Evaluation of the 2012/13 Farm Input Subsidy Programme, Malawi: Final Report

This report evaluates the 2012/13 Malawi Government Farm Input Subsidy Programme (FISP). The main objective of the evaluation is to assess the impact and implementation of the FISP in order to provide information regarding • the overall value for money of investments in the FISP as regards its contributions to agricultural production, food security, farmers’ and consumers’ welfare • means by which future implementation of the FISP might be changed in order to improve its effectiveness and efficiency We consider in turn the two main questions that the report addresses, beginning with the overall contributions and value for money from the FISP. The FISP medium term plans sets out the objectives of the FISP as being to ‘increase food security at household level through agricultural output growth’ by increasing agricultural productivity and input market development. However economic theory and experience from other countries suggests that if implemented consistently, effectively and efficiently at a manageable cost the programme has the potential to drive broad based national economic growth and diversification by raising the productivity of the agricultural land and labour held by the large rural population, lowering food prices, raising real wages, and stimulating non-agricultural demand and supply. This depends upon the ability of the programme to cost effectively increase seed and fertiliser input use in maize production, drive up maize productivity and improve input supply services (the direct impacts of the programme) with the support of complementary policies that support low maize prices, rising real wages and rural diversification (the indirect impacts of the programme). Increases in production and maize productivity as a result of the programme are difficult to assess. Bringing together evidence from a wide range of sources, section 7 of the report suggests that the programme led to increased production of around 723,000MT of maize and 32,000MT of legumes. Malawi’s rapidly growing population means that the programme’s incremental production benefits are increasingly important for Malawi’s national food security. These benefits are however undermined by likely informal exports (despite an export ban) encouraged by pressures from the relatively low dollar denominated maize prices in Malawi following the major devaluation of the Kwacha. The programme also led to increased profitability of maize production by beneficiary households and increased rural incomes by between MK50,000 and MK70,000per household receiving and using a full pack of fertiliser and maize seed (ignoring spillover effects and benefits from receipt of fertiliser that does not contribute to incremental production).For many poorer beneficiaries, who receive only one coupon for 50 kg of fertiliser, it seems that benefits are only sufficient to reduce their food insecurity, and are not enough to enable them to advance their livelihoods – to ‘step out’ or ‘step up’ rather than just ‘hang in’. Addressing this in the context of both limited fiscal resources and rapidly growing population pressure is a major challenge facing the programme and the Government and country as a whole. There is, however, evidence that the FISP is encouraging some diversification out of maize into increased legume production. Assessment of the potential wider indirect impacts of the programme (addressed in section 8) requires comparison of situations with and without the subsidy. A Local Economy Wide Impact Evaluation (LEWIE) model, a novel form of CGE modelling, investigating this suggests that there are significant spillover local growth effects from the subsidy as a result of both its injection of cash into the economy and of the increase in real incomes caused by its raising land and labour productivity. However real wage rates fell during 2012/13 as a result of rising maize prices, which, as mentioned above, have been affected by the devaluation of the Malawi Kwacha and consequent export and inflationary pressures. It is not possible to estimate possible effects of FISP in reducing the extent of the fall in wages. These wider influences on maize prices pose a major challenge to the welfare of poor Malawians and to the Malawian economy, with or without the FISP. Policies that address this and promote low and stable domestic maize prices are essential for FISP to deliver improved food security and the wider growth benefits outlined above – and some specific options are suggested. The overall benefit cost ratio (BCR) for the FISP is estimated at 1.7taking account of only direct impacts, and at1.8if wider indirect impacts are also included. Fiscal efficiency (the ratio of net economic benefits to government expenditure) is estimated at 0.75for direct impacts and 1.04 including indirect impacts. Analysis of national food security scenarios with and without the FISP suggests that in the last 6 years it may have led to average annual savings of maize imports of some 385,000MT, directly offsetting up to between 85 and 110% of programme costs. Benefit cost ratio estimates are however sensitive to some of the parameters used in their calculation, notably maize prices, incremental maize productivity, and fertiliser costs. The Fiscal Efficiency of the programme and its overall cost are also affected by likely high rates of input leakage and of displacement of unsubsidised farmer purchases by subsidised inputs, and by the subsidy rate and low farmer contributions. The importance of low and stable maize prices for programme benefits has been discussed above. More attention to these issues in the implementation of the programme could lead to substantial increases in the effectiveness and efficiency of the programme with increased benefits and/or reduced costs. Analysis of determinants of maize productivity shows that yields are generally increased by early planting, early and good weeding, use of hybrid seed, use of inorganic nitrogenous fertiliser and of phosphate where soils are phosphate deficient, and use of organic fertilisers. Returns to use of inorganic fertiliser are also increased by use of hybrid seed, use of organic fertiliser, and higher plant density. Gains from using subsidised inorganic fertiliser and hybrid seed may also be substantially reduced if use of subsidised inputs leads to delays in planting. These observations, which are widely known, underpin many aspects of the design and implementation of the FISP, for example the increasing provision of hybrid and legume seeds in the subsidy package, the intention to provide coupons and inputs early in the season (with priority given to the south, then centre then north), and the inclusion of both nitrogenous and compound fertilisers. Analysis of the implementation of the programme in section 4 and of the timing of receipt of coupons by households in section 6 shows that a number of reasons (some of them beyond the immediate control of programme management) have led to late access to coupons and inputs – and this tends to raise costs and increase displacement as well as reduce yields. Incremental production is also affected by displacement rates and by leakages of inputs through theft and corruption. Programme costs have been held in check from 2009/10 with much better physical control of quantities of subsidised fertilisers. As noted in section 4, there are opportunities for reducing fertiliser procurement costs (and improving timeliness of delivery) through modified tender and payment procedures. Programme costs could also be reduced by increasing farmer contributions as a proportion of input costs, and there is a difficult balance here between on the one hand supporting those who can least afford inputs and benefit most from a high rate of subsidy, and on the other hand reducing overall programme costs. A third way of reducing programme costs and/or increasing benefits is to reduce displacement and leakage, with improved security of coupons (where there has been substantial improvements in 2011/12 and 2012/13); better transport tendering and monitoring procedures (the latter building on approaches trialled with ESOKO in 2012/13); more timely input delivery, market opening and coupon distribution; and better targeting of inputs to poorer farmers unable to afford unsubsidised inputs. Increased farmer contributions may also decrease the incentives for theft, corruption and leakage. Determination of more precise numbers of farm families and (building on useful innovations in 2012/13) greater farmer access to and understanding of publicly available beneficiary lists could also improve targeting outcomes and accountability and control of coupons. Greater use of use of such systems will, however, have to take account of the support for and benefits from the widespread ‘sharing’ of coupons in the Central and Southern Regions. Increasing attention to matters of accountability, access to coupons, and conditions at markets are to be welcomed and will no doubt be built on as more information becomes available on their strengths and weaknesses. Despite its high cost, the FISP is making a positive set of contributions to the welfare of Malawians, and this represents a considerable achievement by all those involved in its resourcing, design and implementation in challenging conditions. These contributions are however threatened by macroeconomic pressures; by high and increasing population pressure in rural areas; by the high visibility of instances of late implementation, corruption and theft; by evidence of poor targeting; and by political and economic pressures. These contributions and these pressures call for renewed efforts to both work for and demonstrate improved efficiency and effectiveness and increased benefits and probity of the programme. In order to facilitate wider and better informed debate around the FISP, this report will be supplemented by two short policy briefing papers summarising key issues raised regarding FISP implementation and impacts. The value of this report is, however, that it brings together in one place a comprehensive review of the programme. Readers are advised to refer to those sections that are of direct interest and not be put off by the size of the report as a whole. The ‘summary and conclusions’ section at the end of the report contains a longer and more detailed summary of the report

Outcomes of tuberculosis patients who start antiretroviral therapy under routine programme conditions in Malawi

SETTING: Public sector facilities in Malawi providing antiretroviral therapy (ART) to human immunodeficiency virus (HIV) positive patients, including those with tuberculosis (TB). OBJECTIVES: To compare 6-month and 12-month cohort treatment outcomes of HIV-positive TB patients and HIV-positive non-TB patients treated with ART. DESIGN: Retrospective data collection using ART patient master cards and ART patient registers. RESULTS: Between July and September 2005, 7905 patients started ART, 6967 with a non-TB diagnosis and 938 with a diagnosis of active TB. 6-month cohort outcomes of non-TB and TB patients censored on 31 March 2006 showed significantly more TB patients alive and on ART (77%) compared with non-TB patients (71%) (P < 0.001). Between January and March 2005, 4580 patients started ART, 4179 with a non-TB diagnosis and 401 with a diagnosis of active TB. 12-month cohort outcomes of non-TB and TB patients censored on 31 March 2006 showed significantly more TB patients alive and on ART (74%) compared with non-TB patients (66%) (P < 0.001). Other outcomes of default and transfer out were also significantly less frequent in TB compared with non-TB patients. CONCLUSION: HIV-positive TB patients on ART in Malawi have generally good treatment outcomes, and more patients need to access this HIV treatment

Impact of changing diagnostic criteria for smear-positive tuberculosis: a cohort study in Malawi.

We assessed the impact on measured burden and outcomes of the revised World Health Organization and Malawi guidelines reclassifying people with single (including 'scanty') positive smears as smear-positive pulmonary tuberculosis cases. In a retrospective cohort in rural Malawi, 567 (34%) of 1670 smear-positive episodes were based on single positive smears (including 176 with scanty smears). Mortality rates and the proportion starting treatment were similar in those with two positive smears or single, non-scanty smears. Those with single scanty smears had higher mortality and a lower proportion starting treatment. The reclassification will increase the reported burden substantially, but should improve treatment access

Outcomes of patients with Kaposi's sarcoma who start antiretroviral therapy under routine programme conditions in Malawi.

AIDS-associated Kaposi's sarcoma (KS) is the most common AIDS-related malignancy in sub-Saharan Africa, with a generally unfavourable prognosis. We report on six-month and 12-month cohort treatment outcomes of human immunodeficiency virus (HIV)-positive KS patients and HIV-positive non-KS patients treated with antiretroviral therapy (ART) in public sector facilities in Malawi. Data were collected from standardized antiretroviral (ARV) patient master cards and ARV patient registers. Between July and September 2005, 7905 patients started ART-488 (6%) with a diagnosis of KS and 7417 with a non-KS diagnosis. Between January and March 2005, 4580 patients started ART-326 (7%) with a diagnosis of KS and 4254 with a non-KS diagnosis. At six-months and 12-months, significantly fewer KS patients were alive and significantly more had died or defaulted compared to non-KS patients. HIV-positive KS patients on ART in Malawi have worse outcomes than other patients on ART. Methods designed to improve these outcomes must be found

The impact of training non-physician clinicians in Malawi on maternal and perinatal mortality : a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa (ETATMBA) project

Background: Maternal mortality in much of sub-Saharan Africa is very high whereas there has been a steady decline in over the past 60 years in Europe. Perinatal mortality is 12 times higher than maternal mortality accounting for about 7 million neonatal deaths; many of these in sub-Saharan countries. Many of these deaths are preventable. Countries, like Malawi, do not have the resources nor highly trained medical specialists using complex technologies within their healthcare system. Much of the burden falls on healthcare staff other than doctors including non-physician clinicians (NPCs) such as clinical officers, midwives and community health-workers. The aim of this trial is to evaluate a project which is training NPCs as advanced leaders by providing them with skills and knowledge in advanced neonatal and obstetric care. Training that will hopefully be cascaded to their colleagues (other NPCs, midwives, nurses). Methods/design: This is a cluster randomised controlled trial with the unit of randomisation being the 14 districts of central and northern Malawi (one large district was divided into two giving an overall total of 15). Eight districts will be randomly allocated the intervention. Within these eight districts 50 NPCs will be selected and will be enrolled on the training programme (the intervention). Primary outcome will be maternal and perinatal (defined as until discharge from health facility) mortality. Data will be harvested from all facilities in both intervention and control districts for the lifetime of the project (3–4 years) and comparisons made. In addition a process evaluation using both quantitative and qualitative (e.g. interviews) will be undertaken to evaluate the intervention implementation. Discussion: Education and training of NPCs is a key to improving healthcare for mothers and babies in countries like Malawi. Some of the challenges faced are discussed as are the potential limitations. It is hoped that the findings from this trial will lead to a sustainable improvement in healthcare and workforce development and training. Trial registration: ISRCTN6329415

A Randomized Trial of Prophylactic Antibiotics for Miscarriage Surgery.

BACKGROUND: Surgical intervention is needed in some cases of spontaneous abortion to remove retained products of conception. Antibiotic prophylaxis may reduce the risk of pelvic infection, which is an important complication of this surgery, particularly in low-resource countries. METHODS: We conducted a double-blind, placebo-controlled, randomized trial investigating whether antibiotic prophylaxis before surgery to complete a spontaneous abortion would reduce pelvic infection among women and adolescents in low-resource countries. We randomly assigned patients to a single preoperative dose of 400 mg of oral doxycycline and 400 mg of oral metronidazole or identical placebos. The primary outcome was pelvic infection within 14 days after surgery. Pelvic infection was defined by the presence of two or more of four clinical features (purulent vaginal discharge, pyrexia, uterine tenderness, and leukocytosis) or by the presence of one of these features and the clinically identified need to administer antibiotics. The definition of pelvic infection was changed before the unblinding of the data; the original strict definition was two or more of the clinical features, without reference to the administration of antibiotics. RESULTS: We enrolled 3412 patients in Malawi, Pakistan, Tanzania, and Uganda. A total of 1705 patients were assigned to receive antibiotics and 1707 to receive placebo. The risk of pelvic infection was 4.1% (68 of 1676 pregnancies) in the antibiotics group and 5.3% (90 of 1684 pregnancies) in the placebo group (risk ratio, 0.77; 95% confidence interval [CI], 0.56 to 1.04; P = 0.09). Pelvic infection according to original strict criteria was diagnosed in 1.5% (26 of 1700 pregnancies) and 2.6% (44 of 1704 pregnancies), respectively (risk ratio, 0.60; 95% CI, 0.37 to 0.96). There were no significant between-group differences in adverse events. CONCLUSIONS: Antibiotic prophylaxis before miscarriage surgery did not result in a significantly lower risk of pelvic infection, as defined by pragmatic broad criteria, than placebo. (Funded by the Medical Research Council and others; AIMS Current Controlled Trials number, ISRCTN97143849.)

Rotavirus Genotypes in Hospitalized Children With Acute Gastroenteritis Before and After Rotavirus Vaccine Introduction in Blantyre, Malawi, 1997-2019

BACKGROUND: Rotavirus vaccine (Rotarix [RV1]) has reduced diarrhea-associated hospitalizations and deaths in Malawi. We examined the trends in circulating rotavirus genotypes in Malawi over a 22-year period to assess the impact of RV1 introduction on strain distribution. METHODS: Data on rotavirus-positive stool specimens among children aged <5 years hospitalized with diarrhea in Blantyre, Malawi before (July 1997-October 2012, n = 1765) and after (November 2012-October 2019, n = 934) RV1 introduction were analyzed. Rotavirus G and P genotypes were assigned using reverse-transcription polymerase chain reaction. RESULTS: A rich rotavirus strain diversity circulated throughout the 22-year period; Shannon (H') and Simpson diversity (D') indices did not differ between the pre- and postvaccine periods (H' P < .149; D' P < .287). Overall, G1 (n = 268/924 [28.7%]), G2 (n = 308/924 [33.0%]), G3 (n = 72/924 [7.7%]), and G12 (n = 109/924 [11.8%]) were the most prevalent genotypes identified following RV1 introduction. The prevalence of G1P[8] and G2P[4] genotypes declined each successive year following RV1 introduction, and were not detected after 2018. Genotype G3 reemerged and became the predominant genotype from 2017 onward. No evidence of genotype selection was observed 7 years post-RV1 introduction. CONCLUSIONS: Rotavirus strain diversity and genotype variation in Malawi are likely driven by natural mechanisms rather than vaccine pressure