Nutrition Public Expenditure Review: Mainland Tanzania and Zanzibar PER Report July 2018 Nutrition Public Expenditure Review: Mainland Tanzania and Zanzibar About Oxford Policy Management Oxford Policy Management is committed to helping low- and middle-income countries achieve growth and reduce poverty and disadvantage through public policy reform. We seek to bring about lasting positive change using analytical and practical policy expertise. Through our global network of offices, we work in partnership with national decision makers to research, design, implement, and evaluate impactful public policy. We work in all areas of social and economic policy and governance, including health, finance, education, climate change, and public sector management. We draw on our local and international sector experts to provide the very best evidence-based support. Oxford Policy Management Limited Registered in England: 3122495 Level 3, Clarendon House 52 Cornmarket Street Oxford, OX1 3HJ United Kingdom Tel: +44 (0) 1865 207 300 Fax: +44 (0) 1865 207 301 Email: [email protected] Website: www.opml.co.uk Twitter: @OPMglobal Facebook: @OPMglobal YouTube: @OPMglobal LinkedIn: @OPMglobal Nutrition Public Expenditure Review: Mainland Tanzania and Zanzibar Preface UNICEF Tanzania in partnership with the Ministry of Finance and Planning contracted Oxford Policy Management (OPM) to conduct a Public Expenditure Review of nutrition budgets and spending, in mainland Tanzania and Zanzibar. The Team Leader for this assignment was Tim Cammack. Stephanie Allan was Project Manager. Other team members included Emmanuel Maliti, Manisha Marulasiddappa, Ammon Mbelle, Deo Medardi, and Matt Robinson. Errors and interpretations remain the sole responsibility of the authors. © Oxford Policy Management i Nutrition Public Expenditure Review: Mainland Tanzania and Zanzibar Acknowledgements The authors would like to acknowledge the critical inputs provided to this report from the Government of Tanzania and the Revolutionary Government of Zanzibar, in particular from members of the PER Steering Committee chaired by Mr Charles Mwamwaja. Also, we warmly thank everyone who supported our fieldwork, and all those who provided guidance and information in interviews (see Annex A). We also thank counterparts at UNICEF Tanzania, including Hayrullo Malikov, Mauro Brero, Joyce Ngegba and Biram Ndiaye whose diligent engagement over several months has contributed significantly to this review. Lastly, we acknowledge the invaluable data cleaning support provided by Diego Shirima. © Oxford Policy Management ii Nutrition Public Expenditure Review: Mainland Tanzania and Zanzibar Executive summary Tanzania has made significant progress in improving nutrition in the last 25 years with significant reduction in the prevalence of stunting, wasting and underweight among children under five. The prevalence of chronic malnutrition (stunting) among children under five fell from 50% in 1992 to 34% in 2015, while the prevalence of acute malnutrition (wasting) decreased from 8% in 1992 to 4.5% in 2015 (Tanzania Demographic and Health Survey and Malaria Indicator Survey – TDHS- MIS, 2015-16). Despite this commendable progress, levels of malnutrition remain unacceptable, and so the Government of Tanzania and Revolutionary Government of Zanzibar (RGZ) have made improved nutrition a policy priority. The effective supply and coordination of finance is vital for the nutrition effort. Accordingly, this Public Expenditure Review (PER) has been commissioned to assess public expenditures on nutrition and as far as possible to evaluate results against targets in national strategy documents. Amongst other goals, its findings are expected to identify shortcomings in budgetary processes for nutrition and to better direct future budgetary support. The analysis covers two years1 and encompasses spending from government own source funds at national and local level, as well as on and off budget Official Development Assistance (ODA) for nutrition. It follows on from an earlier nutrition PER in Tanzania, the first of its kind in the world, which was concluded in 2014 (Innovex et al., 2014). However, methodological variations and differences in coverage of the two studies have limited the ability to draw comparisons.2 1. Methodology The study follows established PER methodologies (World Bank 2009), and embarks on five pillars of analysis: (1) A review of the policy and institutional framework for nutrition (sections 2.2 and 9.1 of the main report) (2) Level and composition of nutrition sector expenditure (sections 4.1 and 9.2) (3) The budget process and performance from a nutrition perspective (sections 4.2 and 9.3) (4) Efficiency and equity of nutrition spending (4.3 and 9.4) (5) Recommendations (6 and 11) Because within Tanzania, Zanzibar has semi-autonomous status, and nutrition is not deemed a “union matter” the PER treats the Mainland and Zanzibar separately, and reports on them sequentially. Indeed, nutrition efforts in the two localities are informed by different policy frameworks, led by different institutions, and financed through separate budget processes. The methodology employs two main streams of analysis; quantitative data analysis and key informant interviews. Quantitative data analysis focused on government expenditure data (sourced from the mainland’s and Zanzibar’s integrated financial management systems (IFMS) and the local Government EPICOR system), as well as donor expenditure data (as reported on the budget and via bespoke PER templates). These were analysed against demographic and nutrition outcome data, sourced from official census and household survey datasets. 1 2014/15-2015/16 in the case of the mainland, and 2015/16 -2016/17 in the case of Zanzibar 2 Specifically, the 2014 PER covered the mainland only, and only included 15 LGAs (without attempting to come up with a nationwide estimate). It also utilised a different definition of nutrition, given that the NMNAP was not yet in place, which served as the key guiding document for this PER. © Oxford Policy Management 3 Nutrition Public Expenditure Review: Mainland Tanzania and Zanzibar Despite extensive efforts from the PER team and the Governments of Tanzania and Zanzibar, some data gaps and limitations remain at the time of publication. These are documented in full in the report (sections 3.1.4 and 8.1.4), but in summary the most significant gaps are: incomplete and pervasive quality issues in local government expenditure reporting for the mainland; partial expenditure reporting for Zanzibar, and gaps in off-budget ODA reporting (particularly in nutrition-sensitive sectors). A central aspect of the PER methodology was the criteria for determining if a budget line is nutrition-related. A list of key terms was devised for this purpose, which relates to the areas of nutrition relevance as guided principally by the Tanzania National Multisectoral Nutrition Action Plan (NMNAP). Budget line activity and target descriptions were cross-checked against this list to determine whether or not the line counted as nutrition. When a budget line was deemed to be broader than the nutrition activity alone (for example “provision of medicines, medical supplies and equipment to health facilities”) an apportionment percentage (or weight) was applied. Wherever possible, an objective basis was sought to determine an apportionment percentage between 0-100%, including interview notes and policy documents. In the absence of any objective value , a default value of 10% was applied as a conservative estimate. Figure A1: Categorisation of nutrition spending Level 1 Categorisation Level 2 Categorisation Maternal, Infant, Young Child and Adolescent Nutrition (MIYCAN) Nutrition specific Prevention and Management of Micronutrient Deficiencies Integrated Management of Acute Malnutrition (IMAM) Prevention and Management of Diet-Related Non-Communicable Diseases unknown / multiple nutrition specific Nutrition Sensitive Nutrition sensitive Health Agriculture Wash Education Social Protection Environment and climate change Nutrition surveillance, surveys and information management Enabling Environment Nutrition governance (Plans, policies, coordination, capacity) To complement the quantitative expenditure data analysis, interviews were held in July 2017 with representatives from selected LGAs and nutrition relevant MDAs (on the mainland and in Zanzibar) to understand nutrition planning and budgeting processes and the institutional arrangements around these. 2. Findings – mainland Tanzania 2.1 Policy and institutional framework In mainland Tanzania, the Government’s commitment to nutrition is established various policy documents including the Food and Nutrition Policy (FNP), which is operationalised through the NMNAP (and its predecessor, the National Nutrition Strategy (NNS)). The NMNAP sets out a coordinated multi-sectoral approach to nutrition which encompasses a set of priority nutrition- specific interventions (maternal, infant, young child and adolescent nutrition (MIYCAN), prevention © Oxford Policy Management 4 Nutrition Public Expenditure Review: Mainland Tanzania and Zanzibar and management of micronutrient deficiencies, integrated management of acute malnutrition and management of diet-related non-communicable diseases) as well as nutrition-sensitive interventions in the agriculture, health, WASH, education, social protection and environment sectors, and associated governance and surveillance systems. A multi-sectoral institutional framework for nutrition