PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: PIDA694 Public Disclosure Copy Project Name Enhanced Nutrition for Mothers and Children (P131850) Region SOUTH ASIA Country Pakistan Sector(s) Health (90%), Other social services (10%) Lending Instrument Specific Investment Loan Project ID P131850 Borrower(s) Government of Pakistan Implementing Agency Department of Health, Sindh, Department of Health, Balochistan Environmental Category C-Not Required Date PID Prepared/Updated 11-Mar-2013 Date PID Approved/Disclosed 11-Mar-2013 Estimated Date of Appraisal 22-Jan-2013 Completion Estimated Date of Board 30-May-2013 Approval Decision I. Project Context Public Disclosure Copy Country Context Pakistan is the world's sixth most populous country, with a population of 173.51 million. With a per-capita income of US$1,120 in 2011, Pakistan is classified as a lower middle-income country. Pakistan faces significant economic and security challenges. Pakistanis undergoing significant political changes with increased emphasis on provincial autonomy and devolution of authority to the provinces. The 18th Constitutional Amendment passed in 2011 devolved authority from the federal government to the provinces in about 40 areas, including health, which is now fully devolved to the provinces. This has meant that these provinces had to take on a new governing role and an expanded mandate in sectors where they have limited capacity and experience, both of which need to be developed to enable these provincial governments to assume effective authority in these sectors. II. Sectoral and Institutional Context Pakistan is not performing well in terms of improving health and nutrition outcomes or services, especially for the poor. Pakistan is not on track to achieve health and nutrition related Millennium Development Goal (MDG) targets. Inequity in health and nutrition services is a major concern. Access to health and nutrition services is significantly better for wealthier and urban Pakistanis. Pakistan has made minimal progress in improving nutritional outcomes of children and mothers Page 1 of 4 over the last four decades. The 2011 National Nutrition Survey preliminary data revealed that the rates of child stunting have not changed in Pakistan since 1965. Pakistan has high rates of child malnutrition, with 44% of children being stunted (<-2SD height for age) and 22% severely stunted Public Disclosure Copy (<-3SD). A third (32%) of children under 5 years are underweight (<-2SD weight for age) and 12% are severely underweight (<-3SD). Fifteen percent (15%) of Pakistani children under 5 years suffer from acute malnutrition (<-2SD weight for height) and 6% suffer from severe acute malnutrition (<-3SD). One in five children (22%) is born with low birth weight (less than 2.5kg). In addition, micronutrient deficiencies are widespread with high rates of iron-deficiency anemia, zinc, iodine folic acid and vitamin A deficiencies having a particularly damaging impact on the survival, growth, development and productivity of pre-school children and pregnant women. Two out of every three (62%) children under 5 years and half (51%) of pregnant women suffer from anemia. Malnutrition is also prevalent among women of reproductive age with 18% being underweight (low body mass index - BMI). There is no significant difference in the nutritional status of girls and boys at age 5 years in Pakistan. Chronic malnutrition (i.e. stunting) in Pakistan starts during pregnancy and then doubles in the first two years of life, i.e. the “first thousand days�. Malnutrition in Pakistan hinders national economic development. Malnutrition during pregnancy and early childhood hinders cognitive and physical development, reduces learning ability, school enrollment and performance and lowers productivity in adulthood. A study has shown that adults who were malnourished as children had lower wages by 34-47% and lower incomes by 14-28%. As a result, it is estimated that malnutrition costs Pakistan 2.7-4.1% of its GDP annually. Addressing malnutrition has become an important priority in Pakistan. In September 2011, the D-10 Group led by the Ministry of Finance requested provinces to develop nutrition plans, and the Bank (with DFID and ADB) is leading the coordination of development partners. The provincial governments have prepared policy guidance notes and draft strategies that outline the determinants of their malnutrition challenge and identify actions in core sectors to improve nutrition outcomes. Public Disclosure Copy Pakistan has defined the roles for implementing nutrition interventions in the health sector, but most existing nutrition programs are small in scale with very low coverage and minimal equity targeting. Only a few successful interventions have been delivered at scale in the last decade. The existing implementation arrangements for nutrition in the provinces revolve around the Provincial Nutrition Cells in the Departments of Health, which require additional capacity. The Lady Health Workers (LHWs) are the main community-based agents responsible for delivering preventive nutrition interventions, but the last evaluation of the LHW program in 2009 highlighted that, while LHWs performed well in a number of areas, nutrition interventions have not been prioritized by the LHW program. Nutrition services are also available in health facilities, but the delivery of these facility- based nutrition services suffers from the same lack of prioritization as in the LWH program. The low coverage of nutrition interventions is further limited by the fact that at least 30% of the geographic areas of Pakistan are not yet covered by the LHWs. III. Project Development Objectives The development objective for the project is to increase the coverage, in targeted areas, of interventions that are known to improve the nutritional status of children under two years of age, of pregnant and of lactating women. IV. Project Description Component Name Page 2 of 4 Addressing general malnutrition in women and children Addressing micronutrient malnutrition Public Disclosure Copy Communication for development Strengthening institutional capacity V. Financing (in USD Million) For Loans/Credits/Others Amount BORROWER/RECIPIENT 8.54 International Development Association (IDA) 40.89 Pakistan Partnership for Improved Nutrition 15.91 Total 65.34 VI. Implementation Implementation period and implementation agency: This is a five year project (2013-2018) to be managed by the Provincial Nutrition Cells in provincial Departments of Health. Service delivery will be coordinated by the District Health Offices who will implement activities in partnerships with non-governmental partners (e.g. NGOs, PPHI, private sector) through contractual arrangements. Oversight arrangements: The overall coordination of nutrition related activities is with the provincial Departments of Health, which will operationalize oversight committees with slight provincial variation. The committees will provide a provincial mechanism for coordination, strategic vision, oversight, technical guidance and monitoring. Project management: The overall leadership will be provided by the provincial Program Manager for Nutrition who, in his/her capacity as the Project Manager, will be responsible for maintaining appropriate link/ liaison with the Department of Health, partners and will report directly to the Public Disclosure Copy Director General of Health Services during project implementation period. The provincial Program Manager for Nutrition will also act as Secretary to the Oversight Committees. District level implementation: The district administration will be responsible for service delivery. The implementation of the nutrition service package will be undertaken through “public-public partnerships� with District Health Offices (DHOs), National Program for Family Planning and Primary Health Care (NPFPPH), National Maternal, Neonatal and Child Health Program (NMNCH), People’s Primary Healthcare Initiative (PPHI) and the Population Welfare Department (PWD). Collaboration with the NPFPPH and PPHI for involving the Lady Health Workers (LHWs), MNCH program for involving the Community-based Midwives (CMWs) and Population Welfare Department involving population welfare workers. Contract management: For areas not covered by the Lady Health Workers (LHWs), NGOs will be selected through competitive selection processes. At the Basic Health Unit facilities, contractual arrangements will be made with PPHI. It is also anticipated that an agency would need to be hired to provide technical assistance to fill NGO capacity gaps. VII. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Page 3 of 4 Environmental Assessment OP/BP 4.01 ✖ Natural Habitats OP/BP 4.04 ✖ Public Disclosure Copy Forests OP/BP 4.36 ✖ Pest Management OP 4.09 ✖ Physical Cultural Resources OP/BP 4.11 ✖ Indigenous Peoples OP/BP 4.10 ✖ Involuntary Resettlement OP/BP 4.12 ✖ Safety of Dams OP/BP 4.37 ✖ Projects on International Waterways OP/BP 7.50 ✖ Projects in Disputed Areas OP/BP 7.60 ✖ VIII.Contact point World Bank Contact: Luc Laviolette Title: Sr Nutrition Spec. Tel: 5722+158 / 9 Email: llaviolette@worldbank.org Borrower/Client/Recipient Name: Government of Pakistan Contact: Javed Iqbal Title: Secretary Tel: 92-51-9212769 Email: secretary@ead.gov.pk Implementing Agencies Name: Department of Health, Sindh Public Disclosure Copy Contact: Dur-e-Shewar Khan Title: Nutrition Focal Person Tel: 92-21-35223888 Email: d-dsk@hotmail.com Name: Department of Health, Balochistan Contact: Ali Nasir Bugti Title: Focal Person Nutrition Cell Tel: 081-9211592 Email: provincialnutritioncellqta@yahoo.com IX. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Web: http://www.worldbank.org/infoshop Page 4 of 4