Stunting Reduction in Pakistan

Pakistan exhibits significant regional variations in geography and socioeconomic conditions, which directly impact nutritional outcomes such as stunting. Differences in income levels, health care access, and local interventions across provinces mean that national-level data may not fully capture the country’s progress or challenges. With the devolution of federal responsibilities to provincial governments, all four provinces assumed authority for providing social services, leading to variations in policy implementation and outcomes.

To better understand these disparities, our study takes a subnational approach, examining how different provinces have addressed stunting. By identifying areas of progress, the analysis highlights effective strategies and interventions that could be scaled or adapted to regions still facing high levels of childhood malnutrition. This localized approach offers valuable insights into what works and where improvements are needed. To build on recent reforms and harness the country’s potential, our research explored Pakistan’s progress between 2001 and 2018, examining subnational strategies for improving nutrition and reducing stunting. Throughout this narrative, key factors, interventions, policies, and programs that contributed to the decline in stunting will be featured, highlighting opportunities to learn from Pakistan’s progress.

Key insights

• Local tailoring of policymaking and governance: The 2010 devolution of power to Pakistan’s provinces led to improved social services and stunting outcomes, particularly in regions with prior experience in self-governance.

• Expanding social protection programs: Launched in 2008, the Benazir Income Support Program provides cash transfers to poor women, empowering households and aiding in poverty reduction, despite its limited direct impact on nutrition.

• Nutrition as a national and subnational priority: Nutrition became a policy focus after the 2010 floods, leading to the 2011 Integrated Nutrition Strategy and the launch of provincial stunting prevention programs in 2018.

Stunting remains a major challenge for low- and middle-income countries (LMICs). While global rates have declined, progress has been uneven, and many countries are not on track to meet global targets. However, some LMICs have made notable progress, reducing stunting among children under the age of five beyond what economic growth alone would predict.

To support government stakeholders in addressing malnutrition, the Exemplars team conducted research to identify key drivers of stunting reduction and variation between countries., Initially focused on national-level analyses, the research expanded to subnational studies, revealing that while some countries saw limited national progress, others achieved substantial reductions. By studying these “bright spots,” we can uncover effective, context-specific strategies.

As part of this effort, we examined the reduction of stunting in Pakistan, where progress has varied substantially across provinces. From 2001 to 2018, Pakistan’s per capita gross domestic product increased by 45%, rising from US$828 to US$1,198. During the same period, stunting remained relatively stagnant at the national level, decreasing by just over 1 percentage point from 41.5% to 40.2%. However, there was substantial variation at the subnational level and notable progress in stunting rates that underpinned this.

To capture these regional disparities and identify subnational learnings, the Exemplars research focused on Sindh, Punjab (Central, Southern, and Northern), Khyber Pakhtunkhwa (KPK), and Balochistan—regions selected for their differing trajectories in stunting reduction between the 2001–2011 period (when rates were stagnant) and the 2011–2018 period (when rates began to decline). Using a mix of quantitative and qualitative data, the research identified key strategies, policies, and interventions that contributed to progress in some regions while others lagged behind.

The provinces of Punjab and KPK emerged as exemplars in reducing stunting, driven by their early and sustained implementation of nutrition-sensitive interventions that addressed both direct nutritional issues and broader contributing factors. In contrast, the province of Balochistan has struggled to implement nutrition-related reforms. Sindh, despite policy shifts post-devolution, has focused primarily on nutrition-specific interventions that have yet to yield significant improvements. Our analysis found that progress in exemplar provinces resulted from improvements across multiple sectors, which are explored in greater detail throughout this narrative.

National trends

Stunting is driven by a complex interplay of factors, including immediate causes such as inadequate nutrition and infectious diseases, as well as broader influences like gender inequality and a lack of social sector investments. The conceptual framework presented below—developed across all Exemplars in Stunting Reduction countries—outlines these drivers and highlights the diverse factors that shape stunting prevalence.

By cross-referencing quantitative data on stunting rates with qualitative insights, our findings highlighted three national-level shifts around 2011 that played a crucial role in shaping Pakistan’s progress in addressing stunting and broader development challenges. Understanding these shifts—and identifying exemplars and lessons learned—will be crucial for improving child growth and development outcomes moving forward.

Local tailoring of policymaking and governance reforms

The federal government began a process of devolution in 2010, amending the constitution to transfer major responsibilities to provincial governments, with the intention of further decentralizing power to local governments. While initially challenging, this shift has led to tangible development gains, including increased investment in social services such as health and education. Although local elections did not take place until 2015, provinces with greater experience in self-governance saw better progress in reducing stunting.

Expanding social protection programs

In 2008, Pakistan launched the Benazir Income Support Program (BISP), an ambitious anti-poverty initiative that provides over US$1 billion in unconditional cash transfers to more than 5 million poor women. While BISP is not a nutrition program and has not directly impacted stunting rates, it plays a crucial role in poverty alleviation and requires further reform to maximize its effectiveness. By transferring money directly to women rather than heads of household, BISP empowers women and delivers financial support to vulnerable families. This marks a significant improvement over previous years when underfunded and underperforming public systems left many Pakistanis reliant on an uneven private sector, where high out-of-pocket costs often prevented the poorest from accessing essential services. Under the 2019 Ehsaas program reorganization, these reforms continue to contribute to poverty reduction efforts in Pakistan.

Nutrition as a national and subnational priority

Over the years, nutrition has gained prominence as a development priority in Pakistan. Before the devastating floods of 2010, direct nutrition programs were short-term, stand-alone, and donor funded. However, when it became clear that children in flood-affected areas suffered alarming rates of severe acute malnutrition, the government responded to the country’s overarching nutrition crisis by issuing the first Integrated Nutrition Strategy in 2011,, which focused primarily on food insecurity rather than nutrition more broadly. In 2018, three provinces launched stunting prevention programs. Although the implementation of the strategy faced challenges, it pushed nutrition to the forefront of the development agenda. In 2018, three provinces (Sindh, Balochistan, and KPK) launched their first ever stunting prevention programs.

Subnational (provincial) trends

Beyond national-level progress, our research highlights province-specific interventions that have contributed to reductions in stunting. Using data from Pakistan’s 2011 and 2018 National Nutrition Surveys, our quantitative analysis identified the following six key drivers that account for approximately 90% of the observed changes in height-for-age z-scores in the exemplar provinces of KPK and Punjab (Northern and Southern):

• Economic improvement: Rising household incomes and employment, coupled with expanded social safety nets, led to greater access to health care, nutrition, and education.

• Maternal nutritional status: Improvements in maternal health indicators, including body mass index, serum retinol, serum ferritin, and iron-folate levels, played a critical role in reducing pregnancy-related risks.

• Use of fortified foods and iodized salt: Increased consumption of nutrient-enriched foods, such as iodized salt and iron-fortified staples, helped prevent deficiencies and improve overall health.

• Birth history and family planning: Maternal age, parity (i.e., birth spacing), and the adoption of modern contraceptives contributed to a reduction in high-risk pregnancies and improved maternal and child health outcomes.

• Maternal and newborn health care: Greater access to skilled antenatal care providers and visits from Lady Health Workers (LHWs) ensured better prenatal, childbirth, and postnatal care.

• Household improvement: Improved living conditions, particularly through urbanization, led to better access to clean water, sanitation, and safe housing.

KPK, with its history of opposition-led political organizing, saw devolution as an opportunity to accelerate reforms that had previously been difficult to achieve. When the Pakistan Tehreek-e-Insaf party won its first provincial elections in 2013, it leveraged the province’s growing autonomy to advance its development agenda, including investments in nutrition and health. By 2018, KPK and Punjab—both of which had made notable progress in reducing stunting—were the only provinces to establish finance commissions for local governments, further strengthening decentralized decision-making and service delivery.

Provinces that performed well in addressing stunting also had more active programming in key areas of development. For example, KPK has led efforts to eliminate user fees at health facilities, Punjab has made significant strides in education, including initiatives to increase girls’ enrollment, and both provinces have implemented strong legislation to promote women’s empowerment.

National investment in nutrition improvement

The Nutrition PC-1 proposal, estimated at 10 billion Pakistani rupees (US$4.27 billion), has been put forth by federal stakeholders as a solution to address malnutrition in children under five, adolescent girls, and pregnant and lactating women. If put into action, the PC-1 would cover nearly 70 million people in 67 high-burden districts (out of 130 total)—making it one of the largest nutrition investments in Asia, and positioning Pakistan as a regional leader in addressing malnutrition.

The PC-1 proposes a wide range of interventions, starting with the creation of a centralized federal nutrition cell to establish guidelines in line with international commitments, strengthen capacity for the implementation of policies and practices on the ground, and boost research and advocacy activities. In communities, the PC-1 would improve both the quantity and quality of nutrition interventions by strengthening the Lady Health Worker program. It would increase the number of LHWs by 68,000 (there are approximately 100,000 now), reinstate refresher training that had been phased out in most provinces, supply LHWs with key medicines and supplements, and integrate LHWs into the existing health care systems for basic health units and rural health centers. As a result of these reforms, an adequate number of LHWs would be able to focus on providing the highest impact interventions. The PC-1 would also create a new cadre of nutrition counselors to provide equitable access to underserved areas.

While the PC-1 is a strong national initiative, strengthening provincial multisectoral nutrition strategies is becoming increasingly significant, given the shift to devolve governance. Using data to drive resource optimization, which is already happening in some provinces, is crucial to enhancing the effectiveness of these strategies. For example, the government of Sindh recently partnered with the World Bank to model the optimal resource allocation mix across 13 different nutrition interventions, based on current nutrition indicators by district, the impact of each intervention, and the cost of each intervention. This example of evidence-based analysis and stakeholder engagement around nutrition strategies could point the way toward accelerated progress—provided this plan can be ratified and implemented effectively. To date, however, this proposal has not been ratified and scaled.

Strengthening coordination, accountability, and resource allocation

Pakistan has yet to establish a comprehensive, coordinated set of multisectoral nutrition policies and programs. Post-devolution, several provinces developed their own nutrition strategies; however, coverage, quality, and effectiveness remain inadequate due to weak cross-sector collaboration. The federal nutrition cell proposed in PC-1 is a step forward, but additional measures—such as a central accountability mechanism and stronger federal and provincial alignment—are necessary.

A key component of better coordination is data-driven resource allocation. The Sindh–World Bank collaboration provides a model for optimizing funding across nutrition interventions. Expanding this approach nationally through regular public expenditure reviews could improve spending efficiency, track financial targets, and ensure that funds are directed toward the most effective programs.

Furthermore, a nationally coordinated, ambitious nutrition strategy—backed by scaled-up domestic spending and official development assistance—is essential for achieving success at scale. Without continued commitment and financial resources, the full impact of PC-1 will not be realized.

Expanding direct and indirect nutrition interventions

Addressing both direct and indirect determinants of nutrition is crucial for Pakistan’s progress. Among direct interventions, dietary diversity, optimal infant and young child feeding, and the reduction of micronutrient deficiencies require urgent attention. Given the high rates of food insecurity, which affects over one-third of the population (ranging from 0% to 98% across districts), Pakistan must go beyond PC-1’s limited supplementary feeding program, which primarily targets acutely malnourished children and mothers. Reducing chronic undernutrition and food scarcity, while also integrating climate resilience into nutrition policies, should be a national priority.

At the same time, improving water, sanitation, and hygiene (WASH) conditions is essential, as poor sanitation contributes to childhood illnesses and malnutrition. Many mothers avoid seeking health care due to inconsistent public health services, and instead rely on unskilled providers. Expanding WASH programming, particularly in fecal waste management and soil decontamination, along with improving the quality of public health services, could significantly reduce disease-related malnutrition.

Despite efforts to reduce malnutrition in Pakistan, several significant challenges persist. These can be broadly categorized into the following areas:

• Gender inequality and social determinants

• Food insecurity and dietary diversity

• Health system limitations and reproductive health care

Gender inequality and social determinants

Gender inequality is deeply entrenched in Pakistan and plays a critical role in driving malnutrition. Women and girls are particularly vulnerable to the effects of malnutrition due to socioeconomic inequalities and limited access to resources, including education. The female literacy rate stood at just 46% in 2019, far lower than the national average, which contributes to poorer nutritional outcomes for women and children. Early marriage also exacerbates these issues, with 18% of girls marrying before the age of 18 in 2017-2018., Moreover, malnutrition is often correlated with educational attainment, which is often limited for girls in Pakistan. Addressing these social determinants of health, especially through improved education and empowerment for women and girls, is crucial for reducing malnutrition and improving overall nutritional outcomes.

Food insecurity and dietary diversity

Pakistan faces significant challenges related to food insecurity, with more than one-third of the population affected. This food insecurity is compounded by poor dietary diversity, which exacerbates the risk of malnutrition, particularly among children under five, pregnant women, and adolescent girls. Many families, especially in rural areas, lack access to a variety of nutritious foods, and rely heavily on staple crops that are low in essential nutrients. Seasonal fluctuations in food availability further limit access to nutrient-dense foods, such as fruits and vegetables. Although the PC-1 includes a supplementary feeding program, its focus is largely on acutely malnourished children and mothers, leaving a gap in addressing broader food insecurity issues. More comprehensive programs that target food access and improve dietary diversity are needed to tackle the root causes of malnutrition in Pakistan.

Health system limitations and reproductive health care

Pakistan’s health system faces several challenges that impact nutrition outcomes, including limited access to quality maternal and child health care services. The country’s total fertility rate has declined only marginally, and the interpregnancy period has remained static, indicating a need for improvements in reproductive health practices. Although the Lady Health Worker program is a valuable resource for delivering reproductive health services, it faces challenges related to coverage and quality. Furthermore, the lack of access to family planning services and modern contraception contributes to high rates of early marriage and adolescent pregnancies, both of which are associated with poor nutritional outcomes. Strengthening the LHW program and increasing access to reproductive health services, particularly family planning, could help address these challenges and improve maternal and child nutrition in Pakistan.