Zainab Bibi* noticed her infant son was often listless. He barely cried and was too weak to move his limbs about. He was rapidly losing weight, had a sallow complexion and could hardly drink the diluted milk his mother would try to feed him. It was time to take him to the hospital.

The doctor took one look at Zainab’s son and told her he was malnourished and at extreme risk of stunting, or worse, child wasting — the most evident and life-threatening form of malnourishment, when the child’s weight is too low for their height.

He was immediately prescribed the Wawa Mum sachet, a lipid-nutrient supplement launched by the World Food Programme in the wake of the 2010 floods in Pakistan. Zainab was able to acquire sachets through a Benazir Noshunuma Centre, a programme to increase health and nutrition services under the Benazir Income Support Programme (BISP).

“His energy levels have changed so much. He wants to eat. He wants to play. I couldn’t even imagine he’d be where he is just a few months ago,” Zainab Bibi tells Eos. Her son will turn two later this year.

That Pakistan has an unacceptably high rate of child stunting is not news. There is a crisis marring children’s nutritional levels which, while not unnoticed, remains pervasive. Over 40 percent of children in Pakistan are stunted and the country ranks third in the world for this tragic and entirely preventable phenomenon.

The abysmally high rate of malnourishment and stunting among Pakistani children is alarming, with the situation made worse by ad hoc interventions. Now, an ambitious project is attempting to remedy the problems of fragmentation and unsustainable financing…

According to the 2018 National Nutrition Survey, an estimated 45 percent of all deaths of children under five years of age are associated with malnutrition, stunting and wasting, indicating the alarming levels of risk to Pakistan’s children.

THE COST OF STUNTING

The human cost of stunting aside, in the long run, the country will be impacted by high healthcare expenses, illnesses, deaths, decreased physical productivity and impaired cognitive learning, thus perpetuating a cycle of poverty and underdevelopment — adding up to a $7.6 billion burden on the economy.

Stunted children rarely make for productive workers in the future and the cost to Pakistan’s human capital is estimated to be nearly $2.24 billion a year.

Champions for better children’s nutrition (and there have been many in government) have long tried to frame it as an investment in a country’s future. Dr Zulfiqar Bhutta, a leading expert in children and public health, famously said that “a healthy population cohort of children are also your scientists of tomorrow.”

Better human capital means a better economy. With every $1 spent on nutrition, a state can expect $16 in return. It remains one of the most cost-effective drivers of development.

Considering the scale of the problem, remedying child malnutrition and wasting will take years, if not decades. It requires patience and a willingness to forsake immediate credit.

This gap will only widen if Pakistan keeps looking at nutrition as an ad hoc, developmental project or a humanitarian issue, inconsistently funded through short-term projects that collapse the moment its leader moves to a new position or the most recent natural disaster has passed.

As with most crises, a consistent multi-year financial strategy is a necessary prerequisite to improving child and maternal nutrition, to avoid relapse and help children outgrow the menace.

THE CURSE OF AD HOCISM

The nutrition sector receives insignificant budgetary allocations, with up to 90 percent of maternal and child-wasting funding coming from humanitarian donors. Across Pakistan, provinces spend less than $4 per person on healthcare.

In Khyber-Pakhtunkhwa, spending on maternal and child care is less than one percent of the health budget. The provincial health department’s ‘Multi Sectoral Nutrition Strategy’ bluntly acknowledges that “until recently, nutrition has not been given its due place and is generally considered the business of all and the responsibility of none.”

This diagnosis provides insight into the arbitrary nature of most nutrition interventions. Instead of being a consistent line item in the health budget, financing ends up fragmented and responsive to ad hoc programming.

This leads to inefficiencies in the planning process, making supplies of therapeutic foods unreliable. Worse still, it belies the well-meaning intentions of many in the public sector that are working tirelessly to make this an issue of the past.

STRUCTURED SOLUTIONS

Donors, cognisant of this, have been pitching in to solve the problem, but this support also varies.

Unicef’s Child Nutrition Fund (CNF) offers to match any budgetary allocation made specifically by the government to overcome malnutrition. Its conditions are that the government’s budget be allocated and the procurement of the therapeutic foods is done through CNF. Provinces could double their funds and not be limited by the financial constraints, as they have often been in the past.

Pakistan was amongst the first subscribers of the Child Nutrition Fund in 2022, but most provinces have not been able to utilise it. Advocacy, at the highest level, for nutrition-specific interventions is key to get the interest and willingness to take up these initiatives.

Investment in nutrition can be a powerful catalyst for achieving a range of global health and development goals. Improved coordination between donors, federal and provincial health departments, bolstered by research experts, could collectively lead to more efficient allocation of resources, and healthier children.

As an encouraging step in the right direction, the Ministry of Planning, Development and Special Initiatives and its Scaling Up Nutrition (SUN) secretariat in the federal government launched the Pakistan Nutrition Initiative, or PANI,

which has a budget of Rs8.5 billion (about $31 million) and targets 36 districts burdened by stunting.

The project, launched in September last year, brings various projects such as the National Nutrition Action Programme and the Benazir Noshunuma Programme under one umbrella platform, working to address issues of fragmentation and unsustainable financing.

PANI recognises that a multisectoral approach is necessary to address Pakistan’s child malnutrition. It is well-designed and emphasises iron and folic acid supplements. It also introduces a critical monitoring and evaluation component.

While it is currently billed as a three-year programme, PANI has the opportunity to be reconfigured as a permanently institutionalised programme, offers a promising future to Pakistan’s children and sets a precedent for sustainable health interventions for the region.

Zainab Bibi is a fortunate woman, as is her son. With consistent and meaningful effort, Pakistan could turn them into chapter one of the story of how it overcame this crisis.

**Name changed to protect identity*

Rimmel Mohydin is an associate director at CERP, a research-driven organisation. X: @Rimmel_Mohydin

Anum Irfan is a research associate at CERP

Published in Dawn, EOS, August 4th, 2024