Malnutrition and stunting in Pakistan
Losing a generation: the impact of malnutrition
With nearly 44pc of children stunted, if the government fails to reverse the situation, Pakistan is on a dangerous downward trajectory
Globally, nearly half of all deaths (some 2.7 million) annually among children under the age of five are attributable to under-nutrition. Associated with increased risk of morbidity and infections, malnutrition also leads to impaired growth and developmental outcomes. To add, around 159m children under five are stunted with heights much less than normal for that age, and with nearly 240m children at risk of developmental impairment.
Malnutrition is not only confined to children but is also rampant among women of reproductive age suffering from anemia, usually related to iron deficiency as well as wasting among poorer communities that are food insecure. Maternal malnutrition not only leads to increased risk of mortality among women but also contributes to fetal growth restriction (small size of the baby during pregnancy) that, in turn, multiplies the risk of growth faltering and stunting in childhood. The latter can cause long-term detrimental cognitive, motor and health impairments.
In Pakistan, malnutrition is widespread among all ages, and progress to address social determinants over the last several decades had been very slow. According to the National Nutrition Survey 2011, one-third of all children are underweight, nearly 44pc are stunted, 15pc are wasted, half of them are anemic and almost one-third of these children have iron deficiency anemia. These rates have hardly changed over two decades according to the findings of a maternal and child nutrition study group published by Lancet in 2013. Notable differences can be found between the nutritional indicators of urban and rural populations; children among the rural and urban poor are at greatest risk. Among women, 14pc in the reproductive age bracket are thin or wasted (with a body mass index less than 18.5 kg/m2) and this prevalence is highest among households that are food insecure. These differences in maternal and child malnutrition are also remarkable among various provinces and sub-regions, and clustered in areas widely recognised as high-risk districts.
Risk factors for childhood malnutrition in Pakistan
The most pervasive and dominant factor underlying maternal and child under-nutrition is widespread poverty and food insecurity. Despite a largely agrarian economy, many rural and urban families live below the poverty line. Periodic or seasonal food insecurity is reported by almost 40-50pc of families in certain provinces, especially in Balochistan, Sindh, South Punjab and parts of Khyber Pakhtunkhwa and Fata. These are also compounded by poor and unhygienic living conditions, little access to safe water and adequate sanitation that exposes children to high rates of intestinal infections and diarrhoea. Recent data from a Unicef progress report (2013-2015) on improving access to sanitation in Pakistan suggests that about 58m people (36pc) either defecate in the open or have access to shared toilets. In rural areas, 45pc of the population still practice open defecation.
To improve child nutrition and reduce stunting, it is imperative to focus on other parallel factors including improving maternal nutrition and antenatal care; especially the nutrition of adolescent girls and young mothers. Low literacy rates especially among women, their lack of empowerment and involvement in decision-making, early marriages, high fertility rates with a lack of birth spacing, and poor access to healthcare facilities are all important determinants of child and maternal malnutrition. Low levels of education, especially awareness of maternal care are also important drivers of under-nutrition largely through improper feeding or dietary practices.
Additionally, a major contributor to childhood malnutrition is the overall poor state of infant and young child feeding. Pakistan is conspicuous for having the lowest rates for the early initiation of breastfeeding, exclusive breastfeeding rates and timely initiation of complementary feeding, and the highest rate in the region for bottle-feeding. Despite the established benefits of early and exclusive breastfeeding, even among the poorest families, work pressure, lack of breastfeeding support and ignorance leads to the administration of alternative fluids such as tea and even animal milk. Data from the Pakistan Demographic and Health Survey (2012-2013) suggests that immediate breastfeeding is initiated in 18pc of all births, whereas exclusive breastfeeding is carried out for only 38pc of infants younger than six months. The promotion and marketing of infant formulas is a recognised barrier for exclusive breastfeeding. Although legislation exists for prohibiting such practices in Pakistan, many hospitals and physicians still breach the code for exclusive breastfeeding. In other instances, inappropriate introduction of formula milk can contribute to excess burden of intestinal infections and malnutrition. Importantly, the national regulatory and support system does not provide paid maternity leave or breastfeeding support mechanisms for working women to continue exclusive breastfeeding, a factor that has been shown in other countries to be a major barrier to appropriate feeding practices.
After the first six months of a child’s life, appropriate complementary feeding of nutritious and safe foods is a cornerstone of adequate childhood nutrition. However, the general lack of awareness of optimal feeding practices and other social taboos and misconceptions (such as the concept of ‘hot and cold foods’ or inappropriateness of some foods for children, such as meats and fruits) further affects practices. To this must be added measures to prevent common childhood illnesses, such as diarrhoea and acute respiratory infections and improving access to timely and quality care.
What must be done?
A starting point would be recognition that despite better economic conditions and an agrarian population, Pakistan’s nutrition indicators and rates of maternal and childhood nutrition progress have fallen way behind others in the region. This is related to lack of focus on implementing quality programs and addressing disparities. Bringing health and nutrition services closer to women and children and addressing social determinants, such as poverty and lack of women’s empowerment would make the difference. Existing poverty alleviation programmes such as social safety nets like Baitul Maal, Zakat programmes or the Benazir Income Support programs have huge potential for reaching those caught in the spiral of food poverty.
Fortunately, Pakistan has an extensive existing lady health workers programme, that, with improvements, can pave the way to reduce these inequalities. An enhanced focus on promoting exclusive breastfeeding and appropriate complementary feeding through mass media campaigns and existing programs should be prioritised. An effective culturally relevant behavioural change communication strategy must be implemented and sustained. Religious leaders, school teachers and social mobilisers can play an important role in promoting exclusive breastfeeding and appropriate complementary feeding. Healthcare providers must be trained in practices that promote nutrition adequacy for mothers and children, including those that advocate healthy lifestyles, nutrition and physical activity.
Regular monitoring and accountability is critical if Pakistan is to break the logjam for addressing malnutrition. There is a need to ensure regular data on nutrition indicators with more discrete regional or district level information. The situation is ripe for change with greater current emphasis on nutrition and formulation of various national and provincial nutrition focused strategies. Also, there is need for integrating various different sectors and programs to achieve the desired results effectively and efficiently as many of the determinants and influencing factors are outside the health sector. Policymakers need to recognise the importance of improved child health and nutrition for national development — also a key contributor to achieving Pakistan’s sustainable development goals.
The writer is the founding director of the Centre of Excellence in Women and Child Health at the Aga Khan University, Karachi. He can be reached at zulfiqar.bhutta@aku.edu
Why sustainable nutrition can save a generation from stunting
• Pakistan has the third highest percentage of stunted children in the world
• Stunting prevalence is slightly higher in male children (48pc) than in female children (42pc)
• Stunting disparities among urban and the rural populations is 37pc and 46pc respectively
Taking stock of how Pakistan is positioned for accelerating its response on under-nutrition, there is some progress in the right direction. Pakistan, to its credit, has credible data on stunting levels and micro-nutrient deficiencies from the National Nutrition surveys and the global Multiple Indicator Cluster Survey (MICS), providing a basis for charting progress. There is also an understanding of the main drivers of under-nutrition during the critical childhood stunting window — weakly practiced preventive health measures, lack of birth spacing, food insecurity and unhygienic practices. Moreover, a reasonable level of policy commitment is visible, with the government having signed up to the Scaling Up Nutrition movement (SUN) in 2013 (to end malnutrition in all its forms), and having established hubs within the provincial planning and development departments and the Planning Commission (2012), to formulate provincial inter-sectoral nutrition strategies.
However, three to four years into policy commitments there is slow momentum of translation into operations. What is disturbing is that Pakistan has yet to program its multi-sectoral response, with interventions still being debated. Here, the three main challenges are construct, programming and coordination.
The first issue is the present construct: nutrition is being pushed as the ‘new threat’ requiring emergency action. Even if under-nutrition may have recently appeared on the global development agenda, it has always been present in unacceptably high levels. While it requires swift action, it does not require a response framed in emergency humanitarian relief work. Distributing blanket food commodities, pulling in non-governmental organisations (NGOs) as quick fix suppliers, and setting up donor dependent government Pc-1s (a planning commission document used for development projects) cannot be sustained once donor funding ends. Instead, catalytic responses for pulling existing sectors towards select pro-nutrition measures and taking more out of existing actors on the ground is required. In the present discourse in committee rooms and seminars, for instance, the government and NGOs are being perceived as the main doers, but what about Pakistan’s extensive private sector that must be leveraged to supply sanitation, health, and agricultural links to low-income communities? Also, sustainable financing is needed by shifting from the slow moving and project tenured system to the creation of nutrition financing within existing, recurrent budgets.
Programming is another issue. Because provincial inter-sectoral nutrition strategies encompass a wide discourse, the government has proven unable to program nutrition across different sectors. From disaster prevention to urban planning to female literacy, the whole development paradigm has been pushed into under-nutrition, leading to confusion and a paralysis of action. To ensure the task is doable, distinguishing direct responses to the nutrition sector from more distal responses that impact all sectors will prove result-oriented.
Currently, the government is spending an estimated 1pc of its budget on nutrition, and 5pc on relevant sectors of health, food, agriculture, WASH (water, sanitation and hygiene) etc. Merely increasing allocations within relevant sectors isn’t enough as increased funding may have little relevance on nutrition. To start with, provincial governments need to set a target figure for a nutrition budget and then standardise the spending by nutrition ‘specific’ and nutrition ‘sensitive’ interventions.
Currently, the government is spending an estimated 1pc of its budget on nutrition, and 5pc on relevant sectors of health, food, agriculture, WASH (water, sanitation and hygiene) etc.
Nutrition ‘specific’ interventions involving preventive healthcare and the use of micro-nutrients by pregnant mothers and children have been easier to program. For preventive health, the single largest issue revolves around years of neglect of an extensive lady health worker (LHW) programme. The task at hand is to bring LHWs back from polio immunisation drives to their original focus on preventive health, nutrition screening, family planning, as well as extending their reach to uncovered areas. Food fortification – implying the addition of nutrients to food – is a more advanced area of action with salt, oil and wheat fortification initiatives in process, but one that needs to be transitioned from NGO efforts to regulatory capacity within food and local government departments.
It is the nutrition ‘sensitive’ sectors of food security and WASH, where planning for nutrition linkages that are still fuzzy. Local context is important and this is where lessons from countries with similar conditions can help. From the nutrition perspective, food security is not about the country’s wheat production index but about a poor household’s consumption of a diet of minimal required calories and sufficient diversity. Building community awareness about the benefits of a diversified diet through better use of locally available foods, increasing homestead production of nutrient dense foods, and providing vulnerable groups with resources and market access are critical areas for harnessing lessons. WASH also needs to be honed down to affordable and entrepreneurship measures for household water conserving and safety, community self-help toilet schemes, and leveraging the private market for the supply of hygiene products for low-income areas.
An inter-government space is required to populate nutrition-related funding, targets and legislative activity within key sectors.
Third, given that nutrition is a complex multi-sectoral subject, coordinating diverse actors is required; starting with government-donor coordination. Who takes leadership for nutrition in Pakistan — the international donors or the government? So far, donors have been the major investors, but it is the government that needs to come up with how many dollars it will match to each dollar invested by the donor community. Similarly, donors have also taken the lead in the nutrition dialogue, but with many riding the current nutrition agenda, there is dis-coordinated and, at times, even conflicting dialogue. This is counter-productive for a government still trying to figure out the nutrition puzzle.
Furthermore, inter-governmental coordination is essential. An inter-government space is required to populate nutrition-related funding, targets and legislative activity within key sectors. This includes the creation of task forces, councils or supra-ministries, bringing in the relevant ministries which has been the pathway followed by countries having strong inter-sectoral connects. The government also needs to translate their bulky inter-sectoral strategies into an implementation plan around which different ministries can rally.
And then there is coordination with the larger nutrition community. Launched promisingly in all provinces, newly created SUN networks, involving civil society organisations, the private sector, experts, development agencies and the government must be put to use. Here too, it is important to channelise the nutrition community to an actionable plan so as to prevent it from cascading into meetings and random initiatives. Finally, to breathe life into coordination, accountability is required through sub-national and national reporting on annual plans and spending, to inter-government bodies, to SUN networks, to Parliament, to the media. Maybe that can clinch it.
The writer is the director of the graduate program in health policy and management at the Aga Khan University in Karachi.
Sick, starving and dying children: the story of Sindh
Moomal Bheel, a 28-year-old mother of six from Kolhi Daro in Umerkot, waits for treatment for her severely under-nourished 18-month-old son, Dewan. Visiting an out-patient therapeutic centre in Shewani Mohla in Umerkot, she knows her children are dangerously under-nourished, showing varied physical symptoms such as low birth weight, lethargy and low immunity to disease. Regrettably, she too suffers from anaemia. At nutrition centres in Sindh, the nutrition levels of children and women, either pregnant or breastfeeding, is assessed by conducting a mid-upper arm circumference (MUAC) test — an indicator used by community-based practitioners to identify children and mothers in need of treatment by determining their nutrition status and by measuring their height and weight. In baby Dewan’s case, he weighs only 7.5 kilograms with an MUAC of 11.1cm. Under-nutrition is widespread in Umerkot and Tharparkar, so the health condition of Bheel’s children is not unique. With high rates of mortality proving harder to reverse, locals say that funds are missing and the approach to tackling malnutrition is flawed given the lack of medical staff and overall mismanagement. According to the Multiple Indicator Cluster Survey (MICS) 2014, monitoring the situation of children and mothers through household surveys, 48pc of children in Sindh are moderately stunted, whereas 24.4pc are severely stunted. In Umerkot district alone, 66.2pc of children are moderately stunted and 35.2pc severely.
Severe weather conditions in summer coupled with scarcity of food, unsafe and saline drinking water and lack of access to basic health facilities have an adverse effect on the life of communities. Poverty is a significant factor, as is the drought that has impacted sources of livelihood, agriculture and livestock. Until a decade ago, young children and even expectant mothers were healthier because they were able to drink milk from livestock they owned. With shifts in climate killing most of the livestock, many families became too poor to buy milk and basic food essentials — whatever cattle they possess produces just enough milk for consumption with tea and the remaining is sold. Therefore, the alarming increase in stunting and severe malnutrition among children has caused the deaths of scores. For Sahejan Kolhi from Samaro town in Umerkot, poverty is close to killing her children. As a mother of a newborn baby with seven children to feed, she says her family can ill afford foods required to combat malnutrition, let alone a basic daily meal of vegetables or wheat flour. She has a supply of food supplements — wheat soya blend, vegetable oil, and iron and folic acid from an international organisation, but doesn’t remember which one. She also has a supply of therapeutic food – including micronutrient powder and vitamin A capsules – for her four-year old son, Bhooro, suffering from malnutrition.
At a government-run dispensary in Umerkot, nutrition assistant Shazia Sakrani Nohri, administering an out-patient therapeutic programme (OTP), says they screened 1,200 children in August this year; out of which 30pc were suffering severe acute malnutrition. Although 400 to 600 children are screened at this centre every month, limited resources prevent treatment to increasing numbers of suffering children. Treatment includes initial weekly visits to the out-patient centre for three weeks, followed by biweekly visits if there has been no health improvement. With a four-month period required for complete recovery, children are de-wormed and vaccinated as well, Ms Nohri explains, and anaemic children given iron supplements for 14 days.
With donor agencies (Unicef included) supporting the Sindh government to tackle malnutrition through community programming in Umerkot and Tharparkar, district managers working on the ground claim results are beginning to show. Qasim Ibrahim Palijo, involved with the People’s Primary Health Initiative (PPHI), says his organisation manages 22 OTP centres in Umerkot treating children with severe malnutrition, and offering screening for children and mothers and the provision of micro-nutrients. His organisation works with the Nutrition Support Programme (NSP), a component of the Sindh health department. The latter administers the Enhanced Nutrition for Mothers and Children Project providing therapeutic food from Unicef. For their part, local residents have told Dawn that all cases of acute malnutrition are not offered treatment because each OTP centre has a target of enrolling and treating 30 children per month, which means a large number remain sick and starving. Meanwhile, Mr Palijo says they have screened 16,587 children at 22 out-patient therapeutic centres, registered 2,374 with acute malnutrition and treated 1,246 from April 2016 to September 2016.
Also important is the need for food-diversification, say nutritionists, including vegetables, fruits, animal protein, wheat and rice, which are missing in everyday diets. From the time of conception to when an infant is two-years-old, the 1,000 day duration is important for the health of mothers and their children. If mothers suffer iodine deficiency during pregnancy, there is a 70pc chance of birth abnormalities. If a child is micro-nutrient deficient for two years, he will never grow physically and mentally. For the government to remain willfully ignorant, failing to contribute adequate resources for long-term sustainable solutions to food scarcity, is shameful. It is not only poverty coupled with poor health practices that are factors contributing to malnutrition induced deaths. Poor governance, lack of resources, social injustice and gender-based discrimination are all pressing concerns that must be addressed with urgency if a generation of children are to be rescued from a slow, sad death.
The Peruvian model: How it could work for Pakistan
• Chronic malnutrition results in economic losses of 2-3pc of the country’s GDP
• Pakistan’s malnutrition problem can be addressed through its social protection programmes, and improving human capital by educating the poorest
With a population of more than 30 million and home to the Inca culture, Peru is an example of a success story having considerably reduced its chronic malnutrition rates in children. By 2007, stunting rates for children under five were at 29pc. However, in just eight years (2015), these were halved to 14pc — this figure is one third of the measured stunting rates in Pakistan according to a 2011 National Nutrition Survey. For Peru, these figures did not change overnight; factors and actions taken persistently in the same direction could be a model to follow for Pakistan in its effort to alleviate stunting.
With the Peruvian government acknowledging that it faced a chronic malnutrition problem, international donor advocacy through the Child Malnutrition Initiative placed nutrition as a priority. In 2006, all presidential candidates signed a commitment to reduce stunting rates by five points for children under the age of five and in five years — commonly referred to as the ‘5 by 5 by 5’ commitment. That way, no matter who was elected, fighting malnutrition would remain a priority and be directly overseen by the prime minister’s office. Once there was political engagement, ambitious but feasible goals were signed and needs were calculated. With adequate policies and resulting resources for child nutrition made available, a comprehensive and integrated National Strategy for Poverty Reduction and Economic Opportunities was developed. It focused on identification, targeting, delivering and monitoring of the poorest people in rural areas.
As part of this national and multi-sectoral strategy, the government not only consolidated six cost-effective food distribution programs, including supplemental feeding with iron and folic acid for pregnant women and iron and vitamin A for children, but also increased incentives for growth promotion checkups and early stimulation as part of the conditional cash transfer program of the government for children. This was offered to all children, including those in sound health, so they could detect cases before their nutritional status would deteriorate, something that had not been previously practiced in the country. With this incentive, families took their children to health service centres, having previously expanded and improved access for the expected increased intake. Not surprisingly, the percentage of complete child-growth checkups more than doubled, reaching 55pc in those years. In rural areas, where percentages tripled in the same period, 65pc of all children were checked, compared to 21pc before this strategy was implemented.
The suggestion is that such a comprehensive strategy could be applied – and might possibly even work – to address Pakistan’s malnutrition problem by leveraging the current social protection programs, such as the conditional transfer program for education (Waseela-e-Taleem) initiated in 2012 and to improve human capital through education among the poorest. Adding a nutrition component to such a programme, for instance, could certainly help with the detection of chronic malnutrition in children and facilitate the provision of need-specific fortified foods.
With stunting rates in Pakistan at 44pc, chronical malnutrition is not only a tragedy when viewed from a human capital perspective but results in economic losses estimated to be around 2 to 3pc of the country’s GDP.
Finally, the reminder that one of the most innovative and effective measures that led to successfully reducing stunting rates in Peru was a results-based budgeting system would mean accountability and independence. Such a structure permitted a more effective financial management system and improved efficiency of interventions. International agencies such as the World Bank with a $25 million loan or the European Commission with a donation of $61m supported these efforts. From the national government, and according to the official data provided by the ministry of health in Peru, public investment in health between 2009 and 2011 reached more than $ 2 billion for the execution of infrastructure throughout the country.
With stunting rates in Pakistan at 44pc, chronical malnutrition is not only a tragedy when viewed from a human capital perspective but results in economic losses estimated to be around 2 to 3pc of the country’s GDP. It has been proven and tested that nutritional intervention returns up to 16 times the entire amount invested. Peru is an example of success when there is political commitment compounded by well-formed programmes, including immediate cost-effective solutions and proper budgeting to tackle stunting rates. If the provision of adequate nutrition becomes a state priority assisted by multi-sectoral programming and result-based budgeting, then the Peruvian model, resulting in halving stunting rates, can most certainly work for Pakistan as well.
Stephen Gluning is the acting country representative of the World Food Programme and Cecilia Garzon is the head of nutrition at WFP.