Author: Kate Sadler, Philip James, Amir Samnani and Emily Mates
Executive summary
Pakistan, the world’s fifth most populous country, has shown progress in recent years on reducing poverty and mortality rates, and increasing primary school enrolment and immunisation coverage. However, persistent challenges, such as population growth and underdevelopment, are being intensified by recurring emergencies related to food insecurity, climate change and the recent COVID-19 pandemic. In 2022, severe monsoons affected over 33 million people, leaving 20.6 million (including 9.6 million children) in need of humanitarian assistance. Also in 2022, heavy rainfall in the southwest of the country led to flash floods, fatalities, and infrastructure damage, compounding vulnerabilities. Gender inequality, exceptionally high fertility rates (particularly in the poorest wealth quintiles) and limited access to essential services further impact child and maternal nutrition and mortality outcomes.
While Pakistan is in the early stages of programming for multiple micronutrient supplements (MMS), a strong enabling environment is now shaping political, institutional and policy processes for improving maternal nutrition. Pakistan’s Maternal Nutrition Strategy 2022-2027 aims to protect and promote diets, practices and services that support the optimal nutrition, health and well-being of all women. The provision of MMS is a core intervention outlined in this strategy, which includes the target of reaching 50% of all women with MMS programming by the end of 2027.
As part of health and nutrition services in Pakistan, all MMS programming is overseen by the Ministry of National Health Services, Regulations, and Coordination (MoNHSR&C). To date, several organisations have supported MoNHSR&C to deliver MMS as part of wider maternal nutrition programming: these include UNICEF, Nutritional International, the Bill & Melinda Gates Foundation, and many implementing partners. MMS programming in districts experiencing humanitarian emergencies have thus far been delivered through routine antenatal care (ANC) services and as a separate emergency response.
Routine ANC programming delivered through the country’s health service and supported by UNICEF, Nutrition International and other implementing partners has delivered MMS across some of the flood-affected districts and in Union Councils at high risk of polio (scattered across several districts). Sufficient MMS to cover 500,000 pregnant women has been procured and distributed. Ongoing support for routine ANC programming has spanned the nexus between humanitarian and longer-term maternal and child nutrition programming.
Distribution of MMS as part of the emergency floods response across two provinces (Sindh and Balochistan) started at the beginning of 2023. Kirk Humanitarian donated sufficient MMS to cover 2.2 million pregnant women. Over half of this donation was distributed initially through small pilot studies across seven districts, and then through the National Disaster Management Association (NDMA) of Pakistan as part of the emergency response. The delivery of this MMS was initially organised by the provincial-level health directorate to all pregnant women, without being integrated into ANC platforms. However, subsequently it has been agreed that the remaining supply (sufficient MMS to cover 1 million pregnant women) will be delivered through MoNHSR&C to ensure standard protocols for MMS programming within ANC services can be followed.
Important learning for MMS programming across all settings in Pakistan is emerging from the emergency distribution of MMS and an implementation research study. The challenge now is translating the momentum on MMS programming into policy and strategy, ensuring that any learning is embedded in updated programme guidance, along with effective delivery within ANC programming across a complex, devolved health system. This is a real opportunity to improve the quality and coverage of, and demand for, ANC services, and stakeholders in Pakistan have identified key priorities to support this. Resource mobilisation is critically important, and will require the leveraging of mechanisms such as nutrition match funds and emergency donor support. Integrating MMS programming into the existing health system will require the development of clear guidance for, and capacity building of, health workers (both facility- and community-based) to support the switch from iron-folic acid to MMS. The inclusion of MMS on the national essential medicines list, which was achieved in December 2023, should support procurement, financing and supply management, and key informants are hopeful that initial explorations of local MMS production could potentially start to bring the costs of the product down.
Through collaborative efforts and strategic prioritisation, Pakistan can continue to strengthen and scale up ANC services, including MMS programming, and hence have a positive impact on the nutritional status of women and their children across all of the country’s diverse regions.
“Important learning for MMS programming in Pakistan is emerging from the emergency distribution of MMS and implementation research. The challenge now is translating the momentum on MMS programming into policy and strategy.”