Nutrition Governance work by Dr Shehla Zaidi, Women & Child Health Division, Aga Khan University
All government leaders are obsessed with economic growth, those in Pakistan being no exception.
Economic data, collected almost daily, is pored over. And when the data moves in the wrong direction it is cause for much anxiety and embarrassment.
If only it were the same for data on nutrition. This week’s launch of two major evidence-based publications, the Institute of Development Studies’ Seeing the Unseen: Breaking the Logjam of Malnutrition in Pakistan and The Political Economy of Undernutrition in Pakistan by the Aga Khan University is an appropriate moment to reflect on why nutrition deteriorated even as the economy grew.
These works were funded by the UK government’s Department for International Development.
Pakistan has one of the highest levels of malnutrition in the world with over 40pc of children showing stunted height. This means stunted immune systems, stunted brain development and stunted overall life chances. All this adds up to stunted economic development.
A recent authoritative study showed that if South Asia had the same malnutrition levels as Latin America its GDP would be boosted by 11pc.
Unfortunately malnutrition numbers in Pakistan are moving in the wrong direction. Despite this, malnutrition is not making headlines, politicians are not getting nervous about it, nor is civil society making enough noise.
Let’s be clear, stunting rates in Pakistan are higher now at 44pc than they were in 1985 (42pc). This means the number of stunted children has doubled in that period — from six million to 12 million, or 547 stunted children a day.
So, why no action or outrage?
First, malnutrition symptoms are invisible. For example, until malnutrition turns almost fatal, stunted children appear short but healthy. They are not. Their brains are smaller, smoother and less dense so they are less able to learn.
Likewise, their immune systems are damaged — they are less able to withstand the barrage of bacteria and viruses that poor water and sanitation expose them to and get sick more often.
Second, no one is responsible for malnutrition. The only action has so far come from the health sector, but this department alone cannot improve nutrition. There is no central entity across government departments, no nutrition budget and no nutrition government leader.
Third, infants don’t vote, so the political payoff to putting infant nutrition high on the development agenda is not terribly attractive to politicians looking for quick electoral wins.
Fourth, nutrition improvements are blocked by class, gender and regional inequalities.
To give the Pakistan government its due, it has recently signed up to the global Scaling Up Nutrition movement. This is a statement of intent: that the government recognises the scale of the problem and has agreed to make its commitments to doing something about it highly visible.
This is a wonderful first step, but only a first step. Now the government needs to follow up by designating a high-profile office-holder at the federal level and the provinces responsible for action on nutrition.
It also needs to commit funds, as mainly external donors are footing the bill for existing nutrition activities. What happens when they withdraw?
As to what actions are needed, well, actions such as framing nutrition as a key input into economic growth, establishing and funding a nutrition budget, building capacity to address nutrition at the front lines, making sure that the Benazir Income Support Programme has a positive impact on child nutrition, and collecting more frequent nutrition data (you would not run an economy with data collected only once every decade, so why do that with nutrition?).
The government can do this. It has shown that it can achieve success in nutrition when it puts its mind to it: for example, salt iodisation went from 17pc coverage in 2001 to 69pc in 2011.
The time is right for this push. In the aftermath of the 2010 and 2011 floods, Pakistanis understand better the extent of chronic malnutrition. The national nutrition survey of 2011 revealed that the trends are worsening. The 18th Amendment has increased the fiscal and policy space of the provinces to innovate and mobilise around malnutrition reduction — and the signs are that they are gearing up to do this.
In fact, the next five years represent a once-in-a-lifetime investment opportunity for the government. Pakistan population projections show that the ratio of people of working age to those of non-working age will peak in 2030: there will be two people of working age for every person who is either too young or too old to work.
This is called the “demographic dividend” — people working will have to support fewer people than ever before.
But there is one crucial assumption in the use of the word “dividend” — that people entering the labour force will be able to get jobs, and that those jobs will lift them out of poverty.
Well, this assumption simply will not hold if, as infants, these new labour market entrants are stunted. As adults, they will not be able to get the jobs that can drive the Pakistan economy and lift them and their families out of poverty. We need to prevent them from being stunted now, not in 2030.
So we applaud the government for signing up to the Scaling Up Nutrition movement. But now we would like to see some real commitment on the ground, and not only with respect to public spending. Pakistan must also tackle inequalities and political constraints that prevent benefits of economic growth from reaching children. It is smart economics as well as being the right thing to do.
(This article was published in Dawn on October 13, 2013)