Despite promising improvement, Pakistan has one of the highest rates of under-five mortality in
South Asia. Data from 1990 to 2010 show that in the 1990s, Pakistan, India, and Myanmar
had the same under-five mortality rate; rates in Bangladesh and Nepal were higher. All of these
countries improved their rates in the following decade. By 2010, all had drastically lowered their
under-five mortality rates and are now on track to achieve their Millennium Development
Goals (MDGs).
In the Sindh Province of Pakistan, under-nutrition remains a recognized health problem and plays
a substantial role in the region’s elevated maternal and child morbidity and mortality rates. The
devastating burden of under-nutrition has lifelong negative consequences, including stunted growth
and impaired cognitive development. These can permanently disable a child’s potential to
become a productive adult.
In April 2010 the parliament of Pakistan passed the 18
th Amendment, which devolved 17 ministries,
including the Ministries of Agriculture, Education, Food, and Health, from the centre to the
provinces. This was the first time that such power was given to the provinces. Past decentralization
reforms had generally bypassed the provincial tier by decentralizing administrative responsibility
for most social services directly to the sub-provincial district level.
At the same time, there were significant changes in funding modalities. Although the 2010
devolution shifted financing responsibility for devolved ministries to provincial governments,
provincial funding allocations also increased substantially as a result of the seventh National
Finance Commission (NFC) Award of 2010. In Pakistan, the financial status of provincial
governments is dependent on federal transfers of tax revenues to the provinces through NFC
Awards. The 2010 NFC Award was significant because it increased the provincial share of resources
to 56%. It also introduced a more equitable distribution formula, which benefitted smaller provinces
by changing the calculation of the award from a population-based model to a new model that also
factored in economic backwardness, inverse population density, and revenue collection and
generation (Social Policy and Development Centre [SPDC], 2011).
In this report we take a look at strategic opportunities and barriers for action on under-nutrition,
particularly for women and children in Sindh Province in the post-devolution context. We will
assess underlying contextual challenges pertaining to nutrition, horizontal coordination for nutrition
across sectors, vertical integration of existing and past nutrition initiatives, funding, and monitoring
and evaluation, and identify several emerging strategic opportunities. Finally, we will summarize
salient findings and provide broad recommendations for further action in the province.