evidence-based blog of Filippo Dibari

Posts Tagged ‘cost-effectiveness’

Designing programs to improve diets for maternal and child health: estimating costs and potential dietary impacts of nutrition-sensitive programs in Ethiopia, Nigeria, and India

In Under-nutrition on July 10, 2018 at 6:21 am

from: Health Policy and Planning, Volume 33, Issue 4, 1 May 2018, Pages 564–573

William A Masters Katherine L Rosettie Sarah Kranz Goodarz Danaei Patrick Webb Dariush Mozaffarianthe Global Nutrition and Policy Consortium.

(download here)


Improving maternal and child nutrition in resource-poor settings requires effective use of limited resources, but priority-setting is constrained by limited information about program costs and impacts, especially for interventions designed to improve diet quality.

This study utilized a mixed methods approach to identify, describe and estimate the potential costs and impacts on child dietary intake of 12 nutrition-sensitive programs in Ethiopia, Nigeria and India.

These potential interventions included conditional livestock and cash transfers, media and education, complementary food processing and sales, household production and food pricing programs. Components and costs of each program were identified through a novel participatory process of expert regional consultation followed by validation and calibration from literature searches and comparison with actual budgets. Impacts on child diets were determined by estimating of the magnitude of economic mechanisms for dietary change, comprehensive reviews of evaluations and effectiveness for similar programs, and demographic data on each country.

Across the 12 programs, total cost per child reached (net present value, purchasing power parity adjusted) ranged very widely: from 0.58 to 2650 USD/year among five programs in Ethiopia; 2.62 to 1919 USD/year among four programs in Nigeria; and 27 to 586 USD/year among three programs in India.

When impacts were assessed, the largest dietary improvements were for iron and zinc intakes from a complementary food production program in Ethiopia (increases of 17.7 mg iron/child/day and 7.4 mg zinc/child/day), vitamin A intake from a household animal and horticulture production program in Nigeria (335 RAE/child/day), and animal protein intake from a complementary food processing program in Nigeria (20.0 g/child/day).

These results add substantial value to the limited literature on the costs and dietary impacts of nutrition-sensitive interventions targeting children in resource-limited settings, informing policy discussions and serving as critical inputs to future cost-effectiveness analyses focusing on disease outcomes.

Key message

Existing evidence on cost-effectiveness for nutrition improvement focuses on interventions to address specific diseases. We provide a novel participatory approach to assembling cost and impact data for 12 nutrition-sensitive interventions to improve diet quality in three countries: Ethiopia, Nigeria and India. Programs designed by stakeholders often use resource transfers to influence diets despite their high cost; programs altering food access have lower cost. Future work using these data will analyse net cost-effectiveness.

Tracking Nutrition Funding Isn’t Easy, but the Payoff Could be Better Outcomes

In Over-nutrition, Under-nutrition on June 29, 2015 at 1:54 pm

By Amanda Pomeroy-Stevens from Secure Nutrition blog

Malnutrition is one of the greatest challenges to health and development in many low- and middle-income countries—it contributes to 45 percent of all deaths in children under the age of five. Like any national challenge, sufficient, sustained funding is needed to address this issue.

Yet, as stated in the 2014 Global Nutrition Report, the amount of aid (in the form of overseas development assistance) committed to nutrition is only about 1.4 percent of the amount required to meet global goals for reducing undernutrition. This statistic, however, only accounts for the funding we know about; it does not include government commitments, and may not even be a complete picture of donor funding, given the complex and multisectoral nature of nutrition activities.

We need a more accurate picture of funding already committed in order to improve accountability for nutrition programs. And, equally important, we need to know what influences the amount of funding committed to nutrition in each country to improve advocacy efforts.

Uganda, Nepal, and Multisectoral Budgets for Nutrition

USAID ‘s Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project is developing evidence to respond to these crucial needs in Uganda and Nepal. Through our Pathways to Better Nutrition study, we are working closely with Uganda’s Office of the Prime Minister and Nepal’s National Planning Commission to document the rollout of both countries’ national nutrition policies and the funding available for the nutrition activities outlined in each plan.

See SPRING’s short video on their nutrition financing work, above

By following Nepal’s Multisectoral Nutrition Plan (PDF 7MB) and the Uganda Nutrition Action Plan (PDF 1MB), SPRING is tracking a stable set of nutrition-specific and –sensitive activities over three fiscal years to explore if, and how, these policies translate into changes in nutrition funding commitments.

SPRING modified the Scaling Up Nutrition (SUN) Movement’s 3-Step approach to develop a mixed method, country-specific style of budget analysis (PDF 2MB) to produce estimates of government and donor nutrition commitments. The methods rely on data from nationally-recognized and locally-created documents, increasing credibility and local ownership of findings. All budget findings for each fiscal year are validated with stakeholders after the interview and analysis phase to ensure accuracy and stakeholder buy-in of the final results.

Working with country partners, our study is providing the first comprehensive estimates of budgeted nutrition funding for Nepal and Uganda by compiling national-level estimates that include—

  • all six nutrition-relevant sectors named by the national nutrition action plans (NNAPs);
  • government, on-budget donor, and off-budget donor funds;
  • nutrition-specific vs. nutrition-sensitive funds;
  • breakdowns by NNAP objective areas;
  • triangulated data on the “why” and “how” of nutrition funding commitments from government, donor, UN, CSO, academia, and private sector; and,
  • district-level estimates of funding in a few selected districts in each country.

In addition, while expenditure data are scant and often incomplete, our study provides some illustrative comparisons of nutrition commitments to nutrition spending to understand what percentage of commitments are actually disbursed and spent.

Transferring Methods and Skills

As we near the final year of the study, both partner governments have approved SPRING’s budget methodology and are utilizing our initial budget estimates for the SUN Movement regional budgeting workshops. SPRING is also working with SUN and others at the global level to refine the methodology and develop guidance for additional countries seeking to create their own estimates of multisectoral nutrition funding.

Although getting to this level of understanding has taken several years, the benefits of this more detailed methodology are significant. Already country stakeholders have demonstrated increased ownership of the findings and intend to use the results for planning and advocacy. SPRING is now supporting the transfer of nutrition budget analysis skills to nutrition technical staff, following a successful workshop co-hosted by the German development organization DSW, our partners in Uganda.


The Growing Price Gap between More and Less Healthy Foods: Analysis of a Novel Longitudinal UK Dataset

In Under-nutrition on October 15, 2014 at 4:21 pm

Nicholas R. V. Jones, Annalijn I. Conklin, Marc Suhrcke, Pablo Monsivais

Published: October 08, 2014

from PlosOne web site – download the paper



The UK government has noted the public health importance of food prices and the affordability of a healthy diet. Yet, methods for tracking change over time have not been established. We aimed to investigate the prices of more and less healthy foods over time using existing government data on national food prices and nutrition content.


We linked economic data for 94 foods and beverages in the UK Consumer Price Index to food and nutrient data from the UK Department of Health’s National Diet and Nutrition Survey, producing a novel dataset across the period 2002–2012. Each item was assigned to a food group and also categorised as either “more healthy” or “less healthy” using a nutrient profiling model developed by the Food Standards Agency. We tested statistical significance using a t-test and repeated measures ANOVA.


The mean (standard deviation) 2012 price/1000 kcal was £2.50 (0.29) for less healthy items and £7.49 (1.27) for more healthy items. The ANOVA results confirmed that all prices had risen over the period 2002–2012, but more healthy items rose faster than less healthy ones in absolute terms:£0.17 compared to £0.07/1000 kcal per year on average for more and less healthy items, respectively (p<0.001).


Since 2002, more healthy foods and beverages have been consistently more expensive than less healthy ones, with a growing gap between them. This trend is likely to make healthier diets less affordable over time, which may have implications for individual food security and population health, and it may exacerbate social inequalities in health. The novel data linkage employed here could be used as the basis for routine food price monitoring to inform public health policy.

FAO (2013): The economics and nutritional impacts of food assistance policies and programs

In Under-nutrition on June 5, 2014 at 10:55 am

by Erin C. Lentz and Christopher B. Barrett

ESA Working Paper No . 13-04 – August 2013

Agricultural Development Economics Division – FAO

(download the doc)



Recent evidence on malnutrition and poverty raise important questions on the role of food assistance policies and programs. In this review article, we examine evidence on the economic and nutritional impacts of international food assistance programs (FAPs) and policies.
The returns on investments in FAPs are, on average, high but depend considerably on the targeting and cost structures as well as on food quality and role of complementary activities. We disaggregate findings into four classes of recipients. Returns to FAPs are highest for children under two. But, FAPs oriented towards early childhood interventions are less well funded than are interventions aimed at school-age children or at the broader, largely adult population even though available evidence indicates that these latter classes of interventions offer considerably lower average returns in economic, health, and nutrition terms.
Nonetheless, FAP effectiveness in achieving any of several objectives varies with a range of key factors, including targeting, additionality, seasonality, timeliness, incentive effects, social acceptability and political economy considerations.




Cost effectiveness of community-based and in-patient therapeutic feeding programs to treat severe acute malnutrition in Ethiopia

In Under-nutrition on October 25, 2012 at 8:50 am

Tekeste AWondafrash MAzene GDeribe K.

Cost Eff Resour Alloc. 2012 Mar 19;10:4




This study estimated the cost effectiveness of community-based therapeutic care (CTC) for children with severe acute malnutrition (SAM) in Sidama Zone, Ethiopia compared to facility based therapeutic feeding center (TFC).


A cost effectiveness analysis comparing costs and outcomes of two treatment programmes was conducted. The societal perspective, which considers costs to all sectors of the society, was employed. Outcomes and health service costs of CTC and TFC were obtained from Save the Children USA (SC/USA) CTC and TFC programme, government health services and UNICEF(in kind supplies) cost estimates of unit costs. Parental costs were estimated through interviewing 306 caretakers. Cost categories were compared and a single cost effectiveness ratio of costs to treat a child with SAM in each program (regardless of outcome) was computed and compared.


A total of 328 patient cards/records of children treated in the programs were reviewed; out of which 306 (157 CTC and 149 TFC) were traced back to their households to interview their caretakers. The cure rate in TFC was 95.36% compared to 94.30% in CTC. The death rate in TFC was 0% and in CTC 1.2%. The mean cost per child treated was $284.56 in TFC and $134.88 in CTC. The institutional cost per child treated was $262.62 in TFC and $128.58 in CTC. Out of these institutional costs in TFC 46.6% was personnel cost. In contrast, majority (43.2%) of the institutional costs in CTC went to ready to use therapeutic food (RUTF). The opportunity cost per caretaker in the TFC was $21.01 whereas it was $5.87 in CTC. The result of this study shows that community based CTC was two times more cost effective than TFC.


CTC was found to be relatively more cost effective than TFC in this setting. This indicates that CTC is a viable approach on just economic grounds in addition to other benefits such improved access, sustainability and appropriateness documented elsewhere. If costs of RUTF can be reduced such as through local production the CTC costs per child can be further reduced as RUTF constitutes the highest cost in these study settings.


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