How did Pakistan implement?

Lady Health Workers

The Lady Health Workers Program (LHWP) was cited across Exemplars study participants as the most important government measure taken in the campaign to support in effective implementation of programs and reduce anemia prevalence.

Established in 1993, the LHWP has been instrumental in delivering health services directly to communities—an important consideration in a country with such vast rural areas and large swaths of mountainous terrain.¹ The LHWs’ gender enables them to make home visits to women in deeply conservative communities that sometimes discourage women from visiting medical facilities. In many parts of the country, these are the only health care workers women see at any point in their pregnancy.

LHWs provide basic preventive and curative health services, including several that are directly related to anemia prevention.² They are the primary means by which anemia is monitored among WRA. In addition, Exemplars study participants widely credited them as a primary source of reliable nutrition education, nutrition screening, and iron plus folic acid supplementation. In fact, some interviewees in the Exemplars study said the national reach of nutrition programs was essentially defined by the areas that LHWs covered.

Most subnational stakeholders in the Exemplars study emphasized the progress made in local health systems, which they credited to improvements in health worker training, an increase in educational opportunities for health personnel and a subsequent increase in the number of qualified personnel, and an increase in the number of health facilities.

One practical testament to the value of the LHWP was its rapid early growth. By 2005, barely 10 years into its existence, it had already reached its current size of approximately 100,000 LHWs.² Exemplars study respondents noted that a further enlargement of the program would represent a welcome step in the continued improvement of health outcomes across Pakistan.

National commitment to nutrition aligned with global targets

Pakistan strongly emphasized the development of national strategies and objectives that were both linked with global goals and supported by leading international organizations. This had the salutary effect of demonstrating the preeminence of nutritional improvement as a priority.

These domestic strategies and international collaborations took a variety of forms, particularly in the decade immediately preceding our 2011 to 2018 study period. However, they tended to center on a few core approaches—notably, micronutrient supplementation, food fortification, and unconditional income-support services.

A watershed moment in the development of Pakistan’s nutrition policy was the establishment of the Nutrition Wing in the Ministry of National Health Services, Regulations and Coordination in 2001.³ This entity has played a crucial role in advancing nutrition as a public policy priority.

That year also saw the beginning of the Micronutrient Initiative’s work in Pakistan. The Canada-based global nonprofit (since renamed Nutrition International) works with the United Nations and national governments to address deficiencies in such vital nutrients as iron, iodine, folic acid, vitamin A, and zinc.⁴ In Pakistan, the organization has contributed substantially to these efforts, including the provision of technical support to the National Wheat Flour Fortification Program.

The growing emphasis on nutrient fortification was underscored in 2003 when the Ministry of National Health Services, Regulations and Coordination created the National Fortification Alliance of Pakistan, tasked with overseeing food fortification at all levels nationwide. The government also continued to look outward, toward potentially fruitful partnerships with international agencies.

As noted in some detail in the previous section, arguably the most significant governmental measure Pakistan took to reduce anemia was the Benazir Income Support Program, which began in 2008.⁵ This is one of the nation’s largest social protection programs of any kind, providing the poorest households with unconditional cash transfers.

Pakistan’s commitment to nutrition as a national priority is reflected across these programs and policies. The country’s willingness to work with a range of internal and external partners to advance that priority indicates the depth of that commitment, which, in turn, has been a crucial element in the reduction of anemia prevalence.

Effective mechanisms for targeting and implementing social protection programs

As previously described, BISP is an unconditional cash transfer program designed to provide a safety net for the poor and, as a secondary objective, empower women, who would receive the transfers for their households. Pakistan launched BISP in 2008, in the midst of a joint financial, food, and fuel crisis, with support from the UK Department for International Development and the World Bank.

Key components for effective targeting and implementation of BISP included establishing an objective targeting system, strengthening program operations, and instating control and accountability mechanisms for transparent delivery of services to the poorest and most vulnerable populations.⁶

These components are illustrated through several critical levers of BISP program design and execution.

On establishing objective targeting systems, the Pakistani government established the National Socio-Economic Registry to harmonize social protection programs across federal and provincial government levels, with over 30 federal and provincial organizations leveraging the registry to improve targeting to relevant populations of various social protection programs including BISP.

On program operations and efficiency, BISP has gradually updated its payment mechanism as digital technology has advanced, with the goal of increasing efficiency and targeting. BISP has evolved from delivering cash to recipients by hand, to providing recipients with debit cards, to using biometric identification systems to verify recipients at cash out points. Currently, BISP leverages technology based mechanisms to transfer payments, with over 90% of BISP beneficiaries being paid through these mechanisms and thus offering the poorest women access to financial empowerment (i.e., banking accounts).⁶

Autonomy from provincial governments to effectively implement programs to achieve national health & nutrition targets

The passage of the 18th Amendment of Pakistan’s national constitution in 2010 brought about a series of notable changes, including the removal of the executive branch’s power to dissolve Parliament unilaterally and the renaming of the North-West Frontier Province to Khyber Pakhtunkhwa.⁷

Among the most consequential effects of the amendment was the devolution of a wide range of formerly centralized governmental powers to the provinces and other subnational jurisdictions. This included a massive transfer of primary responsibilities for health care policy and funding. As a result, the 18th Amendment and the resulting devolutionary shift are essential parts of the story of how Pakistan and its diverse cluster of smaller governments implemented policies and programs targeted at improving nutrition and health outcomes, including anemia.

However, devolution has not always been orderly, and its effects are still being assessed. Although there was a certain abruptness to aspects of the transfer, Pakistan has set up national targets, guidelines, and organizational mechanisms for program implementation at the subnational level, creating top-down pressure on jurisdictions to improve nutritional outcomes.

In 2011, a year after the passage of the 18th Amendment, Pakistan established the Ministry of National Food Security and Research to help ensure a baseline of sufficient nutrition levels nationwide. In that same year, the national government teamed with the United Nations Food and Agriculture Organization to create the Pakistan Integrated Nutritional Strategy with the express intention of integrating nutrition interventions across provinces and federal departments.⁸

Over the remainder of the Exemplars study period, the national government instated a wide range of nutrition programs while giving responsibility to provincial governments to ensure effective implementation to achieve targets —making clear that nutrition would remain a priority for Pakistan as a whole, even as policy details were devolved to the subnational level. In 2012, Pakistan launched the National Zero Hunger Plan, which outlined national-level targets that subnational jurisdictions would be expected to achieve. In 2013, it signed on to the Scaling Up Nutrition global movement, which seeks to weave nutrition considerations into a wide range of national programs, from health care to agriculture to education.⁹ The National Food Security Policy followed in 2017.¹⁰

By 2018, at the end of the Exemplars study period, Pakistan was ready to build on the province-centered Pakistan Integrated Nutrition Strategy program. It collaborated with Scaling Up Nutrition to enact the Pakistan Multi-sectoral Nutrition Strategy, which updated the guidance to provinces on the devolution of food and nutrition policy.¹¹

By this time, the provinces and other subnational units were already responding to such national-level guidelines and devolutionary policies by developing their own strategies for addressing nutrition needs within their borders.

Technical assistance for effective design and coverage of programs targeted to improve micronutrient intake and status

In addition to effective provincial-level implementation of national programs and priorities related to women’s health and nutrition, support from NGOs and technical assistance providers were an important enabler to drive targeting, coverage, and intake of key initiatives related to improved micronutrient intake and status, particularly among WRA.

Of note is the previously described partnership with Nutrition International (previously Micronutrient Initiative), which has worked with the Nutrition Wing of the Ministry of Health in Pakistan to improve access to micronutrients among women and children, particularly through micronutrient supplementation and food fortification efforts.¹²

Priority programs supported by Nutrition International in Pakistan include: improving coverage of healthcare and nutrition among young girls and WRA particularly in remote rural areas, improving the effectiveness of national and provincial food fortification programs (e.g., universal salt iodization, fortified wheat flour with iron and folic acid, fortification of edible oil and ghee with vitamin A).

Technical assistance provided by NGOs such as Nutrition International have focused on supporting provincial and district governments (incl., Sindh, Punjab, Balochistan, KP) to strengthen maternal and newborn health and nutrition services, including the provision of IFA supplementation for pregnant women. NGOs such as Nutrition International also support pilot communication campaigns in Punjab and Sindh focused on improving maternal nutrition, with the goal to build awareness of maternal nutrition among healthcare providers, frontline health workers, and WRA in the community.

On food fortification, technical assistance from providers such as Nutrition International include the facilitation of industrial production of fortified staple foods, including supporting the scale-up and institutionalization of wheat flour and edible oil fortification in Pakistan. NGOs also support relevant departments in the province-level to develop regulations to ensure implementation and enforcement of food fortification interventions at the community-level. Nutrition International also supported partnerships with the private sector to ensure the effective monitoring and coverage of fortified foods.

Overall, technical assistance from key NGOs such as Nutrition International were critical enablers to the effective implementation of health and nutrition programs driven by provincial governments to reach national targets.