1. Country Team Action Plan Islamic Republic of Pakistan Group - 2

2. Tracks 1 & 2 2 Where are we now? Situation in Pakistan Diarrhea Mortality 11% deaths of children < 5 years occur due to diarrhea. Diarrhea Management Only 37 percent children < 5 years with diarrhea receive Oral Rehydration Therapy or increased fluids with continued feeding ! PDHS, 2007

3. Tracks 1 & 2 3 Where Do We Want To Be? (GOAL) Desired Level of Accomplishment Low osmolarity Oral Rehydration Salt with Zinc Supplementation 20% expected reduction in mortality due to diarrhea by 2013 Country Team Goal Reduction of under five child mortality due to diarrhea in Pakistan Best Practice Chosen for Scale-Up Low osmolarity ORS with Zinc Supplementation needs scaled up across the country, for improved management of diarrhea in children <5

4. What is the evidence to support this best practice? International: Meta-analysis of 8 trials among children receiving zinc supplementation* : –15% reduction in the duration of acute diarrhea –24% reduction in the duration of persistent diarrhea Regional: Community-based trial in rural Bangladesh**: –Children receiving zinc supplementation had 23% shorter duration of diarrhea episodes Local: Hala Project by Aga Khan University & LHW Program, Pakistan *Zinc Investigators’ Collaborative Group. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis or randomized controlled trials. Am J Clin Nutr 2000;72:1516-22. **Jones G et al. How many child deaths can we prevent this year? Lancet 2003;362:65-71.

5. What are the modifications needed to improve the intervention’s scalability? No modification is required to improve the scalability of the intervention

6. Who will be involved in scaling-up? Public Sector –DG Health – National MNCH Program –Lady Health Workers Program –Nutrition Program –National Institute of Health –Health Education Cell –DHIS Cell –Statutory Bodies Pakistan Medical and Dental Council Nursing Council Training Institutes Private Sector –Peoples Primary Health Initiative –NCHD –NGOs

7. What are the opportunities of scaling-up? Local evidence Political commitment –Karachi Declaration endorsement by MOH for best practices –Zinc with low osmolarity ORS is included in LHWs Program and PC1 of National Nutrition Program –Inclusion in IMNCI syllabus Availability of Infrastructure –100,000 Lady Health Workers trained on use of Zinc with low osmolarity ORS –Extensive health delivery structure –National MNCH Program Local pharmaceutical industry has the capacity to manufacture Availability and affordability of Zinc with low osmolarity ORS in the market

8. What are the constraints/challenges of scaling-up? Health Care Providers at all levels and families have been sensitized over the years not to use any medication with ORS Re-sensitize Health Care Providers with new message Replacing available full concentration ORS from the market to make way for low osmolarity ORS with Zinc supplementation Development budget cut down by 40% because of the financial crunch; maximum effect will be on the health sector Revision of MIS reporting tools and instruments

9. What policy, regulatory, budgetary, or other institutional steps are needed? Notification by the Federal Ministry of Health (MOH) Inclusion of low osmolarity ORS with Zinc supplement in the Essential Drugs List Allocation of additional resources by MOH for procurement under National MNCH Program and Provincial/District health budgets Ensuring regular and sustained supplies Revision of existing CAM strategy and development of IEC material for health care providers (all tiers) with new messages Training of health care providers on revised protocols Modify monitoring tools for tracking progress

10. Where, when and how will the best practice be expanded? Expansion to new geographic sites or populations –National coverage Timeframe for scale up –To be determined after provincial/district consultations Dissemination of the best practice through: –National and provincial consultative meetings –Mass and traditional media both at National and Provincial / District levels –Lady Health Workers Program –Pharmaceutical industry –Private health sector/NGOs

11. What will be the costs of expansion and how will needed resources be mobilized? The costs of training, procurement, logistics, CAM, and monitoring will be determined after development of provincial and district work plans

12. How will the process, outcomes and impacts be monitored? How will results be fed into decision-making? Process & Outcomes –Indicators will be determined and incorporated in reporting tools to track progress using DHIS and LHW-MIS Impact –Through national surveys: MICS, PDHS, etc. Decision-making –Making decisions using surveys and routine reports by National Best Practices Secretariat and Provincial BP Cells

13. Tracks 1 & 2 13 What are our action steps? Action Step Responsible PersonTimeline Establishment of the Federal Best Practice Secretariat Pakistan Country Team LeaderBefore March 23, 2010 Establishment of the Provincial Best Practice Cell DG Health/Program Managers MNCH, LHW, Nutrition May 31, 2010 Organization of National and Provincial Consultative Meetings National Program Manager MNCH, Best Practices Country Team April – Sep, 2010 Development of District Specific Action Plans Provincial DG Health/Program Managers MNCH, LHW, Nutrition, EDOs, BP team Oct 30, 2010 Implementation and monitoring of district action plans DG Health/Program Managers MNCH, LHW, Nutrition, EDOs Ongoing