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.
The writer is a
human rights activist and development practitioner with a Masters in Human
Rights from the London School of Economics. He tweets @amahmood72
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