Wasting prevention and treatment – central to stunting reduction in Pakistan
This is a summary of a Field Exchange field article that was included in issue 63 – a special edition on child wasting in South Asia. The original article was authored by Saba Shuja, Eric Alain Ategbo, Yasir Ihtesham and Khawaja Masood Ahmed.
Saba Shuja is a Nutrition Officer for UNICEF Pakistan.
Eric Alain Ategbo is Chief of Nutrition for UNICEF Pakistan.
Yasir Ihtesham is Acting Head of Nutrition for World Food Programme (WFP) Pakistan.
Khawaja Masood Ahmed is the National Coordinator of the Nutrition and National Fortification Alliance of the Ministry of National Health Services, Regulations and Coordination, Government of Pakistan.
Background
The high rates of malnutrition in children under five years of age is a major concern in Pakistan. Over 40% of children under five years are stunted and 17.7% are wasted – 2.5 million children are currently estimated to be severely wasted. Pakistan was one of the first countries to adopt the global Sustainable Development Goals (SDGs) to achieve a 40% reduction in childhood stunting and maintain childhood wasting below 5%. However, little progress has so far been made towards achieving these targets.
The links between wasting and stunting
Growing evidence suggests that wasting is a direct cause of stunting. Studies also indicate that, in wasted children, linear growth slows down until weight gain recovers. The risk of death for concurrently wasted and stunted children is comparable to that of severely wasted children, making this of particular concern.
Common predictors of wasting and stunting in Pakistan include poor maternal nutrition (underweight or low stature) and poor water and sanitation. Both stunting and wasting may already be present at birth and persist concurrently in the first year of life. Thus, maternal factors and suboptimal infant and young child feeding practices play a major role in early infant growth failure. An integrated strategy for the prevention and management of stunting and wasting should therefore incorporate pregnancy and the early infant period.
Low coverage of wasting treatment in Pakistan as a driver of stunting
Despite provincial community-based management of acute malnutrition (CMAM) programmes to manage severe wasting in Pakistan, the coverage of treatment services remains below 5%. This largely results from the emergency-driven nature of CMAM programming and thus short term and unpredictable funding mechanisms and a lack of service integration into the routine health system, particularly in development settings. Efforts are therefore being made to implement wasting treatment services through an existing cadre of government health workers (Lady Health Workers (LHWs)).
Low investment in wasting management in Pakistan has also been influenced by global efforts to scale up multi-sectoral nutrition programming for stunting through the Scaling up Nutrition (SUN) movement. While this has put stunting reduction high on the national agenda, it has also led to ‘divided’ interests. As such, national policy-making and programming for stunting (nutrition-sensitive) and wasting (nutrition-specific) have fallen under separate government entities. This exacerbates the view of wasting as a short-term problem that is quickly reversible with the right treatment. In reality, many children in Pakistan face repeated or persistent episodes of wasting in their early years which contribute to an increased risk of stunting and death. Given the link between wasting and stunting, failure to provide treatment to the majority of wasted children likely contributes to the high prevalence of stunting in Pakistan. Wasting and stunting should therefore be viewed through a single lens, with wasting treatment and prevention included as a component of stunting prevention in both humanitarian and development contexts.
Strategies and programmes to address stunting in Pakistan
Pakistan has developed strategies for stunting reduction at federal and provincial levels under the strategic framework of the Pakistan Multi-Sectoral Nutrition Strategy (PMNS) 2018-2025. This strategy aims to reduce the prevalence of stunting from 40% in 2018 to 33% by 2025. In line with this strategy, all provinces in Pakistan have developed a multi-sectoral response and are implementing this to some extent. In general, the sectors involved include health, agriculture, fisheries and livestock, education, population welfare, water, sanitation and hygiene (WASH) and social protection. Specific actions per sector are described below.
Health sector: Selected nutrition interventions, including iron and folic acid (IFA) supplementation for pregnant women, child deworming, vitamin A supplementation, treatment of severe acute malnutrition (SAM), promotion of infant and young child feeding (IYCF) and multiple micronutrient powders (MNP) are currently delivered through the government health service delivery platform as a routine package of services for women and children. This is delivered vertically through a specific cadre of staff in parallel with the primary healthcare system. Current work to fully integrate this system within primary health care (delivered through LHWs) is ongoing and is central to national coverage of wasting prevention and treatment, as well as to impact on stunting.
Social protection: The Benazir Income Support Program (BISP) is a national conditional cash transfer programme that aims to reduce stunting rates. BISP was launched in 2008 and targets 5.7 million of the poorest and most vulnerable in Pakistan. While families receiving grants receive nutrition counselling to improve their diets, this component is currently quite weak and efforts are underway to link this service with the public healthcare system delivered through LHWs. Recently, a health and nutrition conditional cash transfer programme, Ehsas Nashwonuma, was launched to address stunting in children under 23 months of age in high burden districts. This is funded by the Government of Pakistan (GoP) and implemented through health facilities by the World Food Programme (WFP).
WASH sector: Most multi-sectoral stunting alleviation strategies include WASH interventions focused on hygiene promotion, access to and use of safe water and the promotion of Open Defecation Free (ODF) villages using the Community-Led Total Sanitation (CLTS) approach.
Agriculture and livelihoods to boost food access: Nutrition-sensitive interventions such as the promotion of kitchen gardening, fruit tree plantation, agriculture, fisheries and livestock are included in the multi-sectoral nutrition strategy and reflected in sectoral plans. The role of livelihood and food-based approaches needs strengthening and synergies should be established for complementarity.
Education sector: The education sector is collaborating with the health sector around nutrition interventions for adolescent girls and school-aged children. According to the National Guidelines on Adolescent Nutrition and Supplementation and National Adolescent Nutrition Strategy, all adolescent girls should receive weekly iron folic acid (WIFA) tablets. This strategy is included in national and some provincial nutrition programming and a pilot programme is being implemented in one district to assess its effectiveness, challenges and bottlenecks.
To ensure that stunting reduction is included in planning by all sectors, the Scaling Up Nutrition (SUN) Secretariat of Khyber Pakhtunkhwa (KP) province has developed general nutrition markers and sector-specific nutrition markers for the government to use when assessing funding for proposed projects. There are plans to expand the use of these markers to other provinces.
Opportunities to link stunting and wasting reduction initiatives
A full integrated package of interventions to simultaneously address wasting and stunting in all contexts is needed to tackle the fragmentation of strategies across programmes, projects and geographic areas in Pakistan. Opportunities to integrate stunting and wasting programming exist at provincial level and some progress is being made. There are also donor funded nutrition programmes currently operating in some provinces (Sindh, KP and Balochistan) with varied coverage.
At federal level, a provincial nutrition project (PC1) was initiated in 2020 for the next five years entitled, “Tackling Malnutrition Induced Stunting in Pakistan”. This started as a stunting prevention initiative but a strong wasting management programme has since been integrated within it. This PC1 will target the poorest, most underprivileged and hardest to reach populations in Pakistan, reaching around 35% of the population at a cost of USD2 billion.
In order to accelerate the progress made to date, a comprehensive national and provincial level nutrition review is being planned. This will inform the development of a consensus-based national nutrition policy and standardised nutrition programming approach to guide a more holistic, harmonised response to malnutrition. The Ministry of National Health Services, Regulation and Coordination (MoNHSR&C) and the Ministry of Planning, Development & Reform (MPD&R) will steer the review with technical support from UNICEF. A clear approach to improve the nutritional status of pregnant women and adolescent girls, as well as effective coordination and engagement of stakeholders, central oversight and effective monitoring, will be key to future success. The Pakistan National Nutrition Coordination Council (PNNCC) of the Prime Minister’s Secretariat is proposed as the natural coordination platform. The Ministry of Finance and Planning Commission must also be engaged to ensure adequate financing of nutrition initiatives at federal and provincial/ regional levels.
Conclusions
Children in Pakistan are confronted with a triple burden of wasting, stunting and overweight and obesity. The country must therefore move away from vertical programming of malnutrition towards the coordinated management children who are not growing well. A national nutrition policy, informed by data from the National Nutrition Survey, is critical to accelerated progress in Pakistan. Integration of wasting management within the Primary Health Care system is also central to rapid scale-up and increased coverage of wasting treatment services countrywide. These efforts must be linked with multi-sectoral stunting reduction strategies to optimise efforts towards the overall reduction of undernutrition in the country.
For more information please contact Saba Shuja.