Tackling child malnutrition

In his maiden address to the Parliament in 2018, Prime Minister Imran Khan identified child wasting and stunting as a major social issue warranting immediate policy attention. After a relative indifference for more than two years, he again spoke about child wasting while chairing the first meeting of the Pakistan National Nutrition Coordination Council (PNNCC) on Monday. He emphasised the need to develop a comprehensive plan in coordination with the provinces to address this issue.

Wasting and stunting in early childhood and malnutrition in later years adversely affect human development and national productivity. Hence, policy concern at the highest level, albeit intermittent, is a welcome happening. The search for effective remedies to the malaise must happen in earnest.

According to the 2018 National Nutrition Survey, 18% children under five years of age suffer from wasting, 40% suffer from stunting, 48% are anaemic and 29% are underweight. Although there are little gender differences in these percentages, rural/urban differences are significant. The situation is equally alarming in children of primary school-going age and among adolescents.

The federal and provincial governments will have to design and implement different interventions for different age groups of children given their unique nutrition requirements and feeding practices. These may include improved water and sanitation, better healthcare and food supplements for expecting and nursing mothers, special food allowances for very young children and school meals programmes.

It is the last intervention i.e. a nationwide mid-day school meals programmes that warrants special attention given its success elsewhere and its promise to not only alleviate malnutrition but also improve school enrolment and children’s learning.

A small-scale programme of school meals was launched in Pakistan in the 1990s under the title Tawana Pakistan. It was closed down after a few years of operations due to alleged corruption and implementation deficits. That left bitter memories and senior managers gave a wide berth to any suggestion of launching a similar initiative again. One bad experience, however, especially when it arose from misgovernance rather than a conceptual weakness, should not deter policy communities from serious consideration of a school meal initiative for poor children.

There is much we can learn from the Midday Meal Program (MMP) in India, which is the world’s largest such programme and has been running since 1995. Its purpose was to enhance enrolment, retention and attendance rates as well as improving the nutritional levels of children. Today, MMP in India covers around 120 million children in over 1.26 million schools, with an estimated budget allocation of over ₹105 billion.

MMP started off in India by providing just rice but in 2001, this changed to providing proper cooked meals to every child in every government and government-aided primary school. This cooked meal must meet a nutritional criterion — a minimum of 300 calories of energy and eight to 12 grams of protein per meal. The menu of the MMP was developed keeping in mind children’s requirements and local food habits. The menu varies among states and regions. It usually includes rice and chapattis, pulses, vegetables and sometimes fruit, depending on state budgets.

MMP operates in both decentralised and centralised modes. In the decentralised mode, meals are cooked on-site by local cooks and helpers. This system has the advantage of generating local employment, usually for mothers of school-going children. It also allows for monitoring by both parents and teachers. However, one drawback with a decentralised provision of meals is the absence of inadequate infrastructure and lack of hygiene. In 2013, as many as 23 children died in the Saran district of India after eating contaminated meals.

In the centralised mode, private organisations are contracted for cooking meals and delivering them to schools. Centralised provision is more common in urban areas where schools are located in close proximity and the cost of transportation of food to various schools is small.

Overall performance of the meal programme in India has been excellent. The scheme acted as a source of employment for rural women. It has also been successful in addressing classroom hunger, without any discrimination on the basis of caste, gender or community. Furthermore, enrolment rates have also gone up especially for girls. However, food safety has been a major concern; several incidents of food poisoning have occurred. Initially, countrywide implementation proved difficult as many states were not in a position to meet the costs involved. But now MMP has become almost universal across India, with broadly similar norms.

A similar programme in Pakistan, suitably adapted to local requirements, can achieve similar results. There is no reason for it not to. School meals are the most direct route to improving children’s nutrition. Since meals are served in school, children have an incentive to attend. This will improve enrolment and completion rates.

There are more than 107,000 government primary schools in Pakistan. If provision of cooked meals is assigned to local women whose children study in these schools, this will generate at least as many jobs for poor women. Not a mean achievement by itself.

Perhaps like India we can start with providing dry ration to children. With the exception of the current year when we are facing a wheat deficit, throughout the past decade federal and provincial granaries have held surplus stocks of millions of tons, which could not be exported or otherwise disposed of sans a massive government subsidy. Rather than allowing these stocks to rot in government godowns, why not distribute them to schoolchildren?

If every child attending a primary school is provided a packet of 10 kg per month for nine months in a year, this will require 1.3 million tons of wheat. Only one province, Punjab, has held larger leftover stocks in government granaries in eight out of the last 10 years. It’s a shame that we have consistently held significant surpluses of wheat in government granaries and yet 29% of our children are underweight.

The problem with dry rations, however, is that they become part of the overall household food stock without any guarantee that children will get a preferential share. They may also end up in the local market. Cooked meals, on the other hand, are sure to reach the child, and only the child who is attending school on a given day. They also generate local employment. So, they should be the preferred medium- to long-term intervention.

For sure, a large programme like this will cost money — lots of it. For around 9.8 million children enrolled in the primary stage in government schools, provision of meals at the rate of Rs40 per day for 170 schooldays a year will cost around Rs67 billion. Sounds expensive? Think again — the cost of child malnutrition is much higher.