UNICEF Malawi Nutrition Budget Brief 2020-2021.Pdf

NUTRITION BUDGET BRIEF 2020/21 MALAWI

Halting intergenerational stunting through public investments in nutrition: Towards Achieving Malawi’s Vision 2063

KEY MESSAGES AND RECOMMENDATIONS

The identifiable budget allocated to ‘on-budget’ nutrition programmes declined in both nominal (21%) and real terms (29%) compared to 2019/20, and remains at very low levels in relation to the total budget (0.28%) and GDP (0.03%).

Recommendation: Government is encouraged to protect, and to the extent possible, progressively increase, budget allocations to nutrition programmes in the medium term expenditure framework (MTEF). In parallel, Government should ensure the development and implementation of a comprehensive and coherent nutrition sector financing plan, that also covers financing of nutrition services at district level.

Besides health, nutrition interventions are not adequately covered in annual plans and program based budgets (PBBs) of ministries such as Education and Agriculture.

Recommendation: Government, through the Department of Nutrition and HIV/AIDS (DNHA), is encouraged to mainstream nutrition interventions in sector plans and budgets for ministries, departments and agencies (MDAs) with delegated nutrition responsibilities, such as Education and Agriculture.

Government is yet to devolve the nutrition budget to Local Government Authorities (LGAs), despite having devolved some nutrition services and activities and placing Principal Nutrition and HIV/AIDS Officers (PNHAOs) in every district.

Recommendation: Government should devolve nutrition resources to LGAs to effectively support the delivery of delegated nutrition functions. The devolved budgets should be aligned to financial needs of each district, based on cost estimates.

The procurement of nutrition supplies such ready-to-use therapeutic food (RUTF) has been almost entirely funded by donors since 2014/15. This arrangement is unsustainable and leads to unpredictability of funding.

Recommendation: The Government is encouraged to re- introduce funding for procurement of nutrition supplies under the health budget.

There are several bottlenecks affecting the financing of nutrition supplies across the budget process continuum, including weak budget planning and limited capacity for nutrition supplies financing and accountability.

Recommendation: The Government, with support of Development Partners, should develop tools and standard operating procedures (SOPs) for nutrition supplies quantification and costing and enhance the capacity of relevant staff to effectively manage nutrition supplies procurement and reporting processes. UNICEF MALAWI NUTRITION

This budget brief assesses the extent to which the The analytical approach used in this brief was inspired 2020/21 National Budget contributes to address the by the Lancet framework outlined in Black et al. nutrition needs for children in Malawi. It provides an (2013)1, and further unpacked by the World Bank (2020). analysis of the size and composition of budget allocations Pursuant to the Lancet framework, the brief categorized to nutrition-focused programmes and insights on key nutrition interventions into “nutrition-specific”, nutrition- public financing issues connected to adequacy, allocative sensitive” and “enabling environment”, as defined in Table efficiency, effectiveness and equity of the current and past 1. In addition, the analysis significantly benefitted from the spending. background budget scoping and analysis done by UNICEF Malawi in 2018/19. The methodology is also aligned The budget analysis is based on in-depth review of with the approach proposed in the Nutrition Budget government budget documents, especially the Detailed Brief Guidelines produced by the UNICEF Eastern and Budget Estimates (DBEs) and programme-based budgets Southern Africa Regional Office (ESARO). The situational (PBBs), including for Local Government Authorities overview also benefitted from several reports on nutrition, (LGAs), as published by the National Local Government including the Cost of Hunger in Africa (COHA) report of Finance Committee (NLGFC). The analysis primarily 2015 as well as recent papers on the COVID-19 impact focused on ministries, departments and agencies (MDAs) on nutrition. The financing section significantly benefitted with key nutrition-related responsibilities as assigned by from the immunization and nutrition supplies bottleneck the National Multi-Sectoral Nutrition Policy (NMNP) (2018). analysis study (UNICEF Malawi, 2021). The analysis focuses on the period from 2016/17 (year the PBB was rolled out) to 2020/21, with 2016/17 used as the 1 Black, R. E., Victora, C. G., Walker, S. P., Bhutta, Z. A., Christian, P., et base year for inflation adjustments. al (2013). Maternal and Child Undernutrition and Overweight in Low- income and Middle-income Countries. The Lancet, 382 (9890).

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Table 1 Definition of Key Terms used to Categorize Nutrition-focused interventions

Category Description of interventions Nutrition- Nutrition-specific interventions refer to interventions and programs that address the immediate specific determinants of fetal and child nutrition and development. For the purposes of this brief, such interventions include management of severe acute malnutrition (SAM), school meals, behavior change (specific); deworming; fortified based food; micro-nutrient supplementation, nutritional assessment and community-based promotion activities. Nutrition- Nutrition-sensitive interventions or programmes are those aimed at addressing the underlying sensitive determinants of fetal and child nutrition and development and may incorporate nutrition- related goals and actions. These can also serve as delivery platforms for nutrition-specific interventions. For the purpose of this brief, these are defined to include behavior change (sensitive), water, sanitation and hygiene (WASH) components, early childhood development (ECD), food security; immunization services; community gardening, reproductive health; social protection, livelihoods and women empowerment. Building Defined as services that are desgned to support the functioning and delivery of nutrition and Enabling services. For Malawi, this was defined to include nutrition supervision and coordination, environment policy setting and implementation, monitoring and evaluations, as well as capacity building, research and knowledge management, which largely fall under the Department of Nutrition and HIV/AIDS (DNHA) at the national level. Others include food security (research); operational expenditures, and women empowerment.

Source: Adapted from the World Bank (2020), unpacking of the Lancert Framework

While the above clearly identifies the scope of nutrition interventions considered in the analysis, the Malawi budget is insufficiently disaggregated to allow for a clear identification of the corresponding budget lines. The current status of the integrated financial management information system (IFMIS) does also not allow for a clear- cut identification/disaggregation of nutrition-related budget lines/codes. For that reason, the analysis specifically tracked nutrition-related budget lines of relevant MDAs, guided by two main factors, “visiblility” and “granularity”, which entails sufficient disaggregation. The primary budget lines of focus are presented in Table 2. Although “visible”, several nutrition-sensitive programmes/sub-programmes2 were excluded in the analysis, as they did not satisfy the “granularity” principle. The estimated nutrition budget allocations could therefore be an understatement of the actual size of public investments on nutrition in Malawi.

2 For example, for social cash transfer programme (SCTP) under the MoGCDSW (Vote 320) and NLGFC (Vote 121), public works programme (PWP) under NLGFC, gender equality and women empowerment (MoGCDSW), livestock and food security under the © UNICEF/2020 Ministry of Agriculture (Vote 190).

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Table 2 Nutrition-specific budget lines accounted for in the Analysis

Ministry, Department or Agency (MDA) Project/Sub-programme/Cost Centre Ministry of Health (MoH) (Vote 310) Department of Nutrition and HIV/AIDS (DNHA) Food and Nutrition Security Programme (019) Malawi Nutrition and HIV/AIDS Project (023) Ministry of Agriculture (Vote 190) Afikepo Nutrition Programme3 Adolescent Nutrition-Sensitive Agricultural Pilot Project Ministry of Education (MoE) (Vote 250) Nutrition and Access to Primary Education (NAPE) Ministry of Gender, Community Family Nutrition and HIV (sub-programme 99.03) Development and Social Welfare Resilience, Livelihoods, and Nutrition (sub-programme 70.03) (MoGCDSW) (Vote 320)

3 The programme focuses on achieving optimal nutrition for women of child bearing age, adolescent girls, infants and young children with the overall objective to enhance nutrition and food security in Malawi. It is funded by the EU, United Nations Food and Agriculture Organization (FAO) and the German Cooperation and is implemented in 10 districts, namely Chitipa, Karonga, Mzimba, Nkhata Bay, Kasungu, Nkhotakota, Salima, Chiradzulu, Thyolo and Mulanje.

2. Context and Overview of Nutrition in Malawi

Nutrition is a priority area (7.7) in the third Malawi Growth and Development Strategy (MGDS) III. The MGDS III recognizes that eliminating all forms of malnutrition plays a catalytic role in building a resilient, productive and competitive nation. The Constitution of Malawi also recognizes the need to attain adequate nutrition in Malawi. Recognizing its importance in spurring inclusive and sustained development, the Government developed a solid policy and strategic framework to guide the delivery of nutrition services in Malawi – overall through the Malawi National Multi-Sector Nutrition Policy (2018-2022), which is operationalized through the Malawi National Multi-Sector Nutrition Strategy (2018-2022).

Given its multi-sectoral nature, there are several complementary strategies across different sectors, such as the Nutrition Education Communication Strategy, Multi-sectoral Adolescent Nutrition Strategy, Agriculture Sector Food and Nutrition Strategy, National Micronutrient Strategy and Multi-Sector Maternal, Infant and Young Child Nutrition Strategy. Nutrition is a key component of SDG 24 and an essential component for achieving many of the other targets.

The recently launched vision Malawi 2063 (MW2063) Act (DNHA, 2018). Malawi is also part of the Scaling Up stresses the importance of investing in nutrition to Nutrition (SUN) Movement, which is a global movement support the country’s human capital development as to end malnutrition in all its forms. well as ensure an inclusive and self-reliant economy by 2063. The vision acknowledges the significant impact The national nutrition response is coordinated by the that malnutrition has on children’s future development and Department of Nutrition, HIV and AIDS (DNHA), under health as well as the wider implications on socio-economic the Ministry of Health (MoH). Among others, the DNHA development5. To this effect, the Government committed is responsible for (i) high level advocacy; (ii) spearheading to ensure access to nutritious food, especially in the first the mainstreaming and integration of nutrition in the 1,000 days of life, to improve cognitive development as national development agenda, sectoral policies, programs, well as halting intergenerational stunting by prioritizing and outreach services; (iii) ensuring the implementation of health and nutrition for women and children. MW2063 the nutrition policy by sectors and other stakeholders on also stressed the importance of implementing an inclusive the basis of the defined mandates (see Appendix 1); (iv) and multi-sectoral approach in sectors such as education, tracking sector performance and ensuring accountability; agriculture, health, water, sanitation and hygiene (WASH), and (v) resource mobilisation and tracking. The DNHA is early childhood education and social protection. overseen by the Cabinet, Parliamentary and Principal Secretaries’ Committees on Nutrition, HIV and AIDS. The Government has drafted a Food Security and Nutrition Bill, which is currently awaiting There are ongoing efforts to strengthen the Parliamentary approval, to comprehensively regulate coordination and governance of nutrition response the sub-sector. There are also other pieces of legislation at local level. Each Local Council is ideally supposed to that touch on nutrition such as the Consumer Protection develop a five-year district strategic plan with “reduction Act; the Pharmacy Medicines and Poisons Act; the Malawi of stunting” as the overall goal, as well as annual work Bureau of Standards Act; the Public Health Act; Health plans, based on socio-economic profiles (SEPs) This and Welfare Act; the Prevention of Domestic Violence process, is led by a Principal Nutrition and HIV AIDS Act; the Child Care Justice and Protection Act (2010); the Officer (PNHAO) and implemented through the health, Persons with Disabilities Act; and the Local Government agriculture, nutrition and gender sectors. Most districts

5 See page 38 of the Malawi Vision 2063 report. 5 UNICEF MALAWI NUTRITION

have established nutrition coordination committees less steep. Furthermore, Malawi has reduced wasting that work with established community participation levels from 7% in 2000 to 3% in 2015/2016, also thanks structures and extension workers to implement nutrition to the scaling up of the Community Management Acute programmes. Malnutrition (CMAM) that reached 97% country coverage over the period. Malawi has also made notable strides in At village level, there are area Nutrition Coordinating reducing Vitamin A deficiency (for <5 years) from 59.2% Committtes and Village Nutrition Coordinating in 2001 to a level (3.6% in 2016) where its currently no Committees, responsible for coordination and supporting longer a public health concern in the country. implementation of interventions at community level. Proper coordination and effectiveness of these structures However, significant effort is still needed to accelerate are, however, constrained by low domestic funding. and sustain progress sector targets and SDGs. The Ministry of Local Government (MoLG), with partner Although Malawi has made significant strides in reducing support, is currently championing efforts to ensure the chronic malnutrition, stunting levels of 37% (or over 1.4 nutrition strategic framework is effectively incorporated million children) are still very high, placing Malawi among in District Development Plans (DDPs) as well as district the top ten countries accounting for 84% of stunted implementation plans (DIPs), through a bottom up and children in east and southern african region (ESAR). The inclusive process. Malawi National Nutrition Strategic Plan aims to reduce the prevalence of under-5 stunting from 37% in 2016 to Malawi has made significant strides in some child 32% by 2022, under-5 wasting from 2.7% in 2016 to 1.5% nutrition outcomes over the years. As shown in in 2022. The Malawi Demographic and Health Survey Figure 1, stunting (low height-for-age, a sign of chronic (MDHS) (2015/16) revealed an alarming trend in exclusive undernutrition) and underweight (a composite index of breastfeeding during the first six months of life, declining height-for-age and weight-for-height that accounts for from 71% in 2010 to 61% in 2015. both acute and chronic undernutrition) constantly declined and overweight (high weight-for-height) and wasting (low In addition, while vitamin A deficiency is no longer a weight-for-height) also showed a downward trend, albeit public health problem in Malawi, an unacceptably high prevalence of anemia remains, with 60% of primary school children reported to be zinc deficient, while the consumption of iodized salt has reduced from 95% in Figure 1 2009 to 75% in 2015/166. Accelerating the progress in Trends in Key Nutrition Indicators nutrition outcomes requires smart public investments for the Under-5 Population Cohort that prioritizes evidence-based, cost-effective maternal and early child nutrition multi-sectoral interventions such 60 as those aimed at improving the current poor feeding practices for infants and young children. 55 55 50 53 Inadequate infant and young child feeding practices 47 are key contributors to acute and chronic malnutrition 40 in Malawi. Evidence from the MDHS (2015/16) revealed 37 that only 8% of children (aged 6-23 months) consume 30 24 an adequate diet in Malawi, leading to various forms of malnutrition. These are manifested in low birth weight, Percentage (%) 20 20 17 stunting, underweight, wasting, iodine deficiency 13 12 disorders and anemia. These conditions are generally 9 8 9 10 8 associated with the poor varieties of food at household 5 level and low levels of education regarding sanitation 6 7 6 0 4 3 and hygiene among adolescent girls and women of child- bearing age, as well as socio-cultural behaviors. 1992 2000 2004 2010 2015

Stunted Underweight Overweight Wasted 6 Malawi Micronutrient Survey (MMNS), 2015-2016.

Source: Malawi Demographic and Health Surveys (MDHSs) Reports from 1992 to 2015/16

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Deep-rooted gender imbalances also place women at two. The 2015 COHA report also revealed that reducing a disadvantage compared to men, especially in rural undernutrition by 1.85 percentage points every year areas, further compromising their nutritional status would save the Government of Malawi approximately – and consequently their children’s. Undernutrition US$62 million annually. The savings would increase to reflects under-development and unequal access to US$86 million at a 2.85 percentage points reduction.8 A resources, services and opportunities for every Malawian 2013 Lancet-published study9 revealed that the number to live a healthy and dignified life. It is also important to of U5 deaths in Malawi could be reduced by almost note that undernutrition in Malawi is not a problem limited 15% if Malawians access key evidence-based nutrition to the poorest quintile alone. In fact, although stunting interventions. incidence is higher in poorest families, nutrition-related deprivations are widespread in all wealth quintiles.7 This COVID-19 is disrupting the delivery of essential means that undernutrition should not be looked at only nutrition services in Malawi, such as micronutrient as a consequence of chronic poverty but a development supplementation, community management of acute challenge affecting people from different wealth quintiles. malnutrition (CMAM), growth monitoring, supply chains and health and nutrition education. In addition, the Undernutrition inflicts a significant cost on Malawi. closure of schools for six months in 2020 and early 2021 According to the 2015 Cost of Hunger in Africa (COHA) contributed to eliminating access to school-based nutrition report for Malawi, 23% of all child mortality cases in programmes for millions of children. A 2020 Regional Malawi are associated with under-nutrition. Furthermore, Vulnerability Assessment and Analysis (RVAA) estimated available evidence suggest that a child with moderate a 140% increase in the number food insecure Malawians acute malnutrition (MAM) is up to four times more likely from 1.1 million in 2019/20 to 2.7 million in 2020/21. to die than a well-nourished child while a child with severe acute malnutrition (SAM) is nine times more likely to die 8 GoM, WFP, UNECA and AUC (2016), The Cost of Hunger in Malawi, than a well-nourished child, especially below the age of Implications on National Development Vision 2020: Social and Economic Impacts of Child Under-nutrition in Malawi [Summary Report], Lilongwe. 7 Brown C., Ravallion M. & Van de Walle D, (2017), Are Poor Individuals 9 Bhutta et al (2013) Evidence-based interventions for the improvement Mainly Found in Poor Households? Evidence Using Nutrition Data for of maternal and child nutrition. What can be done and at what cost?, Africa. [Policy Research Working Paper 8001], Washington DC, World Lancet Vol. 382, No 9890, pp 452-477. Bank.

KEY TAKEAWAYS

The cost of not investing in nutrition (inaction) is significant for Malawi and risks hampering the development of the country’s human capital. Effective investment in nutrition requires strengthening inter-sectoral planning and budgeting and strategically resourcing the current sector plans and strategies. Nutrition planning and financing should be evidence-based and address the causes of underperformance in nutrition outcomes of districts and vulnerable population groups.

According to the 2015 Cost of Hunger in Africa (COHA) report for Malawi, 23% of all child mortality cases in Malawi are associated with under-nutrition.

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3. Size of Nutrition Spending

3.1 On-budget nutrition spending Figure 2 The budget allocation to identifiable on-budget nutrition-specific programmes has declined in both Evolution of Identifiable nominal and real terms, for the first time since 2017/18 Nutrition-Specific Budgets (Figure 2). The Government allocated a total of MK6.1 billion to identifiable nutrition-specific programmes in 7,789 2020/21, marking a decline of 21% and 29% in nominal 8,000 and real terms, respectively, as compared to the MK7.7 7,000 billion allocated in 2019/20. This is against a 22.9% 6,121 nominal increase in total government budget for 2020/21. 6,000 The decline in allocations between 2019/20 and 2020/21 is linked to a reduction in on-budget donor contributions for 5,000 5,842 the Afikepo Nutrition Programme, whose budget declined 4,000 3,681 4,208 by almost ten-fold, from MK6.9 billion to MK699 million.

MK, millions 2,887 Government allocations for 2020/21 are still higher than 3,000 3,009 those of any year previous to 2019/20. 2,594 2,000

1,000 The Government allocated a total of 370 MK6.1 billion to identifiable nutrition- 0 370 specific programmes in 2020/21, marking 2016/17 2017/18 2018/19 2019/20 2020/21 a decline of 21% and 29% in nominal and Nominal Real real terms.

Source: Government Budget Estimates (2017/18-2020/21)

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The nutrition-specific budget has declined in relation Outside donor support, most nutrition interventions to total government expenditure (TGE) and GDP continue to find little support and expression in (Figure 3). After peaking to 0.44% in 2019/20, budget national and local budgets, despite a solid policy allocations to nutrition, expressed as a share of TGE, and strategic framework that mainstreams nutrition declined to reach 0.28% in 2020/21 and from a peak of services across different MDAs. A thorough review of 0.13% in relation to the country’s gross domestic product the 2020/21 PBB revealed very limited budget lines and (GDP) to 0.09%, as shown in Figure 3. The relative shares performance indicators related to nutrition in PBBs for key for 2020/21 are, however, still higher than those of any MDAs such as Education and Agriculture. There is also no year previous to 2019/20 (Figure 3). performance indicators and targets appearing in the PBB for the Ministry of Health, which houses the DNHA. The limited visibility of nutrition interventions in Government budgets is more pronounced at sub-national level, where Figure 3 specific nutrition-related issues are virtually non-existent in Trends in Identifiable Nutrition PBBs of almost all Local Government Authorities (LGAs). Budgets as a share of TGE and GDP

0.5 0.44 After peaking to 0.44% in 2019/20, budget allocations to nutrition, expressed 0.4 as a share of TGE, declined to reach 0.28% in 2020/21 and from a peak of 0.13% in 0.3 0.28 0.25 relation to the country’s gross domestic 0.22 product (GDP) to 0.09%. 0.2 Percentage (%)

0.1 0.13 0.09 0.03 0.07 0.06 0.0 0.01 2016/17 2017/18 2018/19 2019/20 2020/21

% of Govt Budget % of GDP

Source: Government Budget Estimates (2017/18-2020/21)

The size of direct public investments on nutrition continue to fall short of the estimated financial needs. For instance, the 2020/21 nutrition budget allocation amount to 17% of the MGDS III cost estimates for comprehensive nutrition programmes10 of approximately MK35 billion. The allocation is even lower when applying the unit cost estimates from the Copenhagen Consensus,11 which indicate that the Government would need to invest approximately MK44 billion per year to deliver a basic package of nutrition interventions to all the children facing chronic malnutrition in Malawi.

10 A basic nutrition package required to achieve MGDS III would cost an annual average of MK35 billion and a total cost of MK175.9 billion over the MGDS III life span (2017-2022) 11 The Copenhagen Consensus is a Think-tank (group of world-renowned Economists) that researches and publishes the smartest solutions to the world‘s biggest problems, including nutrition. For more details, © UNICEF/2020 visit: https://www.copenhagenconsensus.com/ 9 UNICEF MALAWI NUTRITION

3.2 Total12 Nutrition Spending (including off-budget contributions)

Accounting for off-budget contributions, total nutrition public spending on nutrition as a share of TGE is around spending has been steadily increasing since 2012/13. A 2.5% in Rwanda (which has comparably similar stunting global analysis of nutrition spending using latest available levels as Malawi, of 37.9%) and 3.8% in Tanzania (with data from the National Health Accounts (NHA) show an stunting levels lower than that of Malawi, of 34.4%). increasing trend in both government and total nutrition However, it is challenging to directly compare spending spending between 2012/13 and 2017/18. Table 3 shows levels with other countries given the inherent complexities that Government nutrition spending13 as recorded in the and differences in approaches used to measure nutrition NHA has averaged around 1% of TGE and 0.3% of GDP expenditures, due to the multi-sectoral nature of nutrition- while the total nutrition spending has averaged 3.6% of related interventions. TGE and 1.1% of GDP over the period 2012/13 to 2017/18. Available evidence in peer ESAR14 countries show that

12 Total nutrition spending is calculated by including all sources of A global analysis of nutrition spending financing for nutrition in Malawi, namely, the Government, donors, corporations, households, non-profit institutions serving households using latest available data from the (NPISH) (which are institutions that provide goods and services, either free or below the market prices, mainly derive their income National Health Accounts (NHA) show from grants and donations and are not controlled by government) an increasing trend in both government and “other” sources (which refers to “unspecified institutional units providing revenues to financing schemes (n.e.c.)” as per the system and total nutrition spending between of health accounts terminology. 2012/13 and 2017/18. 13 The values for Government nutrition spending as reported in the NHA represent actual expenditures and differ from figures in this budget brief due to inherent complexities and differences in approaches used to measure nutrition expenditures, also linked to the multi-sectoral nature of nutrition-related interventions. 14 See public expenditure reviews (PERs) for nutrition for Rwanda (2020) and Tanzania (2019).

Table 3 Trends in Total Nutrition Spending, 2012-18

Nutrition Expenditure Fiscal Year % of TGE % of GDP (Nominal, MK millions) Category GoM Total GoM Total GoM Total 2012/13 4,873 21,451 1. 0 4.5 0.4 1. 8 2013/14 5,534 27,926 0.8 4.2 0.3 1. 3 2014/15 8,260 23,837 1. 0 3.0 0.3 0.9 2015/16 10,517 26,080 1. 2 2.9 0.3 0.8 2016/17 11,139 40,283 1. 0 3.5 0.3 1. 1 2017/18 12,268 46,951 0.9 3.6 0.3 1. 0 Average (2012-18) 8,765 31,088 1.0 3.6 0.3 1.1

Source: National Health Accounts 2016, 2020

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KEY TAKEAWAYS

Against the worrisome background due to the COVID-19, it is fundamental to ensure nutrition services are delivered and paced up to meet the additional demands linked to COVID-19 and also ensure that gains made are not reversed. The sector’s high dependency on donor funding raises sustainability concerns that could be addressed by Government through the development of a nutrition sector financing plan. The DNHA, working jointly with relevant MDAs, should ensure the mainstreaming of nutrition interventions in annual plans and budgets (outside donor funds) for MDAs with delegated nutrition responses and attaching at least one specific indicator and performance target related to nutrition in their PBBs. Despite its significance, there is no regular data collected on off-budget expenditures on nutrition programmes.

4. Composition of Nutrition Spending

4.1 Composition of On-budget 19% was allocated through the Ministry of Agriculture Nutrition Spending (Vote 190), mainly for the Afikepo Nutrition Programme (MK699 million) funded by the European Union. The other 9% (MK475 million) was allocated through the Virtually all the identifiable on-budget nutrition DNHA under the MoH (Vote 310) and 1% through the spending is centrally allocated (Figure 4). In 2020/21, MoGCDSW (Vote 320) for family nutrition and HIV (sub- about 72% (MK4.4 billion) of the identifiable nutrition programme 99.03) and resilience livelihoods and nutrition budgets were allocated through the Ministry of Education (sub-programme 70.03). (Vote 250) for Nutrition and Access to Primary Education (NAPE) project funded by the German Government while

Figure 4 Trends in the Composition of Nutrition-specific Budgets by MDA

2020/21 475 1,193 4,413 40

2019/20 386 7,378 24

2018/19 2,187 1,450 44

2017/18 2,874 14

2016/17 356 4

0 1000 2000 3000 4000 5000 6000 7000 8000

MK, millions

MoH Ministry of Agriculture MoE MoGCDSW

Source: Government Budget Estimates (2017/18-2020/21)

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The identifiable on-budget nutrition spending is largely There are several potentially nutrition-sensitive budget focused on nutrition-specific programmes,across the 4 lines scattered across different MDAs, which were, MDAs with visible nutrition budgets. A proportion of the however, considered to be too broad to be included DNHA budget could fall under the “enabling environment” in the analysis. For example, budgets for the social cash category, as the Department is responsible for “nutrition transfer programme (SCTP) under the MoGCDSW (Vote coordination, policy setting and implementation, 320) and NLGFC (Vote 121). Other potential nutrition- monitoring and evaluations, as well as capacity building”. sensitive budget lines include ECD (sub-programme However, it was difficult to estimate this proportion due to 99.02) and gender equality and women empowerment the insufficiently disaggregated data. (under the MoGCDSW), the public works programme (PWP) and livelihoods under the NLGFC, community The bulk of the on-budget nutrition resources are awareness and behavior change campaigns (Ministry classified as ‘development budgets’15, funded by of Local Government (Vote 120)), WASH investments, donors (Figure 5). Among others, these resources child immunization, livestock and food security under the are aimed at ensuring availability and accessibility of Ministry of Agriculture (Vote 190), as well as trade and affordable, diversified and nutritious foods for all seasons industry (for issues such as food standards as defined for the target groups, increased utilization of diversified, and protected by the Malawi Bureau of Standards safe and nutritious foods and ensuring an effective food (MBS)). There are also resources for the school meals and nutrition security information system at national and programme (SMP), resilience and livelihoods support that district level. The Government’s own resources are largely are contributing to public investments on nutrition, but recurrent, mostly supporting operational functions for the are largely channeled off-budget. The estimated nutrition DNHA and MoGCDSW. budget allocations in this budget brief could therefore be an understatement of the actual size of public investments 15 Almost all activities funded by donors in Malawi are classified as on nutrition in Malawi. “development”.

Figure 5 Trends in the Composition of Nutrition Budgets by Economic Classification

8,000

7,000 7,378

6,000 5,606

5,000

4,000

MK, millions 3,189 3,000 2,500 2,000

1,000 387 491 410 515 0 2017/18 2018/19 2019/20 2020/21

Development Recurrent

Source: Government Budget Estimates (2017/18-2020/21) © UNICEF/2020

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4.2 Global Composition of Nutrition infrastructure, service level agreements and supply chain Spending (including off-budget) management. On the other hand, the bulk of the nutrition prevention and treatment budgets are directed towards procurement of medicines, medical supplies and other Total nutrition resources generally vary among nutrition commodities. On average (2015/16-2019/20), three functions, namely cross-cutting interventions, 35% of the total nutrition spending was directed towards prevention and treatment. On one hand, investments in nutrition prevention, 33% on cross-cutting nutrition cross-cutting nutrition interventions mainly cover capital activities and 33% on nutrition treatment. medical equipment, health worker salaries and training,

Figure 6 Trends in Total Nutrition Spending by Programmatic Functions16

30 10.2 25 18.0

20 9.7 USD, millions 15 9.4 9.0 2.5 10 2.5 4.6 12.6 5.0 5 3.8 7.8 5.8 3.5 4.6 0 2015/16 2016/17 2017/18 2018/19 2019/20

Cross-cutting Nutrition Activities Nutrition Prevention Nutrition Treatment Source: MoH Resource Mapping Rounds 4 and 5

KEY TAKEAWAYS

Government would need to ensure programmatic balance between the funding for different nutrition functional areas and between development and recurrent spending to enhance the effectiveness and efficiency of available nutrition resources. The presence of significant nutrition-sensitive budgets across several MDAs could be suggestive of the need for the DNHA (jointly with the relevant MDAs and development partners) to establish a framework to track, monitor and support the planning and implementation of public investments on nutrition.

16 The relatively lower amounts for 2018/19 and 2019/20 could be because they are projections derived from the 2016/17 Resource Mapping data. The actual amounts are likely to be higher and will be reflected in the upcoming round 6.

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5. Fiscal Decentralization and Equity Considerations

There are notable inequalities in nutrition outcomes nutrition budgets should therefore aim at achieving along geographic, wealth quintile and education lines. equitable allocation of nutrition budgets across districts by For instance, according to the MDHS 2015/16, stunting factoring district-specific needs and deprivations across levels are much higher among children in rural (39%) than key nutrition and socio-economic dimensions. urban areas (25%). Suprisingly, some food-rich districts – such as Mchinji, Dedza and Ntcheu – have stunting levels The Government is yet to devolve the nutrition of over 40%. However, it is also important to note that budget, despite having delegated some nutrition prevalence rates at district level can mask variations in services to LGAs and placing principal nutrition absolute numbers of stunted children within a district. officers in every district. At present, LGAs do not have For example, Blantyre has one of the highest numbers specific budget lines on nutrition. This means that sub- of stunted children under five years, yet prevalence rate national structures mainly depend on resources from is relatively low (33%) and below the national average development partners and communities to implement of 37%. By looking at prevalence rate alone, districts nutrition programmes. Yet, LGAs are championing local such as Blantyre are usually not prioritized in programme level initiatives such as community based management interventions. of acute malnutrition (CMAM), nutrition care support and nutrition during pregnancy, without a dedicated budget. District level outcome variations possibly suggest The ongoing exercise to cost nutrition services will provide different financial needs for nutrition programmes useful evidence to help inform the DNHA and Treasury on across different districts. However, there is currently the level of resources needed to deliver basic nutrition limited comprehensive information about the equity of off- services at local level. budget nutrition spending from donors. Efforts to devolve

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The establishment of multi-sectoral district food and resources can be mobilized, NGOs and LGAs should nutrition committees, which go down to the antenatal also provide human, technical and financial resources to care (ANC) level, has enabled the participation of support these structures. There are ongoing efforts by the communities in nutrition planning and budgeting. Ministry of Local Government to champion the integration Moving forward, a key challenge is to ensure that all of NAC-DIPs and nutrition programmes to the DDPs. LGAs include nutrition in their DDPs. Whilst community

KEY TAKEAWAYS

The ongoing efforts to synchronize the DDPs and PBBs offer a great opportunity to integrate nutrition programmes in district plans and budgets. Government should devolve nutrition resources to LGAs in line with the already devolved services and based on the results of the ongoing costing of nutrition services at local level. Empowering, capacitating and sustaining local structures is key in bolstering community involvement in nutrition planning, budgeting and service delivery.

6. Financing of Nutrition Programmes in Malawi

The funding for most nutrition programmes in Malawi come from donors (Figure 7). In 2020/21, donor funding accounted for 92% of the resources for visible on-budget Figure 7 nutrition programmes, with Government contribution the Trends in the overall funding of remaining 8%, mainly for recurrent services. The current nutrition programmes in Malawi funding arrangements for procurement of nutrition supplies is highly unsustainable and leads to unpredictability of 3 0.4 0.5 0.4 0.5 funding and unreliable delivery of supplies at service 100 deliver points. 16 32 12 12 32 80 The majority, averaging over 70%, of the nutrition resources are channeled through off-budget means. According to the results of the health sector resource 60 mapping round 6 of 2020 key donors funding nutrition programmes in Malawi are the UK Government, German 40

Government, the European Union (EU) and its Member Percentage (%) States, Irish Aid , the World Bank and the United Nations (UN). The Government, through UNICEF’s support, 20 developed a Nutrition Resource Tracking System (NURTS) to track and monitor the funding for nutrition programmes 0 in Malawi. However, the NURTS is still facing several challenges hindering its effectiveness. 2015/16 2016/17 2017/18 2018/19 2019/20 Source: Health Sector Resource Donor Government Mapping Round 4 and 5

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Significant funding gaps for the procurement of example, a total of US$18 million was required to support nutrition supplies persist. Available data from UNICEF the procurement of nutrition supplies, but only US$8 show that funding gaps for nutrition supplies, such as million was available, culminating in a financing gap of ready-to-use therapeutic food (RUTF), of over 50%, have 54%. persisted between 2018 and 2020 (Figure 9). In 2019, for

Figure 8 Financial Gap Analysis of Nutrition Supplies Financing

19 20 18 0 15 15 -20 10 7 8

5 3 -40

USD, millions -53%

-54% -60 Percentage (%) -5

-10 -8 -10 -80 -15 19.0 -83% -16 -20 -100 2018 2019 2020

Financial Need Available Budget Financial Gap Financial Gap (%) Source: UNICEF Malawi

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The funding gap is exacerbated by the absence of the shifting of the DNHA from the office of the president budget support from the Government dedicated and cabinet (OPC) to the MoH. This suggests that the towards the procurement of nutrition supplies (drugs, unclarified expectations over the mandates of planning medical supplies and other nutrition commodities) and resource mobilization oversight for nutrition supplies since 2014/15. This, in addition to resulting in could have contributed to this diffusion of responsibility. substantial gaps between quantified needs and procured commodities, raises serious sustainability concerns, The key limitation for nutrition supplies budget especially given the unpredictability of donor funding execution is lack of Government funding. Donor funded observed in recent years. While fiscal space challenges nutrition supplies often face unpredictable funding, affect all programmes in MOH, the sustained absence of leading to misalignment between request from facilities a budget line for nutrition supplies procurements further and procured supplies. The bottlenecks identified are reflect serious deficiencies with nutrition supplies budget connected to untimely release of funds by donors and processes within the Department of Policy, Planning lack of linked procurement and nutrition supplies cash and Development (DPPD) and Nutrition Unit of MoH. flow arrangement. There is also lack of capacity with This also frustrates the access of Malawi to matching regards to nutrition supplies financing monitoring due to funding mechanisms for nutrition supplies that require limited capacity of the DPPD and Nutrition Unit in nutrition visible budgeting for nutrition supplies. Addressing the supplies financing monitoring and a lack of consolidated bottlenecks in nutrition supplies financing will therefore nutrition financing tracking tools. require an effective issue-based advocacy strategy. The results from the Resource Mapping Round 5 also show Persistent fiscal space challenges have limited the significant reduction in donor resources directed towards capacity of the Government to finance nutrition nutrition supply chain management since 2016/17. investments. Over the years, the growth in revenue has not kept pace with rising expenditure needs, with The funding situation for the procurement of the estimated real growth in total expenditure (10.7%) nutrition supplies is compounded by the diffusion of in 2020/21 twice that of total revenue (5.4%). The responsibilities regarding nutrition supplies financing. Government has therefore resorted to borrowing, with Interviews carried out during the immunization and nutrition deficit financing averaging 32% of the government budget supplies bottleneck analysis study (UNICEF Malawi, 2021) over the past five years while public debt charges have revealed the absence of role clarity on the department consumed over 20% of domestic revenue. The COVID-19- responsible for championing resource mobilization for induced economic impact is further worsening the fiscal nutrition supplies between the DPPD and the DNHA. It is space situation for Malawi and having knock-on effects also important to note that the absence of a budget line on public financing for traditionally underfunded social for the procurement of nutrition supplies coincided with services such as nutrition.

KEY TAKEAWAY

Government and donors should improve the functionality of the Nutrition Resource Tracking System (NURTS) to enhance the tracking and monitoring funding for nutrition programmes in Malawi, on-budget and off-budget, as well as donor commitments, to improve coordination, efficiency and effectiveness of nutrition spending.

Over the years, the growth in revenue has not kept pace with rising expenditure needs, with the estimated real growth in total expenditure (10.7%) in 2020/21 twice that of total revenue (5.4%). The Government has therefore resorted to borrowing, with deficit financing averaging 32% of the government budget over the past five years while public debt charges have consumed over 20% of domestic revenue.

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7. Nutrition-related System-wide Issues

Capacity in nutrition supplies budget process is primarily with UNICEF and other donors. Within Government, mechanisms for determining monthly nutrition supplies requirements from facilities are in place but are not linked with shipment planning in useful ways. It is therefore important for Government to develop capacity to manage critical steps and information related both shipments and link with supplies requests from facilities. Government should develop and sustain capacity to manage donor nutrition supplies financing information within DPPD and the Nutrition Unit of MoH.

There is very little comprehensive information on the equity, effectiveness, and efficiency of nutrition expenditures in Malawi. Despite the fundamental complexities in measuring public spending on nutrition- focused programmes, it is still crucial to track it to ensure that existing funding is being spent efficiently and is aligned with defined Government priorities. Drawing inspiration from peer countries in ESAR, such as Tanzania and Rwanda, considerations should be made to measure © UNICEF/2020 the effectiveness, efficiency, equity and transparency of public nutrition spending in Malawi, including through There are several bottlenecks affecting the financing public expenditure and institutional reviews on nutrition of nutrition supplies across the budget process and other related financial diagnostics. continuum. At planning stage, there are two key issues. First, there is lack of Government funding towards nutrition supplies procurement due to a lack of budget line for nutrition supplies in the MoH budget; leading to over-dependence on donor financing for nutrition supplies. KEY TAKEAWAY Second, there is weak budget planning and prioritization mechanisms and limited capacity for nutrition supplies The Government, with support financing. This is linked to a combination of weak nutrition of Development Partners, should quantification capacity among Government staff at develop tools and standard operating national and sub-national levels, diffusion of nutrition procedures (SOPs) for nutrition supplies supplies procurement budget planning responsibilities quantification and costing and enhance across DPPD, DNHA and MoH Nutrition Unit and lack of the capacity of relevant staff to an effective resource mobilization framework for nutrition effectively manage nutrition supplies supply chain management. procurement and reporting processes.

There is presently weak nutrition quantification The Government, with support of capacity within Government at national and sub- Development Partners,should consider national levels17. Tools and standard operating procedures undertaking a public expenditure review for nutrition supplies quantification and costing do not exist. (PER) for nutrition.

17 Immunization and nutrition supplies bottleneck analysis study (UNICEF Malawi, 2021).

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Annex 1 Key MDAs with specific nutrition responsibilities as per the NMNP (2018)

MDA Responsibility

The Department of The DNHA is responsible for provision of oversight, strategic leadership, policy direction, Nutrition and HIV/ coordination, resource mobilization, capacity building, quality control and monitoring and AIDS (DNHA) evaluation of the national nutrition response.

Ministry of Health The MoH is responsible for provision of leadership and technical direction in programming (MoH) and delivery of quality and cost-effective clinical and biomedical nutrition services in partnership with relevant stakeholders.

Ministry of Education The MoE is responsible for implementation of the school health and nutrition programmes, (MoE) including school feeding. As outlined in the NMNP (2018), the MoE is expected to facilitate inclusion of nutrition in school curricula at all levels of the education system.

Ministry of Agriculture The Ministry of Agriculture is responsible for food and nutrition security and (MoA) and Minitry of mainstreaming nutrition as a core priority area by focusing on improving food access Forestry and Natural and promoting diversified diets. The MoA will support the production and consumption Resources (MoFNR) of diverse nutritious crops, including bio-fortified foods, and strengthen value chains to improve production, availability, distribution, and access to high-quality and safe nutritious foods. The MoFNR (which now houses the WASH component) is also responsible for coordinating Water, Sanitation and Hygiene (WASH) interventions.

Ministry of Gender, The MoGCDSW is responsible for provision of leadership and technical direction in Community programming gender and nutrition interventions. The MoGCDSW is also mandated Development and to promote women’s empowerment, integration of nutrition in income-generating Social Welfare activities, social protection and welfare programmes, and community mobilisation in (MoGCDSW): support of nutrition. As foreseen in the NMNP (2018), the MoGCDSW also promotes early stimulation, care, protection, and development amongst children (early childhood development).

Ministry of Local The MoLG is responsible for implementation of nutrition interventions at sub-national and Government (MoLG) community levels. It ensures the replication of the multi-sectoral approach to nutrition at the district, municipal and city council levels.

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Acknowledgements For more information, contact: Mamadou Ndiaye This budget brief was produced by Tapiwa Kelvin Mutambirwa under the Chief of Nutrition technical guidance of Alessandro Ramella Pezza and leadership of Beatrice UNICEF Malawi, Targa and Mamadou Ndiaye. Valuable technical inputs were provided by Lilongwe Mamadou Ndiaye, Owen Nkhoma, Nerisa Philime from the Nutrition Section mandiaye@unicef.org and Mathew Cummins, Bob Muchabaiwa and Marjorie Volege from the Regional Office. Special thanks goes to Dominic Albert Nkhoma from the Beatrice Targa University of Malawi - College of Medicine - for providing valuable technical Chief of Social Policy inputs. UNICEF Malawi, Lilongwe [email protected]

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Published by UNICEF Malawi PO Box 30375 Lilongwe, Malawi. Tel: +265 (0)1 770 770 Email: [email protected] www.unicef.org/malawi