PAKISTAN
CASE STUDY
Review of Nutrition Cluster Experiences and
Learning for Transition
(RFPS-USA-2014-501871)
PREPARED BY:
INTERNATIONAL SOLUTIONS GROUP
Nutrition Expert and Author: Vivienne Forsythe
PREPARED FOR:
UNICEF
Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
TABLE OF C ONTENTS
LIST OF ACRONYMS ........................................................................................................................................................... 3
ACKNOWLEDGEMENTS .................................................................................................................................................... 4
BACKGROUND ..................................................................................................................................................................... 5
NUTRITION CONTEXT ............................................................................................................................................................................. 5
HUMANITARIAN COORDINATION .......................................................................................................................................................... 6
THE NUTRITION CLUSTER ..................................................................................................................................................................... 7
CURRENT STATUS OF NUTRITION CLUSTER ........................................................................................................... 9
TRANSITIONED TO WHOM?.................................................................................................................................................................... 9
UNICEF SUPPORT FOR EMERGENCY COORDINATION .................................................................................................................... 11
EMERGENCY NUTRITION WORKING GROUP ENGAGEMENT WITH SUN ..................................................................................... 12
ANNEX I: KEY REFERENCE DOCUMENTS .................................................................................................................13
ANNEX II: LIST OF KEY INFORMANTS .......................................................................................................................13
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List of Acronyms
CLA
Cluster Lead Agency
CMAM
Community-based Management of Acute Malnutrition
DoH
Department of Health
ENWG
Emergency Nutrition Working Group
ERWG
Early Recovery Working Group
FATA
Federally Administered Tribal Areas
IASC
Inter-Agency Standing Committee
IDP
Internally displaced person
IMO
Information Management Officer
KII
Key informant interview
KP
Khyber Pakhtunkhwa Province
MoH
Ministry of Health
MoHSRC
Ministry of Health Services, Regulation and Coordination
NCC
Nutrition Cluster Coordinator
NDMA
National Disaster Management Authority
NGO
Non-governmental organisation
OCHA
Office for Coordination of Humanitarian Affairs
PDMA
Provincial Disaster Management Authority
PINS
Pakistan Integrated Nutrition Strategy
SAG
Strategic Advisory Group
SAM
Severe Acute Malnutrition
SRP
Strategic Response Plan
SUN
Scaling Up Nutrition
ToR
Terms of Reference
UN
United Nations
UNDP
United Nations Development Programme
UNICEF
United Nations Children’s Fund
WFP
World Food Programme
WHO
World Health Organisation
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Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
Acknowledgements
The Nutrition Expert for this assignment would like to thank everyone at UNICEF HATIS who were
involved in this assignment and who gave so generously of their time and insights.
The Nutrition Expert gratefully acknowledges the support of key stakeholders who took the time
to meet virtually to share their perspectives and support the research on Cluster transition in
Pakistan. Additionally, the case study benefited from comments and discussions around the report
from Ms Megan Gayford and the Nutrition Reference Group for this assignment (Diane Holland
and Josephine Ippe of UNICEF), which were also very helpful.
The findings and opinions in this report are those of the Nutrition Expert and should not be
ascribed to anyone else.
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Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
Background
Pakistan is a disaster-prone country. Over the last five years, Pakistan has experienced serious
floods, cyclones and tropical storms, drought; and earthquakes. Pakistan has also had to cope with
major internal population displacement due to ongoing conflicts.
Nutrition Context
Undernutrition has been a serious public health problem in Pakistan for several decades. The
2011 Pakistan National Nutrition Survey confirmed that Pakistan’s population suffers from high
rates of malnutrition and that the situation has not improved for several decades. The survey
showed that two out of every five (44 percent) of children under five are stunted, 32 percent are
underweight and 15 percent suffer from acute malnutrition.1
“Health experts noted that the increasing rate of chronic and acute malnutrition in the country is
primarily due to poverty, higher illiteracy rate among mothers and the government’s lack of
commitment towards ensuring food security to each and every citizen. They also attributed it to
the inherent problems in infant feeding practices and access to “right” foods”.2
A CMAM evaluation conducted in 2011 highlighted that between 2001 and 2011 wasting, a
measure of acute malnutrition, increased in Pakistan. It was estimated at 11.8% in 2001, 13.1%
in 2006, and 16.8% in 2011.3
Understandably, humanitarian emergencies have exacerbated the underlying nutrition crisis in
Pakistan. The flood emergencies in several districts of Sindh, Punjab and Baluchistan in 2010,
2011 and 2012 caused displacement of a considerable number of people and resulted in massive
livelihood losses, damages to infrastructure to health and other basic services, as a result,
nutrition vulnerability has persistently increased. While in Khyber Pakhtunkhwa Province (KP)
and the Federally Administered Tribal Areas (FATA) acute malnutrition among displaced and
hosting communities remains high since 2009 as a result of continued insurgency and conflict.
While nutrition has been included in Pakistan planning process since the 1970s, the reality is that
in practical and operational terms, nutrition has not been seen as a priority in Pakistan for many
years and has not been fully integrated into the health system.
A 2011 Nutrition Cluster Evaluation states “at the time of the 2010 crisis that there was no
national nutrition strategic plan and that while national guidelines/protocol on management of
acute malnutrition had been prepared in 2009, these had never been officially released. As a
result, there were limited number of individuals and organisations that had been exposed to these
guidelines”.4
The 2011 Evaluation Report also states “until 2008, nutrition was not institutionalised within the
Government of Pakistan, and as a result, implementation of nutrition structures has remained
weak at national, provincial and district levels. In 2002, the Ministry of Health (MoH) introduced
a Nutrition Wing whose responsibility was to implement and monitor health related nutrition
activities at the national level, yet this Wing had no specific role in either at either provincial or
1Pakistan
National Nutrition Survey 2011, Aga Khan University’s Division of Women and Child Health, Pakistan’s
Ministry of Health and UNICEF; Report December 2013
2The Express Tribune, “National Nutrition Survey 2011, Food Insecurity affecting 60% of women and children”,
September 18, 2011
3 Evaluation of Community Management of Malnutrition Country Case Study Pakistan, UNICEF Evaluation Office;
September 2012
4 Nutrition Cluster Evaluation Pakistan Flood Response, September 2011.
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Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
districts levels in terms of implementing nutrition activities. And while the Pakistani government,
in collaboration with various humanitarian partners, including UN agencies, International and
national NGO’s has worked in implementing nutrition activities, there was very little impact and
improvement on nutrition indicators. Furthermore, as these projects lack over-arching
coordination at national level or clear synergy.”
The report goes on to say “a Nutrition Section in the Planning and Development Division of the
MoH was created to integrate the multi-disciplinary programs of nutrition into planning, and is
also responsible for coordination, monitoring and evaluating the different nutrition programs.
The Federal Nutrition Syndicate (a high level inter-ministerial body) compromising
representatives from line ministries, NGO’s and other international agencies has also been
created to provide overall planning, policy guidance and inter-agency and inter-provincial
collaboration, but that these entities are not well coordinated.”
In 2008, UNICEF in collaboration with the Department of Health, WFP, WHO and implementing
NGOs; initiated community-based management of acute malnutrition (CMAM) services in
Pakistan. These CMAM services were subsequently scaled up in 2010 as part of the flood
response.
1n 2011 the Pakistan Integrated Nutrition Strategy (PINS) was developed but reportedly (May
2015) has not yet been endorsed by Government. This strategy built on the initial emergency
nutrition responses (2008 & 2010), shifting into longer term development support with a multisector approach. In 2012 the Government endorsed the findings of the 2011 Nutrition Survey and
subsequently declared a public health emergency, given the high levels of acute malnutrition
15%. Since then the Government has also endorsed the SUN movement which was officially
launched in Pakistan in 2013. Despite this government commitment to nutrition in terms of
budgetary allocation remains very inadequate.
In June 2011 the Federal Ministry of Health (MoH) was dissolved and the overall responsibility
for health services policy direction and planning was devolved to the provinces. In September
2013, a new Ministry was created at Federal level; the Ministry of Health Services, Regulation and
Coordination (MoHSRC).
Humanitarian Coordination
The National Disaster Management Authority (NDMA) is the government body with overall
responsibility for Disaster Management Activity in Pakistan. At the subnational level, Disaster
Management Authorities are established at provincial, district and municipal levels in all hazardprone areas.
The Cluster Approach was initially introduced in Pakistan during an earthquake in 2005. It was
reactivated after the cyclone and flooding in 2007 and again in 2010 in response to large-scale
flooding. In 2011, the National Disaster Management Authority initiated a process of deactivation
of clusters, discussion was led by NDMA and UNDP to steer the shift in programmatic priorities
from relief to early recovery, with sector working groups being established to coordinate this
work and to take over the emergency coordination functions, however floods in 2012 led to the
reactivation of the clusters. All national-level clusters were again deactivated in late 2013, again
under a directive from the NDMA, although some subnational-level clusters remained.
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Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
The Humanitarian Country Team and OCHA have remained in Pakistan throughout this period
and to date, supporting ongoing humanitarian responses. The Pakistan Strategic Response Plan
(SRP) for 2015 targets almost three million people for assistance in 2015.5 The key humanitarian
issues outlined in the SRP are as follows:

Displacement and returnees in KP and the FATA;

Food insecurity and under-nutrition with severe malnutrition, exacerbated by natural
disasters and insecurity;

Natural disasters caused by extreme weather patterns; and

Public health concerns.
According to the SRP 2015, national-level coordination is conducted through sector working
groups, sub-national clusters are active in KP and FATA, while all other subnational coordination
is conducted through sector working groups.
The Nutrition Cluster
The Nutrition Cluster was activated for the first time in Pakistan in 2008 in KP, in response to the
conflict-related IDP crisis.6 The Nutrition Cluster was then activated at the national level following
the unprecedented magnitude of the floods in 2010. The Nutrition Cluster supported the
government institutions to coordinate the nutrition response at national and provincial levels, by
establishing one national-level coordination structure and five sub-national coordination “hubs”.
Since the activation in 2010 the status of the Nutrition Cluster at national and subnational level
has changed several times.
In January 2011 following a directive from the NDMA, the Nutrition Cluster started the process of
exiting/transitioning to a Nutrition sub-Working Group. The Nutrition sub-Sector was formed,
Cluster Functions were placed under the Health and Nutrition ERWG which was led and chaired
by WHO and UNICEF, with involvement from the MoH; while the Nutrition sub-Working Group
was chaired by a UNICEF-employed Coordinator. It was agreed that there would be provision to
continue with “residual” life-saving emergency interventions as there were still a large number
of severely and moderately malnourished in therapeutic and supplementary programmes, so
their therapy would be completed, and any new cases would also be treated accordingly. It was
also agreed that the integration of CMAM with IYCF would continue under the new structure.
The 2011 Nutrition Cluster Evaluation found that:

the decision of transitioning to the Early Recovery Working Group was largely a directive
from The Government;

the transition to the Early Recovery Working Group was a very rapid process with no real
planning or phase/out exist strategy;

many Nutrition Cluster partners both at national and hub level felt that the transition was
too early, that the decision to halt the emergency response was not backed up by
evidence; and that while children with SAM were still under treatment, the early process
Humanitarian Strategic Response Plan 2015, Prepared by OCHA on behalf of The Humanitarian Country Team;
February 2015.
6 While the cluster system was first activated in Pakistan in response to an earthquake in 2005, the nutrition cluster
was not included in that activation.
5
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Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
of transition sent out a (false) message especially to the international community that
everything was under control; and

partners also felt that there had been little guidance provided for the process and that
there was a great deal of confusion about the continuity of key activities.
One of the 2011 Nutrition Cluster Evaluations recommendations was that a clear phase-out plan
and strategy be discussed and developed by the Cluster at all Hub levels and any decisions to
phase-out should be supported by credible evidence.
The Nutrition Working Group met throughout 2011, however at the end of 2011/beginning 2012
the National Nutrition Working Group was again transitioned into a Nutrition Cluster as part of a
wider Cluster activation in response to flooding.
The Nutrition Cluster continued to function through 2012 and 2013. During this time the
Nutrition Cluster was active in Islamabad (National Cluster) and in three provinces: Khyber
Pakhtunkhwa/FATA, Sindh and Baluchistan. In the Punjab province, responsibility for emergency
nutrition coordination was assumed by the Department of Health (DoH), while the UNICEF office
in Lahore engaged in emergency preparedness planning in health and nutrition in Punjab with
the DoH.
In Baluchistan and KP/FATSA tribal area the Nutrition Clusters were supported by UNICEF
employed Nutrition Cluster Coordinators (NCC) and Information Management Officers (IMO),
who were ‘double hatting’, so supporting UNICEF programs as well as cluster support. In Sindh
province a dedicated NCC was in position, along with a double hatting IMO. At the National Level,
there was a dedicated NCC and a double hatting IMO.
The Nutrition Cluster did not establish a formal Strategic Advisory Group, although the NCC did
get representatives from key agencies to get together as an informal SAG on an ad hoc/as required
basis, for consultation and collective decision making. A key informant stated that in retrospect it
would have been very useful to have established a formal SAG with oversight for the direction of
the Nutrition Cluster/emergency response in the early stages of activation of the Nutrition
Cluster.
In November 2013, following a directive from NDMA to deactivate the cluster system-wide, the
Nutrition Cluster developed a short paper on transitioning—putting forward six
recommendations for the national-level cluster
1. The National Cluster should transition a National Emergency Nutrition Technical
Working Group, guided by a clear ToR that is based on the six Cluster Functions.
2. The new Ministry of Health Services, Regulation and Coordination (MoHSRC) should cochair the National Emergency Nutrition Technical Working Group.
3. The National Emergency Nutrition Technical Working Group should be aligned to the SUN
coordination structure, and be a strong participant in the process of establishing the
coordination structure under SUN implementation. The linkages to the SUN coordination
should be formalised in the National Emergency Nutrition Technical Working Group
Terms of Reference, once the SUN coordination has been established.
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Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
4. A National Emergency Nutrition Technical Working Group coordinator and IMO should
continue to be supported by UNICEF (dedicated staff). The National Emergency Nutrition
Technical Working Group chairs may discuss with working group members if I/NGO
deputy chair is recommended.
5. The National Emergency Nutrition Technical Working Group Strategic Advisory Group
(SAG) should be formalised, based on the current informal SAG.
While the National Cluster was transitioned to a National Emergency Nutrition Technical
Working Group; most of the other recommendations at national level have not been implemented,
and the paper on Nutrition Cluster transitioning was not actually available through the Country
Office.
The paper recommended that Singh and Baluchistan7 Province Clusters transition to Working
Groups with clear TOR; while KP and FATA should remain as a Cluster(s).
Current status of Nutrition Cluster
Currently at the national level, emergency nutrition coordination functions are undertaken by a
Nutrition Emergency Working Group. At the subnational level emergency coordination functions
are carried out by an active Nutrition Cluster in KP Province and FATA Tribal Area and by
Nutrition Emergency Working Groups in Singh province and Baluchistan.8
All of these coordination mechanisms are heavily supported by UNICEF. At the national level the
Coordinator and IMO are double hatting fulfilling UNICEF Programme functions alongside
emergency coordination functions. At the subnational level there are double hatting staff
members NCC and IMOs employed by UNICEF in KP and FATA tribal Ares and Baluchistan; in
Singh province there is a dedicated coordinator, along with a double hatting IMO. Currently all
UNICEF employed Nutrition Cluster support staff are national staff members, employed on
temporary assignment contracts.
Transitioned to whom?
National level: The National Disaster Management Authority is the government agency
responsible, however this body does not have sector/technical expertise; and the focal person for
nutrition was transferred from the NDMA at the end of 2013. The NDMA appointed a new focal
point for nutrition in 2014, however this individual does not lead emergency nutrition
coordination activities. The Nutrition Cluster Preparedness Plans for 2013 and 2014 highlights
the nascent capacity of the Disaster Management Authorities for nutrition, further-more
according to these documents “the NDMA co-chairs the Nutrition Cluster only when there is a
declared emergency”.9
The Federal MoH was dissolved in 2011 and while a new MoHSRC was established in September
2013 it was reported that there was a lot of confusion regarding the respective roles and
responsibilities of the various departments within the new ministry and hence it was not at all
clear which department should be engaging in emergency nutrition coordination.
Baluchistan had already “transitioned” to an Early Recovery Working Group in 2012 following conclusion of
monsoon flood response - but did not have a clear ToR
8 In line with the wider humanitarian coordination structure as outlined in the SRP 2015 – Clusters are active in KP
and FATA, but all other emergency coordination at subnational and national level is through sector working groups.
9 Pakistan National Nutrition Cluster Preparedness and Response Plan, 2013 and Pakistan National Nutrition Cluster
Preparedness and Response Plan, 2014.
7
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Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
Thus, essentially at national level in reality there was no functional authority to transition
Nutrition Cluster responsibilities to at the end of 2013. It is suggested that given the lack of
capacity in the NDMA and within the context of a nascent Federal MoHSRC it would take years
rather than months for successful transition & subsequent effective deactivation of emergency
coordination functions; to a situation where the coordination functions are being led by
government institutions at the national level. There would be a need to develop relationships with
the MoHSRC, to work out how MoHSRC and NDMA work together and then to start the process of
preparing for transitioning - including capacity building of sections/individuals.
At the subnational level, Nutrition Cells have been established in the DoH at provincial level; and
these Nutrition Cells act as co-leads of sub-National Nutrition Clusters/Working Groups, alongside Provincial Disaster Management Authority (PDMA) and the Nutrition Cluster Coordinators;
and thus responsibility could be transitioned to the Nutrition Cells (with ongoing UNICEF support
through NCC and IMO ).
There is no report of any sort of assessment of coordination capacity having been carried out
prior to transitioning of functions, but the evidence would indicate that certainly at national level
there is not sufficient capacity for transitioning to national institutions, as UNICEF staff continue
to do the bulk of the work.
What does deactivation mean in practical terms?
While the national level Nutrition Cluster has officially been deactivated, in reality, UNICEF is still
taking responsibility for leading and management of the emergency nutrition coordination
functions, under the auspice of an Emergency Nutrition Working Group (ENWG). The staff
perception is that that transition essentially means maintaining the same functions, but at a lesser
level and with reduced human resource capacity.
The national level ENWG sits within the UNICEF office and the UNICEF employed NCC and IMO
staff members who are double hatting do the bulk of the work. The ENWG provides technical
oversight and operational support to the provincial clusters /ENWGs as required/feasible, while
leading strategic direction, standards and guidelines development at national level. The NDMA
endorses all ENWG strategies and plans.
It was reported that at the subnational level the provincial government through the DoH Nutrition
Cell and the PDMA, is taking responsibility more proactively, with support from UNICEF NCCs and
IMOs.
Ongoing humanitarian and emergency nutrition requirement in 2015
According to the 2015 SRP there are significant ongoing humanitarian requirements in Pakistan,
to address conflict related displacement, food insecurity and malnutrition and natural disaster
and public health issues. Specifically in relation to nutrition, there are fifteen partners working to
address emergency nutrition issues, under the SRP; with over one million people targeted to
receive assistance/services in five provinces and one tribal area.10
Humanitarian Strategic Response Plan 2015, Prepared by OCHA on behalf of The Humanitarian Country Team;
February 2015.
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Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
The 2015 SRP outlines that:

the nutrition strategy and interventions will complement longer term Government
development plans and will link with the UN Operational Plan to address food and
nutrition insecurity for the most vulnerable groups;

the multi-sector nutrition strategy (endorsed in all four provinces) provides an overall
framework to ensure programmatic and geographic convergence and linkages with other
sectors;

nutrition interventions are positioned to address critical gaps to ensure continued lifesaving nutrition services; and

the capacity of Government counterparts will be strengthened in planning and
monitoring of nutrition response to ensure quality services delivery and smooth
transition from humanitarian to more focused development interventions.
Name or function?
While the “status” of the Nutrition Cluster has shifted back and forth over the years it would seem
that, certainly at national level, the responsibility for the emergency coordination functions and
bulk of the work has continued to be conducted by UNICEF staff. As reported during the
assignment transition and/or deactivation essentially means “reduced human resource capacity”.
There is a very strong argument that the Nutrition Cluster should not have been deactivated at
the national level in 2013, given the scale of the ongoing humanitarian need and the limited
national coordination capacity (IASC criteria for deactivation). While appreciated that
deactivation may have been a Government directive that was beyond the capacity of OCHA and
UNICEF to change; nevertheless, as designated CLA, UNICEF retains a responsibility to support
the government to fulfil emergency nutrition coordination functions in Pakistan to meet the
ongoing humanitarian needs, after the cluster has been deactivated. It could be argued that
UNICEF has negated this responsibility. Without doubt, two double hatting national staff
members do not have the capacity to optimally fulfil this coordination function with fifteen
partners across five provinces and one tribal area.
UNICEF support for emergency coordination
Review of the staffing for the national Nutrition Cluster from 2012 through to the current date
does not illustrate huge support from the UNICEF Country Office for the nutrition
cluster/emergency nutrition coordination functions in terms of staffing:
11

Dedicated NCC for a six-month appointment (assume UNICEF temporary appointment),

A dedicated NCC for an eight-month period, through a standby partner deployment,11

A double-hatted NCC/Nutrition Specialist (Assessment)

Following this, the ENWG has been supported by a double hatting national programme
officer.
Initially employed as an emergency nutrition specialist but then took on the NCC role after arrival in country.
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Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
Given the scale of the ongoing humanitarian need in Pakistan, the limited capacity of the NDMA,
the fact that the MoHSRC was in early stages of establishment and that responsibility for
emergency nutrition coordination functions within the MoHSRC were not clear; there would
clearly have been a case for UNICEF to provide sustained support for coordination functions for
several years – i.e. a dedicated senior coordinator (P4 level) and potentially an IMO on fixed-term
contracts.
Emergency Nutrition Working Group Engagement with SUN
The Scaling Up Nutrition (SUN) movement was established in 2013, with advocacy for and
support from UNICEF Pakistan. The Nutrition Cluster discussion document of 2013 recommends
that the ENWG actively engages with/participates in the SUN mechanism. However, it was
reported by key informants that while many of the Nutrition Cluster members attend SUN
meetings/participate in the SUN mechanisms, to date (May 2015) emergency nutrition issues
have not been discussed/addressed within SUN.
Use of website for sharing cluster and nutrition working group information.
Pakistan Cluster and Emergency Nutrition Working group used and continue to use the OCHA
Humanitarian Reform website. However KIIs indicate that there are some challenges; as the
platform is inflexible, does not provide the capacity to post everything that the cluster ENWG
would like to post; and it is not easy to use/find documents that have been posted. In the past
(2013) the Nutrition Cluster also used drop boxes to share information among cluster partners.
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Review of Nutrition Cluster Experiences and Learning on Transition: Pakistan
ANNEX I: Key Reference Documents
Evaluation of Community Management of Malnutrition Country Case Study Pakistan, UNICEF
Evaluation Office; September 2012.
Humanitarian Strategic Response Plan 2015, Prepared by OPCHA on behalf of The Humanitarian
Country Team; February 2015.
Nutrition Cluster Evaluation Pakistan Flood Response, September 2011.
Nutrition Cluster Transitioning and Alignment with the SUN Movement in Pakistan; November
2013.
Pakistan National Nutrition Cluster Preparedness and Response Plan, 2013.
Pakistan National Nutrition Cluster Preparedness and Response Plan, 2014
Pakistan National Nutrition Survey 2011, Aga Khan University’s Division of Women and Child
Health, Pakistan’s Ministry of Health and UNICEF; Report December 2013
Synthesis of Cluster Lessons from UNICEF response to the Pakistan Floods (July – December
2010), HATIS, UNICEF; February 2011.
ANNEX II: List of Key Informants
The following individuals were interviewed as part of this virtual case study through Skype
interviews:

Mr Syed Saeed Qadir; Double hatting Nutrition Project Officer/Nutrition National
Working Group Coordinator

Kashid Ali Khan; Double hatting as UNICEF and NNWG IMO

Ms Megan Gayford; Former Nutrition Cluster Coordinator (national level)
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