I CAN always tell when Javed, a cook working in our neighbourhood, is worried about something. When I ask him how he is his worry is the first thing he mentions. And a lot of times it is about the health of his very young granddaughter. She is a healthy child. But she does fall sick once in a while. When she does, Javed’s face reveals it before his words do.

“Have you been to the doctor?” I ask. “I took her yesterday. He gave her an injection. She is better now.” Every visit to the doctor involves an injection. “But what did the doctor say? What was wrong with the child?” I ask. “She had fever and loose motions.” “Yes, those were the symptoms that made you consult the doctor. But what was causing the fever and diarrhoea?” “The doctor did not tell us anything. He just gave her an injection and she is better now.” This is more or less the typical exchange I have with Javed when his granddaughter falls sick.

Infant and child malnutrition and stunting rates are worryingly high in Pakistan. Infant and maternal mortality rates have stopped coming down as fast as they used to. The trends in nutrition, stunting and child deaths are even more worrying given that our numbers, across sources, are showing that poverty rates have been declining in Pakistan for the last couple of decades or so. If poverty is coming down, meaning people have more resources than before, what is making the child malnutrition, stunting and ill health numbers so high?

There are a number of hypotheses that are worth looking into. Drinking water quality and lack of sanitation facilities might have the power to explain a lot about health/nutrition outcomes. Reports on water quality, from across the country have recently been quite alarming. Lack of sanitation facilities, mixing of drinking water with sewage, and few toilets for defecation are linked to the spread of diseases as well.

If doctors were more forthcoming, parents would be better informed about their child’s illness.

Lack of effective immunisation as well as lack of access to effective medicines might be another issue worth looking into. The immunisation rate is still a problem. But so is the quality of medicines that immunised children get: if medicines have not been stored properly, are past their due date, or are not of the quality they are supposed to be even high immunisation rates are not going to be of much help.

Some of the literature also points towards information gaps and lack of knowledge as a possible explanatory factor. Do parents, especially mothers, know what they need to know to ensure the nutritional needs of their children? Do parents know what to do when their child is not well? Do they know how well their child is doing compared to other children at a similar stage of development and how, if their child is not doing as well, to remedy the situation?

My interaction with Javed points to the issue of poor information. Does Javed’s granddaughter become unwell too often? The doctors Javed visits, and these are usually general physicians in our locality, almost never give any feedback to Javed or the parents of the child. It is almost always an injection and/or some medicines that is administered but without the parents’ knowing what ailed their daughter and what the drugs are meant to cure.

These doctors also do not tell the parents how well or poorly the child is doing compared to other children. Javed and the parents of the child never know if three episodes of fever in 15 days is too much, if the child’s weight or height is below par or not and/or if her cranial circumference is increasing within tolerable limits. If they had this knowledge, if they do not face extreme poverty issues and if other things are constant would they not be able to make better decisions about the health of their child?

Though I have used Javed’s example, I know of too many other cases of a similar nature. Given some of the administrative work I do, I get to see how many days of the week colleagues don’t come in because a child at home is ill. The numbers tend to be substantial especially among blue-collar and unskilled workers.

In some cases, parents even delay treatment of a sick child as they cannot afford to be absent from work. But in almost all these cases when I have talked to parents, the issue of information, according to my reading of the situation, has come up in one form or another. Parents do not get proper feedback from healthcare providers; they do not know what preventive measures they can take, what medicines they can use or are given by caregivers; they do not know why their child got sick in the first place and they are almost never told how their child is doing compared to other children.

There is some research in Pakistan on the impact of poverty on nutritional outcomes and researchers have recently also started looking at connections between public good investments (water, sanitation and immunisation) and health outcomes. But we know very little about the connections between knowledge/information issues and health/nutrition outcomes. Is the last one an important issue or not? We need household-level research to figure this out.

Fortunately, information/knowledge issues can be remedied with low-cost interventions. If information/knowledge issues are also contributing to the poor outcomes we are seeing on the nutrition and health side, carefully crafted but low-cost feedback loops for parents can readily and easily remedy the situation. Given the potential, public health researchers should look at such issues on a priority basis.

The writer is a senior research fellow at the Institute of Development and Economic Alternatives and an associate professor of economics at Lums, Lahore.

Published in Dawn, September 8th, 2017