Cost-effectiveness of sunflower oil fortification with vitamin A in Tanzania by scale.

In 2011, Tanzania mandated the fortification of edible oil with vitamin A to help address its vitamin A deficiency (VAD) public health problem. By 2015, only 16% of edible oil met the standards for adequate fortification. There is no evidence on the cost-effectiveness of the fortification of edible oil by small- and medium-scale (SMS) producers in preventing VAD. The MASAVA project initiated the production of sunflower oil fortified with vitamin A by SMS producers in the Manyara and Shinyanga regions of Tanzania. A quasi-experimental nonequivalent control-group research trial and an economic evaluation were conducted. The household survey included mother and child pairs from a sample of 568 households before the intervention and 18 months later. From the social perspective, the incremental cost of fortification of sunflower oil could be as low as $0.13, $0.06, and $0.02 per litre for small-, medium-, and large-scale producers, respectively, compared with unfortified sunflower oil. The SMS intervention increased access to fortified oil for some vulnerable groups but did not have a significant effect on the prevention of VAD due to insufficient coverage. Fortification of vegetable oil by large-scale producers was associated with a significant reduction of VAD in children from Shinyanga. The estimated cost per disability-adjusted life year averted for fortified sunflower oil was $281 for large-scale and could be as low as $626 for medium-scale and $1,507 for small-scale producers under ideal conditions. According to the World Health Organization thresholds, this intervention is very cost-effective for large- and medium-scale producers and cost-effective for small-scale producers.

Delivering Vitamin A Supplements to Children Aged 6-59 Months: Comparing Delivery through Campaigns and through Routine Health Services in Senegal.

BACKGROUND: Using twice-yearly campaigns such as Child Health Days to deliver vitamin A supplements has been a key strategy over the last 2 decades, and was an important component in helping reach the Millennium Development Goals in child health. As countries move to strengthen their routine health services under the Sustainable Development Goals, efforts are underway to shift supplementation from campaign to routine delivery. OBJECTIVE: The aim of this study was to compare cost, coverage, and user satisfaction between twice-yearly campaigns and routine delivery of vitamin A supplements in Senegal. METHODS: Information was collected on cost, coverage, and user satisfaction with both types of delivery, using administrative data, interviews at various levels in the health system, and focus group discussions with caregivers. Both qualitative and quantitative information were obtained, for 2 regions using routine delivery and 2 regions using campaign delivery. RESULTS: Routine delivery receives fewer dedicated resources. Coverage is lower, especially of children >12 mo of age. Districts undertake outreach ("mini-campaigns") to try to improve coverage in regions using routine delivery, in effect using a hybrid approach. Some mothers prefer the administration of supplements at a health facility as it is perceived as more hygienic and involving professional health workers, but others, especially those living further away, prefer house-to-house delivery which was the norm for the campaign mode. CONCLUSIONS: Advance planning for the shift to routine delivery is important in maintaining coverage, as is strengthening the primary health care system by having an appropriate ratio of salaried workers to population. When the system relies heavily on volunteers, and the small incentive payments to volunteers are discontinued, coverage suffers. Routine delivery also relies on good record-keeping and hence literacy. Community understanding of, and support for, supplementation are even more important for routine than for campaign delivery.

Prioritizing research for integrated implementation of early childhood development and maternal, newborn, child and adolescent health and nutrition platforms.

BACKGROUND: Existing health and nutrition services present potential platforms for scaling up delivery of early childhood development (ECD) interventions within sensitive windows across the life course, especially in the first 1000 days from conception to age 2 years. However, there is insufficient knowledge on how to optimize implementation for such strategies in an integrated manner. In light of this knowledge gap, we aimed to systematically identify a set of integrated implementation research priorities for health, nutrition and early child development within the 2015 to 2030 timeframe of the Sustainable Development Goals (SDGs). METHODS: We applied the Child Health and Nutrition Research Initiative method, and consulted a diverse group of global health experts to develop and score 57 research questions against five criteria: answerability, effectiveness, deliverability, impact, and effect on equity. These questions were ranked using a research priority score, and the average expert agreement score was calculated for each question. FINDINGS: The research priority scores ranged from 61.01 to 93.52, with a median of 82.87. The average expert agreement scores ranged from 0.50 to 0.90, with a median of 0.75. The top-ranked research question were: i) "How can interventions and packages to reduce neonatal mortality be expanded to include ECD and stimulation interventions?"; ii) "How does the integration of ECD and MNCAH&N interventions affect human resource requirements and capacity development in resource-poor settings?"; and iii) "How can integrated interventions be tailored to vulnerable refugee and migrant populations to protect against poor ECD and MNCAH&N outcomes?". Most highly-ranked research priorities varied across the life course and highlighted key aspects of scaling up coverage of integrated interventions in resource-limited settings, including: workforce and capacity development, cost-effectiveness and strategies to reduce financial barriers, and quality assessment of programs. CONCLUSIONS: Investing in ECD is critical to achieving several of the SDGs, including SDG 2 on ending all forms of malnutrition, SDG 3 on ensuring health and well-being for all, and SDG 4 on ensuring inclusive and equitable quality education and promotion of life-long learning opportunities for all. The generated research agenda is expected to drive action and investment on priority approaches to integrating ECD interventions within existing health and nutrition services.

Delivering Vitamin A Supplements to Children Aged 6 to 59 Months: Comparing Delivery Through Mass Campaign and Through Routine Health Services in Ethiopia.

BACKGROUND: The delivery of vitamin A supplements in Ethiopia has been shifting from Child Health Days (campaigns) to routine delivery via the community health services. OBJECTIVE: The objective of this study was to compare the cost and effectiveness of these 2 delivery methods. No previous studies have done this. METHODS: A mixed method approach was used. Quantitative data on costs were collected from interviews with key staff and coverage data from health facility records. Qualitative data on the 2 modalities were collected from key informants and community members from purposefully sampled communities using the 2 modalities. RESULTS: Communities appreciated the provision of vitamin A supplements to their under 5-year-old children. The small drop in coverage that occurred as a result of the change in modality can be attributed to normal changes that occur with any system change. Advantages of campaigns included greater ease of mobilization and better coverage of older children from more remote communities. Advantages of routine delivery included not omitting children who happened to miss the 1 day per round that supplementation occurred and not disrupting the availability of other health services for the 5 to 6 days each campaign requires. The cost of routine delivery is not easy to measure nor is the cost of disruption to normal services entailed by campaigns. CONCLUSION: Cost-effectiveness likely depends more on effectiveness than on cost. Overall, the routine approach can achieve good coverage and is sustainable in the long run, as long as the transition is well planned and implemented.

Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?

Maternal undernutrition contributes to 800,000 neonatal deaths annually through small for gestational age births; stunting, wasting, and micronutrient deficiencies are estimated to underlie nearly 3·1 million child deaths annually. Progress has been made with many interventions implemented at scale and the evidence for effectiveness of nutrition interventions and delivery strategies has grown since The Lancet Series on Maternal and Child Undernutrition in 2008. We did a comprehensive update of interventions to address undernutrition and micronutrient deficiencies in women and children and used standard methods to assess emerging new evidence for delivery platforms. We modelled the effect on lives saved and cost of these interventions in the 34 countries that have 90% of the world's children with stunted growth. We also examined the effect of various delivery platforms and delivery options using community health workers to engage poor populations and promote behaviour change, access and uptake of interventions. Our analysis suggests the current total of deaths in children younger than 5 years can be reduced by 15% if populations can access ten evidence-based nutrition interventions at 90% coverage. Additionally, access to and uptake of iodised salt can alleviate iodine deficiency and improve health outcomes. Accelerated gains are possible and about a fifth of the existing burden of stunting can be averted using these approaches, if access is improved in this way. The estimated total additional annual cost involved for scaling up access to these ten direct nutrition interventions in the 34 focus countries is Int$9·6 billion per year. Continued investments in nutrition-specific interventions to avert maternal and child undernutrition and micronutrient deficiencies through community engagement and delivery strategies that can reach poor segments of the population at greatest risk can make a great difference. If this improved access is linked to nutrition-sensitive approaches--ie, women's empowerment, agriculture, food systems, education, employment, social protection, and safety nets--they can greatly accelerate progress in countries with the highest burden of maternal and child undernutrition and mortality.

Weekly iron-folic acid supplementation with regular deworming is cost-effective in preventing anaemia in women of reproductive age in Vietnam.

BACKGROUND: To estimate the cost and cost-effectiveness of a project administering de-worming and weekly iron-folic acid supplementation to control anaemia in women of reproductive age in Yen Bai province, Vietnam. METHODS AND FINDINGS: Cost effectiveness was evaluated using data on programmatic costs based on two surveys in 2006 and 2009 and impact on anaemia and iron status collected in 2006, 2007, and 2008. Data on initial costs for training and educational materials were obtained from the records of the National Institute of Malariology, Parasitology and Entomology and the Yen Bai Malaria Control Program. Structured questionnaires for health workers at district, commune and village level were used to collect ongoing distribution and monitoring costs, and for participants to collect transport and loss of earnings costs. The cost per woman treated (defined as consuming at least 75% of the recommended intake) was USD0.76 per annum. This estimate includes financial costs (for supplies, training), and costs of health care workers' time. Prevalence of anaemia fell from 38% at baseline, to 20% after 12 months. Thus, the cost-effectiveness of the project is assessed at USD 4.24 per anaemia case prevented per year. Based on estimated productivity gains for adult women, the benefit:cost ratio is 6.7∶1. Cost of the supplements and anthelminthics was 47% of the total, while costs of training, monitoring, and health workers' time accounted for 53%. CONCLUSION: The study shows that weekly iron-folic acid supplementation and regular de-worming is a low-cost and cost-effective intervention and would be appropriate for population-based introduction in settings with a high prevalence of anaemia and iron deficiency and low malaria infection rates.

Setting priorities for zinc-related health research to reduce children's disease burden worldwide: an application of the Child Health and Nutrition Research Initiative's research priority-setting method.

OBJECTIVE: To make the best use of limited resources for supporting health-related research to reduce child mortality, it is necessary to apply a suitable method to rank competing research options. The Child Health and Nutrition Research Initiative (CHNRI) developed a new methodology for setting health research priorities. To broaden experience with this priority-setting technique, we applied the method to rank possible research priorities concerning the control of Zn deficiency. Although Zn deficiency is not generally recognized as a direct cause of child mortality, recent research indicates that it predisposes children to an increased incidence and severity of several of the major direct causes of morbidity and mortality. DESIGN: Leading experts in the field of Zn research in child health were identified and invited to participate in a technical working group (TWG) to establish research priorities. The individuals were chosen to represent a wide range of expertise in Zn nutrition. The seven TWG members submitted a total of ninety research options, which were then consolidated into a final list of thirty-one research options categorized by the type of resulting intervention. RESULTS: The identified priorities were dominated by research investment options targeting Zn supplementation, and were followed by research on Zn fortification, general aspects of Zn nutrition, dietary modification and other new interventions. CONCLUSIONS: In general, research options that aim to improve the efficiency of an already existing intervention strategy received higher priority scores. Challenges identified during the implementation of the methodology and suggestions to modify the priority-setting procedures are discussed.

Economic gains of a home fortification program: evaluation of "Sprinkles" from the provider's perspective.

INTRODUCTION: This paper models the effects of a home-fortification program (using Sprinkles which contain zinc and iron and other micronutrients), in Pakistan, a country with high levels of infant mortality, anemia, and diarrhea. It uses the results of randomized trials of the effect of Sprinkles on anemia and on longitudinal prevalence of diarrhea. METHODS: Based on previous literature, the effect of Sprinkles on intermediate outcomes (diarrhea and anemia) is linked to longer-term outcomes (infant and young child mortality, and cognitive achievement and hence adult wages). Three different measures of cost effectiveness are presented: the cost per death averted (effect via zinc supplementation on reduction of longitudinal prevalence of diarrhea); the cost per 'disability adjusted life year' (DALY) saved (same modality); and the gain in earnings due to higher cognitive functioning for each dollar spent (effect via iron supplementation on reduced anemia). RESULTS: We estimated that the cost per death averted is dollars406 (dollars273-dollars3248), the cost per DALY saved is dollars12.2 (dollars8-dollars97) and the present value of the gain in earnings is dollars37 (dollars18-dollars51) for each dollar spent on the Sprinkles program. These estimates were developed for a low-income country (GDP per capita = dollars417) with a high infant mortality rate (IMR = 83/1000), high prevalence of anemia (93%), and high mean longitudinal prevalence of diarrhea (17%). DISCUSSION: These outcomes are particularly favourable in Pakistan. The outcomes are more favourable when used with children 6-12 months. Further longer-run field trials of Sprinkles with larger populations would be helpful.