Every annual budget cycle, the same ritual plays out. Health ministries table their requests, treasury releases a fraction of what was asked, and provinces absorb a fraction of that.
Somewhere between a health budget line and a pregnant woman in Rajanpur or Khuzdar or Pezu, the rupee disappears and no iron or folic acid supplement reaches the dispensaries. Some call it governance failure. We reshuffle departments, commission audits, hold inter-ministerial meetings. Nothing changes, because we have the diagnosis entirely wrong.
This is not governance failure. It is architecture failure – and the two are not the same thing. Governance failures are fixed by changing people. Architecture failures require you to go back and redesign the system based on first principles. Pakistan has been applying the first solution to the second problem for decades.
What actually happens to a nominal rupee notionally tagged to ‘health and nutrition’ once it leaves the federal budget is a story of attrition. NFC transfers take 45-90 days to reach provincial treasuries. Finance departments at the provincial level then hold allocations for another month or two – for reasons that typically have nothing to do with nutrition. By the time money reaches the district level, it has been divided across anywhere between four and six departments: health, social welfare, agriculture, population welfare, education and BISP, with no single officer accountable for it all and no consolidated budget to speak of. Then, even when funds finally reach the facility, PPRA procurement rules run the same 6-9-month tender cycle for iron-folate tablets as for construction equipment. When the Lady Health Worker arrives at the growth monitoring visit, the supplements may not have arrived.
In a goth of Tharparkar or a dera in Tank – where the nearest functional facility can be hours away and a government representative may not pass through for weeks – none of this is mere administrative overhead. Each layer is the end of the road for service delivery. And these are not remote exceptions. Fourteen of Pakistan’s highest-stunting districts are among its most climate-vulnerable. The communities most dependent on the state to deliver for them are the ones the system was never actually designed to reach.
The deeper problem, and the one almost nobody wants to say plainly, is that our fiscal architecture is pulling in the opposite direction of the goals we claim to have. The 10th NFC Award too continued to put 82% weight on population size when distributing resources across provinces. Pakistan, in effect, pays its provinces for having more people. It does not pay them one rupee more for nourishing those people. Stunting rates have no bearing on what a chief minister receives. So, what exactly are we expecting when federal nutrition directives land on the desk of a finance minister whose budget has no incentive built into it? Policy intent without a fiscal signal attached is not really policy.
The 18th Amendment often gets blamed for this, but reversing devolution is neither constitutional nor wise. However, three federal fiscal instruments already exist that can shift behaviour without touching the constitution. Article 160(7) permits conditional grants-in-aid – money that flows when provinces demonstrate performance. The government has statutory authority to amend PPRA rules to accommodate human development needs-related procurement without returning to Parliament. The 11th NFC Award, overdue as it is, offers a window to redesign the formula itself for the horizontal distribution. These instruments work with the constitutional structure, not against it. The question is whether there is appetite to use them.
On payment delivery, the answer is far simpler than the layers of bureaucracy make it look. Kafalat’s digital infrastructure already reaches 9.2 million women. The Benazir Nashonuma programme, Pakistan’s nutrition-conditioned cash transfer, covers only 600,000 mother-child pairs, roughly 6% of eligible BISP households. If enrollment in Nashonuma were made a standard BISP condition for every family with a child under two, with the conditional payment going directly to the mother’s Kafalat card against pre-determined triggers, we would eliminate the health department, the provincial treasury and the supply chain as points of failure in a single policy decision.
No new programme or institution is required, as the rails exist but need parameterisation. Bangladesh ran a near-identical structure and delivered a 7.3% reduction in stunting in two years. Averting one stunting case in Pakistan costs approximately Rs. 120,000. The lifetime productivity a stunted adult loses runs between Rs4 million and Rs7 million, a return of somewhere between 33 and 58 times the outlay. So the delivery infrastructure for this is already built. This is not a design problem but a decision problem.
PPRA reform costs nothing, which makes continued inaction harder to justify. An amendment to PPRA Rules creating a Nutrition Essential Commodities category – direct contracting, pre-qualified suppliers maintained by DRAP, payments cleared in 30 days – compresses the procurement cycle from 6-9 months to 6-8 weeks. No additional budget or superstructure required. It simply recovers a year of lost delivery time that Pakistan reliably wastes in every budget cycle, when human development budget lines need to be multi-year, as are the funding requirements.
The NFC is the most structurally consequential lever. Embedding a sub-weight for human development within an enhanced Demographic Performance reweight of 20% to 25% into the 11th Award – distributing above-pool grants conditional on verified reductions in stunting, measured against biennial MICS data – makes nutrition a revenue question for every chief minister in the country. The design has to be reward-based rather than punitive: no province loses absolute rupees; underperformers simply grow their share at a slower rate. That asymmetry is politically manageable.
More importantly, an NFC formula outlasts governments, IMF programmes and political cycles. Once nutrition performance is built into it, it persists without anyone having to fight for it in each annual budget negotiation. That durability is the whole point, ensured through the newly formed multi-stakeholder National Population Council, which will provide national and provincial oversight with a whole-of-state approach to this matter of national emergency.
The final piece is statutory. The Fiscal Responsibility and Debt Limitation Act sets ceilings on deficits and debt but says nothing about minimum social expenditure. That silence lets any government quietly cut nutrition spending and remain perfectly within the law. A FRDLA amendment fixing a minimum nutrition floor at, say, 1% of GDP converts nutrition from a preference to an obligation. It should be IMF-compatible, since no programme has ever required a country to breach its own fiscal responsibility legislation. And because removing it requires a parliamentary majority, it is structurally far harder to reverse than any annual budget decision. That is by design.
Pakistan is not short on nutrition commitments. It is short on binding ones. The government has the authority and the tools to connect federal intention to district delivery through four carefully crafted structural adjustments: amend the FRDLA, reform PPRA, embed nutrition performance in the NFC formula, and pay pregnant women directly rather than routing their entitlements through six departments and a procurement process that was designed for highways and bridg es.
The $17 billion GNI drag from malnutrition is the cost of inaction and has already answered whether Pakistan can afford to act. The question that has gone unanswered for too long is whether the ‘how’ will finally be treated with the same seriousness as the ‘what’. Instruments that align incentives produce compliance. Directives that ignore incentive structures produce the system we already have.
The writer is an adviser to the federal minister for finance and revenue. He is a seasoned banker with over 30 years of expertise. He can be reached at: [email protected]
Disclaimer: The viewpoints expressed in this piece are the writer’s own and don’t necessarily reflect Geo.tv’s editorial policy.
Originally published in The News
2026-10-03 09:53:00
