04 Apr 2023

Nutrition in emergencies: The role of accountability in ensuring better response

Dr Shabina Raza, Country Director, Nutrition International/ Convener, SUN Civil Society Alliance Pakistan. Irshad Danish, Senior Advocacy Advisor, Nutrition International / Chair, Global SUN Civil Society Network

Image by Nutrition International

Devastating floods in Pakistan impacted millions of people in 2022, causing widespread damage to homes, crops, livestock and livelihoods. The country has been a victim of numerous disasters over the past 20 years, including earthquakes in 2005 and floods in 2008 and 2010. Partly as a result of this, Pakistan’s malnutrition crisis is one of the worst in the world, and has not improved for decades. Today, more than 25 million children and women, including more than seven million in areas affected by the 2022 floods, need immediate access to essential nutrition services.

Malnutrition rates increase significantly during emergencies, with infants, young children, and pregnant and lactating women being particularly vulnerable due to limited access to essential nutrition services. Poverty, lack of clean drinking water, loss of livelihoods and poor diets exacerbate the impact of emergencies.

Levels of malnutrition in Pakistan

Pakistan faced numerous nutrition challenges before the 2022 floods, with stunting affecting 40.2% of children under five, wasting affecting 17.7%, and underweight affecting 28.9%. Nearly 15% of women were undernourished, and 37.8% were living with obesity. Micronutrient deficiencies were also a concern, with 41.7% of women anaemic, 79.7% vitamin D deficient, 27.3% vitamin A deficient, and 26.5% calcium deficient.1

The impact of acute malnutrition is severe. It increases the likelihood of sickness and death, while sickness increases the risk of undernourishment. To address these challenges, humanitarian projects should adopt an inclusive approach, prioritising vulnerable individuals, and involving affected communities in planning and evaluation. Other recommendations include establishing formal accountability mechanisms, promoting transparency and reporting, and regularly assessing the effectiveness of interventions.

Response by the government and civil society

With the support of development partners and United Nations agencies, the government of Pakistan has taken various steps to assist people affected by floods. These include providing relief goods such as food, shelter and medical assistance, as well as financial compensation for damages and loss of property. The government has also established relief camps and centres to provide aid. Additionally, the government has implemented long-term rehabilitation and reconstruction programmes to help affected communities recover and rebuild.

However, the effectiveness of disaster response efforts could have been improved by promoting better coordination and engagement between government agencies and humanitarian actors at both national and sub-national levels.

Nutrition International has been working in Pakistan since 2001 to improve the health and nutrition of women and children. They have focused on improving the coverage of vitamin A and zinc supplements, managing childhood diarrhoea, improving the universal salt iodisation programme, and ensuring access to essential nutrients. These efforts help build resilience in national health and nutrition systems, and ensure that populations vulnerable to extreme weather events have adequate nutrition.

Nutrition International is both the convener of the Scaling Up Nutrition Civil Society Alliance (SUN CSA) Pakistan (a network of more than 230 civil society organisations), and also Chair of the Nutrition Development Partners Forum (an independent strategic working group comprised of UN agencies, bilateral donors and international NGOs). As part of these roles, Nutrition International developed and disseminated guidelines for the government and humanitarian organisations involved in food distribution to ensure ration and food packages were nutritionally balanced (available as a PDF). As a result of advocacy by Nutrition International and others, Pakistan’s Ministry of National Health Services Regulations and Coordination issued a letter recommending national and provincial stakeholders include fortified food products in the packages distributed to people affected by the floods. In addition, the Ministry of Health issued guidelines to humanitarian agencies to discourage bottle feeding and promote breastfeeding during relief and recovery activities.

The role of civil society in promoting accountability

Strong technical standards, humanitarian principles and accountability mechanisms lead to more effective and efficient programming. For example, the Sphere humanitarian standards project has developed specific technical standards on food security and nutrition for emergencies that are grounded in the beliefs, principles, duties and rights declared in its Humanitarian Charter. These standards and guidelines help to ensure that assistance is provided in a way that respects the rights and dignity of people affected by crises, and that the assistance provided is accountable and of good quality. They must be considered in the monitoring and evaluation of nutrition interventions in emergencies, to ensure the responsible use of power by humanitarian actors.

Civil society plays a key role in monitoring government policies and actions, and in holding the government accountable. Since the 2022 floods, civil society coalitions in Pakistan (including SUN CSA Pakistan, the National Humanitarian Network (NHN), the Pakistan Humanitarian Forum and Alliance 2015) have highlighted nutrition and food security-related issues at district, provincial and national levels. Civil society organisations have also advocated with the global humanitarian community to highlight the needs of the most vulnerable families.

Most of these issues were acknowledged by the government and donors, and the humanitarian response was reshaped accordingly. Both the government and private sectors (all non-governmental organisations, such as INGOs, the UN, philanthropic groups, businesses and individuals involved in humanitarian response efforts) are now placing a greater emphasis on nutrition and food security in their relief and recovery efforts, with these areas becoming a key focus in the planning and implementation of interventions.

Civil society platforms such as SUN CSA Pakistan and NHN review their progress against workplans and report back to their general bodies. They also invite relevant government bodies to their review meetings, ensuring alignment and the sharing of lessons learnt.

What more needs to be done?

To better address Pakistan's malnutrition crisis, humanitarian projects must prioritise an inclusive approach that reaches marginalised populations, including those with disabilities, older people, minority ethnic groups and those marginalised due to their social status. The specific needs of individuals experiencing vulnerability must be considered at all stages of the project cycle.

To improve accountability in disaster response, the government of Pakistan should involve all actors by maintaining clear communication and coordination, promoting transparency and reporting, and establishing formal accountability mechanisms. These mechanisms should include complaint and feedback systems, investigations and audits to address complaints or concerns.

It is also important to actively engage affected communities in the planning, implementation and evaluation of disaster response efforts to ensure that assistance meets their needs. Regular appraisals should assess effectiveness, identify areas for improvement and share results with stakeholders to inform future interventions.

All actors have a role to play in addressing both immediate needs during emergencies and the long-term impact and underlying problems of malnutrition. Strengthening coordination and accountability mechanisms is critical to ensuring that the government, civil society and affected communities can improve the way they work together to deliver real impact.

The views and opinions expressed in this article are those of the authors alone and do not represent the official position of the Global Nutrition Report or associated individuals, institutions and organisations, unless explicitly stated.


Data from Pakistan’s National Nutrition Survey 2018. Available at: https://www.unicef.org/pakistan/media/1951/file/Final%20Key%20Findings%20Report%202019.pdf. For internationally comparable nutrition data, see the Global Nutrition Report’s Country Nutrition Profile for Pakistan. Available at: https://globalnutritionreport.org/resources/nutrition-profiles/asia/southern-asia/pakistan/