SAFANSI The South Asia Food and Nutrition Security Initiative guiding policy and investment in human nutrition in four provinces of pakistan Female and childhood malnutrition rates in the While a country-wide Pakistan National Nutrition Islamic Republic of Pakistan are among the Survey was carried out in 2011, the four provincial highest in the world. The effects of malnutrition governments of Balochistan, Khyber Pakhtunkhwa, are generally divided into stunting, which refers Punjab, and Sindh undertook their own reviews to height deficit by age, wasting, which refers to to guide public policy directed at improved weight deficit by height, and underweight, which nutrition in the years that followed, and to inform refers to weight deficit by age. Some 43.7 percent provincial strategies for program development of children under five years of age in Pakistan and investment. These included assessments of exhibit the effects of stunting, and the country prevailing rates of stunting, wasting, underweight has the second highest rate of severely wasted and overweight people, and micronutrient children in the world. deficiencies, focusing on particularly debilitating ones such as vitamin A, iron (anemia), and iodine. The persistently high burden of malnutrition in The assessments would help determine priorities Pakistan and generally low level of investment in for policies and interventions that target human interventions to address the issue were documented nutrition-related objectives, including those which in a series of articles in the British medical journal are especially applicable and cost-effective in the The Lancet following severe flooding in 2010 and shorter term. 2011 that exposed the extent of the problem. The World Bank responded to the series by initiating This focus on the most practical aspects of food dialogues with the Government of Pakistan and and nutrition security reflects the priorities and other partners concerning systematic surveys of objectives of the South Asia Food and Nutrition nutrition outcomes. Security Initiative, more often abbreviated as “SAFANSI,” which actively supported the research undertaken by the planning and development departments of the four provinces. Whereas notions of food security and malnutrition have often been conceived of rather bluntly in terms of sufficient caloric intake, SAFANSI’s treatment of nutrition security focuses on the micro- and macro-nutrient content of the calories consumed as well. The need for this attention to dietary quality has become more urgent throughout much of the South Asia region, in a context of economic growth, increasing agricultural productivity, and declining poverty rates, in which much of the food that has become available and affordable lacks nutritonal value. Public investment in agricultural interventions that effectively promote food security are The drivers of consumer preferences and behavior more likely to purposefully target women farmers and household gardeners, given their can be complex, and often include the aggressive roles within the household and the tasks they carry out in production for home consumption. (Photo: Rama George-Alleyne / World Bank) marketing of highly processed, low quality foods. August 2018 South Asia Region And longstanding constraints to the delivery of Governments approach human nutrition through highly nutritious but generally more perishable their respective line ministries and the agencies foods, such as limited cold storage facilities, that fall under those ministries’ jurisdiction – a persist through much of the region, particularly division of labor and responsibility defined by in the remote, rural areas characteristic of much academic discipline and professional field that of Pakistan. SAFANSI represents an adaptation is generally paralleled in the organization of by the World Bank and its partners in South Asia international development agencies. to purposefully accommodate this broader notion of food and nutrition security and more complete Food production and supply makes agriculture understanding of what malnutrition may consist of. an intuitively straightforward sector of the economy to start at, though issues concerning A perspective that entails how human development food availability, accessibility, and quality make affects economic development is a useful starting agriculture’s role in food security (not just supply) point. It can be used to clarify how investment more complicated than it first appears. Access to in areas such as the biofortification of foods and sufficient and sufficiently nutritious food is clearly education about diets may lead to results and affected by commodity prices and how affordable outcomes in the wider economy, and to how it food is to households in different income relates to development effectiveness. The causal categories. Yet access also varies depending on relationships between health and economic growth how food is distributed within households, and are often referred to in terms of “pathways.” even in households that are classified overall Pathways through which poor nutrition impinges as food secure, certain members suffer from on economic growth include its direct effects on malnutrition. individual productivity, particularly in physically demanding jobs. A somewhat less direct pathway In Punjab for instance, SAFANSI-supported is through the effects malnutrition has on cognitive research found stunting to be evident among at development and a child’s learning potential - least one quarter of young children living in food effects which wield a well-established negative secure households – a proportion that increases impact on earnings later in life. A third pathway to 32 and 42 percent among children living in food is manifest mainly through the costs incurred by insecure households without hunger and food generally poorer health and greater vulnerability insecure households with hunger respectively. to infection of individuals who have experienced episodes of malnutrition. The upshot of this type of finding is that public investment in agricultural interventions that All of these entail long term consequences of poor effectively promote food security are more likely to nutrition outcomes that not only include pre-natal purposefully target women farmers and household and early post-natal development, but which are gardeners, given their roles within the household most severe and lasting when experienced in the and the tasks they carry out in production for home first thousand days of life. Targeting this window consumption. These roles make them central of time therefore presents itself as an urgent agents in promoting the diversification of the priority in the provision of health services, though foods that are available to their families, including recent evidence points to the pre-pregnancy small livestock husbandry. The diversity of the nutritional status of women having even greater foods available to households through their own significance. And they immediately point to the production or through the market proves far more remarkable cost effectiveness of investments in significant than the quantity of food produced. vitamin and mineral (micronutrient) supplements, iron and iodine fortification of foods, and school- Women, and younger women of reproductive age based nutrition and health programs. in particular, are also natural and urgent priorities for health services that aim to improve nutrition 2 outcomes. The outreach of these health services tends to rely heavily on how well-informed the women are about matters such as diet quality, immunization, and sanitary behaviors like hand washing before handling food. It also depends on their awareness of what to do, and what kind of health practitioner to consult, in case of serious conditions like diarrheal infections among children. Increasing female school enrollment is a priority in each of the four provinces. Proper techniques of breastfeeding and the timing and sequence with which semi-solid foods are introduced into children’s diets carry significant advantages to the long-term health and well- being of nursing women as well as their children, and this is something that is critical for women It is critical for women and mothers to be well-informed about matters such as diet to be aware of. All of the four provinces analyzed quality, immunization, and sanitary behaviors like hand washing before handling food to improve nutrition outcomes. (Photo: World Bank) in the Pakistan health policy reviews pointed to these as major areas in which policy can be brought effectively to bear on the poor state of The four nutrition policy guidance notes prepared maternal and childhood nutrition in the country. for Balochistan, Khyber Pakhtunkhwa, Punjab, And the education of girls, long before they are of and Sindh stress the practical significance of reproductive age, yields benefits that cut across inter-sectoral coordination between agriculture, all the “sector” lenses through which public policy education, water supply and sanitation, and social views human nutrition issues. Educated women safety nets. The effective work of each sector are far more likely to avail themselves of health and the ministries and agencies responsible for services and to understand the essentials of them are aptly represented as necessary but hygiene, as well as to command higher incomes and not sufficient conditions to improved nutrition have access to more employment opportunities. outcomes. Progress in each respective field is They also tend to play more prominent roles in moreover recognized as contributing to overall household decision making about how income is economic development by ensuring a healthier, spent to satisfy the needs of household members. more productive workforce, reduced exposure to These findings are corroborated by SAFANSI- poverty and food insecurity, lower rates of illness, supported research elsewhere throughout the and higher incomes with fewer costs. South Asia region, as well as by similar studies in other regions. The recommendations presented in the policy guidance notes are organized into interventions, Water supply and sanitation is another sector coordination between sector agencies, and issues that relates directly to nutrition because even that apply to nutrition but transcend any one with adequate food intake, diarrheal and other sector – principally gender and private sector infections deprive the body of its ability to absorb investment. The private sector is seen as playing and utilize nutrients. The safe handling of water is a particularly important role in supplying essential a major issue. Even in a setting such as Sindh, in commodities like soap, nutritional supplements, which 85.7 percent of households use water that and fortified foods as well as in marketing is safe at its source, pathogens have numerous messages that aim at promoting their use by opportunities to enter the water supply during consumers. It is also seen as a major actor in the collection, storage, and transport. provision of medical facilities. 3 Percentage of children under 5 affected The resulting clarification of priorities has been instrumental in guiding program development and increasing investment. This in turn has led to Stunting Wasting a gradual expansion in the coverage of integrated Underweight packages of health-related interventions. It has also seen a marked improvement in the 52.2 49.8 47.8 understanding of what greater cohesion consists of when rolling out interventions in multiple 39.6 40.5 39.2 sectors, and between those in agriculture, social safety nets, education, and water supply and 29.8 sanitation in particular. 24.1 16.1 17.5 17.3 SAFANSI has played a catalytic role in defining 13.7 and advancing the food and nutrition agenda in the World Bank’s work program in South Asia, Balochistan Sindh Khyber Punjab as well as in governments in the region, where policy makers’ commitment to nutrition-sensitive food and agriculture systems has become more Percentage of children affected pronounced. The Initiative’s first phase was carried out between 2010 and 2015, and the development of its second phase, launched in December Idone** Iron* of 2014, was informed by the experience and Vitamin A* lessons derived from its first five years. Phase II 73.5 72.5 is financially supported by the United Kingdom’s 68.5 Department for International Development (DfID) 56.8 60.3 and European Commission, while the World Bank 53.3 51 continues to serve as its trustee, responsible for 47.3 its administration, program development, and 39 oversight. 35 35 26 Balochistan Sindh Khyber Punjab ** School age children * Children under five Partners SA FANSI Administered by: This results series highlights development results, operational innovations and lessons emerging from the South Asia Food and Nutrition Security Initiative (SAFANSI) of the World Bank South Asia region. Disclaimer: The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Executive Directors of the International Bank for Reconstruction and Development / The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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