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AMIDST bureaucratic shakeups, chronic structural inadequacies and a lack of focus on project sustainability, the future of the country’s nutrition movement may lose steam if funding agencies that are apparently spearheading the movement shift their focus elsewhere.

The World Bank’s Human Capital Index (HCI), released last week, once again drives home Pakistan’s persistently alarming socio-economic condition.

Pakistan’s HCI score is 0.39, which means that a child born today will be 61 per cent less productive as a future worker than if they had been provided with complete education and full health. To put things in perspective, the worldwide average is 0.57 while the South Asian average is 0.46.

The report’s health component uses two indicators: the rate of stunting of children under age five and the adult survival rate. Stunting, according to the World Health Organisation, is a consequence of ‘poor nutrition, repeated infection, and inadequate psychosocial stimulation’.

The National Nutrition Survey (NNS) 2011 showed a Global Acute Malnutrition (wasting) rate of 15.1pc, higher than the 13pc figure of the previous NNS 2001. More than 30pc of children are underweight and 44pc stunted.

Ever since then efforts have been underway by UN partners towards management of malnutrition all over Pakistan.

The terms ‘multi-sectoral’ and ‘capacity building’ are being bandied about in political corridors. While based on a basic truth the rampant usage of these terms once again drives home the unsustainable nature of the work being done

‘Filling the nutrition gap’ by the World Food Programme points out that the high prevalence of child malnutrition in the country has shown little improvement over the past four decades. While an April 2018 staff note by the State Bank of Pakistan states that public-sector health expenditures as a percentage of GDP have been falling consistently since the 1990s.

“An analysis of the provinces reveals that they have been largely unable to utilise the funds that they have already allocated for health-related schemes due to various issues like delays in the decision-making process, complex regulations for appraisal of projects, contractor’s complaints for timely payments.”

Nevertheless, with a new political party that came in with a largely populist rhetoric, at the wheel, there is an expectation for progress. Prime Minister Imran Khan, in his maiden and follow-up speech, may have been the first head of government to mention the terms ‘stunting’ and ‘wasting’, showing at least a basic understanding of the situation.

But awareness alone does not do much. The ground realities of a country in the clutches of an ever-tightening economic position are very different; the finance minister cut the federal development budget by almost Rs250 billion to Rs725bn in his first budget speech.

Cutting the development budget may actually not have an impact on donor-funded projects, says Faheem Junejo, project director of the Saaf Suthro Sindh project.

“Donor-funded projects are affected to some extent but not a lot since parts of a donor project are interlinked with fund releases from our end. In the majority of the cases, you’re forced to make sure your side of the funding is available.”

Even internationally-funded projects must come hand in hand with a long-term single-minded focus across political circles, a sustained prioritisation of issues. Countries that have successfully managed to align support around reform have seen impressive levels of improvement. Peru managed to reduce its rate of stunting by roughly 15 percentage points over an eight-year period.

Yet the momentum cannot be maintained indefinitely through international agency and donor engagement. Till the time both the bureaucracy and the political hierarchy don’t own the issue, the country shall continue sliding down all human capital indexes there are. A capable bureaucracy that strives to link sectoral programmes together while actively implementing policies is the only way forward.


Long-term also means looking into project sustainability. While current donor efforts may provide the initial thrust needed to tackle the nutrition emergency and set the ground work, sooner or later the government itself will need to raise the pennant. Remember, malnutrition requires long-term, preventative action.

Using his project as an example, Mr Junejo said, “I will have to prepare my team at the ground level to ensure that there is no slippage in the villages once the project ends. If the union council secretary is assigned the target of visiting villages once in two months with results being reported at the provincial level, and slippage does occur it can be taken care of immediately.”

This, he says, is not planned. It is something he’s hoping to implement himself.

The current usage of ‘buzzwords’ is an interesting phenomenon that highlights donor will. The terms ‘multi-sectoral’ and ‘capacity building’ are being bandied about in political corridors. While based on a basic truth — a multi-sectoral strategy is after all the need of the day since change cannot be brought about in isolation — the rampant usage of these terms once again drives home the unsustainable nature of the work being done.

“Sometimes it happens that one minister is politically more important and powerful than another. A local government minister, for example, may not follow a minister of planning and development. The minister of health remained the most important minister in the last tenure. He didn’t listen to anybody. That’s the ground reality. This is the real challenge. If there is someone stronger in terms of face value, things may work smoother,” he says.

Another area that needs to be addressed is the lack of coordination among provinces, the federation and donors: reinventing the wheel despite the presence of a coordinating body.

“For example, the European Union and the World Bank have a similar programme. We had to ask them to separate out their geographical areas. The provincial government doesn’t know what a lot of small-scale donors are doing as they go directly to the district, sign a memorandum of understanding with the deputy commissioner and just start work,” Mr Junejo concludes.

Published in Dawn, The Business and Finance Weekly, October 15th, 2018