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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 17.7mg iron/child/day and 7.4mg 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.
This study estimated costs and impacts on dietary intake of priority nutrition-sensitive programs to improve maternal-child health in SSA and South Asia. Our mixed methods approach included regional meetings with expert stakeholders from a variety of institutional, sectoral and disciplinary backgrounds in SSA and South Asia; delineation of program components and economic mechanisms for dietary change; and literature reviews to validate and calibrate estimated program costs and impacts on dietary intake. Additional details on these processes are outlined below, and the analytical framework is described in Table 1. Analytical framework for estimating program costs and impacts PPP, purchasing power parity To identify a set of programs most likely to be high priorities for government or donor funding, we organized and held in-person meetings with a range of regional nutrition and program experts on South Asia (hosted in Nepal in December 2015) and SSA (hosted in Ethiopia in February 2016). The goal of these meetings was to identify nutrition-sensitive programs that local experts consider to be of greatest relevance to child nutrition in eight countries with high burdens of undernutrition: India, Nepal, Bangladesh, Ethiopia, Nigeria, Ghana, Tanzania and Uganda. For this analysis we retained the 12 programs for which a full set of cost and impact data could be calculated, which limits coverage to India, Ethiopia and Nigeria. Our participatory approach ensured that interested parties could not pre-determine which programs would be considered or how their cost-effectiveness would be calculated. At these meetings, a total of 48 specific nutrition-sensitive programs were considered, identified based on interventions that were currently being implemented, under debate as potential additions to existing activities, or new programs with high promise for efficacy. For each proposed program, the following information was discussed: (1) the description of the program; (2) the mechanisms for impact on dietary behaviours; (3) the target foods and nutrients to be increased; (4) the location and demographic characteristics of the target population; (5) the lead authority and implementing organization for the program; (6) the types and costs of resources required for program implementation, using an ingredients approach (unit needs and costs) and separately considering start-up, recurring costs and evaluation; and (7) the additional regional expert contacts relevant to that program. Additional details on the methods and results of these two regional meetings are documented elsewhere (Masters et al. 2017). From the 48 programs identified at our regional expert meetings, we focused on 12 for analysis in this paper (Table 2) based on the following three criteria: First, we included only programs that participants described as relevant for India, Ethiopia or Nigeria, or for the South Asian or African contexts more generally, so as to align results with country priorities of the Bill & Melinda Gates Foundation which supported this project. Next, we included only programs that targeted children under 5, relevant to linking changes in dietary intake to disease outcomes for maternal-child health. Finally, we excluded programs for which required resources for implementation were not sufficiently documented to compute program costs. Program elements by country PSNP, productive safety net program; ANC, antenatal care; ND, no data; SSB, sugar-sweetened beverage; FV, fruit and vegetable To estimate the impacts of each intervention on diet quality, we began by identifying the potential economic mechanism(s) by which each program might alter children’s food intake. These included (1) transfer of resources or cash to alter the purchase or use of home-grown foods (hereafter referred to as resource transfers); (2) changing food prices to alter purchasing behaviour (hereafter referred to as access changes); (3) changing dietary preferences to alter the purchase or use of home-grown foods (hereafter referred to as preference changes); and (4) transfer of food items to increase intake (hereafter referred to as food transfers). We then used previous studies of each mechanism to quantify the intervention’s likely effect on dietary components involved in five diet–disease relationships for which we had identified evidence for etiologic effects and significant disease burdens in these regions, namely iron and anaemia, vitamin A and mortality, zinc and diarrhoea, zinc and stunting, and animal protein and stunting. For each program’s impact on any or all four of these dietary components (iron, vitamin A, zinc and animal protein) we then conducted a comprehensive review of the program evaluation literature to identify published studies of similar interventions. This process began with literature searches using the following search terms alone and in combination: impact, diet, diet diversity, iron, zinc, vitamin A, animal protein, fruit, vegetable, dark green leafy vegetable, cash transfer, conditional, poultry production, small livestock production, animal husbandry, home gardens, complementary food production, complementary feeding, mass media campaign, radio campaign, nutrition education, community education, community demonstrations, peer videos, micronutrient sachets, community mills, income elasticity and price elasticity. Those online searches were complemented by direct contacts with the expert participants from our regional meetings. To identify the most suitable published studies, we searched for outcome and/or impact evaluations that matched the proposed programs on the following criteria: (1) country of interest, (2) target population of interest, (3) mechanism used to alter dietary intake, and (4) target foods and nutrients. In cases where criteria (1) and (2) could not be met, evaluations in other countries and/or target populations in the same region that met the remaining criteria were chosen. Our main countries of interest were India, Ethiopia, and Nigeria, while the larger regions of interest included SSA and South Asia. The target population of interest included children under 5 years of age. Target nutrients of interest included vitamin A, animal protein, iron and zinc. Studies were included if they either reported changes in intakes of these target nutrients or changes in intakes of foods that are major sources of these nutrients. Studies were excluded if they did not meet any of the aforementioned criteria, if they did not report changes in dietary intake, if they were not experimental in nature, or if they were published before 1995. We also excluded studies from high-income countries [World Bank Classification (The World Bank 2017a)]. In one instance (Educational Entertainment in Ethiopia; see Table 2), the proposed program had only been implemented to change agricultural practices, rather than dietary intake. For this program, we used the existing program’s reported change in uptake of targeted practices as a proxy for changes in dietary behaviours. From these searches, titles and abstracts were reviewed for relevance using criteria outlined above. The full texts of potentially relevant studies were retrieved. For studies meeting inclusion and exclusion criteria, key data were extracted including country, study design, target population, description of intervention and control groups, intervention components, duration of the intervention, target foods and/or nutrients of intervention, method for assessing dietary intake and intervention effects on diet for the target population. In cases where multiple studies met inclusion criteria for a given program, the closest match was chosen based on our pre-specified criteria outlined above. For each dietary factor of interest, we utilized primary survey data (Global Nutrition and Policy Consortium 2017) to estimate intake by demographic strata within countries (Smith et al. 2016). For programs with multiple nutrient targets, multiple impact sources were chosen as necessary to produce impact estimates for all target nutrients. For studies that reported the effects of programs or interventions on food intake rather than nutrient intake, local food composition tables were used to convert food intakes into nutrient intakes. For each of the 12 programs, information on priority target populations was collected at the regional meetings. This information was used in combination with census data or population estimates and demographic data for each country (United Nations 2017) to estimate the total target population for each program. Whenever possible, published reports on potential impact of each program were used to adjust the target population to estimate actual reach, whenever possible. Data on differences between targeted and reached populations were available for three of programs listed in Table 2 from the sources in Table 3; for other programs, costs and impacts were estimated on the basis of reaching the full target population. Potential impacts of each program on dietary intakea For the 12 selected programs, resources and costs determined from the regional meetings were reviewed for completeness and face validity. Missing or outlier costs were researched in the scientific literature for relevant matches or, if necessary, derived from similar items priced for other interventions within the same region. Costs were distributed across different budget item categories for specificity. Resource needs and costs were calibrated and validated against published reports from similar program interventions identified using the search process described above. Resources and costs were also calibrated and validated across all of the 12 programs so that costs for a given type of resource could easily be compared across the 12 interventions. Total costs for each program were computed in net present value (NPV) terms to combine start-up and recurring costs, using purchasing power parity (PPP) adjusted prices to facilitate comparisons across countries and over time. PPP adjustment accounts for differences in both currencies and purchasing power in each country. All costs were reported in USD using 2015 PPP exchange rates (The World Bank 2017b). Start-up costs corresponded to the first 12 months of each program, and recurring costs to each subsequent year of intervention. A standard inflation rate of 0.03 per year was applied for costs arising from 2 two through the end of the program, and NPVs were calculated using a discount rate of 0.05.
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