1. 1 Malawi Public Expenditure Review: Nutrition 21 November 2007

2. MALNUTRITION: A SILENT CRISIS IN MALAWI INVEST NOW!!!!! UNICEF/Pirozzi

3. 3 Malnutrition: A Silent crisis in Malawi Malnutrition is underlying cause in over 50% of child deaths under the age of 5 in the world, and is therefore key to reaching MDG#4 (reducing child mortality rate) Malnutrition diminishes future productivity and therefore has long- term impact for society In Malawi 48% of children under-5 are stunted (2004 DHS), i.e. one in every two children 22% of children under-5 are severely stunted, i.e. they will suffer permanent physical and mental retardation that may lead to reduced productivity and intellectual ability Micronutrient deficiency disorders especially of Vit A, iron and iodine are also a public health problem that undermine human capital development in the country Data shows that little progress has been made in combating malnutrition in Malawi since 1992

4. 4 Consequences of malnutrition The consequences of malnutrition, though abstract are overwhelming and could significantly undermine Malawi ’ s development efforts. – Reduced intellectual ability (failure to reach academic and professional potential) (MDG # 2 - education) – Lowered immunity – Increased frequency & severity of infectious diseases (MDG #4) – Increased absenteeism Reduced concentration at school – Reduced performance at school

5. 5 What have been the key expenditure trends? Nutrition has for a long time received very little attention at all levels insipite of its direct impact on human capital development Government spends less than 0.05% of GDP on alleviating malnutrition Total annual expenditures on direct nutrition interventions are about 1.5 percent of GDP, almost entirely funded by donors More than one-third of all expenditures are on therapeutic and school feeding programs

6. 6 Main Findings

7. 7 (1) Most of the nutrition expenditure is on programs that are costly and do not have a lasting impact Almost half (44%) of nutrition expenditures are curative in nature & will therefore have no lasting effects on feeding practices and reducing malnutrition – Examples of curative programs are supplementary and therapeutic feeding. Malawi is also implementing school feeding programmes aiming at increasing enrollment and reducing dropout rates especially among girls while promoting nutrition among school aged and adolescent children. – These programs are very expensive to run & do not change people ’ s dietary patterns (e.g. School feeding costs around US$15 per child per year; but Government only spends US$17 per pupil in primary education) Preventive programs are needed to tackle malnutrition, such as programs to increase dietary diversification, nutrition education, micronutrient supplements, lactation, & growth promotion as stipulated in the Essential Nutrition Actions (ENA) package recently adopted by government to promote women and child nutrition

8. 8 (2) Current nutrition programs do not adequately target priority groups High priority groups include children under-5, & pregnant and postpartum mothers: Few interventions specifically target the under-2s, which is the period when most malnutrition occurs. Initiatives to promote appropriate Infant and young child feeding such as BFHI and ENA have not received adequate support. Only a third of nutrition expenditures target young children and pregnant mothers School feeding programs are not properly integrated in other nutrition promotion interventions

9. 9 (3) There is little coordination between government and donors in tackling malnutrition Nutrition is considered as a cross cutting issue such that nutrition programs are carried out by various ministries (education, agriculture, health, trade and industry) There has been no clear coordination and rationalization of the nutrition programs over the years Each donor is working with government on supporting a nutrition program without properly coordinating with other development partners The creation of the dept. of Nutrition HIV and AIDS in OPC, however, is aimed at spearheading coordinated implementation of Nutrition Programmes in the country

10. 10 (4) There seems to be inadequate knowledge of determinants of malnutrition The 2006 Poverty & Vulnerability Assessment showed similar incidence of malnutrition among children from all income categories of households – i.e. malnutrition is a problem in poor as well as rich households. Therefore, in addition to income, other factors are also critical determinants of malnutrition – Resources for care, Mothers ’ education, feeding practices – Water and sanitation Need more in-depth analysis & knowledge of determinants of child malnutrition at household level

11. 11 Recommendations

12. 12 Need to invest in nutrition for long lasting benefits Prevention of malnutrition in various population groups with emphasis on under 2 is crucial for economic growth, development and prosperity.

13. 13 (1) There is need to reduce expenditure invested in nutrition programs that are costly and not expected to have a lasting impact There is need to scale up and strengthen nutrition programmes that promote maternal, infant and young child nutrition and that of other vulnerable groups such as ENA, Behaviour Change Communication and Education programs, micronutrient promotion and supplementation, & diet diversification School feeding programs & adult food distribution should be scaled down

14. 14 (2) There is need to focus on programs that target the under-5s Institute a national community nutrition program to target the priority age groups in a low cost and effective manner. (This could be facilitated with presence of adequate numbers and trained Community Workers unlike volunteers) Malawi could replicate the Honduras Community-Based Integrated Child Care program which focuses on the under-2s. – Community service providers monitor monthly growth of under-2s. – If they notice that growth is not normal, they identify the underlying problem & deal with it – Education about diet diversification and good nutrition practices must be part of the response to combat malnutrition

15. 15 (3) There is need to improve coordination between government and donors Government should take the lead to rationalize and coordinate the many existing programs addressing nutrition within a prioritized set of interventions (Govt has already taken steps to improve coordination, monitoring, joint planning, supervision and focused implementation of nutrition programmes, MGDS, UNDAF, Creation of a coordinating Dept within OPC), This will ensure that more appropriate approaches to dealing with malnutrition are being used, in order to provide an effective response to the malnutrition crisis

16. 16 (4) There is need to embark on a research agenda to better understand the determinants of malnutrition in Malawi Given the findings of the poverty and vulnerability analysis that child malnutrition is not highly correlated with poverty levels, there is need to deepen our understanding of non-income factors linked to the underlying and basic causes of malnutrition There is a need to deepen the understanding of non- income factors, design evidence-based policies and programs that would promote prevention other than cure.