NJOMBE, Tanzania – As the regional nutrition officer in Tanzania’s Njombe region, Ester Kibona has overseen the rollout of many projects to improve nutrition.
Yet malnutrition in the southern highland region, one of the country’s breadbaskets, remains rampant. More than half of children under the age of 5 are stunted, compared to a 34 percent national average. Kibona also regularly sees the effects of micronutrient deficiencies that come from unbalanced diets.
“We have been putting a lot of efforts to fight child malnutrition,” she said. “Unfortunately, none of the initiatives is effective enough given the results we desire.”
Despite a strategic and financial commitment to reduce malnutrition, government officials said they were regularly hearing similar reports from across the country. So in 2014, the Tanzanian government commissioned a public review of its nutrition financing to find out why the money it was spending wasn’t translating into consistent improvements across all communities.
The initiative, the first of its kind in sub-Saharan Africa, pointed the government to areas where money was not reaching the people it was intended to or was not being spent effectively. Guided by the results, the government has boosted its nutrition budget while trying to teach officials how to spend more strategically.
A Top Priority
For decades, countering malnutrition has been one of the government’s top health and development priorities, said Obey Assery, an economist in the prime minister’s office who is responsible for coordinating nutrition policy. As early as 1973, the country had created the Tanzania Food and Nutrition Centre – a government body tasked with addressing malnutrition.
“We have put a number of interventions to fight malnutrition, such as food fortification and policy review,” he said.
The results have been encouraging. Stunting rates among children under 5 years old dropped from 50 to 34 percent between 1992 and 2015. Acute malnutrition fell from 7 to 5 percent and underweight from 24 to 14 percent. But those results have also been uneven, with rural areas such as Njombe not seeing the same benefits as other parts of the country.
“It is puzzling to see that the government is still struggling to reduce malnutrition,” Aidan Eyakuze, the executive director of the local governance think-tank Twaweza, told News Deeply. “They spend much time on research and consultancies, but whether those translated into changes in children’s nutritional status and well-being is uncertain.”
The government decided to find out exactly why those changes weren’t consistently happening on the scale it had hoped. Beginning in 2014, the Ministry of Finance, in collaboration with the United Nations Children’s Fund, started a four-month public expenditure review of nutrition funding.
They discovered problems at every level.
“Various nutrition interventions were not bringing the desired results due to poor allocation of funds from the central government and lack of strategic plans in respective districts,” said Rachel Ntiga, a data analyst with the Ministry of Finance.
To begin with, the resources weren’t enough. Government spending on nutrition increased from $12.5 million in fiscal year 2010 to $21.3 million in fiscal year 2012, but even the increased total was only 22 percent of total national expenditure. “This level of resource allocation was inadequate to address the nutrition challenges in the country,” the review concluded.
And allocations weren’t necessarily translating into actual spending. It turned out that in both fiscal years 2011 and 2012, only about 23 percent of the money allocated for nutrition programs was actually disbursed due to budget shortfalls from the central government.
The review also found flaws in which programs were prioritized. Given the limited funding, the review recommended that the government specifically target children under 2 years old and pregnant women, who are often the most vulnerable to the effects of malnutrition. Instead, there were often no specific plans. None of the 15 local government councils the reviewers visited had specific strategic plans for nutrition interventions.
A New Approach
The findings proved a catalyst for nutrition officials and are the backbone of the National Multisectoral Nutrition Action Plan (NMNAP) the government released last year.
“The 2014 Public Expenditure Review on Nutrition has acted as a compass to guide present and future policy decisions,” economist Assery said. The new NMNAP even carries the tag line: “From Evidence to Policy to Action.”
Officials are now prepared to invest to achieve goals that include reducing the stunting rate to 28 percent nationally by 2021 and maintaining an acute malnutrition rate of 5 percent. The NMNAP comes with a price tag of $268 million – a dramatic increase on previous nutrition spending.
At the same time, officials appear to have learned the lesson of over-promising and under-delivering when it comes to funding. In a bid to be fully transparent, the government has acknowledged that only $70.5 million of the NMNAP budget has been sourced so far – though they are working with donors to identify additional resources. But if the rest of the money is not found, officials confirm they will have to scale back some of the programs.
Sabas Kimboka, a senior nutritionist with the Tanzania Food and Nutrition Centre, said the findings also inspired the government to recalibrate the kinds of programs it was emphasizing. Of the NMNAP’s seven expected outcomes, the top priority is to improve nutritional behaviors specifically for pregnant women and the caregivers of children under 2 years old, as well as adolescents.
And there is a new focus on making sure those priorities are adopted by local leaders.
“Fighting malnutrition requires not only commitment at the national level, but also proper allocation and actual disbursement of nutrition funds at the district level, where the trickle-down effect is likely to occur,” Ntiga told News Deeply.
The government has deployed a total of 168 nutrition officers across the country’s districts to emphasize the basics of how to address malnutrition and ensure everyone is on board with the national priorities. They are also working with community officials to form committees explicitly dedicated to nutrition, which will be responsible for overseeing local programming and budgeting to try and ensure that this time every community benefits from reduced malnutrition.