A stunted generation

Almost one in every two children in Pakistan under five years of age suffers from stunting. Stunting means impaired physical growth of children manifested in their short heights, primarily caused through prolonged malnutrition during early childhood. Unfortunately however, stunting is not only limited to compromised physical growth but it also leads to hampered brain development, poor health in adolescence and inhibited learning in schools resulting in low performing labour force for future, only if these children survive that long. Almost half of all deaths in children under five are attributed to malnutrition or under-nutrition.

While the global prevalence of stunting has come down from a whopping 40 per cent to less than 24 per cent during the last 25 years, Pakistan has lagged way behind in this race, faring worse than even most of the African countries. According to a recent UNICEF report, an estimated 80 per cent of the world’s 165 million stunted children live in just 14 countries, with Pakistan being one of them with roughly 45 per cent prevalence. Other countries in South Asia such as India, Bangladesh and Myanmar are comparatively better with stunting incidence of 39, 36 and 35 per cent respectively, while Sri Lanka is far ahead on the curve with only 15 per cent prevalence. Within Pakistan, the situation is worst in Fata and Balochistan with more than 50 per cent of stunted children, but Sindh, K-P and Punjab are also not far behind.

It is almost impossible to treat or cure stunting, if malnutrition is not prevented at an early age, meaning that no matter what we do now, this stunted generation of almost 10 million Pakistani children is going to be there, adding tremendously to the disease burden of the country and significantly and adversely impacting the labour force productivity when they grow up. Not only is stunting known to result in significant loss of IQ in children, it is also expected to create a significant economic dent. The economic impact of overall malnutrition deficiencies in Pakistan has been estimated to cause three per cent of GDP loss annually, which is double the loss caused by energy deficit. At individual level this would mean sustained poverty, low income and in turn an environment ripe for stunting and malnutrition of next generation, creating a vicious cycle.

Stunting is mainly caused by under-nutrition of children, frequent infections or adverse health of mothers during pregnancy. There is also a strong link with poor sanitation practices, due to spread of bacteria and consequent infections. It is therefore no surprise that stunting is most common in poor rural households, where the rearing of children is left to mostly illiterate mothers, in unhygienic environments and with poor access to quality food products.

While in the long run, the solution for stunted growth can be none other than improved education and literacy levels, enhanced household incomes, better health conditions and access to sanitation, there is a need to think out of the box in the short term to address this grave challenge.

The time between the start of pregnancy to the second birthday of a child is critical to prevent stunting. There is a need to make best use of these 1,000 days window where the children are most likely to be affected. The solution to stunting has to be based on enhancing awareness and improving access. It means making mothers realise what they need and making that available to them. However, this solution cannot be implemented in isolation and has to be linked with overall regulatory environment, public policy and existing poverty alleviation initiatives.

The public and private primary healthcare apparatus provides the right tier for any intervention for prevention of stunting. The staff at primary healthcare facilities, along with midwives should be integrated into a wide scale awareness and diagnostic programme, where mothers and newborns should be registered and provided appropriate nutritional and sanitation advice. Regular monitoring and data gathering should provide insights that can be used for better targeting.

Alongside nutrition programmes sponsored by government and development partners, there is also a need to ensure wider availability of fortified food such as wheat flour and vegetable oil with requisite amounts of essential micronutrients. This could be done through having appropriate regulations in place for the private sector. Punjab has taken the lead in this regard and there has been some collaboration between Punjab Food Authority and Flour Mills Association, however there is a need to scale up such initiatives. Furthermore, compliance with such regulations should be rewarded through tax breaks and incentives, as this would entail increased costs for the private sector.

Last but not the least, there is a need to create synergies with other poverty alleviation programmes. For instance, government is running a massive cash transfer programme through Benazir Income Support Programme. There is a need to leverage this investment through introducing conditional cash transfers, linked with regular health checks through public health facilities. Peru provides a great example, where government has successfully used cash transfers to desired nutritional outcomes for families having children of five years and below. As a result, the prevalence of stunting in the country has fallen by half during the last 10 years.

Considering the massive scale of the problem, it would need persistent efforts over many years to address. However, if not prevented, the consequences can be catastrophic. We already have a generation without nutrition, impacting the next 30 years of our country’s future but without a concerted effort and action now, it may last forever.

Published in The Express Tribune, October 26^th, 2016.

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