged entity but is
being run on an ad-hoc arrangement.
Additionally, the future of the Nutrition Cell in
the DoH KPK is not clear as the provincial
authorities are occupied with internalising and
responding to the challenges of the 18th
amendment. There is little understanding about
IYCF and CMAM as programmatic measures at
provincial level. Meanwhile, the longer-term
nutrition program (the World Bank supported
PC1) to support the nutrition in KPK is awaiting
approval from provincial authorities.
Sindh: A Late Wakeup Call
While Sindh province had some well-established
vertical programmes such as EPI, there
were no institutional nutrition programmes,
and there seemed to be little commitment
within the health department for nutrition
when the floods arrived. The provincial nutrition
focal person, a dedicated female doctor,
had limited influence over the Executive
District Officers (EDOs), partly because nutrition
was not particularly embedded within the
health department and partly because she was
a woman.
The response to the 2010 floods
The massive floods came as a surprise to Sindh.
Out of 16 districts, nine were severely hit. Some
districts were not directly affected, but received
large numbers of displaced people. There was
no experience to draw upon for the response to
a major emergency. There was very limited
capacity for nutrition-related programming
within the government and NGOs
A couple of CMAM pilot projects had been
implemented in food insecure areas during
2009 that were not flood affected. While
support was provided from these districts, and
other expertise was brought in from KPK
province (as they had previous experience in
CMAM), it still was not sufficient for the scale
of response required. No contingency plan was
available in Sindh. Initial planning was undertaken
on the basis of NNS 2001, the most
recently available data at the time.
“All assumptions for planning were made on the
basis of 2001 survey [NNS]. The resultant
response was therefore wholly insufficient. While
operations had to start immediately, problems
with planning and the delays in supplies resulted
in a worryingly slow response”
Provincial level programme manager of health
department
Involvement of LHWs and PPHI
In Sindh province, the LHWs were not permitted
to engage in the CMAM programme, until
direction was given from the Federal level. The
PPHI programme was able to offer some space
at their facilities for CMAM activities (e.g. OTP
and/or SFP). However, the staff at the BHUs
were not involved in programme implementation,
which was undertaken by NGO staff,
Pitfalls and challenges
At the start of CMAM, the government faced a
range of challenges. For example, the concept of
‘nutrition’ was regularly confused with food
aid. This misunderstanding stretched also to
civil society.
“We received an overwhelming response from
the civil society. A number of NGOs approached
us and showed interest in working on nutrition.
But the moment they came to know that the
nutrition is not about food distribution, that
interest vanished”
Provincial Programme Manager
These misunderstandings were compounded
when blanket food support arrived causing a
change in focus of the programme. Community
perception was shifted from CMAM as a treatment
programme to that of food distribution.
There was a great deal of demand for edible oil
and biscuits, but not for medicine. The change
to blanket distributions caused a great deal of
problems in the community. Once the situation
was stabilised, blanket feeding was replaced by
targeted interventions. Despite conducting
social mobilisation, there were serious misunderstandings
regarding the targeting, with
community members preferring the blanket
distributions. Security was compromised at
some of the distribution sites.
“When the community saw the vehicles of nutrition
staff, they emerged as a mob, armed with
canes. They were angry because the previous staff
had distributed goods to much of the vulnerable
population, including their kith and kin. They
thought that the nutrition people were there for
the same kinds of distributions.”
INGO Representative
Mobile teams were introduced to cover remote
rural areas, however they proved quite costly.
As described above, capacity challenges
were the biggest hurdle to the scale-up of
CMAM provision in Sindh province. Positions
were not adequately filled and the high
turnover of project staff compounded the problem.
There were generally very limited
handover processes amongst government staff
when turnover occurred, affecting the continuity
of programming.
The government faces a lack of capacity for
many reasons, with the humanitarian community
sometimes contributing to the shortage of
skilled manpower:
“Donors can help to incapacitate the government.
In order to make their projects successful, they
identify, attract and lure the government
personnel with attractive package. This further
incapacitates the government system”
Provincial Manager from Health Department
Punjab: Slow and Steady, and with a
Vision
The Government of the Punjab had already
been proactively developing and implementing
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