08 May 2013

Seeing the Unseen: Breaking the Logjam of Undernutrition in Pakistan

Today sees the launch of the new IDS Bulletin on Undernutrition in Pakistan, coincidentally during the week of the Pakistan elections.

Pakistan is one of the few countries where stunting rates are actually increasing and so my two fantastic co-editors Zulfiqar Bhutta and Haris Gazdar and I put out a call for Pakistani authors to write about malnutrition in Pakistan: what was driving it, what could be done about it, and what needed to happen for solutions to be put in play. We reviewed and present 12 interesting papers (see list below).

The timing seems to be good for nutrition in Pakistan. First, in dealing with the acute malnutrition from the floods of 2010, the Pakistan people woke up to the incredibly high levels of chronic malnutrition in their country (the first part of the title of the Bulletin is "Seeing the Unseen" refers to this). Second, the devolution of power in the health system in 2010-11 has brought a fresh set of government interests to the table and it is hoped that this will allow some regions at least to form new alliances to reduce malnutrition, away from existing bureaucratic barriers and traps. Finally, the National Nutrition survey of 2011 has given a transparent and clear picture of the levels, patterns and causes of malnutrition in the country.

The Bulletin, supported by DFID, talks about all of this. It showcases some government initiatives that have worked (the Tawana school feeding programme which was nevertheless closed down amid claims of corruption, and the salt iodisation programme) and it explores the political opportunities and problems faced in getting nutrition higher up the development agenda. View the overview pre peer review version here.

Getting the two main political parties to pay attention to nutrition will not be easy. The voters are most worried about security and jobs. If the manifestos of political parties reveal their souls, what do the manifestos of the PPP (who lead the current coalition) and the PML-N parties say? The PPP manifesto mentions nutrition 6 times, the PML-N manifesto, not at all. The PPP manifesto links nutrition to schooling, health, empowerment, family planning and social protection (the Benazir Income Support Programme). The PML-N manifesto is more concerned with economic growth. On the face of it, the platforms for nutrition to take hold seem stronger in the PPP manifesto, but for both parties, we need to make the connection between nutrition, economic growth and stability. The evidence from elsewhere is available, but it would be so much more powerful if there was some Pakistan evidence too.

What about the elephants in the room?
Neither manifesto talks much about security, terrorism or corruption--three issues that the Bulletin authors did not have much to say about either. This is understandable--it is difficult to talk publicly about these issues, but we need to know more about the effective delivery of nutrition services in such a fragile and conflict affected contexts. This is surely a good future agenda for nutrition research--how do we need to think differently and act differently in these contexts, and who are the "we" in the first place?

On April 15, Pakistan signed up to the Scaling Up Nutrition movement. This is a good sign. Another would be to create a nutrition budget, allocate resources to it, make sure the Benazir Income Support Programme is nutrition sensitive, sign off on the National Nutrition Survey findings and build up the Pakistan nutrition research community.  Pakistan ranks poorly on the Hunger and Nutrition Commitment Index (HANCI).  I hope the elections and SUN can begin to change that, slowly but surely.


Seeing the Unseen: Breaking the Logjam of Undernutrition in Pakistan

IDS Bulletin 44.3
Editor Haddad, L., Bhutta, Z. A., and Gazdar, H.
Publisher IDS
This Bulletin will be published on 9 May. Order your copy by contacting bookshop@ids.ac.uk
After a lost decade, there is clearly a groundswell of momentum for nutrition in Pakistan, driven by a confluence of policy, evidence and events. This momentum needs to be sustained at the national level, reinforced at the provincial and sub-provincial levels, and converted into action.
The articles in this IDS Bulletin highlight some of the key features of undernutrition in Pakistan and its drivers. The correlates of undernutrition in Pakistan are no different than any other country: infection, poor diet quantity and quality, and unequal gender relations. High levels of poverty and fragility make the context for undernutrition reduction more difficult. Yet, the articles here also show that government nutrition interventions can work. But if the log jam of malnutrition in Pakistan is to be broken for good, malnutrition will have to be viewed as a development outcome – one that is a foundation for other outcomes such as economic growth and social cohesion – and this will only be achieved by viewing nutrition through a political-economy lens.
The collection of 12 articles in this issue represents a contribution to the potential moment of change. They do three things: (1) describe the nutrition status and its correlates and causes, (2) assess some of the interventions employed to combat undernutrition, and (3) analyse the political context within which these interventions emerged and will have to operate in the future. They aim to give additional definition to the debate of what it is desirable and possible to do to accelerate undernutrition reduction in Pakistan and why it is essential to do so.
Sartaj Aziz

Seeing the Unseen: Breaking the Logjam of Undernutrition in Pakistan
Zulfiqar A. Bhutta, Haris Gazdar and Lawrence Haddad
Evaluation of Nutrition Surveys in Floodaffected Areas of Pakistan: Seeing the Unseen
S.M. Moazzem Hossain, Mah Talat, Erin Boyd, Shamim Rafique Chowdhury, Sajid Bashir Soofi, Imtiaz Hussain, Imran Ahmed, Rehana Abdus Salam and
Zulfiqar A. Bhutta

Towards Improved Food and Nutrition Security in Sindh Province, Pakistan
Shahid Fazal, Paola María Valdettaro, Joanna Friedman, Cécile Basquin and
Silke Pietzsch

Inflation and Food Security in Pakistan: Impact and Coping Strategies
Haris Gazdar and Hussain Bux Mallah
Impact on Health and Nutrition Outcomes in Sindh Province, Pakistan
Imtiaz Hussain, Sajid Bashir Soofi, Seema Hasan, Nelofer Mehboob,
Masawar Hussain, Arjumand Rizvi and Zulfiqar A. Bhutta

Impoverished Rural Districts of Pakistan: An Independent Evaluation of Impact on Educational and Cognitive Outcomes in Sindh Province, Pakistan
Sajid Bashir Soofi, Imtiaz Hussain, Nelofer Mehboob, Masawar Hussain, Zaid Bhatti,
Saiqa Khan, Seema Hasan and Zulfiqar A. Bhutta
Achieving Universal Salt Iodisation (USI) in Pakistan: Challenges, Experiences and the Way Forward
Ahmed K. Masuood and Tausif Akhtar Janjua

Agriculture and Nutrition in Pakistan: Pathways and Disconnects
Mysbah Balagamwala and Haris Gazdar

Engaging Development Partners in Efforts to Reverse Malnutrition Trends in Pakistan
F. James Levinson on behalf of the Pakistan Nutrition Development Partners Group

Missing Dimensions in Addressing Child Malnutrition in Pakistan: Lessons from the Tawana Experience
Kausar S. Khan, Ghazala Rafique and Sohail Amir Ali Bawani

Nutrition Policy in the Post-devolution Context in Pakistan: An Analysis of Provincial Opportunities and Barriers
Shehla Zaidi, Shandana Khan Mohmand, Noorya Hayat, Andres Mejia Acosta and
Zulfiqar A. Bhutta

The Emerging Social Contract: State–Citizen Interaction after the Floods of 2010 and 2011 in Southern Sindh, Pakistan
Ayesha Siddiqi

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