The cost of inaction: a global tool to inform nutrition policy and investment decisions on global nutrition targets.

At present, the world is off-track to meet the World Health Assembly global nutrition targets for 2025. Reducing the prevalence of stunting and low birthweight (LBW) in children, and anaemia in women, and increasing breastfeeding rates are among the prioritized global nutrition targets for all countries. Governments and development partners need evidence-based data to understand the true costs and consequences of policy decisions and investments. Yet there is an evidence gap on the health, human capital, and economic costs of inaction on preventing undernutrition for most countries. The Cost of Inaction tool and expanded Cost of Not Breastfeeding tool provide country-specific data to help address the gaps. Every year undernutrition leads to 1.3 million cases of preventable child and maternal deaths globally. In children, stunting results in the largest economic burden yearly at US$548 billion (0.7% of global gross national income [GNI]), followed by US$507 billion for suboptimal breastfeeding (0.6% of GNI), US$344 billion (0.3% of GNI) for LBW and US$161 billion (0.2% of GNI) for anaemia in children. Anaemia in women of reproductive age (WRA) costs US$113 billion (0.1% of GNI) globally in current income losses. Accounting for overlap in stunting, suboptimal breastfeeding and LBW, the analysis estimates that preventable undernutrition cumulatively costs the world at least US$761 billion per year, or US$2.1 billion per day. The variation in the regional and country-level estimates reflects the contextual drivers of undernutrition. In the lead-up to the renewed World Health Assembly targets and Sustainable Development Goals for 2030, the data generated from these tools are powerful information for advocates, governments and development partners to inform policy decisions and investments into high-impact low-cost nutrition interventions. The costs of inaction on undernutrition continue to be substantial, and serious coordinated action on the global nutrition targets is needed to yield the significant positive human capital and economic benefits from investing in nutrition.

Therapeutic efficacy of recombinant human growth hormone in children with different etiologies of dwarfism from a pharmacoeconomic point of view.

Treatment outcomes for different causes of childhood dwarfism vary widely, and there are no studies on the economic burden of treatment in relation to outcomes. This paper compared the efficacy and healthcare costs per unit height of recombinant human growth hormone (rhGH) for the treatment of growth hormone deficiency (GHD) and idiopathic short stature (ISS) with a view to providing a more cost-effective treatment option for children. We retrospectively analyzed 117 cases (66 cases of GHD and 51 cases of ISS) of short-stature children who first visited Weifang People's Hospital between 2019.1 and 2022.1 and were treated with rhGH for 1 to 3 years to track the treatment effect and statistically analyzed by using paired t tests, non-parametric tests, and chi-square tests, to evaluate the efficacy of rhGH treatment for GHD and ISS children and the medicinal cost. The annual growth velocity (GV) of children with GHD and ISS increased the fastest during 3 to 6 months after treatment and then gradually slowed down. The GV of the GHD group was higher than that of the ISS group from 0 to 36 months after treatment (P < .05 at 3, 6, 9, and 12 months); the height standard deviation scores (HtSDS) of the children in the GHD and ISS groups increased gradually with the increase of the treatment time, and the changes in the height standard deviation scores (ΔHtSDS) of the GHD group were more significant than those of the ISS group (P < .05 at 3, 6, 9, and 12 months). (2) The medical costs in the pubertal group for a 1-cm increase in height were higher than those of children in the pre-pubertal group at the same stage (3 to 24 months P < .05). The longer the treatment time within the same group, the higher the medical cost of increasing 1cm height. RhGH is effective in treating children with dwarfism to promote height growth, and the effect on children with GHD is better than that of children with ISS; the earlier the treatment time, the lower the medical cost and the higher the comprehensive benefit.

Tackling access and payer barriers for growth hormone therapy in Saudi Arabia: a consensus statement for the Saudi Working Group for Pediatric Endocrinology.

Prompt diagnosis and early treatment are key goals to optimize the outcomes of children with growth hormone deficiency (GHD) and attain the genetically expected adult height. Nonetheless, several barriers can hinder prompt diagnosis and treatment of GHD, including payer-related issues. In Saudi Arabia, moderate-to-severe short stature was reported in 13.1 and 11.7 % of healthy boys and girls, respectively. Several access and payer barriers can face pediatric endocrinologists during the diagnosis and treatment of GHD in Saudi Arabia. Insurance coverage policies can restrict access to diagnostic tests for GHD and recombinant human growth hormone (rhGH) due to their high costs and lack of gold-standard criteria. Some insurance policies may limit the duration of treatment with rhGH or the amount of medication covered per month. This consensus article gathered the insights of pediatric endocrinologists from Saudi Arabia to reflect the access and payer barriers to the diagnostic tests and treatment options of children with short stature. We also discussed the current payer-related challenges endocrinologists face during the investigations of children with short stature. The consensus identified potential strategies to overcome these challenges and optimize patient management.

The economic burden of pediatric growth hormone deficiency in Italy: a cost of illness study.

PURPOSE: Growth hormone deficiency (GHD) is a rare condition with a worldwide prevalence of 1 patient in 4000 to 10,000 live births, placing a significant economic burden on healthcare systems. The aim of this study is to generate evidence on the economic burden of children and adolescents with GHD treated with rhGH and their parents in Italy. METHODS: A cost of illness analysis, adopting the prevalence approach, has been developed, producing evidence on the total annual cost sustained by the Italian National Health System (NHS) and by the society. The study is based on original data collected from a survey conducted among Italian children and adolescents with GHD and their parents. RESULTS: 143 children/adolescents with GHD and their parents participated to the survey, conducted from May to October 2021. Patients had a mean age of 12.2 years (SD: 3.1) and were mostly males (68.5%). The average direct healthcare cost sustained by the NHS was € 8,497.2 per patient/year; adding the out-of-pocket expenses (co-payments and expenses for private healthcare service), the total expense was € 8,568.6. The indirect costs, assessed with the human capital approach, were € 847.9 per patient/year. The total of direct and indirect cost is € 9,345.1 from the NHS perspective, and € 9,416.5 from a social perspective. The total cost incurred by the Italian NHS for children with GHD (range: 5,708-8,354) was estimated in € 48.5-71.0 million, corresponding to 0.04-0.06% of the total Italian public health expense in the year 2020. CONCLUSIONS: The total annual cost for GHD children is close to € 10,000, and is mainly due to the cost of rhGH treatment. This cost is almost entirely sustained by the NHS, with negligible out-of-pocket expenses. The economic burden on the Italian NHS for the health care of established GHD children is fourfold higher than the prevalence of the disease in the overall Italian population.

Global, regional and national epidemiology and prevalence of child stunting, wasting and underweight in low- and middle-income countries, 2006-2018.

In 2016, undernutrition, as manifested in childhood stunting, wasting, and underweight were estimated to cause over 1.0 million deaths, 3.9% of years of life lost, and 3.8% of disability-adjusted life years globally. The objective of this study is to estimate the prevalence of undernutrition in low- and middle-income countries (LMICs) using the 2006-2018 cross-sectional nationally representative demographic and health surveys (DHS) data and to explore the sources of regional variations. Anthropometric measurements of children 0-59 months of age from DHS in 62 LMICs worldwide were used. Complete information was available for height-for-age (n = 624,734), weight-for-height (n = 625,230) and weight-for-age (n = 626,130). Random-effects models were fit to estimate the pooled prevalence of stunting, wasting, and underweight. Sources of heterogeneity in the prevalence estimates were explored through subgroup meta-analyses and meta-regression using generalized linear mixed-effects models. Human development index (a country-specific composite index based on life expectancy, literacy, access to education and per capita gross domestic product) and the United Nations region were explored as potential sources of variation in undernutrition. The overall prevalence was 29.1% (95% CI 26.7%, 31.6%) for stunting, 6.3% (95% CI 4.6%, 8.2%) for wasting, and 13.7% (95% CI 10.9%, 16.9%) for underweight. Subgroup analyses suggested that Western Africa, Southern Asia, and Southeastern Asia had a substantially higher estimated prevalence of undernutrition than global average estimates. In multivariable meta-regression, a combination of human development index and United Nations region (a proxy for geographical variation) explained 54%, 56%, and 66% of the variation in stunting, wasting, and underweight prevalence, respectively. Our findings demonstrate that regional, subregional, and country disparities in undernutrition remain, and the residual gaps to close towards achieving the second sustainable development goal-ending undernutrition by 2030.

Estimating the health burden of aflatoxin attributable stunting among children in low income countries of Africa.

Numerous population-based studies have documented high prevalence of aflatoxin associated childhood stunting in low income countries. We provide an estimate of the disease burden of aflatoxin related stunting using data from the four African countries. For this empirical analysis, we obtained blood aflatoxin albumin adduct biomarker based exposure data as measured using ELISA technique and anthropometric measurement data from surveys done over a 12-year period from 2001 to 2012 in four low income countries in Africa. We used these data to calculate population attributable risk (PAR), life time disease burden for children under five by comparing two groups of stunted children using both prevalence and incidence-based approaches. We combined prevalence estimates with a disability weight, measuring childhood stunting and co-occurrence of stunting-underweight to produce years lived with disability. Using a previously reported mortality, years of life lost were estimated. We used probabilistic analysis to model these associations to estimate the disability-adjusted life-years (DALYs), and compared these with those given by the Institute for Health Metrics and Evaluation's Global Burden of Disease (GBD) 2016 study. The PAR increased from 3 to 36% for aflatoxin-related stunting and 14-50% for co-occurrence of stunting and underweight. Using prevalence-based approach, children with aflatoxin related stunting resulted in 48,965.20 (95% uncertainty interval (UI): 45,868.75-52,207.53) DALYs per 100,000 individuals. Children with co-occurrence of stunting and underweight due to exposure to aflatoxin resulted in 40,703.41 (95% UI: 38,041.57-43,517.89) DALYs per 100,000 individuals. Uncertainty analysis revealed that reducing aflatoxin exposure in high exposure areas upto non-detectable levels could save the stunting DALYs up to 50%. The burden of childhood all causes stunting is greater in countries with higher aflatoxin exposure such as Benin. In high exposure areas, these results might help guide research protocols and prioritisation efforts and focus aflatoxin exposure reduction. HEFCE Global Challenge Research Fund Aflatoxin project.

Child Undernutrition in Sudan: The Social and Economic Impact and Future Perspectives.

The nutrition situation in Sudan is one of the worst in northeast Africa and it is characterized by persistently high levels of acute and chronic malnutrition that have increased over the last two decades. The underlying causes of malnutrition are multi-sectoral and are mainly due to inequalities, inadequate food practices, and limited access to healthcare services. Based on the report The Economic and Social Impacts of Child Undernutrition in Sudan, this study assesses the impact that malnutrition has on health, education, and productivity in Sudan. The country is estimated to have lost an equivalent of about 11.6 billion Sudanese pound (1 United States dollar = 55.3 Sudanese pound) in 2014, which represented 2.6% of the gross domestic product (GDP). Productivity-related losses contributed the largest costs at 1.5% of GDP followed by health and education sectors at 1.1% and 0.1%, respectively. In 2020, the outbreak of the COVID-19 pandemic further exposed the fragility of Sudan's health, social, and economic system. It is mandatory that all stakeholders address child nutrition as a main concern and stunting is incorporated in the center of the development agenda. In particular, the national development frameworks should be updated to ensure the reduction of the stunting prevalence and to put in place a comprehensive multi-sectoral nutrition policy, strategy, and plan of action.

Drivers of stunting reduction in Nepal: a country case study.

BACKGROUND: Chronic child malnutrition represents a serious global health concern. Over the last several decades, Nepal has seen a significant decline in linear growth stunting - a physical manifestation of chronic malnutrition - despite only modest economic growth and significant political instability. OBJECTIVE: This study aimed to conduct an in-depth assessment of the determinants of stunting reduction in Nepal from 1996 to 2016, with specific attention paid to national-, community-, household-, and individual-level factors, as well as relevant nutrition-specific and -sensitive initiatives rolled out within the country. METHODS: Using a mixed-methods approach, 4 types of inquiry were employed: 1) a systematic review of published peer-reviewed and gray literature; 2) retrospective quantitative data analyses using Demographic and Health Surveys from 1996 to 2016; 3) a review of key nutrition-specific and -sensitive policies and programs; and 4) retrospective qualitative data collection and analyses. RESULTS: Mean height-for-age z-scores (HAZ) improved by 0.94 SDs from 1996 to 2016. Subnational variation and socioeconomic inequalities in stunting outcomes persisted, with the latter widening over time. Decomposition analysis for children aged under 5 y explained 90.9% of the predicted change in HAZ, with key factors including parental education (24.7%), maternal nutrition (19.3%), reduced open defecation (12.3%), maternal and newborn health care (11.5%), and economic improvement (9.0%). Key initiatives focused on decentralizing the health system and mobilizing community health workers to increase accessibility; long-standing nationwide provision of basic health interventions; targeted efforts to improve maternal and child health; and the prioritization of nutrition-sensitive initiatives by both government and donors. National and community stakeholders and mothers at village level highlighted a mixture of poverty reduction, access to health services, improved education, and increased access to water, sanitation, and hygiene as drivers of stunting reduction. CONCLUSIONS: Improvements in both nutrition-specific and nutrition-sensitive sectors have been critical to Nepal's stunting decline, particularly in the areas of poverty reduction, health, education, and sanitation.

Equity and Distributional Impact on Stunting of a Nutritional Package Targeting Children Aged 6-36 Months in China: Findings from a Modeling Study.

BACKGROUND: Despite rapid economic development, child stunting remains a persistent problem in China. Stunting prevalence varies greatly across geographical regions and wealth groups. To address child undernutrition, the Ying Yang Bao (YYB) nutritional package has been piloted in China since 2001. OBJECTIVE: We aimed to evaluate the distributional impact of a hypothetical rollout of the YYB nutritional package on child stunting across provinces and wealth groups in China, with a specific focus on equity. METHODS: We used data from China Family Panel Studies and built on extended cost-effectiveness analysis methods. We estimated the distributional impact of a 12-month YYB program targeting children aged 6-36 months across 25 provinces and two wealth groups along three dimensions: the cost of the YYB program; the number of child stunting cases averted by YYB; and the cost per stunting case averted. Children in each province were divided into poverty and non-poverty groups based on the international poverty line of $5.50 per day. We also conducted a range of sensitivity analyses. RESULTS: We showed that 75% coverage of YYB could avert 1.9 million stunting cases among children aged 6-36 months, including 1.3 million stunting cases among children living under the poverty line, at a total cost of ¥5.4-6.2 billion ($1.5-1.8 billion) depending on the type of YYB delivery. The cost per stunting case averted would greatly vary across Chinese provinces and wealth groups, ranging from ¥800 (around $220, Chongqing province) to ¥23,300 (around $6600, Jilin province). In most provinces, the cost per stunting case averted would be lower for children living under the poverty line. CONCLUSIONS: YYB could be a pro-poor nutritional intervention package that brings substantial health benefits to poor and marginalized Chinese children, but with large variations in value for money across provinces and wealth groups. This analysis points to the need for prioritization across provinces and a targeted approach for YYB rollout in China.

Drivers of stunting reduction in Ethiopia: a country case study.

BACKGROUND: Chronic undernutrition in children continues to be a global public health concern. Ethiopia has documented a significant decline in the prevalence of childhood stunting, a measure of chronic undernutrition, over the last 20 y. OBJECTIVES: The aim of this research was to conduct a systematic assessment of the determinants that have driven child stunting reduction in Ethiopia from 2000 to 2016, focused on the national, community, household, and individual level. METHODS: This study employed both quantitative and qualitative methods. Specifically, a systematic literature review, retrospective quantitative data analysis using Demographic and Health Surveys from 2000-2016, qualitative data collection and analysis, and analyses of key nutrition-specific and -sensitive policies and programs were undertaken. RESULTS: National stunting prevalence improved from 51% in 2000 to 32% in 2016. Regional variations exist, as do pro-rich, pro-urban, and pro-educated inequalities. Child height-for-age z score (HAZ) decomposition explained >100% of predicted change in mean HAZ between 2000 and 2016, with key factors including increases in total consumable crop yield (32% of change), increased number of health workers (28%), reduction in open defecation (13%), parental education (10%), maternal nutrition (5%), economic improvement (4%), and reduced diarrhea incidence (4%). Policies and programs that were key to stunting decline focused on promoting rural agriculture to improve food security; decentralization of the health system, incorporating health extension workers to improve rural access to health services and reduce open defecation; multisectoral poverty reduction strategies; and a commitment to improving girls' education. Interviews with national and regional stakeholders and mothers in communities presented improvements in health service access, women and girls' education, improved agricultural production, and improved sanitation and child care practices as drivers of stunting reduction. CONCLUSIONS: Ethiopia's stunting decline was driven by both nutrition-specific and -sensitive sectors, with particular focus on the agriculture sector, health care access, sanitation, and education.

Drivers of stunting reduction in Senegal: a country case study.

BACKGROUND: Senegal has been an exemplar country in the West African region, reducing child stunting prevalence by 17.9% from 1992 to 2017. OBJECTIVES: In this study, we aimed to conduct a systematic in-depth assessment of factors at the national, community, household, and individual levels to determine the key enablers of Senegal's success in reducing stunting in children <5 y old between 1992/93 and 2017. METHODS: A mixed methods approach was implemented, comprising quantitative data analysis, a systematic literature review, creation of a timeline of nutrition-related programs, and qualitative interviews with national and regional stakeholders and mothers in communities. Demographic and Health Surveys and Multiple Indicator Cluster Surveys were used to explore stunting inequalities and factors related to the change in height-for-age z-score (HAZ) using difference-in-difference linear regression and the Oaxaca-Blinder decomposition method. RESULTS: Population-wide gains in average child HAZ and stunting prevalence have occurred from 1992/93 to 2017. Stunting prevalence reduction varied by geographical region and prevalence gaps were reduced slightly between wealth quintiles, maternal education groups, and urban compared with rural residence. Statistical determinants of change included improvements in maternal and newborn health (27.8%), economic improvement (19.5%), increases in parental education (14.9%), and better piped water access (8.1%). Key effective nutrition programs used a community-based approach, including the Community Nutrition Program and the Nutrition Enhancement Program. Stakeholders felt sustained political will and multisectoral collaboration along with improvements in poverty, women's education, hygiene practices, and accessibility to health services at the community level reduced the burden of stunting. CONCLUSIONS: Senegal's success in the stunting decline is largely attributed to the country's political stability, the government's prioritization of nutrition and execution of nutrition efforts using a multisectoral approach, improvements in the availability of health services and maternal education, access to piped water and sanitation facilities, and poverty reduction. Further efforts in the health, water and sanitation, and agriculture sectors will support continued success.

Drivers of stunting reduction in Peru: a country case study.

BACKGROUND: Peru reduced its under-5 child stunting prevalence notably from 31.3% in 2000 to 13.1% in 2016. OBJECTIVES: We aimed to study factors and key enablers of child stunting reduction in Peru from 2000-2016. METHODS: Demographic and Health Surveys were used to conduct descriptive analyses [height-for-age z scores (HAZ) means and distributions, equity analysis, predicted child growth curves through polynomial regressions] and advanced regression analyses. An ecological (at department level) multilevel regression analysis was conducted to identify the major predictors of stunting decline from 2000 to 2016, and Oaxaca-Blinder decomposition was conducted to identify the relative contribution of each factor to child HAZ change. A systematic literature review, policy and program analysis, and interviews with relevant stakeholders were conducted to understand key drivers of stunting decline in Peru. RESULTS: The distribution of HAZ scores showed a slight rightward shift from 2000 to 2007/2008, and a greater shift from 2007/2008 to 2016. Stunting reduction was higher in the lowest wealth quintile, in rural areas, and among children with the least educated mothers. Decomposing predicted changes showed that the most important factors were increased maternal BMI and maternal height, improved maternal and newborn health care, increased parental education, migration to urban areas, and reduced fertility. Key drivers included the advocacy role of civil society and political leadership around poverty and stunting reduction since the early 2000s. Key enablers included the economic growth and the consolidation of democracy since the early 2000s, and the acknowledgement that stunting reduction needs much more than food supplementation. CONCLUSIONS: Peru reduced child stunting owing to improved socioeconomic determinants, sustained implementation of out-of-health-sector and within-health-sector changes, and implementation of health interventions. These efforts were driven through a multisectoral approach, strong civil society advocacy, and keen political leadership. Peru's experience offers useful lessons on how to tackle the problem of stunting under differing scenarios, with the participation of multiple sectors.

Drivers of stunting reduction in the Kyrgyz Republic: A country case study.

BACKGROUND: Chronic malnutrition among infants and children continues to represent a global public health concern. The Kyrgyz Republic has achieved rapid declines in stunting over the last 20 y, despite modest increases in gross domestic product per capita. OBJECTIVE: This study aimed to conduct a systematic, in-depth assessment of national, community, household, and individual drivers of nutrition change and stunting reduction, as well as nutrition-specific and -sensitive policies and programs, in the Kyrgyz Republic. METHODS: This mixed methods study employed 4 inquiry methods, including: 1) a systematic scoping literature review; 2) retrospective quantitative data analyses, including linear regression multivariable hierarchical modeling, difference-in-difference analysis, and Oaxaca-Blinder decomposition; 3) qualitative data collection and analysis; and 4) analysis of key nutrition-specific and -sensitive policies and programs. RESULTS: Stunting prevalence has decreased in the Kyrgyz Republic, however, subnational variations and inequities persist. Child growth Victora curves show improvements in height-for-age z-scores (HAZ) for children in the Kyrgyz Republic between 1997 and 2014, indicating increased intrauterine growth and population health improvements. The decomposition analysis explained 88.9% (0.637 SD increase) of the predicted change in HAZ for children under 3 y (1997-2012). Key factors included poverty (61%), maternal nutrition (14%), paternal education (6%), fertility (6%), maternal age (3%), and wealth accumulation (2%). Qualitative analysis revealed poverty reduction, increased migration and remittances, food security, and maternal nutrition as key drivers of stunting decline. Systematic scoping literature review findings supported quantitative and qualitative results, and indicated that land reforms and improved food security represented important factors. Key nutrition-specific and -sensitive policies and programs implemented involved breastfeeding promotion, social protection schemes, and land and health sector reforms. CONCLUSIONS: Improvements in stunting were achieved amidst political and economic changes. Multilevel enablers, including poverty reduction, improved food security, and introduction of land and health reforms have contributed to improvements in health, nutrition, and stunting among children in the Kyrgyz Republic.

How countries can reduce child stunting at scale: lessons from exemplar countries.

BACKGROUND: Child stunting and linear growth faltering have declined over the past few decades and several countries have made exemplary progress. OBJECTIVES: To synthesize findings from mixed methods studies of exemplar countries to provide guidance on how to accelerate reduction in child stunting. METHODS: We did a qualitative and quantitative synthesis of findings from existing literature and 5 exemplar country studies (Nepal, Ethiopia, Peru, Kyrgyz Republic, Senegal). Methodology included 4 broad research activities: 1) a series of descriptive analyses of cross-sectional data from demographic and health surveys and multiple indicator cluster surveys; 2) multivariable analysis of quantitative drivers of change in linear growth; 3) interviews and focus groups with national experts and community stakeholders and mothers; and 4) a review of policy and program evolution related to nutrition. RESULTS: Several countries have dramatically reduced child stunting prevalence, with or without closing geographical, economic, and other population inequalities. Countries made progress through interventions from within and outside the health sector, and despite significant heterogeneity and differences in context, contributions were comparable from health and nutrition sectors (40% of change) and other sectors (50%), previously called nutrition-specific and -sensitive strategies. Improvements in maternal education, maternal nutrition, maternal and newborn care, and reductions in fertility/reduced interpregnancy intervals were strong contributors to change. A roadmap to reducing child stunting at scale includes several steps related to diagnostics, stakeholder consultations, and implementing direct and indirect nutrition interventions related to the health sector and nonhealth sector . CONCLUSIONS: Our results show that child stunting reduction is possible even in diverse and challenging contexts. We propose that our framework of organizing nutrition interventions as direct/indirect and inside/outside the health sector should be considered when mapping causal pathways of child stunting and planning interventions and strategies to accelerate stunting reduction to achieve the 2030 Sustainable Development Goals.

A cross-sectional study on selected child health outcomes in India: Quantifying the spatial variations and identification of the parental risk factors.

This study examined association between selected child health indicators- anaemia, stunting and no/incomplete immunization by inter-linking maternal characteristics at district level and parental characteristics at individual level. A spatial analysis and a binary logit model estimation were employed to draw inferences using the data from the fourth round of National Family Health Survey, 2015-16 of India. Significant spatial clustering of the selected child health outcomes was observed in the country. Mother's educational attainment explained significant district level differential in the selected child health outcomes. At the individual level, parents who are very young, not-educated, socially excluded, belong to poor class were found to be significantly associated with the poor child health outcomes. This study indicates that parental characteristics, such as age, educational attainment and employment substantially determine child health in India, suggesting that an intervention by targeting the households where children are vulnerable is important to improve child health in the country.

Impact of stakeholder perspectives on cost-effectiveness estimates of four specialized nutritious foods for preventing stunting and wasting in children 6-23 months in Burkina Faso.

BACKGROUND: Multiple specialized nutritious food options are programmed for supplementation in humanitarian and development settings. However, comparative cost-effectiveness evidence is lacking, let alone incorporation of perspectives from uncompensated stakeholders. A Burkina Faso trial evaluated the cost-effectiveness of Corn Soy Blend Plus w/ oil (CSB+ w/oil, reference arm), Corn Soy Whey Blend w/oil (CSWB w/oil), Super Cereal Plus (SC+), and Ready-to-Use Supplementary Food (RUSF) in reducing stunting and wasting among children 6-23 months old. This paper presents cost-effectiveness findings from multiple stakeholders' perspectives, including caregivers and program volunteers. METHODS: An activity-based costing with ingredients approach was used to summarize cost of the 18-month-long blanket supplementary feeding for each enrolled child (in 2018 USD). Time data were collected using self-reported and observational instruments. Cost-effectiveness relative to CSB+ w/oil assessed incremental cost per enrolled child against incremental outcomes: prevalence of stunting at 23 months of age and number of months of wasting. Two combined perspectives were compared: program (donor, implementer, and volunteer) versus program and caregiver (adding caregiver). RESULTS: A total of 6112 children were enrolled. While similar effectiveness was found in three arms (CSWB w/oil was less effective), costs differed. Product cost and caregiver time to prepare study foods were major drivers of cross-arm cost differences from the respective combined perspective. The two major drivers were used to construct uncertainty ranges of cost per enrolled child from program and caregiver perspective: $317 ($279- $355) in CSB+ w/oil, $350 ($327- $373) in CSWB w/oil, $387 ($371- $403) in RUSF, and $434 ($365- $503) in SC+. Cost from program and caregiver perspective was a substantial increase from program perspective. CSB+ w/oil was most cost-effective in reducing stunting and wasting, and this main finding was robust to changing perspectives and all corresponding sensitivity analyses when uncompensated time was valued at minimum wage ($0.36/h). The break-even point for uncompensated time valuation is >$0.84/h, where RUSF became the most cost-effective from the program and caregiver perspective. Relative cost-effectiveness rankings among the other three arms depended on choice of perspectives, and were sensitive to values assigned to product cost, international freight cost, opportunity cost of time, and outcomes of a hypothetical control. Volunteer opportunity cost did not affect arm comparisons, but lack of compensation resulted in negative financial consequences for caregivers. CONCLUSIONS: Evaluating cost-effectiveness by incorporating uncompensated stakeholders provided crucial implementation insights around nutrition products and programming. TRIAL REGISTRATION: Trial registration number: NCT02071563. Name of registry: ClinicalTrials.gov URL of registry: https://clinicaltrials.gov/ct2/show/NCT02071563?type=Intr&cond=Malnutrition&cntry=BF&draw=2&rank=9 Date of registration: February 26, 2014. Date of enrollment of first participant: July 2014.

Socioeconomic Inequalities in Child Malnutrition in Bangladesh: Do They Differ by Region?

Socioeconomic inequality in child malnutrition is well-evident in Bangladesh. However, little is known about whether this inequality differs by regional contexts. We used pooled data from the 2011 and 2014 Bangladesh Demographic and Health Survey to examine regional differences in socioeconomic inequalities in stunting and underweight among children under five. The analysis included 14,602 children aged 0-59 months. We used logistic regression models and the Concentration index to assess and quantify wealth- and education-related inequalities in child malnutrition. We found stunting and underweight to be more concentrated among children from poorer households and born to less-educated mothers. Although the poverty level was low in the eastern regions, socioeconomic inequalities were greater in these regions compared to the western regions. The extent of socioeconomic inequality was the highest in Sylhet and Chittagong for stunting and underweight, respectively, while it was the lowest in Khulna. Regression results demonstrated the protective effects of socioeconomic status (SES) on child malnutrition. The regional differences in the effects of SES tend to diverge at the lower levels of SES, while they converge or attenuate at the highest levels. Our findings have policy implications for developing programs and interventions targeted to reduce socioeconomic inequalities in child malnutrition in subnational regions of Bangladesh.

Rojiroti microfinance and child nutrition: a cluster randomised trial.

OBJECTIVE: To determine whether Rojiroti microfinance, for poor Indian women, improves child nutrition. DESIGN: Cluster randomised trial. SETTING: Tolas (village communities) in Bihar State. PARTICIPANTS: Women and children under 5 years. INTERVENTIONS: With Rojiroti microfinance, women form self-help groups and save their money to provide loans to group members. After 6 months, they receive larger external loans. Tolas were randomised to receive Rojiroti immediately or after 18 months. OUTCOME MEASURES: The primary analysis compared the mean weight for height Z score (WHZ) of children under 5 years in the intervention versus control tolas who attended for weight and height measurement 18 months after randomisation. Secondary outcomes were weight for age Z score (WAZ), height for age Z score, mid-upper arm circumference (MUAC), wasting, underweight and stunting. RESULTS: We randomised 28 tolas to each arm and collected data from 2469 children (1560 mothers) at baseline and 2064 children (1326 mothers) at follow-up. WHZ was calculated for 1718 children at baseline and 1377 (674 intervention and 703 control) at follow-up. At 18 months, mean WHZ was significantly higher for intervention (-1.02) versus controls (-1.37; regression coefficient adjusted for clustering ß=0.38, 95% CI 0.16 to 0.61, p=0.001). Significantly fewer children were wasted in the intervention group (122, 18%) versus control (200, 29%; OR=0.46, 95% CI 0.28 to 0.74, p=0.002). Mean WAZ was better in the intervention group (-2.13 vs -2.37; ß=0.27, 95% CI 0.11 to 0.43, p=0.001) as was MUAC (13.6 cm vs 13.4 cm; ß=0.22, 95% CI 0.03 to 0.40, p=0.02). In an analysis adjusting for baseline nutritional measures (259 intervention children and 300 control), only WAZ and % underweight showed significant differences in favour of the intervention. CONCLUSION: In marginalised communities in rural India, child nutrition was better in those who received Rojiroti microfinance, compared with controls. TRIAL REGISTRATION NUMBER: NCT01845545.