Nutrition Expenditure Review Preliminary Findings - Zambia 2023 Conference

1. NUTRITION EXPENDITURE REVIEW PRELIMINARY FINDINGS NUTRITION CONFERENCE, 14THSEPTEMBER 2023 THEME: “STRENGTHENING AND ACCELERATING DELIVERY OF MULTISECTORAL NUTRITION INTERVENTIONS THROUGH EVIDENCE-DRIVEN PROGRAMMING”

2. Malnutrition and the economy 60  Zambia has a high rate of stunting compared with similar countries in the region  There is a strong correlation between stunting and GNI, which is a complex two-way relationship: stunting can be seen as both a result of low income, and a causal factor in limiting national income Prevalence of stunting, height for age (% of children Burundi 50 Congo, Dem. Rep. Mozambique 40 Angola Ethiopia Rwanda Zambia under 5) Nigeria 30 Tanzania Uganda Zimbabwe Namibia South Africa 20 Kenya Ghana 10 0 0 1000 2000 3000 4000 5000 6000 7000 8000 GNI per capita, Atlas method (current US$) Source: World Bank indicators; Gross National Income (GNI) calculated using the Atlas method to minimise effect of short term exchange rate fluctuations and adjust for variance in inflation; stunting prevalence is based on most recently available figures, the year used thus varies by country

3. Background • The Government of the Republic of Zambia (NFNC)and UNICEF have engaged Mokoro Ltd, a UK-based not-for-profit company to conduct a Nutrition Expenditure Review (NER). • Overall objectives are to assess the adequacy, efficiency, equity, effectiveness and sustainability of public expenditure on nutrition. • The following tasks were specified: • Assess sources of revenue and financing structure of nutrition programmes and interventions • Analyse size, composition, equity and effectiveness of nutrition budget and spending in Zambia • Determine level of overall public spending on nutrition; relate this to nutrition outcomes • Assess whether allocation of nutrition resources accords with stated policy priorities • Specific recommendations will be made for the improvement of nutrition public expenditure.

4. Methodological overview • Significant time was spent defining the scope, assessing data sources, agreeing the taxonomy (based on Lancet frameworks, also utilising government documents e.g. NSNFP 2017-2021), and discussing key methodological decisions such as use of weights. All this was done in collaboration with the NFNC and in consultation with the NER Task Group • Fieldwork in-country was undertaken by Mokoro and NFNC, and involved interviews with government and cooperating partners (CPs) on nutritional expenditure in Zambia, and workshops with government to discuss and agree the budget lines for inclusion in analysis. • Fieldwork included interviews and workshops key CPs and government at national, provincial and district level. • Collation of a useable dataset for analysis has been laborious. The shift from ABB to OBB budget data has been a factor in this. • Note: the graphic sets out a linear process, but in fact many areas of investigation occurred simultaneously, or were returned to at various stages. Nutrition and PFM landscape review Assess the PFM determinants of expenditure Synthesis of evidence to produce NER Estimate the size, distribution and composition of expenditure Analyse expenditure: adequacy, efficiency, effectiveness, equity and sustainability

5. Scope of NER The Nutrition Expenditure Review will consider the state of nutrition in Zambia, its structure and financing, and the relevant public financial management landscape. Data analysis will cover: • Budget and expenditure • Government expenditure and cooperating partner expenditure (on and off budget) • National and subnational (Ministries, Provinces and Districts; a snapshot of Council) • Four years (2018 – 2021) • Seven sectors (health, agriculture, fisheries and livestock, social protection, education, water and sanitation, disaster mitigation management) Findings and recommendations will go beyond the study period of 2018-2021 to respond to the current situation in Zambia.

6. Zambia’s nutrition status • Child undernutrition, micronutrient deficiencies are widespread; overweight and obesity increasing o 35% U5s stunted, amongst highest rates globally – varies by province, 29% in S & W provinces, 45% Luapula, 46% Northern o Important: Only 13% of children 6 – 23 mo are fed a minimally acceptable diet (adequate diversity, frequency, quantity) o Anaemia affects 58% of 6-23 month old; large variation by age - 77% of 9-11 mo olds. • Maternal undernutrition is widespread o 31% of women 15-49 yrs are anaemic – leads to increased maternal mortality, poor birth outcomes and reduced productivity o Important: Higher education and wealth do not necessarily protect women against poor iron nutrition • Exposure to nutrition programs & interventions is inadequate o Only 73% children 6-23 mo old receive Vitamin A supplements, 64% receive deworming meds; only 11% of children receive iron supplements – Note: per DHS 2018 survey report, an update is expected in mid 2024. o Important: Overall only 19% of preschool children are reached by community-based nutrition-specific interventions o Coverage of messages around good child feeding practices is very low (42%) – suboptimal feeding is not being addressed

7. Nutrition and GRZ public finance systems • PFM for nutrition services • Strategic top-down budgeting approaches not fully translated to ministry level, especially closer to ground • Discontinuity in the system between budget preparation and budget execution • Expenditure data challenges complicates budget monitoring and reporting, within year and across years, interrupting planning  budgeting  spending links • These are broader PFM system issues – cannot be solved for nutrition • Integration of nutrition into planning and budgeting • Nutrition multi-sector multi-stakeholder structures key to integration of nutrition as planning, spending coordination and accountability structures • However, in Zambia they are dependent on CP funding and not consistently active • Local government financing and nutrition • Increase in Constituency Development Fund impact on expenditure at subnational level • Flow of central government financing for basic health services, when finance devolved, is not clear and will have critical implications for adequacy and distribution of health sector nutrition services

8. Preliminary results • Preliminary results suggest a substantial increase in nutrition expenditure over the time period considered. • Drivers of this include increased expenditure on the following large programmes (among others): • Social Cash Transfers (SCTs) • COVID response (e.g. purchase and storage of national food reserves) • Farmers Input Support Programme • Primary school feeding • The share of nutrition-specific, direct expenditure has also notably increased. • Nutrition expenditure figures for 2018-2021, disaggregated by sector, nutrition classification, funding source, will be provided in the report and analysed with respect to adequacy, efficiency, equity, effectiveness and sustainability.

9. Preliminary recommendations Our recommendations will draw from the NER quantitative and qualitative analysis of expenditure to consider ways to improve adequacy, efficiency, effectiveness, equity and sustainability of nutrition expenditure. Recommendations will also cover key PFM issues affecting nutrition expenditure, for example: • Integration of nutrition into public finance systems: recommendations on mechanisms to integrate nutrition into planning, budgeting and monitoring of expenditure • Sustainability of nutrition coordination structures: recommendations to ensure nutrition coordination structures are active and sustainable • Short, medium and long-term nutrition financing strategy • Financing of devolved basic health function: considerations to help ensure that intergovernmental fiscal transfer system appropriately finances nutrition services when basic health services are devolved.

10. Timeline and next steps • Phase I: Inception stage (completed) • Phase 2: Methodology development, data mapping and analysis (mainly completed) • Literature review • Technical methodology workshop • Data mapping • Fieldwork: interviews and data collection • Follow up work as required • Nutrition expenditure analysis • Internal and external consolidation and validation workshops • Phase 3: Reporting (in process) • Report: to be finalized in October • Policy brief: subject TBC, to be finalized in November • Presentation of final products: November date TBC

11. Thank you