Breaking the Logjam of Malnutrition in Pakistan

Lessons from the IDS Bulletin: IDS, AKU and CSSR
Lawrence Haddad Institute of Development Studies UK

Lawrence Haddad, IDS Sussex

• Nature of the Malnutrition problem • The consequences • The opportunities in Pakistan • Pointers to action

Lawrence Haddad, IDS Sussex

Drawn from the IDS Bulletin

Lawrence Haddad, IDS Sussex

3 partners, 12 papers, 30 authors, 26 based in Pakistan

Malnutrition in Pakistan
60% 50% 40% 30% 20% 10% 0% NSWP:1965 NNS:1977 NNS:1985-7 Underweight
Lawrence Haddad, IDS Sussex

53% 48% 40% 32%

NNS: 2001-02

NNS 2011

Malnutrition in Pakistan
60% 50% 40% 30% 20% 10% 0% NSWP:1965 Stunting NNS:1977 NNS:1985-7 Wasting NNS: 2001-02 Underweight
Lawrence Haddad, IDS Sussex

53% 49% 43% 48% 42% 42% 40% 44%







NNS 2011

In terms of children..
• A doubling of the numbers of stunted children under 5 years of age
– 6.35 million stunted in 1985 – 11.8 million stunted in 2011 – Increase of 200,000 per year--or 547 a day

Lawrence Haddad, IDS Sussex

Vitamin A deficiency in children under 5 is increasing rapidly
Trends in serum retinol status 2001-2011 among children under 5
21% 13% 15% 33% 32% 24% 33%



1% Pakistan

Urban NNS 2001

1% Rural Pakistan Urban NNS 2011 Moderate(0.35 - 0.70 µmol/L) Rural

Severe (<0.35 µmol/L)

Source: NNS 2001 and 2011

Lawrence Haddad, IDS Sussex

• Mortality
– 45 % of all under 5 child deaths (3 million deaths) are caused by undernutrition

• Health
– Underweight is the number 4 contributor to the Burden of Disease in South Asia

• Education
– Preventing stunting adds about one grade to school attainment

• Jobs
– Hourly earnings up by 20% – Wage rates up by 48% – 33% more likely to escape poverty

• Economy
– Asian GDP 11% lower given its stunting rates compared to Latin America
Source: Haddad 2013, Nutrition for Growth Background Paper
Lawrence Haddad, IDS Sussex

Table 12 HANCI commitment levels and stunting levels for children under 5 years of age Percentage of under-5 stunting (severe and moderate) <20 High commitment Brazil 20-29 Peru 30-39 Philippines >=40 Guatemala Malawi Madagascar Indonesia Moderate commitment Gambia Ghana Burkina Faso Vietnam Mali Tanzania Bangladesh Mozambique Rwanda Zambia Low commitment China Senegal South Africa Uganda Sierra Leone Cambodia Nepal Niger Ethiopia Benin Pakistan India Nigeria Cameroon Kenya Liberia Lesotho Sudan Myanmar Afghanistan Yemen Burundi Congo, DR

In the past, a low commitment to malnutrition reduction
Very low commitment Togo Mauritania Angola Guinea Bissau


Lawrence Haddad, IDS Sussex

Things to Strengthen

Lawrence Haddad, IDS Sussex

Time of opportunities in Pakistan
• Heightened awareness of malnutrition
– Floods of 2010-11 – National Nutrition Survey 2011 – But will the attention last?

• Potential for innovation and expanded accountability for nutrition due to the 18th Amendment
– But have resources also been devolved?

• Government joined the Scaling Up Nutrition Movement in 2013
– Government Focal Point for the SUN Movement and support will be provided by the Planning Commission – Advanced development of multi-sectoral nutrition strategies – But will resources be diverted to nutrition & new resources found?

• The PPP Election manifesto mentioned nutrition 6 times, the PML-N manifesto, not at all
– But the PML-N is focused strongly on economic growth…and we know what better nutrition status can deliver Lawrence Haddad, IDS Sussex

Things that have worked
• Iodized salt 17% coverage in 2001 to 69% in 2011 • Tawana School Feeding Programme in Sindh
– Rigorous evidence that it improved literacy and numeracy rates – Suggestive evidence that it reduced the prevalence of wasting and underweight
Lawrence Haddad, IDS Sussex

Potential areas of opportunity?
• Benazir Income Support Programme
– Reaches 40% of population living below the poverty line – Does it have positive impact on nutrition status? Can it be made more pro-nutrition? – First impact evaluation results in December 2013 – Nutrition redesign of such a programme had a massive impact in Peru

• Increased focus on Agriculture as a driver of growth
– Opportunity for better connections?

• Increased attention to Reproductive, Maternal, Newborn and Child Health
– Scale up of interventions could prevent 58% of an estimated 367 900 deaths (15 900 maternal, 169 000 newborn, 183 000 child deaths) and 49% of an estimated 180 000 stillbirths in 2015. (Bhutta et. al. 2013)

• Potential "Demographic Dividend” will not be realised without investment in maternal and early childhood nutrition
Lawrence Haddad, IDS Sussex

MyWorld: Post 2015 citizen votes for priorities
Out of 16 possibilities, 11,700 votes

1. A good education 2. Better job opportunities 3. An honest and responsive government 4. Better healthcare 5. Protection against crime and violence 6. Affordable and nutritious food 7. Support for people who can’t work 8. Freedom from discrimination and persecution 9. Access to clean water and sanitation 10. Equality between men and women
Lawrence Haddad, IDS Sussex

Regions on the demographic upswing

Ratio, working-age to non-working-age population

South-Eastern Asia 2.25 Latin Am. & Carib. South-Central Asia 2.00 Western Asia Northern Africa Sub-Saharan Africa 1.75

Invest in nutrition to realize the demographic dividend



1.00 1950 1975 2000 2025 2050

World Population Prospects: The 2008 Revision
Lawrence Haddad, IDS Sussex

• Nature of the Malnutrition problem in Pakistan is severe and not improving • The consequences are substantial, particularly for economic growth • There are opportunities in Pakistan—time is right to scale up action • Pointers to action
Actively participate in the SUN movement, establish a nutrition budget Increase health spending to scale up reproductive, maternal, newborn and child health interventions Focus BISP on nutrition Look for opportunities to connect agriculture and nutrition more, improve women’s status
Lawrence Haddad, IDS Sussex

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