Malnutrition and lack of fortified food is one of the biggest challenges in Pakistan. Maternal and neonatal death occurs due to lack of nutritious and fortified food. Across the world, billions of people suffer from at least one micronutrient deficiency – be it Vitamin A, Vitamin D, Iodine Iron etc.

According to findings from the 2011 National Nutritional Survey in Food Fortification  more than 50% of children were vitamin A deficient. About 40% of women and children were deficient in zinc, and 70% of pregnant women and 40% of children were deficient in vitamin D. Moreover, persistent high rates of stunting (44%) and wasting (15%) among children under five are an important reminder that children are currently being denied their human right to nutrition.

According to finding from the Multiple Indicators Cluster Survey, 2014 (MICS, 2014):

In the comparative analysis of Punjab and Sindh, the indicator prevalence rate of Sindh province is headed upward, while contraceptive prevalence rate is going downward as compared to Punjab. These indicators are also reflecting the crises of children under five.

Nutrition has thus received little attention from policymakers and it has historically been dealt with through a “project-based approach under Planning Commissions documents (PC1s)”. It is important to understand that nutrition is not a standalone subject and needs to be addressed through legislation and mandated through multi-sectoral approaches.

The 18th Amendment gave provinces a big opportunity and provinces started work on their nutrition guiding notes and strategies. In Punjab and Sindh, 'Inter-Sectoral Nutrition Committees and Technical Working Groups' have been set up, with support and lobbying from UNICEF, the World Bank and UN agencies. However, the ownership and capacity of Punjab and Sindh government to tackle malnutrition remains to be comprehended.

Planning & Development (P&D) department may play a pivotal role in ensuring accountability in the implementation of Multi-Sectoral Nutrition Strategy, 2015 through its “Inter-Sectoral Nutrition Committees and Technical Working Groups” in Punjab and Sindh. Similarly, there needs to be devolution to local government system aimed at institutionalizing citizens’ participation through institutionalized local governance system. There also needs to be devolution of administrative, political and financial responsibility and authority, which provides another big opportunity for local governments to devise strategies, plans and legislation according to the needs and demands of citizens.

It was on January 6, 2015 that Planning and Development Department Punjab approved Multi-sectoral Nutrition Strategy 2015 for implementation at all levels. There is an urgent need for the true implementation of the strategy and a great responsibility lies on government representatives of health, education, agriculture, food security and social safety nets programs who need to concentrate on their roles and responsibility. For, malnutrition is an issue faced by vulnerable and marginalized families, those who don’t have access to resources and government services. Therefore, it is the responsibility of the civil servants to reach out to those who are beyond their access and save their lives.

It is noteworthy that budgetary constraints always remain an obstacle in the implementation of policies, legislation, programs and schemes at various levels of government, particularly at the districts or local government levels. The critical factor behind budgetary constraints is that at the district level, particularly the health department, there is no critical gap analysis of previous budget utilization and concrete planning for next fiscal year budget. Hence, there are untimely budgetary constraints in the head of medicines, maintenance, supplies and development schemes.

There has to be need-based, and critical gap analysis based, budgetary planning. Local government system may provide sound foundation for concrete budgetary planning through local level district chairman, vice chairman, union council level chairman and vice chairman according to the needs of citizens and critical gap analysis of past budgets. It is important for the district chairman and vice chairman to constitute oversight committee budget planning for the next fiscal year, which must bridge the gap between district and union council level institutions in formulation of legislation and providing recommendations for budgetary allocation for health, nutrition, agriculture and education.

Under the Local Government System Act 2015, establishing health authorities may provide sound grounds in result-based planning of budgets. I am sharing a Punjab district trend analysis of medicines allocations in district Layyah in the below table:

The trend analysis of medicines allocations in district Layyah reflects downward movement in the budget allocations, released and utilization as against upward movement in the budget demanded over the period of analysis. The medicine budget allocated in fiscal years 2014-2015 to health institutions of Layyah was Rs.58.06 million as against allocations of Rs.74.73 million. Therefore, it is obligatory that district level health management must do realistic planning according to the previous budget utilization analysis and critical gap analysis of budget utilization.

Rationally, food fortification is the answer to the greatest challenges of maternal and infants’ deaths caused by malnutrition. Fortification is a complementary strategy to combat malnutrition. Food industries are the vehicle to make food fortification happen. According to expert opinions, fortified edible oil and wheat flour are great carriers of micronutrients for children and mothers. If people are unable to get nutritious food then it is the easiest route to fortified, edible ghee/oil, grain floor, salt, rice, which automatically provide nutritious diet to people. Thereby, it is the biggest responsibility of food industrialists to revise and amend their strategies according to the current dismal situation of malnutrition and provide fortified food to the consumers.

We need to divert our attention both at the supply side and demand side of Food Fortification i.e. Advocacy & Lobby with food industries to provide us “fortified food” and Advocacy & Lobby with state to “legislate” for making food fortification mandatory in Pakistan as well as to empower citizens/consumers through public advocacy.

We don’t have to reach the perfect solution. Food fortification is a good solution for combating malnutrition which is time tested, cost effective and proven. We can fight against vitamin, minerals, Iren and folic acid through fortification. The immediate and best policy level action requires legislation to make fortification mandatory across Pakistan. It is the citizens who have to make the conscious choice.

It has been shown that successful implementation of a sustainable food fortification programme requires a regulatory environment wherein appropriate government legislation is enacted and systems exist through which compliance can be effectively monitored and enforced. Therefore, we ask for help in urging leaders of the state to raise budgets for nutrition; making sure the true implementation of Multi-sectoral Nutrition Strategy, 2015; mandating the legislation on food fortification across Pakistan; building the technically capacity of food inspectors; increasing the quantity of food inspectors; urging food industries to provide fortified food and improve nutrition for all children and women; and taking strategic actions for formulation and implementation of standardized protocols for inspection and sample collection from manufacturers and markets.

It is noteworthy that in April 2013 Pakistan joined the Scaling up Nutrition (SUN) a global initiative which is under the overall supervision of Planning & Development Department at the federal level. SUN is an opportunity for the national and provincial governments to draw on the support of international donors, UN agencies, and civil society to make progress against malnutrition. Academia and Research Networks is in place in P&D at the federal level. Food Fortification Alliance comprising of representatives from INGOs, UN, Donors and civil society is working at the federal level. The only need is regulatory environment in which appropriate government legislation is enacted and systems exist through which compliance can be effectively monitored and enforced.

It is sad to note that in Pakistan epidemics related issues or emergency related issues gain importance on when government immediately takes actions like dengue fever in Punjab, polio cases etc. But realistically, we have to stand at the forefront of developing countries, those who we are competing against in Sustainable Development Goals. Now, Sustainable Development Goals are chasing us to save the lives of mothers, infants and children in Pakistan.

Last but not the least, we urge food industries, flour mills associations, food technology institutions, academia particularly edible oil/Ghee, wheat flour and rice to provide fortified food. We urge government of Pakistan to form Cabinet committees at the federal and provincial level for the formulation of legislation on food fortification as it is the only solution for tackling malnutrition holistically. We urge citizens of Pakistan and consumers to raise demands to food industries for the provision of fortified food. We urge food authorities to strictly monitor the compliance for food industries. We demand that food authorities be established at the regional and district level while integrating with the provincial level food authorities. Food authorities must be mandated with ensuring monitoring of compliance within the food industries. We urge local governments to put demands and recommendations for food fortification and nutrition friendly legislation

This will allow us to save lives of dying mothers, infants and children. We are accountable for provision of transparent services to the vulnerable and marginalized citizens of Pakistan.