BY DR ABDUL BASEER KHAN ACHAKZAI
Pakistan is one of the most populous countries in the world with a population of 221 million, and the country has a big burden of malnutrition.
Unfortunately, there has been little improvement in the situation over the past decades. The little progress that has been made in addressing undernutrition is insufficient for the country to accelerate the human capital development required for its socio-economic growth and to ensure that country meets the Sustainable Development Goals (SDG).
Reasons for slow progress, among others, include inadequate funding for nutrition sector and poor optimization of resource allocation to various nutrition interventions. Federal and Provincial governments have allocated little resources to the nutrition programme.
Development partners, through their support, have the potential to contribute more to nutrition programme in Pakistan. It is indispensable to channel these efforts to get the best results.
Around 40% children under the age of five years are stunted. 42% mothers are anemic, while 27% suffer from Vitamin A and 80% from Vitamin D deficiency
The National Nutrition Survey (NNS), 2018-19, shows some appalling outcomes. Approximately 40% children under the age of five years are stunted. These figures exceed WHO emergency threshold levels. The survey also revealed high rates of micronutrient deficiencies among children and women with 54% children being anemic, 52% Vitamin A and 62 % Vitamin D deficient. Similarly, 42% mothers are anemic, while 27% suffer from Vitamin A and 80% from Vitamin D deficiency.
Over half of the households (63.1%) were found to be food insecure, more so in urban (68.2%) areas than rural (60.0%). Households experiencing a severe grade of food insecurity were 18.3%. About 17.7% children nationally suffered from wasting, with a higher percentage in rural (18.6%) compared to urban (16.2%) strata. Boys (18.4%) were more likely to suffer from wasting than girls (17.0%). Wasting rates have increased from the previous two editions of NNS in 2001 (13.1%) and 2011 (15.1%).
The survey suggests that that boys have worse nutrition indicators than girls in almost all cases
NNS 2018 for the first time assesses the nutritional status of adolescent girls and boys (aged 10–19 years). The survey suggests that that boys have worse nutrition indicators than girls in almost all cases, which is a point worth exploration.
The outcomes of NNS 2018 clearly indicate that malnutrition is rampant among women, children and adolescents in Pakistan. In addition to high levels of stunting, wasting and micronutrient malnutrition, Pakistan has also begun to see a substantial burden of overweight and obesity, thus creating a triple burden of malnutrition.
This is caused by a combination of dietary deficiencies, poor maternal and child health, high burden of morbidity, and low micronutrient content in the soil, especially iodine and zinc.
Stunting, wasting and micronutrients deficiencies have profound effects on immunity, growth, and mental development of children. Furthermore, the high rates of malnutrition and micronutrient deficiencies among women of reproductive age point to a vicious cycle of malnutrition which may underlie the high burden of morbidity and mortality among women and children (both boys and girls) in Pakistan and could also contribute to high risk of non-communicable diseases in the future.
increasing acute malnutrition and chronic malnutrition may be primarily due to poverty, low levels of maternal education, gender inequalities, lack of awareness
As the qualitative component of NNS 2018 suggests, increasing acute malnutrition and chronic malnutrition may be primarily due to poverty, low levels of maternal education, gender inequalities, lack of awareness, poor access to improved water and sanitation facilities and food insecurity Inadequate infant feeding practices and lack of access to age-appropriate foods are also major contributors.
Although the nutrition situation in Pakistan is alarming and much effort will be needed to achieve SDG2 targets, there is much scope for evidence-based interventions.
The frameworks and delivery platforms exist; urgent action is needed for the development and strategic implementation of a comprehensive nutrition strategy in Pakistan which addresses malnutrition in all its forms.
Despite no federal funding and no PC1 for Federal Nutrition Program, Nutrition Wing, Ministry of NHSR&C, in collaboration with Provincial Departments of Health, UN Agencies, NGOs and partners has continued to respond with effective interventions for the prevention and treatment of malnutrition among the most vulnerable segments of the population especially women and children.
interventions for improving the nutritional status of the population focus on prevention of stunting, counseling, breast feeding, food fortification and community management of acute malnutrition
These interventions for improving the nutritional status of the population focus on prevention of stunting, counseling, breast feeding, food fortification and community management of acute malnutrition. In addition, Adolescent nutrition, has been recognized as an important step and foundation for elimination of malnutrition among mothers and children.
This is because adolescent girls are future mothers and their appropriate nutrition is instrumental in having healthy mothers which consequently leads to a healthier society. This inclusion of Adolescents in Nutrition Programming Globally has led to the 1000 Days + approach.
Some of these recommendations include;
The Mo NHSRC being the responsible entity for coordination and collaboration with all provinces/ regions and the development partners may immediately consider to develop and deploy extensive human resources for nutrition at district level. A critical mass of people is required at all levels from policymakers, implementers, supervisors, health care professionals and community workers. These workers should have expertise and training in nutrition and work full time on nutrition activities in both nutrition sensitive and specific sectors.
There are significant nutritional needs for women of reproductive age in Pakistan, and some of the associations with maternal height reflect intergenerational problems, and others reflect more acute exposures during pregnancy. Addressing fetal growth retardation and small for gestational age births, estimated to account for over a quarter of all births, may also reduce the burden of stunting in young infants and improve developmental outcomes. Targeting women nutrition way before pregnancy and during adolescence and preconception care provides a window of opportunity, which can bear enduring results for generations to come.
A Centre of excellence for nutrition is required for development of need based policy reference with global and regional best practices to support the provinces
Improving nutrition will require food safety and social protection. Pakistan has cash transfer programs (EHSAS) and Pakistan Bait‐ul‐Maal funds, and these transfers can be conditionally linked to health and nutrition services, with upward revision in cash transfer amounts to adjust for food inflation and linkage of beneficiaries with livestock and agriculture schemes.
Pakistan must do better to improve rates of exclusive breastfeeding. This requires mass education and stringent implementation of the ‘International Code of Marketing of Breast‐milk Substitutes’. Additionally, support structures for working mothers to continue breastfeeding must be provided including paid maternity leave beyond the current limitations, availability of child care centers and designated area for breastfeeding at work place as well as support for women working in the non‐formal sectors.
Beyond breastfeeding, Pakistan has never had a concerted programme to improve complementary feeding, which is a major determinant of linear growth deviation after 6 months of age. The current focus and guidelines on complementary feeding are particularly poor. Interventions are needed to optimize the timing of introduction of complementary foods, with appropriate low‐cost fortified foods or in food secure households, appropriate home available diets. In high‐risk food insecure households, consideration should be given to the provision of low‐cost commodities for complementary feeding.
Amidst the water scarcity crisis in Pakistan, public‐sector investments are essential in providing secure and safe water to the population.
A comprehensive and a massive national campaign must be launched to disseminate accurate health/ nutrition messages, and to improve environmental and living conditions, promote the use of toilets and reduce the risks of fecal contamination.
Based on these recommendations and as per directions and guidance of National Health Task Force under the chair of the honorable Prime Minister of Pakistan, a comprehensive PC1 for stunting prevention has been developed by the Nutrition Wing.
Sehat Sahulat Program beneficiaries, 15 million women of reproductive age group and 6 million children under the age of 3 years will be benefiting
The title of the PC1 is “Tackling Malnutrition Induced Stunting in Pakistan” with the objective “To significantly reduce malnutrition related stunting in Pakistani children in the next 5 years, and virtually eliminate it in children born in 2023 by 2030”.
Through this PC1 40% Sehat Sahulat Program beneficiaries, 15 million women of reproductive age group (including annual 3.5 million pregnant and lactating women) and 6 million children under the age of 3 years in the country will be benefiting directly or indirectly through nutrition interventions by 2025.
It is important to mention here that the EHSAS Nashwonuma Program, recently launched in 11 districts of the country has the same model of stunting prevention that is envisaged in this PC1 and it would contribute positively in the overall goal of elimination of stunting from Pakistan. Further Collaboration and Coordination between the two initiatives is expected in the near future also.
Pakistan National Nutrition Coordination Council (PNNCC) constituted to be the highest nutrition coordination body to support EHSAS program is a great step to get patronage and commitment of different sectors involved in addressing malnutrition in the country.
However dire the situation of nutrition in Pakistan is, it is definitely ripe for change with a greater current emphasis on nutrition and formulation of various national and provincial nutrition focused strategies; policy makers and planners need to recognize the importance of improved child health and nutrition for national development and look at nutrition strategies as a net investment in the nation’s future.
(The author is director National Nutrition Program, Ministry of National Health Services, Regulation & Coordination, Government of Pakistan.)