# **1. Introduction**

Pakistan, a lower middle-income country with the sixth largest population in the world, has an exceptionally high level of child undernutrition. Its stunting rate, at 45%, ranks worse than 124 out of 132 countries; its wasting rate, at 11%, ranks worse than 106 out of 130 countries; and its trends in these indicators in relation to the 2025 World Health Assembly targets are viewed to be off track (IFPRI 2016).

Pakistan’s high level of child undernutrition may have produced sizeable economic costs, through the loss of human capital and increased health costs. Empirical studies for developing countries— as well as meta-studies of the cumulative evidence—find that undernutrition has negative effects along many margins.<sup>1</sup> Suboptimal early child growth, measured by stunting status and other indicators, is found to be associated with lower motor, cognitive, emotional, and social development, and higher rates of illness, disability, and premature death.<sup>2</sup> An estimated 45% of global child deaths in 2011 are attributed to stunting and wasting status, along with other measures of undernutrition (Black et al. 2013). Suboptimal early child growth is also found to be associated with poorer socioeconomic outcomes in adolescence and adulthood, measured by, for example, education attainment, student academic achievement, employment, and labor earnings.<sup>3</sup> In the case of Pakistan, using panel data from villages in four districts, Alderman et al. (2001) find that suboptimal early child growth is significantly associated with a lower likelihood of subsequent primary school enrollment, especially for girls.<sup>4</sup> In this study, we conduct a narrative review of what is known about the child undernutrition problem in Pakistan. The main questions we ask for the country are:

- (1) What do household diets look like?

- (2) How do undernutrition rates vary spatially?

- (3) How have undernutrition rates evolved over time?

- (4) What are the average levels of factors considered to be associated with undernutrition based on the international literature?

- (5) What individual, mother, household, and community factors are associated with undernutrition?

(6) What are the effects of potentially relevant interventions on undernutrition?

The review also serves as a basis for thinking through what more we should know and how we should learn this, and what we should do to address the country’s child undernutrition problem.

We synthesize evidence from studies published between 1990 and 2016, from empirical and qualitative research, and from representative and purposive samples of children, households, and government primary health workers. The evidence is drawn mostly from journal articles and working papers. We also present child nutrition statistics drawn from recent large-scale household

> 1 Most of the evidence comes from analyses of observational data, either cross-sectional or panel data, controlling for potentially confounding factors.

> 2 For example, see Black et al. 2013; Gandhi et al. 2011; Walker et al. 2011; Martorell et al. 2010; Grantham-McGregor et al. 2007; Kuklina et al 2006; Gardner et al. 1999.

> 3 For example, see Adair et al. 2013; Black et al. 2013; Galler et al. 2012; Carba et al. 2009; Maluccio et al. 2009; Hoddinott et al. 2008.

> 4 To arrive at a causal estimate, the authors instrument for early child growth using wheat, milk, and rice price changes.

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