Asia Pac J Clin Nutr 2008;17 (S1):357-360 357 Review Article Tawana project-school nutrition program in Pakistan- its success, bottlenecks and lessons learned Salma Halai Badruddin PhD 1 , Ajmal Agha FCPS 1 , Habib Peermohamed CMA 1 , Ghazala Rafique FCPS 1 , Kausar S Khan PhD 1 and Gregory Pappas MD PhD 1 The Aga Khan University, Department of Community Health Sciences, Karachi, Pakistan Tawana Pakistan Project, a multifaceted pilot project (Sept. 2002 to June 2005) was funded by the Government of Pakistan to address poor nutritional status and school enrolment of primary school age girls. The core strategy was to create safe environment empowering village women to take collective decisions. Through reflective learning process women learnt to plan balanced menus, purchase food, prepare and serve a noon meal at school from locally available foods at nominal costs (USD 0.12/child). Aga Khan University partnered the government for the design, management, monitoring and evaluation of the project, 11 NGO’s facilitated implementation in 4035 rural government girls’ schools. Training was provided to 663 field workers, 4383 community organizers, 4336 school teachers and around 95 thousand rural women. Height and weight were recorded at baseline and every 6 months thereafter. Wasting, underweight and stunting decreased by 45%, 22% and 6% respectively. En- rolment increased by 40%. Women’s’ ability to plan balanced meals improved and >76% of all meals provided the basic three food groups by end of project. Government bureaucracy issues, especially at the district level proved to be the most challenging bottlenecks. Success can be attributed to synergies gained by dealing with nu- trition, education and empowerment issues simultaneously. Key Words: Pakistan, primary school, rural population, school lunch, nutrition education INTRODUCTION Pakistan is situated in the north-western part of the South Asian subcontinent. The state is made up of four provinces; Punjab, Sindh, North West Frontier Province (NW FP) and Balochistan; some federal units including Northern Areas; and Azad Jammu and Kashmir (AJK). Malnutrition and low levels of education are still major problems, for girls in rural Pakistan. A recent national survey in Pakistan revealed that among girls five to twelve years of age 25% were stunted and 15% wasted. 1 In 2005 literacy rate among females of age 15 years or more in Pakistan was 36% 2 In rural settings only 22% of girls above 10 have completed primary level or higher schooling as compared to 47% boys. 3 Low literacy and educational achievement is associated with the low status of women and the perceived lack of benefit of girls education for their families. Childhood malnutrition and infectious disease account for a major portion of childhood mortality and morbidity. 4,5,6 In Pakistan, malnutrition is not simply a health hazard but also a serious impediment to national development. In the face of these challenges the Government of Paki- stan implemented the Tawana Pakistan Project (TPP); a multifaceted pilot nutrition and social development project to combat malnutrition and increase school enrolment among primary school girls. This large scale program was conducted over a two year period, in 4035 girls’ primary schools in the rural areas of the poorest districts of Pakistan identified from the list provided by the government. The project provided freshly prepared balanced noon meals from locally available foods, to over 418 thousand girls at about 0.12USD/child/day. The project was similar to the model “Focusing Resources on Effective School Health (FRESH) suggested by WHO, UNESCO, UNICEF and the World Bank. 7 This paper describes the Tawana Pakistan Project and the process whereby community women were trained and empowered to run a school nutrition program in their communities and the impact of TPP in the communi- ties. PROCESS The core strategy was to create a safe environment for village women to take collective decisions. The project was managed and implemented by a consortium including The Department of Community Health Sciences of the Aga Khan University (AKU/CHS), and two arms of the Minis- try of Social Welfare and Special Education; the National Implementation Unit and the Pakistan Baitul Maal. AKU/CHS provided the technical support for the design, management, monitoring and evaluation of the project. In addition to providing technical support AKU/CHS trained and managed 11 NGO’s that supported the local government and communities to implement the project. Corresponding Author: Dr Ghazala Rafique, The Aga Khan University, Department of Community Health Sciences, Stadium Road, Karachi, Pakistan Tel: 92- 21- 486-4887; Fax: 92-21-493-4294 Email: ghazala.rafique@aku.edu; salma.badruddin@aku.edu Manuscript received 9 September 2007. Accepted 3 December 2007.