In the Sindh Province of Pakistan, under-nutrition remains a recognized health problem and plays a substantial role in the region’s elevated maternal and child morbidity and mortality rates. Forty per cent of children are underweight and 73% of children and 62% of pregnant women are anaemic. In this report a nutrition governance framework was applied to research and analyse the provincial experience with nutrition policy in Pakistan, looking both at chronic and acute malnutrition. Thirty-one in-depth interviews and three focus group discussions with key stakeholders were also conducted along with a review of published and grey literature. Findings were validated and supplemented by consultative provincial roundtable meetings. Sindh is faced with contextual challenges as well as low emphasis to under-nutrition across all sectors. Contextually, despite better visibility of agriculture compared to KPK and Baluchistan, Sindh has the highest level of food insecurity amongst all four provinces and has several underdeveloped districts with higher prevalence of under-nutrition. Although schemes such as cash transfers to poor, school feeding, and food distribution to disaster affectees are in place, there is a lack of connections between relevant sectors and also lack of effective capture by the at-risk group of low-income pregnant women and children less than three years of age. Strategic opportunities are recommended which include political championing at the highest level to leverage nutrition into development priorities across party lines; technical support to cohesively define nutrition priorities across sectors and across urban and rural Sindh; strengthen governance; integration of nutrition within the operational budgets of key sectors to have a better chance of maintaining continuity; improve effectiveness of central convening structures; strengthen vertical accountability within sectors; address inequities in food insecurity and long-term disaster mitigation and recovery.