Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694842049127.pdf (Pakistan)
Scaling Up Nutrition (SUN) Provincial Unit Planning and Development Board Government of Punjab Provincial Nutrition Response Plan for COVID-19 1 Scaling Up Nutrition (SUN) Provincial Unit Planning and Development Board Government of Punjab Provincial Nutrition Response Plan for COVID-19 Acronyms and Abbreviations ADP ANC BHU BMI CMAM COVID DHQ DHIS DMAC EmoNC IEC IMNCI IMR Annual Development Plan Ante Natal Care Basic Health Unit Body Mass Index Community based Management of Acute Malnutrition Coronavirus Disease District Headquarter Hospital District Health Information System District Malnutrition Addressing Committee Emergency Obstetric and Newborn Care Information Education and Communication Integrated Management of Newborn & Childhood Illness Infant Mortality Rate IRMNCH Integrated Reproductive Maternal Newborn Child Health INGO International Non-Government Organization IYCF LHS LHV LHW MIS MSNC MUAC Infant & Young Child Feeding Lady Health Supervisor Lady Health Visitor Lady Health Worker Management Information System Multi-Sectoral Nutrition Center Mid Upper Arm Circumference NTEAM Nutrition Technical Assistance Mechanism NNS NGO OPD ORS ORT OTP National Nutrition Survey Non-Government Organization Outpatient Department Low Osmolarity Oral Rehydration Salt Oral Rehydration Therapy Outpatient Therapeutic Program 3 Acronyms and Abbreviations P&D PC-1 PDHS Planning and Development Department Planning Commission – Performa 1 Pakistan Demographic Household Survey P&SHD Primary and Secondary Healthcare Department PHED PDS PLW PNC PSPU PFA RISE SBA SAM SOP Public Health Engineering Department Pakistan Demographic Survey Pregnant and Lactating Women Post Natal Care Policy and Strategic Planning Unit Punjab Food Authority Responsive Investment for Social Protection and Economic Stimulus Skill Birth Attendant Severe Acute Malnutrition Standard Operative Procedure SHNS School Health and Nutrition Supervisor SC SUN TAN THQ UNICEF WASH WB WFP WHO Stabilization Centre Scaling-Up Nutrition Technical Assistance for Nutrition Tehsil Headquarter Hospital United Nation’s Child Fund Water & Sanitation for Hygiene World Bank World Food Programme World Health Organization 4 Message Chairman Planning and Development Board Government of Punjab COVID-19 is a high-stakes test of policy makers all over the world.
It has led to a disturbing loss of human life worldwide and presents an unprecedented challenge to public health, food security, social and economic systems.

Following the successful tackling of first wave of COVID -19 outbreak, recently, the second spell of outbreak has started.

Millions of people are at risk of falling into extreme poverty, while the number of undernourished children and women could increase many folds.
Many people are unable to feed their families with nutritious food because entire economic system of family and individual has been disrupted especially in low socioeconomic communities.

We must prepare ourselves to face any food insecurity challenges in the province and shall be committed to pooling our skills, experience and financial resources to support low socio-economic and marginalized communities.
Planning and Development (P&D) Board has prepared a comprehensive document to set the direction of public sector investments in the COVID-19 situation under Responsive Investment for Social Protection and Economic Stimulus (RISE) Framework.
The RISE provides strategic directions, aligning policies and shall be used while formulating next year’s Annual Development Plan as well as realigning ongoing projects to set their priorities according to current underlying food security situation and malnutrition challenges through poverty reduction schemes, social protection programs and strengthening of ongoing program on health and nutrition.

Punjab Nutrition Response Plan for COVID-19 is also linked with the RISE Framework.
The ten thematic areas of plan are according to the needs of time to minimize the negative repercussions of COVID-19 on health and nutrition status of community especially on women and children.

I must appreciate the efforts of Dr. Suhail Saqlain, Member (Health), Mr. Saleem Masih, Senior Chief (Health) and all the other government and non-government organizations representatives who provided their valuable inputs and attended several meetings to prepare comprehensive nutrition response plan.
I would also like to thank NTEAM’s TAN Project of Nutrition International for its support in providing technical assistance in this regard.

The Planning and Development Board will ensure effective implementation and supervision of plan through its Multi-sectoral Nutrition Cell (MSNC) and Scaling up Nutrition (SUN) unit.

Hamed Yaqoob Sheikh 5 Message Secretary Planning and Development Board Government of Punjab Pakistan is facing a silent crisis of malnutrition.
According to the National Nutrition Survey (NNS), the indicators of nutrition need special attention.

The province of Punjab has prioritized nutrition interventions, and because of the current investments made in nutrition, indicators in Punjab has improved.

However, the COVID-19 pandemic is a health and economic crisis threatening the food security and nutrition of millions of people around the world.

The pandemic hits us at a time of immense global challenges.
Before the virus spread to an alarming situation resulting in inevitable health and nutrition crisis of mass severity and scale, we need to tackle all the nutrition dimensions of this crisis.

Addressing the COVID-19 challenges require us to work together across sectors and borders both to mitigate the immediate impacts and to re-plan the system accordingly for the post-COVID-19 epidemic scenario.
The Planning and Development Board, Government of Punjab with the support of Multi- Sectoral Nutrition Center (MSNC) and SUN Unit Punjab has been successful in finalizing ‘Provincial Nutrition Response Plan’ to counter malnutrition during and after COVID-19.

It gives an insight into the socio-economic impact during and after the outbreak and identifies the priority areas which would significantly alleviate the negative repercussions.
Intending to make nutrition a priority, the P&D Board is pleased to provide all the necessary support needed at every point so that health and nutrition remains a top priority for all of us.
Imran Sikander Baloch 6 Message Member Health/ Executive Director Multi Sectoral Nutrition Center (MSNC) Government of Punjab The entire world has been experiencing an emergency for more than six months and the fear of second wave of outbreak of COVID-19 pandemic is the biggest public health challenge for the authorities in 21st of economic crises, food insecurity, meagre health and nutrition condition.
The federal and provincial governments are actively engaged to mitigate the impact of COVID-19, especially in the marginalized communities.

Special social protection programs, the opening of businesses by following the SOPs, food safety programs and provision of health and nutrition services during this pandemic are the remarkable achievements of the government in this critical time.
The strategies to control the spread of the virus and its complication have been applauded all over the world including World Health Organization (WHO).

During and after the pandemic it has been observed that the health and nutrition status of women and children are more affected due to their different biological and social needs.
The inaccessibility of health services, food insecurity issues, unemployment of daily wagers women and limited business activities made it difficult for low socio-economic class families to maintain a normal healthy life.

Thus, chances of malnutrition among children and women may increase many folds.

There is a need to develop and adopt a multi-sectoral approach to cope up with the consequences.
Public health agencies, government development partners, NGOs and INGOs can work together to fight the spread of the disease.

Multi-Sectoral Nutrition Center (MSNC), Planning and Development Board, and Government of Punjab can take a lead to implement COVID-19 Nutrition Response and Recovery Plan developed by SUN Provincial Secretariat Punjab team.
I am thankful to Nutrition International for their technical assistance support to SUN Unit Punjab through their Nutrition Technical Assistance Mechanism’s (NTEAM) Technical Assistance for Nutrition (TAN) project supported and funded with UK aid from the UK government.
I also appreciate the efforts of IRMNCH & Nutrition Program Primary & Secondary Healthcare, Policy and Strategic Planning Unit (PSPU), Punjab Food Authority (PFA), Nutrition International, WHO, UNICEF for their active contribution to Punjab COVID- 19 Nutrition Response and Recovery Plan.
Dr. Sohail Saqlain 7 Message Country Director Nutrition International Pakistan The unprecedented global crisis triggered by COVID-19 poses grave risks to the nutritional status of people living in vulnerable situations, especially women and children in the low and middle-income countries, unwinding hard-won development gains made over the past decade.
Nutrition International has been working in Pakistan since 2001 in partnership with federal and provincial governments to deliver proven nutrition interventions to high-need communities.

These interventions aimed at improving Vitamin A supplementation, and zinc & oral rehydration salts supplementation for childhood diarrhoea management, accentuating production of adequately iodized salt and increasing iron and folic acid consumption through fortified wheat flour and, fortified oil & ghee.
In the efforts to strengthen nutrition governance in Pakistan, Nutrition International is proud to be part of the formulation of the Punjab Provincial Nutrition Response Plan for COVID-19 by extending technical assistance through our Nutrition Technical Assistance Mechanism’s (NTEAM) Technical Assistance for Nutrition (TAN) project, funded with UK aid from the UK government.
The plan includes nutrition guidelines laid by international organizations and directions provided by national and provincial technical working groups aimed at supporting the province of Punjab to work on priority areas and control the pandemic’s grave effects.

The plan will guide actions of the provincial government, donors, and partners to protect health and nutrition status of the most marginalized.
At this time, it is most crucial that nutrition is integrated into every phase of the pandemic response because the right nutrition at the right time can mean the difference between life and death for the most vulnerable.
Nutrition International would like to congratulate and thank all the stakeholders - federal and provincial governments, development partners, academic experts, and researchers who have worked hard towards developing this plan and look forward to continuing collaboration for effective implementation of this plan.
Dr. Shabina Raza 8 Message Senior Chief Health Planning and Development Board Government of Punjab There is an imminent threat that malnutrition indicators may surge during and post COVID-19 pandemic.

It would be an enormous challenge for Pakistan as a country to tackle the increase in morbidity & mortality, the unexpected additional financial burden on the households and increase in the expenditures of the governments.
Considering these, relevant policies must be prepared to keep the situation in control during and after this outbreak to improve nutrition and health indicators as to the earlier years.

The provincial Nutrition Response Plan if implemented effectively, would alleviate the repercussions of COVID-19 to an optimum extent on nutrition and health status of the population, especially among women and children.
SUN secretariats/Units have been established at the provincial level to lead efforts for scaling up nutrition in their respective provinces.

Punjab was the first province to establish a provincial Multi-Sectoral Committee for Nutrition under the Planning & Development (P&D) Department.

It includes representatives from relevant sectors, industries, and co-opted members from the United Nations/Donors.
We appreciate Nutrition International for their technical assistance support to the Government of Punjab for advancing the overall provincial SUN agenda in light of COVID- 19.

I congratulate Dr. Muhammad Nasir, NTEAM technical assistance provider for effective coordination and development of Punjab Nutrition Response and Recovery Plan 2020.
Saleem Masih 9 Editorial Board Prepared by Dr. Muhammad Nasir, Nutrition International NTEAM TA Provider SUN Unit Planning & Development Board Reviewed by Mr. Saleem Masih, Senior Chief Health Approved by Dr. Sohail Saqlain, Member Health Planning & Development Board/ Executive Director MSNC Contributors/Advisors ▪ Dr. Khurram Mubeen, Deputy Director IRMNCH & Nutrition Program Punjab ▪ Dr. Asif Khan Niazi, Deputy Director IRMNCH & Nutrition Program, Punjab ▪ Mr. Imtiaz Shahid, DS (B&P) School Education Department ▪ Mr. Dawar Adnan Shams, Communication Specialist, MSNC, P&D Board ▪ Mr. Syed Omar, M&E Assistant, MSNC, P&D Board ▪ Mr. Shahraiz Malik, Creative Graphic Designer, MSNC, P&D Board ▪ Mr. Syed Mujtaba, Sector Specialist WASH, MSNC, P&D Board ▪ Mr. Jaffar Ali, Sector Specialist Social Protection, MSNC, P&D Board ▪ Mr. Asad Khan, Planning Officer, PHED ▪ Ms. Warda Nisar, Punjab Food Authority ▪ Javeria Khalid, Assessment Officer, PSPA ▪ Mehran Hussain, ARO I, P&E Cell, Agriculture Dept Lahore ▪ Mr. Irshad Danish, Consultant, Nutrition International ▪ Mr. Asim, Nutrition International ▪ Dr. Eadara Srikanth, Asia Project Manager-TAN, Nutrition International ▪ Dr. Rupinder Sahota, Asia Project Officer-TAN, Nutrition International ▪ Ms. Srisha Singh, Asia TAN Consultant, Nutrition International ▪ Dr. Yahya Gulzar, World Health Office ▪ Dr. Shafiq ur Rehman, Nutrition Specialist, UNICEF ▪ Ms. Uzma Bukhari, Nutrition Officer, UNICEF ▪ Mr. Ateeq Ur Rahman, Program Officer, SUN Secretariat, P&D Board ▪ Mishal Pervaiz Khan, Provincial Fortification Alliance, Food Department ▪ Mudassir Safdar, Food Fortification Program 10 Table of Contents Executive Summary Introduction Situation of nutrition indicators in Punjab Socio-economic impact Services affected during COVID -19 Thematic areas of concern during COVID-19 pandemic Provision of safe services at health facilities especially at OTP and SC Strengthening of community services during COVID-19 Promotion of adolescent girls & maternal nutrition Promotion of breastfeeding and IYCF practices Prevention and management of infection disease Capacity building of staff Strengthening of monitoring and supervision mechanism Multi-sectoral nutrition approach during COVID-19 Communication and awareness during COVID-19 Impact of COVID-19 on gender equity Conclusion References 12 14 15 17 18 19 49 50 11 Executive Summary COVID-19 not only has disrupted the normal life, but also has left marginalized and deprived people at higher risk of economic crises, food insecurity, meagre health and nutrition condition.
Besides this, unemployment of daily wage workers, limited business opportunities and transportation issues, have made the conditions worse.

The institutional capacities of public and private sectors have also weakened during this pandemic.

Federal and provincial authorities are directly engaged in controlling the COVID-19 pandemic and providing relief to affected people in terms of cash, food and livelihoods.
The actions taken by the Government of Pakistan and provinces to combat this pandemic have yielded encouraging results.

Out of 371,508 people infected with the corona virus till 20th November 2020, 88.5% of them have been recovered.

The death rate is 2% which is one of the lowest in the region and in the world.

In expert’s opinion, speedy recovery and low death rate is due to a large number of young population, strong immunity, effective strategies and timely initiatives taken by the government.
A similar situation of COVID-19 pandemic is being faced by Punjab, the largest province of Pakistan.

Initially, rapid increase in the cases disrupted businesses and severely affected social life, health and nutrition of population.

A continuous increase in new cases and number of deaths in the month of April, May and June-2020 further affected the life of vulnerable population negatively.
With strategic policies in place and its effective implementation by the Government of Punjab, led to a significant decline in incidence of new cases in the province from July 2020.

The emerging second wave of COVID-19 in Pakistan is again a serious threat for economy and individual well-being, with marginalized communities being most affected.
COVID-19 Cases update in Punjab Death Cases due to COVID-19 in Punjab Total Cases New Cases Total Death Death in Month Figure 1: Total and monthly COVID-19 cases update in Punjab Figure 2: Total and monthly COVID-19 death cases update in Punjab Source: Ministry of Health and Regulation, Government of Pakistan 12 The Government has re-initiated smart lockdown* and micro lockdown policies in large cities of Punjab.
Continuous disruption in businesses, limited access and availability of services, and unemployment will have an affect on the lives of the people.
Children and women will be most affected because of their different biological and social needs, and maintaining their health and nutrition status would be a challenge during this pandemic due to unavailability of sufficient, safe and nutritious food along with low outreach of health services in the hard to reach areas such as: those not covered by Lady Health Workers, river belt areas and urban slums.
Pregnant women and children from deprived households and low socio-economic class have been severely affected and about 150,000 additional children across Punjab are projected to be malnourished during this pandemic.1 Similarly, malnutrition in pregnant women will lead to low birth weight and malnourished children which will ultimately upsurge the morbidity and mortality amongst women and children.
To mitigate the effects of COVID-19 and prevention of malnutrition among women and children, effective measures needs to be adopted by the government.

This ‘Nutrition Response and Recovery Plan’ highlights the areas that should be focused to maintain and improve health and nutrition status of population during and after COVID-19.
The plan is prepared by reviewing the nutrition guidelines laid by international organizations, national and provincial technical working group’s direction and in line with the discussion of relevant departmental experts.

Based on these deliberations, ten thematic areas were selected.

The plan will further discuss the priority actions on these areas.
Smart lockdowns are aimed at restricting maximum no of Infected Persons in a targeted manner to an identified hotspot, to contain/ retard local COVID-19 spread and thereby break the transmission cycle of disease.
This would also entail increased epidemiological interventions as testing, tracing, quarantine and isolation of suspected and confirmed cases in an identified hotspot 13 Introduction Almost 53% of Pakistan’s population is living in Punjab, with a population mark crossing 110 million (Census in 2017).

The province is home to various industrial zones and vast agricultural land and supplies 70% of all cereal production to the country.

Punjab is also a leading producer of cash crops (wheat and sugarcane).
The health system across Punjab has improved significantly in the last decade because of the focused approach, allocation of resources and effective monitoring by the government.

Despite improvements in health system, the health and nutrition indicators in the southern region of Punjab are still alarming due to issues such as low literacy rate, poverty and poor infrastructure.

The Government of the Punjab is setting up a separate secretariat in South Punjab.
This initiative will not only improve the governance in this region but also the health and nutrition indicators.

The Government of the Punjab in its post-devolution phase (after 18th Constitutional amendment in 2010) made huge investments in the nutrition portfolio to address the situation.
Nutrition Program was integrated into National Program for Family Planning (Lady Health Worker Program) and Mother and Child Health Program in 2013 with the name of Integrated Reproductive Maternal Newborn Child Health and Nutrition Program (IRMNCH & Nutrition Program) and then a separate two years nutrition program for the year 2016 to 2018 with support of World Bank was launched.
To ensure continuity of activities and to scale up nutrition preventive and therapeutic services all over Punjab, the Chief Minister’s Stunting Reduction Program 2017-2021 with a budget of PKR 8.9 billion is being implemented.
Besides this, an effective network of 43,200 Lady Health Workers covering about 68% rural and 35% urban population have been engaged to provide door-to-door services including screening of children and women, counselling on infant and young child feeding (IYCF), and iron and folic acid (IFA) distribution to adolescent girls, pregnant and lactating mothers.
The onset of the COVID-19 pandemic and its rapid spread severely complicated human life specifically its immense negative effects on the poor and the vulnerable part of the society.

In addition to health implications, loss of jobs of daily wagers, factory workers and shut down of small businesses increased poverty by many folds.

A large number of populations have shifted below the poverty line.

It is expected that this outbreak would lead to massive negative effects on children and women.
The recent findings of GALLOP Pakistan study highlights reduced expenditure by the poor people to fulfill their basic needs and daily food requirements.

Availability of quality food is also a problem for them because of inflation and unavailability of healthy food.
14 Situation of Nutrition Indicators in Punjab Recognizing the need to address malnutrition at a priority basis, the Planning and Development Board, Government of Punjab is focusing on scaling up nutrition specific and sensitive actions, thereby improving nutrition indicators.
Several initiatives are being taken by the Government such as “Multi-Sectoral Nutrition Strategy (MSNS)” and a “Stunting Reduction Framework” encompassing strategies from all relevant departments and sectors contributing towards improving nutrition indicators, with specific roles and responsibilities.
Stunting in Punjab (36% in MICS 2011 and 31.5% in MICS 2018) is still high and is considered as a major problem of public health significance.3 This is a physical manifestation, resultant from insufficient and poor-quality diets, prevalence of infections, and poor feeding practices over an extended period.

Though, stunting on an average has shown a decline in Punjab, some districts have shown extremely high level of stunting and are amongst the worst-ranked districts of the country.
Figure 3: District wise stunting in U5 Children Acute malnutrition, known as ‘wasting’ (15.1% in MICS 2011 and 7.5% in MICS-2018) is partly caused by arid conditions and occasional drought in some areas.

It is more broadly a manifestation of poverty, inadequate care and feeding practices, food insecurity (quantity, quality and diversity), unhygienic conditions including access to safe drinking water, and lack of timely and affordable health care.
Wasting under 6 months of age, common in Pakistan, is reflective of maternal malnutrition.

In addition, around 5-7% of children are both stunted and wasted.

15 Figure 4: District wise wasting in U5 Children Underweight, a type of chronic malnutrition (32.6% reported in MICS 2011 and 21.2% in MICS 2018) is mainly caused by low intake of food/nutrients over long periods, repeated illness/infections, eating disorders, digestive problems like inflammatory bowel disease and thyroid disease etc.
High burden of underweight children is common in some southern districts of south Punjab.

Figure 5: District wise underweight in U5 Children 16 Around 67% of households in Pakistan are unable to afford a minimum nutritious diet from their current food expenditure.

According to the Global Hunger Index 2019, Pakistan ranks 94 of 117 qualifying countries, with dire performance when compared to other countries.
However, it is also evident that even among families who can afford, dietary diversity is poor, and diets are unhealthy.

The cumulative effect of lost manpower hours, healthcare expenses and lower productivity due to malnutrition in monetary terms in Pakistan is at least 7.6 billion USD or around 3% of its Gross Domestic Product (GDP) every year.2 These estimates are conservative, as most of the economic burden of malnutrition in Pakistan is long term and inter-generational.
Socio-economic impact The WHO advisory committee on COVID-19 promotes social distances to limit the transmission of coronavirus.

A partial lockdown, smart lockdown and complete lockdown policy have been used by the states as per their caseload and facilities.

Initially, Pakistan started 'contact tracing policy' followed by the lockdown all over the country.

After a short span, when the number of cases dropped the smart lockdown policy was implemented in high prevalence regions.
According to World Bank estimates, Pakistan's economy is likely to shrink by 1-2 percent.

The recent Gallup Pakistan survey highlights that the food security situation could get worse, affecting about 6.9 million households in a day.

Moreover, food shortage is expected, and poor distressed people are looking for cheap sources of food.

Though, most households have spent their savings; government agencies and voluntary organizations are helping poor and marginalized people.
However, all needs of this specific group could not be met.

Their health issues are getting worse during this pandemic which ultimately results in an increase of morbidity and mortality.

This may cause the risk of malnutrition in women and children, and if not treated timely, it will lead to severe complications and damage to their lives.
17 Services affected during COVID -19 COVID-19 has changed the priorities of the government, of which the main focus areas are: saving the lives of people, COVID-19 outbreak control, provision of livelihoods, food security and restoration of businesses.

Programs and institutes are performing with low budgetary support because of the shift in funds from development schemes to COVID-19 emergency initiatives.
The achievements made during the last few years may be compromised because of slow performance of public and private sectors institutes.

The fear of reversal of progress made till date in health and nutrition sectors is rising day by day.

The data of 24/7 Basic EmoNC (emergency obstetric and neonatal care) facilities nutrition services shows declining trends.

There are also declining trends in the admission of severely malnourished children at 58 stabilization centres in Punjab.
The difference in admission in January 2020 and July 2020 is close to half, about 45% decline in admission is because of the shortage of health staff and their deputation to COVID isolation wards, limited OPD services, transportation issues and fear of visiting health facility units during COVID-19.
COVID-19 has restricted the movement of lady health workers during this outbreak, due to the possibility of contracting the infection during house-to-house visits, and fear of spreading the same in their catchment area and risking their own lives as well.

Besides this, the provision of Personal Protective Equipment (PPEs) to workers has also been a major issue during this time.
The activities of distribution of IFA to pregnant and lactating women, and adolescent girls, distribution of multi micronutrient sachets among 6 to 23 months of children and family planning commodities was not consistent in their catchment area.
In the current situation, a further increase of 14.3% Global Acute Malnutrition (GAM) rate is expected during and after COVID-19 pandemic and it is anticipated that there will be an additional 150,000 malnourished children in all over the province.4 18 Thematic areas of concern during COVID-19 pandemic The international, national guidelines, studies, and research articles on the effects of COVID- 19 on health and nutrition status of individuals, especially children and women were reviewed.
After discussion with technical representatives from concerned departments and other stakeholders, ten important thematic areas have been selected in this nutrition response plan to mitigate the effects of COVID-19 on health and nutrition condition of the population, as elaborated ahead.

Following are the ten thematic areas selected: 1.

Provision of safe services at health facilities especially at OTP and SC 2.

Strengthening of community services during COVID-19 3.
Promotion of adolescent girls and maternal nutrition 4.

Promotion of breastfeeding and Infant Young Child Feeding (IYCF) practices 5.

Prevention and management of infectious diseases 6.

Capacity building of staff 7.

Strengthening of monitoring and supervision mechanism 8.

Multi-sectoral nutrition approach during COVID-19 9.

Communication and awareness during COVID-19 10.


Impact of COVID-19 on gender equity An activity plan along with the department(s) responsible for its implementation have been detailed-out for each thematic area.

As a monitoring mechanism, the Multi-sectoral Nutrition Cell Planning & Development Board will coordinate and conduct fortnightly review meetings for an update on implementation of the plan.
19 Thematic area I Provision of safe services at health facilities especially at OTP and SC 20 Provision of safe services at health facilities especially at OTP and SC As the COVID-19 pandemic has disrupted the functioning of entire health system, the treatment and prevention of diseases are compromised because of limited access to health facilities.
Children and women suffering from malnutrition are facing difficulties to manage their well-being due to interruption in the preventive and curative care which may lead to increased cases of malnutrition-related complications.

Therapeutic nutrition interventions are carried out in all 36 districts of Punjab.

A total of 1710 OTP sites and 58 Nutrition Stabilization Centers are functioning under IRMNCH & Nutrition Program.

About 67% of health facilities are providing therapeutic services across Punjab.
The expansion of therapeutic nutrition sites during and after the outbreak will provide relief and ease to the people living in remote areas.

To ensure quality treatment of malnourished children, the quality of nutrition Management Information System (MIS) needs further improvement.

The real-time data of children registered in OTP is available through android based nutrition MIS.

This will be helpful in analyzing gender-segregated data to know the effects of COVID-19 on gender.
Similarly, a strong quality check system to improve the nutrition-therapeutic program is required.

The protection and safety of staff working in OTP/SC must be ensured by providing them with PPEs and trainings.

The national nutritional technical committees have issued revised guidelines for Severely Acute malnourished children for COVID-19.
These guidelines may be followed in Punjab with the approval of the provincial nutrition technical committee.5 Table.1 Activity plan for provision of safe services at health facilities especially at OTP and SC S.No.
Activities Timeline 1 2 Preparation of gender sensitive guidelines for OTP & SC staff on personal protection during COVID-19 15th January 2020 Revision of therapeutic protocol in emergency context of COVID-19 15th January 2020 Concerned Department/ Program/Partner Technical committee of Primary and Secondary Health on Nutrition/ WHO/UNICEF/ NI Provincial technical working group & IRMNCH & Nutrition Program/ WHO/UNICEF/WFP 21 Table.1 Activity plan for provision of safe services at health facilities especially at OTP and SC S. No.
Activities Provision of uninterrupted therapeutic and supplementary food (RUTF,F-100, F 75, Resomal, etc.)
for the treatment of malnourished children and women at OTP & SC Timeline Concerned Department/ Program/Partner Priority / Weekly/ Monthly supplies IRMNCH & Nutrition Program/UNICEF/ WHO/WFP/NI Provision of PPEs for community and health facility staff Priority / Weekly/ Monthly supplies IRMNCH & Nutrition Program along with all development partners Expansion of OTP services at public health facilities Year 2020-21= 39 Year 2021-22=300 Year 2022-23=300 IRMNCH & Nutrition Program along with all development partners Refresher training of healthcare provider on personal protection and continuation of nutrition services during COVID-19 30th March 2021 Development of messages and other IEC material for personal protection and continuation of nutrition services 15th January 2021 Desk Review of Nutrition MIS with special focus on gender segregated data Fortnightly IRMNCH & Nutrition Program along with all development partners IRMNCH & Nutrition Program along with all development partners IRMNCH & Nutrition Program along with all development partners Screening, referral of malnourished children to OTP and SC Daily on priority basis IRMNCH & Nutrition Program 10 Strengthening of referral system between OTP and SC to shift complicated SAM cases 30th December 2020 IRMNCH & Nutrition Program 22 Thematic area II Strengthening of community services during COVID-19 23 Strengthening of community services during COVID-19 In Punjab, community-based MNCH, RH and Nutrition services are provided through Lady Health Workers (LHWs), Community Midwives and School Health Nutrition Supervisors (SHNS).
The Lady Health Workers’ network is an essential part of the health system and almost 68% rural and 35% urban population is covered by them.

They register under five- year children, maintain their record of breastfeeding, complementary diet, growth monitoring and immunization.
They also register all pregnant and lactating women in their catchment area, providing them iron-folic acid tablets and other micronutrient supplements.6 Also, they organize community support group meetings regularly to generate awareness more specifically on health and nutrition issues.

However, during COVID-19 all these activities were interrupted.
Though, LHWs have resumed the activities they have not yet returned to normal working condition due to following reasons: ▪ Shortage of personal protective equipment ▪ Lack of information on COVID-19 and its prevention measures ▪ Training and capacity building issues- The authorities have banned classroom training, and virtual orientations were not possible in the rural areas ▪ The fear among the health workers that they might spread the disease during door- to-door visits ▪ Limitation to visitors in homes during the pandemic ▪ Shortage of supplies and essential items due to the logistic and transportation issue Before the outbreak of COVID-19, the specific role of LHWs in nutrition program was screening of children under the age of five, identification of malnourished children, referral to the nearest OTP site, and regular follow-up visits for compliance of treatment.
They treat children suffering from diarrhea and pneumonia and refer them to the health facility for further treatment in case of any complication.

LHWs visit households to increase awareness of reproductive health and nutrition.
They have a well-defined role to ensure improvement of adolescent and maternal nutrition.7 There is a need to revive all the activities of LHWs in the community by providing them with personal safety equipment, uninterrupted supply of medicines and essential equipment and training.

In addition, the roles and responsibilities of LHWs need to be revised with fieldwork SOPs until the situation of COVID-19 pandemic is not resolved.
24 With the threat of an emerging second wave of COVID-19, the government is considering to close the schools now after their re-opening.

In Punjab 1890 School Health and Nutrition Supervisors (SHNSs) are working at union council level for health and nutrition screening of students and capacity building of teachers and administrative staff.

When the schools were closed, they worked with LHWs in community for generating awareness on health and nutrition issues.
Their services may be utilized to strengthen the community nutrition component either in the school or at village level.

SHNS may be involved in all nutrition related capacity building program, nutrition education, and other preventive and curative activities during COVID-19.

Table 2.

Activity plan for strengthening of community services during COVID-19 S. No.
Activities Timeline Concerned Department/ Program/Partner Development of guidelines for personal protection of community staff (LHWs, Vaccinator etc.)

15th January 2021 Provision of personal protective equipment for field staff Priority basis.

weekly/monthly supplies Refresher training of community staff on prevention COVID-19 and safety protocol.
30th March 2021 Training of community staff on communication skills 30th April 2021 Technical Committee of Primary & Secondary Healthcare/ development partners Primary & Secondary Healthcare Department & development partners Primary & Secondary Healthcare Department & development partners Primary & Secondary Healthcare Department & development partners Provision of all necessary equipment/medicine and other logistic Immediate/Regular IRMNCH and development partners Refresher trainings of community staff on updated preventive and treatment protocol of COVID-19 Monthly/fortnightly Primary & Secondary Health Department/ IRMNCH/Partners 25 Table 2.
Activity plan for strengthening of community services during COVID-19 S. No.

Activities Timeline Activation of Sehat committees and women support group meeting by following SOPs in the light of COVID-19 pandemic 15th December 2020 Concerned Department/ Program /Partner Provincial technical working group/ IRMNCH & Nutrition Program Capacity building of community staff to deal with suspected and confirmed COVID-19 cases and isolation protocol.
15th November 2020 Primary & Secondary Healthcare, IRMNCH & Nutrition Program Training of SHNS on prevention of COVID-19 and early detection of cases and response in schools.
Start from 30th January 2021 and continue on monthly basis Primary & Secondary Healthcare/ School education/PSPU Teachers training by SHNS on prevention and protection from COVID- 19 and student screening SOPs Start from 15th January 2021 and continue on monthly basis Primary & Secondary Healthcare/ School Education/PSPU Establish referral system of COVID-19 suspected/ symptomatic student an teachers 15th February 2021 Primary & Secondary Healthcare, PSPU Identification of suspected students’ household and ensure screening of all household members by COVID-19 rapid response team Priority basis after case detection Primary & Secondary Healthcare Department 26 Thematic area III Promotion of adolescent girls and maternal nutrition 27 Promotion of adolescent girls and maternal nutrition To break the cycle of intergenerational malnutrition, it is necessary to focus on maternal and adolescent girl’s nutrition.
Although the intervention related to this component was included in the current nutrition PC-1 of Nutrition Program, however, no comprehensive efforts were made during the last few years.

COVID-19 directly hit the health and nutrition status of women, especially those from lower socio-economic status.

Therefore, the chances for intergenerational transfer of malnutrition has increased by many folds.
A model of continuum of care and necessary support to women and adolescent girls to prevent the transfer of malnutrition to the next generation is highly required.

Thus, concrete steps need to be taken to prevent malnutrition in the adolescent girls, pregnant and lactating mothers.

In Pakistan, the sizeable portion of women suffer from anaemia, calcium, and vitamin D deficiency.
Many women belonging to low socio-economic status have severe and moderate malnutrition which leads to several health complications including birth defects, miscarriage, and maternal and infant mortality.8 The following activities may be performed to ensure good health and nutrition services for adolescent girls and women during this pandemic.

Table 3: Activity plan for promotion of adolescent girls and maternal nutrition S. No.
Activities Timeline Development of reproductive and nutritional guidelines during COVID- 19 for adolescent girls and women of reproductive age 1st January 2021 Concerned Department/ Program /Partner IRMNCH/ Primary and Secondary Healthcare/ UNFPA/Pathfinder Capacity building of health staff on revised reproductive and nutrition guidelines 15th February 2021 Health & development partners Screening of adolescent girls and women of reproductive age group through BMI, MUAC Daily / Regular IRMNCH/ Primary and Secondary Healthcare and development partners 28 1 2 3 Table 3: Activity plan for promotion of adolescent girls and maternal nutrition S. No.
Activities Timeline Focus on prevention and treatment and screening of anemia in adolescent and women Daily/ Regular Growth monitoring of adolescent girls and pregnant women, etc.

Daily/ Regular Counseling of pregnant and lactating mothers about healthy dietary habits, diet diversification, personal hygiene, IYCF practices, and breastfeeding, etc.
Daily/ Regular Provision of IFA, Calcium & Vitamin D supplementation Daily/Regular Promotion of birth space and provision of Family Planning commodities Daily/ regular Provision of multi-micronutrient to underweight adolescents and women Daily/ Regular 10 Provision of supplementary food to severe underweight adolescent/pregnant women when required Daily/ Regular Concerned Department/Progra m /Partner IRMNCH/ Primary and Secondary Healthcare & development partners IRMNCH/ Primary and Secondary Healthcare & development partners Primary & Secondary Health Department/ IRMNCH/ Partners Provincial technical working group/ IRMNCH & Nutrition Program Primary & Secondary Healthcare, IRMNCH & Nutrition Program/ Population Welfare Department Primary & Secondary health Department/ IRMNCH/ Partners Primary & Secondary Health Department/ IRMNCH/ Partners 29 Thematic area IV Promotion of breastfeeding and IYCF practices 30 Promotion of breastfeeding and IYCF practices The WHO and UNICEF have issued extensive guidelines for promotion and continuation of breastfeeding practices during COVID-19 pandemic.
These guidelines have instructions for lactating mothers and healthcare providers regarding the maintenance of breastfeeding during the pandemic and the precautions that need to be taken when a mother or her baby is suffering from COVID-19 to continue breastfeeding.9 The first 1000 days are critical for child mental and physical development.

The timely introduction of semi-solid food in addition to breast milk in infants is vital for a healthy life.
Introducing semi-solid food from the age of six months and its continuation with age improves health and nutrition status of children.

Majority of the women know the importance of complementary diet, but there is lack of proper information and different options to prepare home-based foods that fulfil the requirement of children according to their age group.

The department may prepare local recipes for women and healthcare providers which can be provided to mothers having children less than five years.
Growth monitoring and micronutrients supplementation should be continued for 6 to 24-months children to promote IYCF practices during COVID-19 pandemic.

Table 4.

Activity plan for promotion of breastfeeding and IYCF practices S. No.
Activities Timeline Preparation of safe breastfeeding and IYCF practices guidelines during COVID-19 Priority basis Notified before 15th January 2021 Concerned Department/ Program /Partner Provincial nutrition technical committee/ IRMNCH/ development partner Prohibition of distribution of formula milk in ration pack of socio-economic compromised families Guideline/ Directives to all stakeholder 1st January 2021 PDMA/Health & development partners Issuance of notification to all Medical Superintendents and in charges of health facilities to promote/ protect safe breastfeeding and IYCF during COVID-19 30th January 2021 IRMNCH & Nutrition Program, Primary & Secondary Healthcare Department, Specialized Healthcare and Medical Education, Development Partners 31 1 2 3 Table 4.
Activity plan for promotion of breastfeeding and IYCF practices S. No.

Activities Timeline Concerned Department/ Program /Partner Formation of breastfeeding promotion and protection committee in Secondary and Tertiary Health facility.
15th March 2021 Establish Lactation Management Clinic in THQ and DHQs 15th February 2021 IRMNCH/ Primary and Secondary Healthcare and specialized Healthcare Department IRMNCH/ Primary and Secondary Healthcare and Specialized Healthcare Department Promotion of breastfeeding and IYCF in community through LHWs/ Religious scholars and politicians.
Daily/ regular Primary & Secondary health department/ IRMNCH/ Partners 4 5 6 7 Baby friendly hospital initiative At least in 3 hospital up to 15th May 2021 Specialized Healthcare and Medical Education department/ Primary & Secondary Healthcare/DG Health/IRMNCH & Nutrition Program Primary & Secondary Healthcare, IRMNCH & Nutrition Program/ Law Department Revision of breastfeeding Law and submission to Law department 30th January 2021 8 9 Revision of breastfeeding implementation plan in context of COVID-19 30th February 2021 Primary & Secondary Health Department/ IRMNCH/ Partners 10 Infant feeding board meeting Quarterly Primary & Secondary Health Department/ IRMNCH/ Partners 32 Thematic area V Prevention and management of infectious diseases 33 Prevention and management of infectious diseases Repeated infections in children lead to acute and chronic malnutrition and if a child is malnourished his/her duration of disease, its severity, morbidity, and mortality may increase to many folds.
Malnutrition and infection are linked to each other as malnourished children are susceptible to life-threatening infections, of which diarrhea and pneumonia are one of the major contributors of mortality in children.

Therefore, extra measures should be taken at the community and health facility level for prevention and treatment of infectious diseases.

The possibility of spread and severity of diarrhea and pneumonia are much more during COVID-19 outbreak.
LHWs are providing initial management to thousands of diarrheal and pneumonia cases in children, every month.

If their services are disrupted during COVID-19, it would lead to an increase in the severity of the infection.

Limited healthcare facilities and transport issues further increase the duration and severity of infectious diseases in children and women.
Healthcare Authorities and Public Health Engineering Department (PHED) may take necessary measures to prevent these infectious diseases.10 Table 5: Activity plan for prevention and management of infectious diseases S. No.

Activities Timeline Concerned Department/ Program /Partner Ensure availability of all essential medicines of infection prevention at health facilities and with LHWs.
Collection of No stock report on Monthly basis Health / Development Partner Ensure availability of safe drinking water at health facilities during and after COVID-19 Priority basis / Monthly report PHED/ Health/MSNC Ensure availability of soap and hand washing facility in all hospitals 30th January 2021 Health/WHO/UNICEF Establish and implement infection prevention and control mechanism at all health facilities Priority / 30th March 2021 Health Ensure proper waste management, especially infectious and hazardous waste Priority basis and monthly updates Health/Waste Management Companies/Local Government 34 6 7 8 Table 5: Activity plan for prevention and management of infectious diseases S. No.
Activities Timeline Refresher training of health staff, community and sanitary workers on infection prevention 15th February 2021 Concerned Department/ Program /Partner Health/ IRMNCH/ development partners/MSNC Capacity building of mothers of under five years children on prevention of diarrhea and pneumonia, hygienic practices and safe drinking water 30th December 2020 IRMNCH/Primary & Secondary Healthcare/ development partners Establish mechanism for referral and treatment of emergency diarrheal and pneumonia complicated cases from community to health facility Monthly updates IRMNCH/Primary & Secondary Healthcare/ Specialized Healthcare Department 35 Thematic area VI Capacity building of staff 36 Capacity building of staff To continue health and nutrition services during COVID-19, it is of utmost importance that special training should be given to the health workers at all levels.
As the healthcare workers are at high risk, they are afraid of providing services during the pandemic.

The current DHIS data reveals a decline in health services, especially ANC, PNC, and deliveries by SBA.

The default rate of malnourished children admitted at OTPs has increased by many folds.

Moreover, there is apprehension and hesitation amongst people to visit health facilities.

The healthcare staff feels unsafe to serve without availability of PPEs.
Therefore, special training guidelines may be developed to train healthcare providers and for the other departments staff who are working as frontline workers to fight against COVID-19.
The important topics for capacity building program for community and healthcare staff may be as follows:11 ▪ Breastfeeding, its importance during COVID-19 ▪ Complementary feeding practices ▪ Knowledge for preparation of affordable nutrient-dense recipes for children by the households ▪ Treatment of malnourished children and PLWs during COVID-19 ▪ Safety protocol of health facilities (OTP and SCs) during COVID-19 ▪ Guideline for community staff to continue the nutrition services in the community ▪ Behavioral change therapies related to healthy eating ▪ Infection prevention Table 6: Activity plan for capacity building of staff S. No.
Activities Timeline Development of sectoral capacity assessment plan of staff Priority Basis and Biannually Concerned Department/ Program /Partner Health / development partner/ MSNC Identification of knowledge gaps of staff and review of available material of COVID-19 prevention 15th February and Biannually Health / development partner/ MSNC 37 1 2 Table 6: Activity plan for capacity building of staff S. No.
Activities Timeline Concerned Department/ Program /Partner Formation of technical group to review national and international guidelines, and prepare departmental COVID-19 prevention guidelines.

30th January 2021 Health/ IRMNCH / development partners/ MSNC Development of capacity building plan by following the COVID-19 prevention SOPs.

30th January 2021 Arrangement of resources like finance, logistics and PPEs etc.
for capacity building plan 15th January 2021 Development of monitoring checklist to ensure quality TOTs and Trickle-down trainings (Cascade model) 15th January 2021 Development of feedback mechanism to improve the capacity building program and to revised and update contents 1st February 2021 IRMNCH/Primary & Secondary Healthcare/ development partners Health/ IRMNCH / development partners/ MSNC/PDMA Health/ IRMNCH / development partners/ MSNC/ all relevant sectors Health/ IRMNCH / development partners/ MSNC/ all relevant sectors 38 Thematic area VII Strengthening of monitoring and supervision mechanism 39 Strengthening of monitoring and supervision mechanism Every department has its monitoring and evaluation system to track the progress on target and indicators.
Like any other activities, monitoring and supervision also faced disturbance during COVID-19.

With strict restriction of large gatherings, the performance review meetings were suspended, supervision and monitoring visits of senior officers and M&E staff were limited, and the MIS staff was shifted to COVID-19 response unit; thereby, weakening the routine monitoring system.
There is a need to review the existing monitoring and supervision mechanism and revise targets by keeping in mind the pandemic situation.

Moreover, the purpose of monitoring is to know the performance of sectors/programs and to ensure the quality of the program in terms of its suitability, applicability, acceptability, efficiency and accuracy.12 Thus, stressing the need to strengthen the system for improving delivery of services.

Table 7.
Table 7.

Activity plan to strengthen monitoring and supervision mechanism S. No.

Activities Timeline Concerned Department/ Program /Partner Review and revision of monitoring system of all concerned sectors in COVID-19 context Issuance of guideline by 30th January 2021 Health/development partner/MSNC/other Development of review system, feedback and follow up mechanism to ensure quality of data.
30th January 2021/ Monthly Health/development partner/MSNC/other Establishment of online system for coordination, capacity building and programmatic and departmental progress review.
30th January 2021 Health / development partner/MSNC/other Arrangement of progress review meetings by following strict COVID-19 protection SOPs Monthly Health/development partner/MSNC/other Establishment of SMS based real time data base and android based monitoring system to minimize physical contact 30th December 2020 Health/development partner/MSNC/other Provision of PPEs for monitoring & supervisory staff and availability of resources for field visits Priority Basis up to 30th December 2020 Health/development partner/MSNC/other Strengthening of provincial, divisional, districts coordination mechanism to regularize the review mechanism of progress Monthly Health/development partner/ MSNC/other 40 Thematic area VIII Multi-Sectoral nutrition approach during COVID-19 41 Multi-Sectoral nutrition approach during COVID-19 To ensure multi-sectoral coordination of nutrition-sensitive and specific sectors, we need a strong coordination mechanism.
In Punjab, a comprehensive multi-sectoral nutrition program under the Planning & Development Board, Government of Punjab has been established.

MSNC is an innovative approach to get maximum support from nutrition- sensitive sectors like WASH, Livestock, Social Protection, Food, Agriculture, etc.

The considerable achievements of MSNC are the establishment of the structure of the Provincial steering committee, District Malnutrition Addressing Committee (DMAC) and Tehsil Malnutrition Addressing Committee.
The regular meetings of these forums are effective in tracking and supporting the nutrition initiatives at the grass-root level.13 Use of these forums to monitor the activities of provincial nutrition plan will minimize the COVID-19 outbreak effects on nutrition program and initiatives.

Table 8: Activity plan for multi-sectoral nutrition approach during COVID-19 S. No.
Activities Timeline Concerned Department/ Program /Partner Training of Multi sectoral departments on COVID-19 prevention and safety protocol 15th March 2021 MSNC/ SUN Unit Development of revised DMAC Guidelines to monitor COVID-19 response and recovery Plan 30th March 2021 Revision of DMAC agenda to include COVID-19 response plan 15th February 2021 Oversight of all nutrition response plans at provincial level Regular/ monthly Arrangement of regular follow up meetings to monitor progress on provincial nutrition response plan Monthly Financial tracking and increase budgetary allocation/ utilization Quarterly MSNC / SUN / Planning & Development Board MSNC / SUN / Planning & Development Board MSNC / SUN / Planning & Development Board MSNC / SUN / Planning & Development Board MSNC / SUN / Planning & Development Board 42 Table 8: Activity plan for multi-sectoral nutrition approach during COVID-19 S. No.
Activities Timeline Strengthening mechanism of availability of safe and nutritious food.

Priority Basis Concerned Department/ Program /Partner Punjab Food Authority/MSNC/SUN/ Planning and Development Board Media campaign to promote safe and nutritious food during and after COVID-19.
Priority Basis PFA/Health/ MSNC Development of guidelines for safe and nutrition food for school children 15th February 2021 Social protection scheme to marginalized and malnourished women and children 30th December 2020 Health & PFA Provincial technical committee on nutrition Punjab Social Protection Authority/ Health and development partners/MSNC Development of mechanism to monitor and supervise all social protection schemes related to health & nutrition 30th December 2020 MSNC/PSPS/Health/ DMAC Engagement of social sector (Private & Government) in COVID-19 relief and recovery Priority Basis MSNC/Health/ PSPA/DMAC Establish linkage of health and social protection/ welfare sector to provide relief to poor families for their basic health and nutrition needs.
1st February 2021 MSNC/Health/ PSPA/DMAC Provision of food (eggs/meat/fish) through livestock department to vulnerable and socio-economic compromised families on subsidize rate.
Priority Basis MSNC/ Live stock/ Social Protection Authority Provision of seeds/ plants to vulnerable and socio-economic compromised families for kitchen gardening 15th February 2021 MSNC/ Agriculture/ Social Protection Authority 43 Thematic area IX Communication and awareness during COVID-19 44 Communication and awareness during COVID-19 During the coronavirus outbreak, it is common to see a lot of controversial & inappropriate messages on social media platforms.
Nutritional messages must be used correctly & should have acceptability according to local norms of society.14 These messages are essential to generate awareness regarding IYCF (early and exclusive breastfeeding, complimentary feeding), dietary counseling about a balanced and diverse diet, WASH messages, family planning, etc.

All nutrition-specific and sensitive sectors should be involved in raising awareness and mobilizing the community on the importance of nutrition during COVID-19.
A multi-sectoral approach and interactions with the other relevant sectors such as Population, WASH, Education, Social Welfare & Protection, Agriculture and Food can play a significant role to achieve the desired results of nutrition education during COVID -19.

Table 9: Activity plan for communication and awareness during COVID-19 S. No.
Activities Timeline Concerned Department/ Program /Partner Development of sectoral communication plan for COVID-19 30th January 2021 Health/ MSNC/ all relevant sectors Allocation of budget to create mass level awareness among staff and people Priority Basis up to 30th January 2021 Health/ MSNC/ Development Partners Review and revise communication material of COVID-19 and nutrition and approval from concerned technical forum before dissemination 30th January 2021 Health/ MSNC/ all relevant sectors Formation of technical forum consisting of technical and communication specialists 30th January 2021 Health/ MSNC/ all relevant sectors Development of social media campaigns and web-based information hub for COVID-19 15th February 2021 Health/ MSNC/ all relevant sectors Engagement of technical experts in webinars and conferences to provide up to date knowledge to staff and community Weekly/ Monthly Health/ MSNC/ all relevant sectors 45 Table 9: Activity plan for communication and awareness during COVID-19 S. No.
Activities Timeline Concerned Department/ Program /Partner 7 8 9 10 Development of mechanism to deliver SMS based messages to staff and people for protection of COVID -19 and continuation of services Development of short videos, brochures, banners, and streamers for mass level awareness on COVID -19 protection 30th December 2020 Health/ MSNC/ all relevant sectors 28th February 2021 Health/ MSNC/ all relevant sectors Quarterly media campaign for awareness of COVID-19 protection and nutrition Quarterly Health/ MSNC/ all relevant sectors Monitoring of media activities to prevent unauthentic, wrong, and irrelevant information related to nutrition, health and COVID-19 Immediate and regularly Health/ MSNC/ all relevant sectors 46 Thematic area X Impact of COVID-19 on gender equity 47 Gender equity and impact of COVID-19 During the COVID-19 outbreak, women and girls are experiencing more adverse effects than men on health and nutrition needs.
Accessibility problems, family financial issues and lack of empowerment are making it harder for women to fulfil their nutrition, health, and hygiene needs.15 The risk is many folds, if women are pregnant and are not able to get proper ANC, PNC, balanced diet coupled with insufficient nutrition and poor dietary habits.

This leads to premature birth, still birth, miscarriage, physical and mental problems in babies, and serious complications on mothers well-being.
Non-availability of nutritious food will induce micronutrient deficiency, anaemia, and protein-energy malnutrition in lactating mothers.
The accessibility issue of family planning services is again a serious risk to their health and nutrition status.16 Provision of better sexual, reproductive and nutrition services to women and girls during and after this pandemic is to be ensured which is only possible when all relevant sectors provide gender-segregated data and prioritize gender equality in service delivery.

Table 10: Activity plan to response the impact of COVID-19 on gender equity S. No.
Activities Timeline Departmental guidelines may be issued to ensure gender equality in all relief operations/ routine services during and after COVID-19 outbreak December 2020 Identify gender equality gaps in nutrition services during COVID-19, development of coordination mechanisms, action plan to reduce those gaps 20th February 2021 Strengthen the MIS data system of all department concerned with health and nutrition and to ensure gender segregated data 15th March 2021 Development of short-term capacity building program of staff to ensure gender equality during and after COVID -19 30th December 2020 Development of guidelines to ensure sexual, reproductive and nutrition services to women, adolescent and children during COVID -19 15th January 2021 Concerned Department/ Program /Partner MSNC/ Health /NGO/ Development Partners / Women protection Department MSNC/ Health /NGO/ Development Partners / Women protection Department MSNC/ Health /NGO/ Development Partners / Women protection Department MSNC/ Health /NGO/ Development Partners / Women protection Department Health/ IRMNCH/ SUN unit/ MSNC/ UNFPA/ Pathfinder Ensure that gender guidelines/ policies are fully incorporated & implemented in all concerned departments 30th December 2020 MSNC / Health / development partners 48 Conclusion Families belonging to the low socio-economic background are facing more issues to fulfil their needs compared to the others.
They are unable to meet the nutritional requirement of their household members, especially children and women.

It is also an enormous challenge for the government to provide nutrition support to all vulnerable segments of society.

This Nutrition Response Plan comprises of the principal thematic areas that should be focused to strengthen and improve the ongoing nutrition initiatives of government.
During preparation of this plan, priority was accorded to identify the areas' and activities that are more sensitive in this outbreak situation.

Institutional strengthening, allocation of sufficient budget and effective governance would improve the current actions and program on nutrition.

The number of malnourished children is expected to rise during this pandemic.

Therefore, improvement in the performance of existing malnutrition treatment centers, OTP and SCs in Punjab is crucial.
The need to set up new OTPs and SCs is rising to assure appropriate and effective nutrition services near to the community.

Lady health workers working in the community need to be provided with special training to continue the nutrition activities during COVID-19 along with essential medicine, nutrition supplements and necessary equipment so that they can perform the screening of children and women, with promotion of IYCF, awareness on adolescent and maternal nutrition.
To prevent the long-term effects of chronic malnutrition, there is a need to increase the efficiency of nutrition-sensitive sectors such as agriculture, WASH, livestock, and population.

It is equally important to regularly review the performance of all nutrition-specific and sensitive sectors through nutrition response plan and take immediate and effective steps to address the issues that arise.
Response to COVID-19 with focus on the identified thematic areas is bound to enable the Government of Punjab with efficient and effective tackling of the pandemic along with having a significant impact on prevention and management of malnutrition.

49 References 1. http://www.agripunjab.gov.pk/ 2.

Coronavirus attitude tracker survey Pakistan Trend & Cross-Sectional Analysis of Results April 2020 special report on economic impact of lockdown due to coronavirus on Pakistani households.
Trend & Cross-Sectional Analysis of Results 3. http://bos.gop.pk/MultipleIndicatorClusterSurvey2017-18 4.

Impacts of COVID-19 on childhood malnutrition and nutrition-related mortality Published Online July 27, 2020 https://doi.org/10.1016/ S0140-6736(20)31647-0 See Online/Comment https://doi.org/10.1016/ S0140-6736(20)31648-2 5.

Nutrition Guidelines for Health Facilities Staff for COVID-19 Response by Ministry of Health & Regulation Pakistan 6.
Simplified Guidelines for the delivery of Infant Young Child Feeding (IYCF) in the context of COVID-19 by Ministry of Health & regulation Pakistan 7.

Emergency Response Plan IRMNCH & Nutrition Program Primary & Secondary Healthcare Department 8.

Guideline: Implementing effective actions for improving adolescent nutrition 9.

Breastfeeding and COVID-19 Scientific brief WHO 23 June 2020 10.
World Health Organization (WHO) COVID-19 Strategic Preparedness and Response Plan: Operational Planning Guidelines to Support Country Preparedness and Response (Published 12 Feb 2020) www.who.int/docs/default-source/coronaviruse/covid-19-sprp- unct-guidelines 11.

Simplified Guidelines for SAM/MAM treatment in the context of COVID-19 by Ministry of Health & regulation Pakistan 12.

Summary Note UNICEF Pakistan Response Strategy to Covid-19 13.
Nutrition development partners position paper on Nutrition in COVID-19 Context and beyond (Nutrition International and UNICEF Pakistan) 14.

Recommendations of Nutrition Working Group meeting on COVID-19 Response plan Date: 7th April ,2020 15.

Gender and COVID-19 Advocacy brief WHO 14 May 2020 16.
COVID19 Gender Women's empowerment Women's nutrition SUN Civil Society Network, SUN Country Network 0 * Originally published by CanWaCH – Written by World Vision Canada 50 Prepared by: Scaling Up Nutrition (SUN) Provincial Unit Planning and Development Board Government of Punjab Supported by: Nutrition International