ACCORDING to surveys, undernutrition in Pakistan has changed little over the years. However, from a less talked about issue in yesteryears, nutrition has become a much talked about issue. Political momentum has gained, more funding is flowing in, more NGOs are ‘nutrition active’, and a spate of nutrition seminars are being held in large hotels. But has all this solved Pakistan’s nutrition challenge? No.

So what leads to undernutrition? We already know from extensive surveys that food insecurity, weak preventive health measures, along with poor hygiene and sanitation practices (leading to recurring diseases in the population) are the chronic drivers of undernutrition in Pakistan. However, the problem lies in the framing of the response.

Three disconnects need to be addressed. First, undernutrition does not require a response framed in emergency relief work; we need sustained thoughtful policies. Second, undernutrition does not require large, stand-alone nutrition projects creating additional project management units and supply chains; we need course correction and plugging missed opportunities within existing programmes. Third, there is a mistaken belief that the government is the main executor of nutrition programmes; while the government’s role is critical for pro-nutrition policies and sector management, it is not needed everywhere for intervention delivery.

For WASH to make a mark, it requires moving towards a visible focus on water.

It is time to disentangle our nutrition narrative into sustainable responses that impact the drivers of undernutrition in Pakistan. The health sector often bears the brunt of blame and is subject to intense media scrutiny, but it can only deliver part of the action required. Global trends show that the menu of health-related actions comprises embarrassingly simple, low cost, but deeply impactful solutions: birth spacing, immunisation, diarrhoea management, breastfeeding, vitamin supplementation, deworming and hand-washing.

Constructing more hospitals in underserved areas will not alleviate undernutrition, as carried in media tickers. As a case in point, at least two-thirds of pregnant mothers and young children visit health practitioners for routine healthcare. But when it comes to the provision of low cost, pro-nutrition measures, they get overlooked. Additionally, a large tier of paid community-based Lady Health Workers are also on ground, providing services to at least 42 per cent of the population at their doorstep. These days, they are active in administering polio drops, but their original mandate of preventive healthcare, nutrition monitoring and family planning has been sidelined for years.

The two other important sectors — Water, Sanitation and Hygiene (WASH) and food security — do not have such neat prescriptive lists of interventions when it comes to addressing the undernutrition problem. The responses to these vary with the ground realities of the country.

In Pakistan, the WASH response is largely restricted to calls for repeated hand-washing for infant-child feeding, while awareness campaigns in a few districts aim to shock and shame communities to move away from open defecation. But for WASH to make a mark, it requires moving away from the comfort zone of awareness creation on hygiene to a visible focus on water. A simple calculation shows that the required number of hand-washing done by mothers after toilet use, and before food preparation and the feeding of infants, comes to at least 12 hand washes a day. This requires adequate water supplies. For many rural communities, fetching water from distant sources is time consuming; whereas in low income urban communities, water is a scare commodity to be purchased. Soap is another luxury, as only 15pc of the poorest households wash hands with soap, versus 97pc of the highest income households.

Another issue that falls through the slats in nutrition discourse is the quality of drinking water. Untreated water has lifelong impacts on the guts of young children, reducing food absorption and making them vulnerable to a host of diseases. According to the Pakistan Council of Research in Water Resources, only an estimated 25-39pc of households have safe water for consumption. Thus, WASH interventions must move towards an expanded menu of activities: water harvesting; low-cost household water storage; treatment for quality, faecal sludge management; entrepreneurial self-help toilet schemes for sanitation; and affordable hand-washing and toilet hygiene products to low income consumers.

When it comes to food insecurity, the third critical driver of undernutrition, it is the ‘family food security’ that we are concerned about. Are sufficient meals being consumed, and are these of nutritious value? No amount of wheat distributions or food handouts can cater to Pakistan’s burgeoning population, nor are these interventions sustainable. What is needed is a collision across policies governing food markets, agricultural production and social protection.

In the immediate term, spiking prices of essential nutrients must be regulated boldly and not skirted around, as this particularly hits the urban cash-strapped poor and cash-reliant tenant farmers. And this needs to be accompanied by food literacy on affordable, locally grown nutrient-dense foods in the diverse districts of Pakistan. Food supplements linked to social protection schemes targeting the most vulnerable areas can be brought in as an added on measure for the 18pc severely food insecure households. For the medium term, Pakistan’s agricultural policies need a deliberative focus on supporting small farmers with homestead production of nutrient dense foods.

In crafting a nutrition response, one must not forget that Pakistan’s poor are dependent on private markets for provision of much of the healthcare services, sale of WASH hardware and hygiene products, purchase of food supplies, and for agriculture and livestock linkages. The private sector must be engaged to develop business models tilted towards the poor, while the government must continue to develop capability to manage the private sector efficiently. This has perhaps been the most ignored area of Pakistan’s struggling nutrition response.

The penny must drop. Rather than isolated, heavily donor-funded nutrition projects, the countries’ nutrition response requires course correction of existing preventive health-WASH-food policies and programmes, along with intelligent management of market systems for workable and affordable win-win interventions.

The writer is a graduate of Harvard University in health policy and management.

Published in Dawn, September 1st, 2019