Zareena Kakar, 35, was the first woman from her village to start a job as a lady health visitor (LHV) 16 years back. It may be a normal activity for women in most part of the country, but for a woman from a small village of Qilla Saifullah district in Balochistan, it was a gigantic step.

"Early years of my job were too tough. Molvis (clerics) in our area issued decrees saying that doing a job was ‘haram’ for women," Zareena Kakar recalls, adding that the village people and even her relatives used to look down upon her. "It took me two years to get permission to step into first household as an LHV in my own village. Situation has changed a bit now. A good number of people have started sending their daughters to school."

She complained that almost half of the population in the area still does not accept women like her. "About 50-60 per cent people in our area do not let us step into their houses. But now I am not alone. There are 28 LHVs working in our union council -- Kan Mehtarzai in tehsil Muslim Bag."

For Zareena and her colleagues, the food supplement programme started by the World Food Programme (WFP) in her area a couple of years ago was a game-changer. Malnourishment among children is a serious issue in her area, but their focus used to be polio a couple of years ago as seven cases of polio were reported in the district in 2011.

"People always wanted us to give something in return to vaccinate their children. WFP gives LHVs food supplements to be distributed among malnourished children in their areas. This helps us create a cordial relationship with families for better polio vaccination," she says, maintaining that during the last one and half years not a single polio case was reported from her district which used to be a polio hotspot only a couple of years back.

An important Pashtun district of Balochistan bordering with Afghanistan, Qilla Saifullah is situated about 135km south of Quetta. The road from Quetta to Qilla Saifullah passes through one of the most beautiful landscapes of the country. Semi-barren mountains, small orchards of almond and apple, large herds of sheep and goats, mud houses and vast range of lands on both sides of the road makes it a memorable journey.

The district lags behind most of the districts of the country in almost all key socio-economic indicators. According to a study, ‘Socio-Agricultural Correlation and Regionalisation: A Case of the Districts of Pakistan’ appearing in Journal of Basic and Applied Sciences in 2014, Qilla Saifullah district is ranked 70th out of 77 districts in social ranking. The district also falls among top 20 food insecure districts of the country.

Agriculture (including livestock), which depends on rains and centuries old traditional irrigation system Karez, is the mainstay of the district’s economy. "Less rains, growing poverty, small number of lady health workers and insufficient funds impede access to the affected people. After Sindh, Balochistan has the highest level of food insecurity in the country,"says Akhtar Shah, District Nutrition Coordinator Qilla Saifullah.

WFP, along with government of Balochistan, launched a project from 2013-2015 to assist around 108,271 malnourished children, pregnant and lactating women and prevent stunting and micronutrient deficiencies in nine districts of Balochistan. "Ten out of 20 most food insecure districts are from Balochistan. WFP has launched programmes to assist children and mothers in nine districts of the province, including Qilla Saifullah," Amjad Jamal, spokesperson for WFP tells TNS, adding that his organisation reached over to 178,926 pregnant and lactating women and children under-5 and distributed a total of 1587.13 MT food in 2013. "Against the threshold level of 15 per cent classified by the WHO, as many as 16 per cent of children in Balochistan are acutely malnourished, 52.2 per cent up to five-year of age stunted and 39.6 per cent are underweight."

WFP has provided LHV a special tape for measuring ‘Mid Upper Arm Circumference (MUAC)’ of children under five to determine malnourishment severity and appropriate treatment plan. The tape has three colours, with the red indicating severe malnutrition, the yellow indicating moderate malnutrition and the green indicating normal nutritional status. "Our teams which consist of LHVs go door to door to screen the moderate to severe malnourished children," Zohaib Qasim, programme officer WFP Balochistan, tells TNS. He says a 100 gram sachet of special food supplement of WFP known as Acha Mum which contains all important nutrients that a child needs up to age of 5 years, is provided to children with moderate acute malnourishment for at least a month. "One sachet is enough for one child for a day. The severe malnourished children are referred to district hospital situated at Qilla Saifullah city situated almost 80 kilometres away from Kan Mehtarzai."

Qasim says majority of the people are so poor that they cannot afford taking their children to the hospital in Qilla Saifullah. "We have trained LHVs to help such children."

Lal Bibi, 22, another LHV from the area, says that in village Machi Bagh which has 104 households and around 1,000 population in union council Kan Mehtarzai, about 40 children are malnourished. She says family size is usually large in her area while mothers are mostly illiterate. "Literacy rate among mothers under my area of supervision is not more than five per cent. The total coverage of LHVs in our union council is less than 50 per cent. There are only 10 LHVs for 4,000 households in the union council." She says that WFP also provides food supplements for only 21 children per LHV per month. "We need more food supplements as problem is huge in our area. Two children and one mother have died during the last two months in the households under my supervision."

Qasim Zohaib of WFP says that one of the major challenges in implementation of the programme is to find appropriate and skilled people. "We need to train people. Locals in these areas also do not like assistance with a foreign link. We also have limited resources. We have to make preferences which sometimes also create problems for implementation."

For experts and majority of people in other areas of the country, deaths of two children and one mother in a village of 1,000 population would be alarming, but for the elders of the area the case is different.

"10-15 years ago, there used to be 4-5 deaths of children every month in our village. The death rate among mothers was also very high. Situation is almost under control now. Two of my grandsons benefited from WFP and both of them are in very good shape now," says Shah Muhammad, 75, resident of Machi Bagh village. Shah Muhammad cannot remember taking her wife to a doctor for any kind of treatment. "There is no lady doctor in our area. We do not like taking our women to male doctors. We take our women to Muslim Bagh which is 25 kilometres from our village. It takes a lot of time and money. These lady health workers are a blessing for the area."

Dr Alia Naz, one of the only four lady doctors in Qilla Saifullah district, says that small interventions like Acha Mum would be a game-changer in such areas suffering from malnutrition and lack of better health facilities. "Maternal and child mortality rate is highest in Balochistan. 158 out of 1000 children die during birth as compared to 103 in other parts of Pakistan while 7.8 out of 1000 mothers lose their lives during pregnancy in Balochistan as compared to 2.72 in rest of the country." She says total LHVs coverage in Qilla Saifullah is only 48 per cent.

Dr Naz says people had strong reservations against Acha Mum in the start and majority of them denied giving the food to their children. But when they saw good results of this food supplement among other children, many people started demanding food supplements for their children. "We need to declare a health emergency for child and mother in this province," Dr Naz concludes.