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Field Article
an agenda for better health, even before the
advent of 18th amendment. To improve quality
of health care delivery, setting up standards and
institutional development the province rigorously
followed the Punjab Healthcare
Commission.
The 2010 flood response
The floods also came as a surprise to Punjab
province. Neither government nor civil society
expected such a massive disaster. Punjab’s
previous experience in CMAM was limited to
two small pilot projects in Rajan Pur and Kot
Addu districts during the floods in 2008.
As the floods emerged, NGOs from KPK
came forward with assistance, but their scale of
operations was diluted due to the lack of skilled
force to run operations of this size. Programme
sustainability and ownership were the prime
concerns from the outset of the Punjab
Government’s response. The government was
in the driving seat and showed authority in
addressing the issues. It held the NGOs
accountable for their work. It started with the
setting of ground rules, for instance:
“Before initiating new hiring, government
defined the minimum structural requirements
for CMAM. It was decided to avoid unnecessary
and overstaffing on one hand and to ensure that
the government employees perform their duties”
(and not shift the task to the contracted
employees). “The most critical element in the
effectiveness of the response was the strong
commitment of the then able leadership in department
of health.”
Provincial Manager, Health Department
A distinguishing feature of the response in
Punjab was that, unlike the other provinces, the
government only involved public sector health
facilities (BHUs and RHCs). No non-governmental
facilities were involved in the response.
Strong government commitment and leadership
at provincial level helped to ‘sell’ the idea
of CMAM as an appropriate emergency
response. An example of this was that the
provincial health secretary personally took an
interest in the performance monitoring reports
and questioned district managers on any poor
results.
In summary, although the (government’s)
response could be viewed as slow in Punjab,
the strong foundation of CMAM will likely
have a long term impact on nutrition in emergencies
in Punjab.
Coordination and use of the LHWs for
CMAM
During the initial phase of the response, there
was confusion about the roles and responsibilities
of various partners. The cluster approach
partly addressed the issue, but this was finally
resolved after the signing of MoUs between UN
agencies.
A Technical Advisory Group (TAG) was
established by the government, which
managed the various stakeholders and their
different mandates and priorities well. The
National Programme for Family Planning and
Primary Health Care (FP and PHC) in Punjab
was given a lead role in responding to flood
disaster. This decision was based on the facts
that:
• There was limited field level visibility/say
of the provincial Nutrition Cell.
• The National Programme for FP and PHC
had effective implementation and monitoring
mechanisms in place.
• The ‘community-based management’ aspect
of CMAM could only be addressed through
community-based workers, i.e. LHWs.
This bold decision caused a stir in the federal
programme implementation unit at national
level because they were not comfortable with
the involvement of LHWs in the nutritional
aspects of disaster response. Nevertheless the
provincial government’s strong determination
ensured that their decisions were not undermined
by the federal office.
The quality and content of training of LHWs
has been questioned in the past. The province
has addressed these concerns through a
number of measures, for instance: Previously
there were multiple, fragmented and weak
trainings on nutrition. However a new training
manual of LHWs comprising of vitamin A, IDD
infant and young child feeding (IYCF) and
CMAM was drafted, with the training given in
a single 5-6 day package. This plan is awaiting
approval by the TAG.
Prior to the 18th amendment, the federal
programme office had been following a trickle
down training approach, i.e. the federal office
developed the training material and gave training
to national level trainers, who trained
provincial trainers, who trained district health
facility staff, who trained the LHWs. This tiered
approach often diluted the quality of training.
The new approach of direct nutrition training
for LHWs is expected to improve their skills
and knowledge on nutrition.
In Punjab, CMAM experience illustrated that
the LHW can quickly become overburdened
managing large numbers of beneficiaries,
taking anthropometric measurements, etc,
which can compromise the quality of her work.
To address this, the chowkidar (guards) were
instructed to provide support for managing
queues at the facility, and assistants were asked
to help with measurements and records. This
nutrition assistant (graduate level) preferably
has a diploma in nutrition (compared to LHW
who are minimum 8th grade standard).
The future for CMAM in Punjab
Implementation through NGOs is a costly business
and poses serious challenges for
sustainability. The government has planned to
gradually acquire NGO-operated projects
through the LHW programme, with no new
signings of PCAs. However, the NGOs are
encouraging a period of transition:
“The role of NGOs should not be undermined.
Some of these organizations have demonstrated
strength in social mobilisation and they have
engaged the population through economic opportunities,
such as microcredit, which can be
employed to improve nutrition. Hence the role of
NGOs should be considered as complementary
and the transition should be gradually phased
out.”
INGO Representative
At present, the government is developing an
‘Integrated Module on Prevention and
Treatment of Malnutrition’ that contains both
IYCF and CMAM. It will include all three
anthropometric measurements, i.e. weight-forage
(WFA), height-for-age (HFA) and MUAC,
to capture both chronic and acute malnutrition.
While the initial focus of the government
and NGOs was purely on CMAM and not on
underlying factors associated with SAM, the
importance of IYCF in relation to CMAM has
since been realised.
“Gradually the focus has shifted and now more
and more is being enquired about the progress on
IYCF. We now say that if a CMAM site is without
a breast feeding corner and counselling services,
it should not be claimed as a CMAM site.”
INGO Representative
However, the effective integration of IYCF and
CMAM still requires a great deal of advocacy,
particularly to increase community awareness
and knowledge.
Conclusions and the way forward
“The programme is doing self advocacy. Unlike
Polio where the prevention doesn’t show any
visible effect, the community has a chance to
witness real positive change among malnourished
children. They found that once bed ridden, a child
gets up and starts playing and taking interest in
life after induction in CMAM programme. This
resulted in self advocacy and people from the
uncovered areas started visiting the facilities”.
Provincial Manager
The positive outcome of the 2010 floods is that
a country-level response established nutrition
as an important area of intervention in the eyes
of government, partners and the community.
Despite all the hurdles, setbacks and concerns
of inefficiencies, the country now has substantial
local experience in the public and private
sectors for implementing CMAM. This wealth
and variety of experience needs to be employed
in the policy and planning decisions.
Under the post-18th amendment scenario,
the sole responsibility of health and nutrition
policy and planning now rests with the
provinces. The weak capacity of some
provinces might require technical coordination
and support from the existing arrangement at
the federal level. The provinces need to define a
nutrition policy in order to mainstream nutrition
in the public health system. This would
require an evidence base, which can be solicited
from the other provinces. However, a central,
federal-level venue could provide inter-provincial
coordination and promotion of
evidence-based practices. At present, the
Nutrition Wing of the Cabinet Division could
undertake this function.
The institutionalisation would require longterm
vision and investments. This includes the
introduction and embedding of relevant topics
in the curricula and training courses of community
based, auxiliary and the clinical care
providers. The cost effectiveness would logically
be achieved through strengthening
nutrition services within the existing PHC
system instead of introducing a vertical
programme.
The trickle down of provincial nutrition
policy and strategies depends on the district
level leadership, capacity and commitment.
This might require training of district management,
including sensitisation on nutrition
issues, building capacity in needs assessment,
and planning and management of nutrition in
emergencies and non-emergency contexts. At
the district level, nutrition should be made part
of ‘a package’ because a child with multiple
problems cannot be treated and managed by
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