After a lost decade, there is clearly a groundswell of momentum for nutrition in Pakistan, driven by a confluence of policy, evidence and events. This momentum needs to be sustained at the national level, reinforced at the provincial and sub-provincial levels, and converted into action. The articles in this IDS Bulletin highlight some of the key features of undernutrition in Pakistan and its drivers. The correlates of undernutrition in Pakistan are no different than any other country: infection, poor diet quantity and quality, and unequal gender relations. High levels of poverty and fragility make the context for undernutrition reduction more difficult. Yet, the articles here also show that government nutrition interventions can work. But if the logjam of malnutrition in Pakistan is to be broken for good, malnutrition will have to be viewed as a development outcome – one that is a foundation for other outcomes such as economic growth and social cohesion – and this will only be achieved by viewing nutrition through a political-economy lens.

In 2010 Pakistan experienced the worst floods recorded in its history; millions of people were affected and thousands lost their lives. Nutrition assessment surveys led by UNICEF were conducted in flood-affected areas of Punjab and Sindh provinces to assess the nutrition status of children between 6–59 months while Aga Khan University (AKU) undertook a parallel assessment including micronutrient status in their project areas within Balochistan, Sindh and Punjab. Standardised Monitoring and Assessment of Relief and Transition (SMART) methodology was used. 881 children from Sindh, 1,143 from Punjab and 817 from AKU project areas were measured for anthropometry and their households were interviewed. The findings indicated that while immediate life-saving interventions were essential, there was also an urgent need to address chronic malnutrition. Through high-level dissemination of the survey results, treatment and prevention of malnutrition has become a priority for the provincial and federal government in Pakistan and for donors.

The 2011 National Nutrition Survey (NNS) in Pakistan showed that Sindh province continues to have some of the worst undernutrition rates in South Asia. For determinants of acute and chronic malnutrition to be better understood, Action Against Hunger (ACF) conducted a Nutrition Causal Analysis (NCA) in two districts of Sindh province, where persistently critical prevalences of wasting were recorded, for example, Dadu district with GAM and SAM rates at 19.5 per cent and 5.3 per cent respectively (October 2011). ACF findings confirmed that Infant and Young Child Feeding (IYCF) practices do not receive the attention required to prevent the irreversible damages caused by undernutrition when occurring during the critical 1,000 days window. The study also showed a high occurrence of illnesses related to poor access to water and sanitation infrastructures, as well as a high level of poverty paired with the lack of alternative income sources.

Food security will remain an important component of any strategy for nutritional improvement in Pakistan. The country experienced acute price spikes and shortages during 2007 and 2008, corresponding with food price inflation and volatility in global markets. This led to the clearer articulation of a food security approach based on a closer alignment with world prices and the establishment of a cash transfer programme to compensate poor households. This article presents the results of a qualitative study of food security among rural and urban households in selected regions to better understand the perceptions, behaviour, processes and coping strategies of the poor with regard to food security in general, and price shocks in particular. The study offers insights into gaps in existing policy approaches to food security and potential areas of pro-nutrition policy change.

We independently conducted the impact assessment of the Tawana Pakistan Project (a school-based feeding programme to improve the nutritional status of primary school girls in impoverished rural districts of Pakistan). The evaluation was conducted among school-going girls in four districts of Sindh, Pakistan. Pre- and post-intervention data was collected for anthropometric measurements, nutritional status and physical examination. Paired analysis of 1,028 girls (5–12 years) was undertaken using McNemar's test.¹ Our findings revealed a significant association of the school-based nutrition programme with reductions in the proportion of wasting (p<0.0001; CI 12.2%–15.7%) and underweight (p<0.0001; CI 9.2%–14.5%) while no association was established for stunting (p = 0.0817; CI 0.3%–5.5%). The results support the potential for such programmes in improving the nutritional status of primary school girls in impoverished areas and gains in health and improved growth.

This article presents findings of cognitive and performance assessment among recipient and non-recipient school girls in the catchment schools of the Tawana Pakistan Project using standardised matrices. This is the first such evaluation of the relationship of a school feeding programme with developmental outcomes in rural Pakistan. There was evidence of benefits of the school feeding programme on a range of outcomes with significant improvement in the literacy and numeracy scores. The paired analysis showed a significant improvement (p<0.001) in Raven's Coloured Progressive Matrices and Draw-a-Person test while no association was established in grade performance assessment (GPA). The correlation analyses in terms of the effects of intervention on child cognitive development confirmed the positive correlation in all aspects. DID estimates also revealed an improvement in cognitive outcomes due to the programme. Findings support such potential programmes for improving educational and cognitive outcomes of primary school girls in impoverished districts of Pakistan.

This article aims to describe the history, progress, success and challenges of the Universal Salt Iodisation (USI) programme in Pakistan, which was launched in 1994. Revitalised in 2005 with financial assistance and technical, operational, logistic and commodity support from the Micronutrient Initiative (MI), it is now being implemented in 102 districts of Pakistan. With an increase in household utilisation of iodised salt from 17 per cent in 2001 to 69 per cent in 2011, severe iodine deficiency among women and school-aged children has decreased to 3 per cent and 2 per cent respectively. Strong government ownership and commitment, coupled with effective monitoring and supervision, have been the driving force of the USI Pakistan programme. These, combined with quality control measures, stringent regulatory and enforcement mechanisms, availability of fortificants in the open market and demand generation are the necessary requirements for programme sustainability.

Results of the latest nationwide nutrition survey show that the ‘South Asian paradox’ of persistently high rates of undernutrition despite respectable rates of economic growth appears to hold true for Pakistan. Although nutrition has largely been framed as a health issue in Pakistan, it is an outcome of complex processes. Amongst various economic sectors, agriculture – a sector that employs 45 per cent of the workforce in Pakistan – might have direct implications for nutrition outcomes through drivers such as the availability and diversity of food and income distribution. Using evidence from Pakistan, this article reviews trends and policymaking in agriculture and applies a framework for analysing pathways between agriculture and nutrition. It then goes on to highlight potential disconnects in the agriculture-nutrition linkage and identifies areas for future research.

After two decades of failed efforts to launch a national nutrition programme and nutrition action largely limited to low coverage interventions, a promising multisectoral nutrition scenario is unfolding in Pakistan led by provincial and regional officials and a well-coordinated group of development partners. The process has emerged from the confluence of three recent events in the country: the floods of 2010 and 2011; the passing of a constitutional amendment in 2010 which had the effect of dissolving the federal government's Ministry of Health and devolving responsibilities for health and nutrition to the provinces and regions; and a National Nutrition Survey in 2011 with results indicating that chronic malnutrition in the country had actually deteriorated over the previous decade. This article discusses the paths leading from these events to the present opportunities to address malnutrition aggressively and systematically, examines the sensitisation, advocacy and strategy development processes employed, and presents both the potential promise and the risks involved in the new provincial and regional nutrition undertakings.

This article uses the Tawana Pakistan Project (TPP) as a case study of how to promote self-sustaining improvements in nutrition status. The programme used a participatory approach to mobilisation around malnutrition, had a transparent information system for monitoring resources, and brought a focus on deeper structural issues to the analysis of malnutrition. We argue that Tawana was cancelled because it did not provide sufficient opportunities for leakage and diversion. This amply illustrates the political nature of nutrition. Yet efforts to reduce malnutrition continue to focus primarily on technical fixes. For long-term change researchers and programme implementers will need to understand the political space they operate within. Tawana was not perfect but it offered a glimpse of a different way forward, one that struck a balance between inclusiveness and action; transparency and accountability; and health and social science perspectives. It affected politics and was undone by them. It is not too late to include these concepts and approaches in future nutrition policies and interventions.

In this article we take a comparative look at strategic opportunities and barriers for action on nutrition in Pakistan's four provinces in the post-devolution context. Provinces have faced historically common constraints of lack of a comprehensive policy and minimal allocations by the state, driven by low visibility of nutrition, siloed working of sectors and weak coalitions. Provinces also face common contextual impediments of poverty, patriarchy, and inadequate health and WASH coverage, with two provinces also constrained by inequitable power structures. Recent focusing events have provided a window of opportunity to the provinces for action on nutrition leading to definite movement towards horizontal coordination for nutrition, upscaled funding and stronger vertical integration. However, there are variations in the extent of coalition building on nutrition, supportive leadership, governance and community outreach. The Pakistan experience shows that strategising for nutrition needs to move beyond a closely tailored national policy to accounting for sub-national potential and constraints.

This article looks at the post-disaster context of Lower Sindh, a region devastated by super floods in 2010 and 2011, in an attempt to understand what government policies were implemented to assist people whose lives had been washed away. Based on fieldwork conducted in three districts of Lower Sindh this study emphasises that while a general narrative seems to suggest that the Pakistani state's post-disaster policies and interventions were insufficient, ineffective or both, there is significant evidence to demonstrate the relative success and universal outreach of government interventions. This also had a significant impact on food security in the aftermath of the disaster. The government response to the floods has in fact contributed towards a fundamental shift in state-citizen relations. This underdeveloped and still emerging ‘disaster citizenship’ in Pakistan is based on entitlements and rights rather than a citizenship more commonly understood to be based on identity, kinship or patronage.