Nutrition: beyond the noise

Published November 18, 2017
The writer is a senior faculty member at Aga Khan University.
The writer is a senior faculty member at Aga Khan University.

UNDERNUTRITION is a challenging development dilemma in Pakistan that has been in the policy spotlight over the last few years — in-depth surveys, seminars, donor missions, government meetings, political statements, media write-ups and the increasing involvement of a number of local and international NGOs highlight the concern. Everyone is talking about undernutrition, and everyone is claiming that they are tackling the issue. Yet why is action so slow? Part of the problem is that the ‘noise’ created about nutrition is detracting from programming a credible response.

Undernutrition was ‘discovered’ in Pakistan by the 1965 National Nutrition Survey. From being an aid orphan for many decades, it has become an aid darling — with recent donor attention propelling a neglected issue onto the policy table. But with too many claimants suddenly trying to manage the nutrition agenda, there is a lack of coordinated dialogue, even at times a conflicting dialogue, with the danger of it cascading into random initiatives. Four years since Pakistan’s joining the global Scaling Up Nutrition network, the menu of interventions is still being debated. With the exception of one province, the multisectoral response to nutrition is yet to be programmed, financed and implemented.

The inter-sectoral nutrition strategies developed by the Punjab, Sindh, Khyber Pakhtunkhwa and Balochistan governments are the only multisectoral policy instruments for nutrition. These provide a discourse stretching from disaster prevention to urban planning to female literacy — in fact the whole development paradigm has been pushed into undernutrition — with the result that nutrition has become too big to be programmed, leading to a paralysis of action.

Moving Pakistan’s response from a potential to an active promise requires game changers.

Putting strategies into action requires fewer actions that are directly linked with the causal pathway of undernutrition in each province. As the heaviest impact of undernutrition is on children under five years, the sectors of health, food security and water, sanitation and hygiene (WASH) are the most salient for framing a response.

To programme a credible response, it is important to understand that Pakistan’s nutrition dilemma calls for both urgent and sustained responses.

Distributing blanket food commodities and donor-dependent government PC-1s cannot be sustained once the donor wave of funding finishes. More sustainable interventions are required, and these do not need large, separate, heavily funded nutrition projects.

Within the ambit of health, the pressing and continuing need is to plug missed opportunities of not providing nutrition-relevant services to those using the health system. For example, more women than ever now go for pregnancy checkups. However, in only 45 per cent of the checkups are pregnant women provided with iron supplementation. Going forward calls for acceleration of simple, preventive, low-cost interventions such as birth spacing and pregnancy care, vitamin and mineral supplementation of mothers and young children, breastfeeding and infant-feeding awareness, disease prevention in infants, etc. These do not require separate projects and supply chains, but convergence of service delivery.

Food security for nutrition needs to be carefully differentiated from the country’s food security production function, which is tracked in terms of wheat sufficiency in the market. The pervasive issue from the nutrition lens is that the majority of the country’s population does not consume a nutritiously diverse diet — only 38pc of high income and 12pc of low-income groups consume an adequately diverse diet. Actionable pathways including changing food consumption patterns through awareness building, better use of locally grown food and diversified home food production. But a parallel issue is the insufficient quantity of diet consumed by the poor — only 17pc of the poorest households consume sufficient calories in their diet — calling for food safety nets built on existing social security programmes, as well as making food markets work better for the poor.

Surprisingly, the WASH sector has received little attention, despite its relevance to chronic undernutrition in Pakistan’s children. Nutrition interventions have centred on handwashing advice and some recent efforts to shame communities into refraining from open defecation practices. But how much time is required to fetch a bucket of water in Pakistan’s many villages lacking piped water? Or how much money is needed to purchase a tank of water in urban slums? Pakistan is expected to rank as the most water-stressed nation in South Asia by 2040. And current surveys estimate that only 28pc of households have safe drinking water.

Untreated water not only causes illness episodes in young children but also blunts food absorption, leading to chronic undernutrition. Water access and quality needs to be placed at the forefront of nutrition interventions for many of Pakistan’s districts. Innovations are emerging from Bangladesh as well as Africa on ‘WASH for nutrition’ — communal water harvesting, household water storage and conserving technologies, self-help toilet schemes, private manufacturer/retailer linkages for affordable supply of soaps, cleaning products and hardware products to low-income neighbourhoods.

Moving Pakistan’s response from a high potential to an active promise requires game changers. Nutrition advocates continue to draw attention to inadequate funding. Indeed, so far, donors have been the major investors; the government needs to come up with how many dollars it will match for each dollar invested by the donor community.

But the more pressing issue for Pakistan is better spending of existing funding. The financing paradigm must shift from the slow-moving, project-tenured PC-1 system to the creation of nutrition financing within the recurrent budgets of the health, local government, agriculture, livestock and social protection sectors. Actors need to be expanded from government and NGOs to include Pakistan’s extensive private sector. A promising beginning has been made in terms of fortification of salt, wheat and oil with essential micro-nutrients by working with private-sector mills, often small units, to supply enriched rations to low-income markets.

Similar efforts need to be extended to the health and WASH sectors to regulate, incentivise and build linkages of the private sector for supply of nutrition-impactful services to low-income communities. Multisectoral initiatives such as nutrition require a differentiated set of skills for coordinated action, joined-up planning and monitoring across sectors. Can donor agencies take the onus of transitioning from funding of commodities to investment in critical capacity building and innovations?

The writer is a senior faculty member at Aga Khan University.

Published in Dawn, November 18th, 2017

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