In the past few years it has become a norm that a few hundred newborn babies and infants will inevitably die in Sindh’s beautiful Tharparkar desert every year. Conflicting figures are quoted in the media and by government functionaries, about the number of deaths and their causes. Even if one fully agrees with the official version, unfortunately, there are no visible actions on part of the government of Sindh or the federal government to tackle the deadly issue on sustainable basis. As a result, we see the inhabitants of Mithi offering special prayers in temples amid a rising death toll of children and their helplessness in the face of it. Irrespective of the fact of whether 200-plus children died in the past 50 odd days or 75 newborns and infants breathed their last in Tharparkar’s hospitals, even a single preventable death is criminal. Why are we unable to respond to this situation?
Child health and nutrition experts and child rights activists believe that it is due to a lack of understanding of the issue at the decision-making level and the lack of political will to respond to it. If someone is going to look at it and try to resolve it from the health perspective only, then we will continue to see such horrific figures of newborns deaths for the years to come as is the case for the past few years. It should be understood that there are multiple factors for the current situation in Tharparkar and there is a need for multi-sectoral interventions to address the social, economic and cultural reasons behind this mayhem. Similarly, responding to malnutrition also requires a multi-sectoral approach involving health, education, social protection, water and sanitation, and the agricultural and private sectors. There needs to be a high-level commitment from the leadership to plan and implement multi-sectoral interventions.
According to the findings of The Lancet as well as leading nutrition and child health experts in the world, including Pakistan, most of the irreversible damage due to malnutrition happens during conception and in the first 24 months of life, meaning that the risk begins from the day of conception to up to two years of age (also referred to as the first 1000 days). Poor nutrition for mothers during pregnancy, too few calories, poor quality of food, repeated infections such as diarrhoea and malaria, poor feeding practices and so on are some of the major causes of malnutrition in Pakistan. Tharparkar is no different. Rather, these issues are much severe there because of poverty, poor water and sanitation resources, high rates of child marriage, the lack of education, family planning and health facilities in far-flung areas like Nagarparkar, which makes the situation worse.
The nutrition challenge facing Sindh is substantial. Sindh has a dangerously high rate of nutritional stunting among children under the age of 5 (49.8 per cent) as compared to 43.7 per cent of the national average. The prevalence of underweight children is 40.5 per cent as compared to 31.5 per cent of the national average, while wasting prevalence is 17.5 per cent as compared to 15.1 per cent of the national average. As per the World Health Organisation’s standards, a national average of 15 per cent or above is labeled an ‘emergency’. These figures have not changed significantly in the past decade and require special attention at all levels. I believe the figures in Thar region will be even worse than the provincial figures for Sindh.
Since the Tharparkar child deaths are viewed as something related to malnutrition and health, the whole focus is on health response, which is not something new. Traditionally, in Pakistan, nutrition has been viewed as a problem to be looked after only by the health sector planning commission or the Ministry of Health at the federal level and Department of Health at the provincial level. This narrow approach then excludes those remedies that would cater to the wider economic and social contexts that predispose a community to poor nutrition. Major findings of the National Nutrition Survey 2011 clearly indicate the urgent need to address malnutrition through an integrated approach, which addresses immediate, underlying and basic causes of malnutrition. This is a challenge to mainstream nutrition and to ensure that all relevant departments and stakeholders are cognisant of their roles and have effective coordination.
Responding to malnutrition issues using a multi-sectoral approach was a practice realised a few years back and the government of Sindh notified the Provincial Nutrition Steering Committee and Inter Sectoral Technical Working Group in December 2012. The Technical Working Group had a number of meetings with the support of the Development Partners for Nutrition Group and Sindh became the first province to adopt the Sindh Inter Sectoral Nutrition Strategy in late 2013.
The Sindh Inter Sectoral Nutrition Strategy is ambitious and seeks to reduce chronic malnutrition in children under two years of age, by 10 percentage points from an estimated 49.8 per cent to 39.8 per cent by the end of 2016. Likewise, Anemia in children is to be reduced from 73 per cent to 62 per cent and maternal anemia from 59 per cent to 49 per cent, through sustainable, effective and inter-sectoral interventions by the end of 2016. The target group for the nutrition in interventions includes pregnant and lactating mothers. A 1,000-days-plus approach is used, with nutrition supplies and provision of food vouchers and meals to women living in difficult conditions.
The strategy further focuses on the introduction of incentives such as conditional cash transfers and food vouchers to encourage enrolment and daily attendance of children of Benazir Income Support Programme beneficiaries in schools, mid-day meals through school feeding programmes and the introduction of policy and strategy for introducing mid-day meals for all students in high-risk areas. The Sindh Inter Sectoral Nutrition Strategy further calls for increased access to safe water and sanitation through rehabilitation, improvements, extension and augmentation of schemes. It also calls for ensuring the provision of drinking water and sanitation facilities in schools operating in prioritised districts in rural areas and to create an enabling environment for improving food security. In addition, it envisages increasing the ratio of female agriculture extension officers and field assistants and building training centres for them at district level.
Now, one simple question would be whether there are more difficult situations or high-risk areas all over Sindh and not just in Tharparkar alone. What has been done in Tharparkar so far when regarding the implementation of the Sindh Inter Sectoral Nutrition Strategy? Have any steps been taken to implement these strategies? What has been done for female empowerment and income-generation opportunities for women in Tharparkar? What is the status of the implementation of the Sindh Right to Free and Compulsory Education 2013, the Sindh Protection and Promotion of Breastfeeding and Child Nutrition Act 2013 and the Sindh Child Marriages Restraint Act 2014? The implementation of the Sindh Inter Sectoral Nutrition Strategy and all these laws is essential in improving the situation of child deaths in Tharparkar.
The government of Sindh should take concrete measures for the implementation of the related strategies and legislation and make budgetary allocation for the implementation of the Sindh Inter Sectoral Nutrition Strategy. Tharparkar could be made a case study for a pilot multi-sectoral intervention to respond to this situation. Steps should be taken to promote women employment and income, social safety nets such is BISP should focus on Tharparkar, increase the number and enhance the skills of health care providers and lady health workers to promote exclusive breastfeeding for six months. The private sector should be encouraged as well to play their due role. They can support other sectors in development and implementation of standardised messages through capacity building of their outreach workers in the areas of nutrition promotion. The government of Sindh should also promote tourism in beautiful and scenic Tharparkar to increase income-generation opportunities.
Published in The Express Tribune, March 3rd, 2016.