Country of ‘first boys’: nutritional inequalities

Pakistan’s progress to tackle severe malnutrition among children under five has been quite slow

By Mustafa Talpur
June 11, 2024
Flood victims gather to receive food handout in a camp following rains and floods during the monsoon season in Sehwan on September 14, 2022. — Reuters

The failure to provide equal education and health opportunities when combined with the denial of equal access to basic nutrition adds to the miseries of the already underprivileged people and brings lifelong disadvantages affecting both the cognitive and physical wellbeing of last children, especially ‘last girls’.


The failure to provide basic nutrition to a majority of children who are supposed to be the future of the country means that the entire country relies on a few hundred thousand ‘first boys’ who attend elite private schools; are well-nourished; and have access to the best healthcare system.

There is no other injustice which society can inflict than excluding a majority of our future generation from enjoying well-deserved freedom from hunger, disease and illiteracy. Will ‘first boys’ always control politics, economy, public institutions and bureaucracy for this unfortunate nation of 230 million people? An important question is: can the wisdom of a tiny minority of ‘first boys’ find the best solutions to complex world problems and lead the nation, or shouldn’t these injustices end for the betterment of all?

Pakistan’s progress to tackle severe malnutrition among children under five has been quite slow. The country has the highest malnutrition rate in South Asia. All key nutrition indicators, including stunting, underweight, and wasting rates, remain significantly high in comparison with other South Asian countries. The prevalence of stunting in Pakistan is 40 per cent among children under five.

According to the National Nutrition Survey 2018, 40.2 per cent of children under five are stunted; 17.7 per cent suffer from wasting; and 28.9 per cent are underweight. Even the prevalence of stunting, wasting and underweight in war-torn Afghanistan is lower than that in Pakistan.

The average national stunting rates mask large variations among provinces, urban and rural areas and different income groups. The incidence of stunting in urban areas is 34.8 per cent while it is 43.2 per cent in rural areas of Pakistan, revealing the urban-rural divide. There are also major disparities among provinces. Stunting in Punjab is 36.4 per cent, lower than the national average, while in KP, it is 40 per cent – close to the national average. In Sindh and Balochistan, stunting among children is 45.5 per cent and 46.6 per cent respectively – above the national average.

It is alarming to note that child stunting in the rural areas of Sindh is 62 per cent – six out of 10 children under five in rural Sindh are stunted, the highest among all the provinces. The rural stunting rate in Punjab, KP and Balochistan is 32 per cent, 42 per cent and 47 per cent respectively.

Geography and income are the defining factors of malnutrition among children. For example, 22 per cent of children in the top 20 percent income group are stunted, while 62 per cent of children from low-income groups are stunted. The same is the case with the urban-rural divide, especially in Sindh.

Stunting reduction in Pakistan is slow. According to the National Nutrition Survey 2018, the prevalence of stunting in 2001-2 was 41.6 per cent which reduced to 40.2 per cent in 2018 – a reduction of only 1.4 percent in 16 years. Pakistan’s demographic and health surveys show some improvements from 2012-13 to 2017-18. In 2012-13, there were 45.6 per cent of children under five years who were stunted. By 2018, this was reduced to 39.7 per cent (change of 5.9 percentage points), this is a little over 1.0 per cent per year. Even with this rate of progress, it will take 40 more years to achieve zero stunting. This means that Pakistan will be unable to achieve child nutrition by 2047, at the age of 100 years.

Fortunately, there is not much difference between boys and girls with regard to stunting. Stunting rates in girls are lower than that in boys, which is slightly good news. However, gender-segregated data of different income groups is not available.

The nutritional status of women is also a factor of poor birth outcomes and underweight babies. In Pakistan, 5.0 per cent of women are shorter than standard, and 9.0 per cent of women are underweight. Women in rural areas are more likely to be shorter in height than women in urban areas. In Sindh, 6.2 per cent of women are shorter compared to the national average of 5.0 per cent and 5.4 per cent, 1.9 per cent and 4.2 per cent in Punjab, KP and Balochistan respectively.

Nutrition is a complex and multifaceted issue with many factors contributing to malnutrition. It is not just poverty and lack of access to food, because the prevalence of stunting is also high in second- and middle-wealth quintile groups. Other factors that affect the nutritional status of children may include low drinking water quality; poor sanitation and hygiene facilities and practices; low access to or unavailability of healthcare services; and a lack of awareness among parents on the importance of early childhood nutrition.

Provincial and federal governmentss must prioritize child health, education, and nutrition to achieve the dividends of their young population in the future. Unless there is serious investment, institutional response, well-coordinated efforts by the federal and provincial governments, Pakistan may not be able to take a leap forward. An unskilled, uneducated and malnourished future labour force without adequate female participation will lead nowhere. Among all the provinces, Sindh lags in all three key indicators – education, health, and nutrition. Hence, it must redouble its efforts on an emergency basis to catch up with clear policy, an institutional road map and investment along with improving governance.

Considering the current political disarray; low or negligible priority and investment for education, health and nutrition; and poor governance including the declining performance of public institutions and the judiciary, there is less hope until this conversation becomes popular in society and mass mobilization compels those in power to act without any delay.


The writer is an Islamabad-based environmental and human rights activist.