Filling the Nutrient Gap in Pakistan: Insights to address malnutrition

Dr Aliahmad Khan is a nutritionist with the World Food Programme Pakistan Country Office in Islamabad.

Muhammad Aslam Shaheen is Chief of Nutrition and SUN Focal Point in Pakistan at the Ministry of Planning Development and Reform.

Frances Knight and Giulia Baldi supported the Pakistan ‘Filling the Nutrient Gap’ process from the World Food Programme Headquarters in Rome.

Click here to listen to an interview with the authors on ENN's Media Hub

Background

Malnutrition is widespread across Pakistan; in most cases, the situation has remained severe or even deteriorated in the last 50 years. Almost half of children under five are stunted, 15% are wasted and nearly all are deficient in at least one micronutrient (Government of Pakistan & UNICEF Pakistan 2011); (Blankenship 2016). The exact burden of the problem varies across the country, but in all cases progress is hampered by the complexities of poverty, food insecurity, very limited dietary diversity, increasing prevalence of overweight and obesity, population growth, security issues, rapid urbanisation and vulnerability to natural and manmade shocks.

The ‘Fill the Nutrient Gap’ analysis

The Fill the Nutrient Gap (FNG) initiative was developed to gain further insights and develop strategies to address one of the two prerequisites to prevent the immediate causes of malnutrition, i.e. adequate nutrient intake (the other being disease prevention). The FNG is an in-depth analysis of secondary data on nutrition indicators, food access and availability, dietary intake, preferences and practices, food security, household food expenditure and socio-economic conditions, as well as analysis of dietary affordability and intervention modelling using the cost-of-diet (CoD) tool¹. Through this, the nutrient gap in a country can be better defined in terms of who (vulnerable population groups), where (regions, urban/rural), when (seasonality), why (compounding factors) and how (quantity and/or quality of nutrient intake).

Secondary data also contributes to an analysis of the enabling environment, including national legal and regulatory framework, policy, programmes and partnerships relevant to nutrition, to inform entry points for sustainable action. The analysis then identifies and models the potential economic and nutritional impact of possible interventions to address this gap across the identified sectors and entry points.

The FNG can inform multi-sector decision-making regarding which interventions are needed to respond to nutrient gaps and improve nutrient intake for key target groups through entry points, especially from the health, agriculture, social  protection, education and private sectors. The process places emphasis on improving the quality of and access to nutritious food, especially during the critical period of the first 1,000 days, but also considers other windows of opportunity, such as improving the nutrient intake of adolescent girls.

FNG in Pakistan

In Pakistan, the FNG process began in late 2016 under the leadership of the SUN Focal Point at the National Ministry of Planning and Development, with support from WFP and in collaboration with the SUN Core Group² and National Nutrition Committee, made up of representatives from government, UN, donors, international NGOs and the private sector (via the SUN Business Network).

Multiple stakeholders from a range of sectors (representing nutrition, food security, agriculture, health and education/ academia) were engaged to introduce the analysis, define the scope of the FNG and identify and consolidate the secondary data. Over 190 data sources, from national health surveys to district-level qualitative studies, were reviewed and any identified data gaps were followed up to ensure that all relevant information was considered. Meetings were then held to gain insights on preliminary findings from the analysis of secondary data and intervention modelling.

Key insights from the FNG

The benefit of the FNG secondary data analysis is the ability to combine and present existing data in order to reveal new insights into the contributing dietary-related factors behind undernutrition. In Pakistan, the key findings are:

• Affordability is the greatest barrier to achieving a nutritious diet. The CoD analysis revealed that 67% of households could not afford a nutritious diet;  
• Early undernutrition in infants and young children highlights a problem with maternal and adolescent diets; a quarter of all children are already stunted by the age of six months (Government of Pakistan & UNICEF Pakistan 2011);
• Both dietary quality and quantity are issues in Pakistan and deficiencies in intake of energy, animal protein and multiple micronutrients are common; the minimum acceptable diet is met by less than 3% of infants and young children (Government of Pakistan & UNICEF Pakistan 2011);
• The high prevalence of micronutrient deficiencies and poor household and individual dietary diversity across socio-economic groups, provinces and urban/rural areas suggest that diets are universally poor;
• There is an increasing prevalence of overweight and obesity in women and children; over 40% of women are obese or overweight (Government of Pakistan & UNICEF Pakistan 2011). Moreover, the double burden of obesity and stunting affects the most vulnerable households, where stunting prevalence is highest; one in four stunted children have an overweight mother (Government of Pakistan & UNICEF Pakistan 2011; Blankenship 2016);
• The nutrition challenges are compounded by rapid population growth, dramatic urbanisation, vulnerability to shocks and a complex security situation.

A variety of strategies to respond to these identified nutrient gaps were modelled in the CoD software and the following were identified as key priorities:

• The nutrient requirements of adolescent girls are the most expensive to meet among the modelled household members, given the heightened nutrient needs during this time of growth and development. Interventions targeting adolescent girls could therefore have a greater impact on reducing overall household unaffordability of a nutritious diet;
• Fresh food vouchers (FFVs) (providing daily servings of animal-source foods and vegetables) are the most effective way to reduce the cost of meeting the nutrient needs of adolescent girls compared to provision of supplements, special nutritious foods or fortified staples;
• Specialised nutritious foods (SNFs) such as super cereal plus (SC+), Wawa Mum or Maamta are the most effective way to reduce the cost of meeting the nutrient needs of children aged 12-23 months and pregnant and lactating women. For example, provision of SC+ or Wawa Mum reduced the cost of nutritious diets for children aged 12- 23 months in Urban Balochistan by up to 81% and 64% respectively in winter months;
• Cash transfers (CTs) further contribute to improving affordability of nutritious diets for the households, provided that adequate demand-creation strategies, such as conditionalities and provision of nutrition behaviour change and education, are in place to help ensure that the money is spent on nutritious food;
• Staple food fortification is useful but is not enough to meet the entire needs of key vulnerable groups;
• Combined packages that include FFVs, SNFs and CTs for the key target groups are the most effective way to improve affordability of nutritious diets;
• The cost of providing nutritious household diets was higher during the lean season (summer months) in both rural and urban areas in all provinces and modelled interventions were less effective at reducing nonaffordability during these periods; seasonal variation in diet access needs to be taken into account when developing interventions to ensure effectiveness;
• Different sectors need to be used as entry points for interventions, including social protection, markets (availability of nutritious foods and physical access to markets), education, health and agriculture.

The modelling results encouraged stakeholders to think about the implications of different combinations of interventions and entry points for filling the nutrient gap. Further costing of the intervention options for different sectors at various levels of coverage would then be required to complement the analysis and guide/inform investment decisions.

The FNG also identified areas or themes where little or no primary data was available. A key data gap was information on the current food and nutrient intake of infants and young children, pregnant and lactating women and adolescent girls, as well as information on decision-making, intra-household food distribution and barriers to improving intake.

FNG dissemination workshops

In March 2017, workshops were held in Karachi, Quetta, Lahore and Peshawar provinces which were coordinated by the Pakistan SUN Secretariat and Provincial SUN units with the support of WFP country and provincial offices. The province- level findings of the FNG were presented to representatives from a range of sectors, including health and nutrition, agriculture, social protection, education and food fortification. Participants then worked together to identify and prioritise context-specific interventions, programmes and actions affecting the enabling environment to fill nutrient gaps for key target groups, and contribute to fight malnutrition in the short, medium and long term. Data gaps and future research priorities were also discussed.

The FNG findings from the provincial workshops were then presented to national-level stakeholders to identify overarching recommendations for actions that would support provincial activities, as well as strengthen the enabling environment for nutrition at the national level.

Challenges and lessons learnt

A key challenge to the initial design of the FNG analysis in Pakistan was the complexities of policy frameworks in a post-devolution context. Policy priorities and level of progress towards developing and implementing multisector nutrition action plans differ between provinces and there is a lack of harmonisation with national policy development activities. To address this challenge and respond to the complexities of the context, the FNG analysis and dissemination process was first carried out in the four provinces. Following this, findings from the province-level analysis and outcomes from the provincial workshops were fed jointly into a national workshop; representatives from each province participated.

A crucial lesson learnt from the FNG experience in Pakistan was the importance of leadership of the process by the SUN Secretariat and national and provincial governments. The SUN Core group was instrumental in sharing information, contributing to the analysis plan, validating and interpreting preliminary findings and participating in workshops. The SUN secretariat, through their positions within national and provincial government departments, played a critical leadership role in the coordination of FNG events and success in terms of representation from multiple sectors and stakeholders.

Acknowledgements: WFP Pakistan Country Office team, with particular thanks to Cecilia Garzon and Pablo Rodriguez (in addition to the co-author); WFP Regional Bureau Bangkok (Katrien Ghoos, Jessica Blankenship); the SUN Country Coordinator's team at national and provincial level; and the SUN Core Group in Pakistan.

References

Government of Pakistan & UNICEF Pakistan. National Nutrition Survey Pakistan 2011. www.humanitarianresponse.info/system/ files/documents/files/59_National Nutrition Survey-2011.pdf

Blankenship J. Nutrition in the Cities: Secondary data analysis of nutrition status for urban children under 5 years of age in Pakistan – Draft Report. Islamabad, 2016

¹See www.heacod.net/countries/reports/cotd-softwareversion-2-2016.

²The Core group is made up of Ministry of Planning Development & Reform – Nutrition Section/SUN Secretariat; Ministry of National Health Services Regulation & Coordination – Nutrition Wing; Ministry of National Food Security & Research – Food Commissioners; WFP; WHO; UNICEF; FAO; World Bank; DFID; DFAT (Australian Aid); European Union; Save the Children; Micronutrient Initiative (MI); Global Alliance for Improved Nutrition (GAIN); and Harvest Plus.