EVER so often we ‘discover’ something courtesy the media — problems that have been there for long, in fact have been frequently talked about with solutions being presented, but with no listeners in the political world. Such has been the case of child deaths in Thar. Politicians quickly reacted to the news as a case of ‘who dunnit?’ indulging in frequent mud-slinging, and finally the prime minister got involved pledging a Thar bailout package.
But health experts are finally speaking out to put the record straight. Children have been dying from entirely preventable causes such as pneumonia, diarrhoea and newborn sepsis in Pakistan and other developing countries since decades — it is an issue that has been discussed by paediatricians and the UN for long.
Thar is no exception but is one of the obviously more disadvantaged districts where such deaths occur in higher numbers. It is not a case of starvation. And health facilities in Thar are as bad or as good as other disadvantaged districts. The underlying reason is low immunity in undernourished mothers, underweight babies and stunted children.
Problems of nutrition are not only found in Thar.
We must get one thing straight. Thar is not the only district with high numbers of undernourished children. The adjoining cluster districts of Umerkot, Mirpurkhas, and Sanghar, and the upper Sindh districts bordering Balochistan have almost equally high rates.
Balochistan at least has districts with even higher levels of undernutrition. Punjab, despite being the breadbasket of Pakistan, has no reason to be complacent. Southern Punjab districts have high levels of undernutrition, similar to Balochistan and Sindh. The reasons vary somewhat with arid zones and insufficient water for food production in Balochistan and certain districts of Sindh, the low capture of food produced due to large feudal landholdings in southern Punjab and Sindh, lack of sanitation leading to recurrent diseases, low literacy levels in mothers, formidable distances to health facilities, and lack of family planning.
But to sum it up, these districts share one thing in common — poverty. And Pakistan does not have a development vision for tackling poverty. Economic policies assume that benefits will just trickle down to the poor. And knee-jerk policy responses to malnutrition result in either food distribution campaigns that are expensive and insufficient, or ambitious plans to set up state-of-the-art clinics that would hardly draw people settled in remote villages and with little health awareness. So what is needed?
First, responses need to be expanded, whether it is to food distribution or health infrastructure. A new development vision is called for key underprivileged districts involving sustained cross-sectoral work in agriculture, public health engineering, social protection, health, population welfare and education. Nutrition also requires investment in community mobilisation networks and skilled workers at the village level.
Second, there are presently large disconnects between key sectors, with each having its siloed vertical planning, different time scales for implementation and a slow-moving bureaucracy. Breaking these silos requires joint funding across sectors for special districts, common beneficiaries, an approved cross-sectoral plan and a central monitoring database. Some countries have done this through conditional cash transfer programmes targeting women and children and involving income, education, health, food supplementation and family planning.
Third, government entities designated to provide leadership for development and nutrition have been missing in action. Pakistan started out well by institutionalising nutrition at the Planning Commission in 1973 as a subject across sectors, but its operationalisation came much later in the 2000s and remained confined to small-scale projects in the former federal health ministry. Post devolution, the provincial planning and development departments in the provinces have the official mandate to tackle undernutrition but although ambitious strategies have been formed, the silence on Thar reporting shows ill-preparedness.
Fourth, external donors have always been footing the bill for nutrition activities. What happens when they withdraw? Post devolution, provinces have increased fiscal and strategic space to act on nutrition. To prevent these funds from being absorbed by inflation, government salary increases, security and terrorism, quick action is needed to ring-fence funds. Piggybacking on the Benazir Income Support Program is one such route, devolved district authorities or special programmes are other fiscal options.
Whatever option Pakistan chooses, political championing is needed at the highest level to come up with a new development vision which straddles key sectors and reaches beyond Thar to other districts. It needs to cut across party lines to avoid the danger of marginalising nutrition. Undernourished children are the real markers of the state of development.
The writer is a policy researcher and faculty member at a private medical university.
Published in Dawn, December 1st, 2014