Ehsaas Nashonuma: Nutritional interventions to prevent stunting in children

Since 1967, which is when the first national nutrition survey was carried out in Pakistan, trend lines tracking nutrition outcomes have failed to show remarkable change.

Rates of stunting, wasting and underweight currently stand at 40.2 percent, 17.7 percent and 31.5 percent, respectively as shown by the 2018 National Nutrition Survey. In 81 districts, the prevalence of stunting is higher than 40 percent and in 34 districts (Kalat, Kachi, Hangu, Vehari, Poonch, Badin, Tharparkar, Kharmang, Kharan) the stunting rate is higher than 50 percent. Stunting leads both to physical as well as cognitive impairment; that in turn undermines human capital development with negative consequences for national growth and progress.

Stunting is a problem of deprivation with many drivers. It isn’t just food insecurity, income poverty and inadequate dietary intake but a range of factors related to food systems, household conditions, maternal factors such as age at marriage, the duration between two pregnancies, repeated infections and health seeking behaviours that are at play.

Given varied causal factors, policy prescriptions are equally diverse, and fall within the mandates of many ministries. Addressing poverty and food insecurity, investments in water, sanitation, living conditions and health systems as well as girls’ education and empowerment are critical. In a recent multi-country study, economic growth, remittances, land reforms, as well as social protection have emerged as strong remedies to address stunting.

Although a whole-of-government effort is needed to prevent stunting, studies have shown that social protection can play an important role through conditional cash transfers. This can enable access to the most vulnerable and prevent another generation from becoming stunted.

With this in view, the prime minister in his maiden speech to the nation signaled action against stunting as one of his policy priorities. Early on in the tenure of the government, we embarked upon a process to design a health and nutrition conditional cash transfer programme. Today, Ehsaas Nashonuma is rapidly being deployed nationwide. The programme aims to prevent stunting in children and is focused on the first 1000 days of life, as beyond that, stunting becomes irreversible.

Pregnant and lactating women (PLW) and their children less than two years of age from Ehsaas beneficiary families are the target group. Benefits include quarterly conditional cash transfers which are weighted in favour of the girl child. The cash benefit is linked with consumption of Specialized Nutritious Food (SNF), health awareness sessions, antenatal and postnatal checkups and immunization. SNF is packaged as sachets for the programme and beneficiaries get a three-month provision of 90 packets. They are meant to bring back empty sachets as evidence of consumption to get a refill and their cash transfer. Benefits are limited to two children so as not to create a perverse incentive.

There are several innovations in Ehsaas Nashonuma. First, Ehsaas Nashonuma’s programme design of encouraging consumption of SNF alongside health interventions, make it a first of its kind, globally. In other global nutrition programmes – Bolsa Familia in Brazil and Progresa in Mexico – awareness sessions and immunisations are typically tied to cash but consumption of SNF is not.

Second, the design of Ehsaas Nashonuma reversed the way development projects are executed in the country. Since the era of the MDGs, the global convention has been for development partners to design and fund programs and for governments to execute. In this case the government has a political commitment to address Stunting; it has allocated its indigenous budget and has contracted a UN agency with expertise in SNF production and supply chain management, to help execute this program.

The third factor relates to building synergy. Previously, Unicef had set up ‘treatment rooms’ in district hospitals to address malnutrition. Specialised food sachets were given to malnourished children. Although this intervention was valued by communities, it was not supported by governments beyond provision of physical space. Now, Ehsaas Nashonuma has integrated malnutrition treatment in its scope and has also linked cash transfers to consumption of these malnutrition sachets.

We commenced planning in early 2019. By end 2021, we had deployed 50 centers, in 15 districts and had completed an evaluation, which provided the evidence and rationale to upscale Ehsaas Nashonuma nationwide. Evaluation showed that Ehsaas Nashonama intervention improved overall wellbeing of mothers and children after inclusion of specialised food in their diet. In addition, cash transfers helped women acquire self-reliance and self-dependency.

The Covid context was an imperative to accelerate the upscaling of Ehsaas Nashonuma given the potential risk that families would resort to negative coping strategies. We hope to complete the building of Ehsaas Nashonuma centers in every district of the country by the end of this financial year.

The government is supporting purchases and institutional distribution of Specialized Nutrition Food through Ehsaas Nashonuma for families in the lowest quintile – or the Ehsaas beneficiary families. However, since stunting is also prevalent in higher quintiles and in families belonging to affluent classes, we hope the product will also be made commercially available, so that those who can well afford this product are able to access it and prevent their next generation from getting stunted.

The writer is a senator and special assistant to the prime minister for poverty alleviation and social safety. She tweets @SaniaNishtar