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Choo EM, Kemp CG, Sagun KC, Paudel U, Wun J, Cunningham K, Acharya P, Rana PP, Levin C. The costs of Suaahara II, a complex scaled-up multisectoral nutrition programme in Nepal. MATERNAL & CHILD NUTRITION 2024:e13658. [PMID: 38704754 DOI: 10.1111/mcn.13658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 03/18/2024] [Accepted: 04/12/2024] [Indexed: 05/07/2024]
Abstract
Limited evidence exists on the costs of scaled-up multisectoral nutrition programmes. Such evidence is crucial to assess intervention value and affordability. Evidence is also lacking on the opportunity costs of implementers and participants engaging in community-level interventions. We help to fill this gap by estimating the full financial and economic costs of the United States Agency for International Development-funded Suaahara II (SII) programme, a scaled-up multisectoral nutrition programme in Nepal (2016-2023). We applied a standardized mixed methods costing approach to estimate total and unit costs over a 3.7-year implementation period. Financial expenditure data from national and subnational levels were combined with economic cost estimates assessed using in-depth interviews and focus group discussions with staff, volunteers, community members, and government partners in four representative districts. The average annual total cost was US$908,948 per district, with economic costs accounting for 47% of the costs. The annual unit cost was US$132 per programme participant (mother in the 1000-day period between conception and a child's second birthday) reached. Annual costs ranged from US$152 (mountains) to US$118 (plains) per programme participant. Personnel (63%) were the largest input cost driver, followed by supplies (11%). Community events (29%) and household counselling visits (17%) were the largest activity cost drivers. Volunteer cadres contributed significant time to the programme, with female community health volunteers spending a substantial amount of time (27 h per month) on SII activities. Multisectoral nutrition programmes can be costly, especially when taking into consideration volunteer and participant opportunity costs. This study provides much-needed evidence of the costs of scaled-up multisectoral nutrition programmes for future comparison against benefits.
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Affiliation(s)
- Esther M Choo
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Christopher G Kemp
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - K C Sagun
- Helen Keller International, Patan, Nepal
| | | | - Jolene Wun
- Independent Consultant, Washington, District of Columbia, USA
| | | | | | | | - Carol Levin
- Department of Global Health, University of Washington, Seattle, Washington, USA
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Iannotti L, Kleban E, Fracassi P, Oenema S, Lutter C. Evidence for Policies and Practices to Address Global Food Insecurity. Annu Rev Public Health 2024; 45:375-400. [PMID: 38166503 DOI: 10.1146/annurev-publhealth-060922-041451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
Food insecurity affects an estimated 691-783 million people globally and is disproportionately high in Africa and Asia. It arises from poverty, armed conflict, and climate change, among other demographic and globalization forces. This review summarizes evidence for policies and practices across five elements of the agrifood system framework and identifies gaps that inform an agenda for future research. Under availability, imbalanced agriculture policies protect primarily staple food producers, and there is limited evidence on food security impacts for smallholder and women food producers. Evidence supports the use of cash transfers and food aid for affordability and school feeding for multiple benefits. Food-based dietary guidelines can improve the nutritional quality of dietary patterns, yet they may not reflect the latest evidence or food supplies. Evidence from the newer food environment elements, promotion and sustainability, while relatively minimal, provides insight into achieving long-term impacts. To eliminate hunger, our global community should embrace integrated approaches and bring evidence-based policies and practices to scale.
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Affiliation(s)
- Lora Iannotti
- E3 Nutrition Lab, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA;
| | - Eliza Kleban
- E3 Nutrition Lab, Brown School, Washington University in St. Louis, St. Louis, Missouri, USA;
| | - Patrizia Fracassi
- Food and Nutrition Division, Food and Agriculture Organization of the United Nations, Rome, Italy
| | - Stineke Oenema
- UN-Nutrition Secretariat, Food and Agriculture Organization of the United Nations, Rome, Italy
| | - Chessa Lutter
- Division of Food Security and Agriculture, RTI International, Washington, DC, USA
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Neufeld LM, Nordhagen S, Leroy JL, Aberman NL, Barnett I, Djimeu Wouabe E, Webb Girard A, Gonzalez W, Levin CE, Mbuya MN, Nakasone E, Nyhus Dhillon C, Prescott D, Smith M, Tschirley D. Food Systems Interventions for Nutrition: Lessons from 6 Program Evaluations in Africa and South Asia. J Nutr 2024:S0022-3166(24)00176-7. [PMID: 38582386 DOI: 10.1016/j.tjnut.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 04/08/2024] Open
Abstract
Although there is growing global momentum behind food systems strategies to improve planetary and human health-including nutrition-there is limited evidence of what types of food systems interventions work. Evaluating these types of interventions is challenging due to their complex and dynamic nature and lack of fit with standard evaluation methods. In this article, we draw on a portfolio of 6 evaluations of food systems interventions in Africa and South Asia that were intended to improve nutrition. We identify key methodological challenges and formulate recommendations to improve the quality of such studies. We highlight 5 challenges: a lack of evidence base to justify the intervention, the dynamic and multifaceted nature of the interventions, addressing attribution, collecting or accessing accurate and timely data, and defining and measuring appropriate outcomes. In addition to more specific guidance, we identify 6 cross-cutting recommendations, including a need to use multiple and diverse methods and flexible designs. We also note that these evaluation challenges present opportunities to develop new methods and highlight several specific needs in this space.
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Affiliation(s)
- Lynnette M Neufeld
- Food and Nutrition Division, Food and Agriculture Organization of the United Nations (FAO), Rome, Italy.
| | - Stella Nordhagen
- Knowledge Leadership Team, Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Jef L Leroy
- Nutrition, Diets and Health Unit, International Food Policy Research Institute, Washington, DC, United States
| | - Noora-Lisa Aberman
- Knowledge Leadership Team, Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Inka Barnett
- Institute of Development Studies (IDS), University of Sussex, Brighton, United Kingdom
| | - Eric Djimeu Wouabe
- Evaluation and Adaptive Learning, Results for Development (R4D), Washington, DC, United States
| | - Amy Webb Girard
- Nutrition and Health Sciences Program, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Wendy Gonzalez
- Knowledge Leadership Team, Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Carol E Levin
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Mduduzi Nn Mbuya
- Knowledge Leadership Team, Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | - Eduardo Nakasone
- Department of Agricultural, Food and Resource Economics, Michigan State University, East Lansing, MI, United States
| | - Christina Nyhus Dhillon
- Knowledge Leadership Team, Global Alliance for Improved Nutrition (GAIN), Geneva, Switzerland
| | | | | | - David Tschirley
- Department of Agricultural, Food and Resource Economics, Michigan State University, East Lansing, MI, United States
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Gelli A, Duchoslav J, Gladstone M, Gilligan D, Katundu M, Maleta K, Quisumbing A, Bliznashka L, Ahun M. Impact evaluation of a maternal and child cash transfer intervention, integrated with nutrition, early childhood development, and agriculture messaging (MAZIKO-IE): a study protocol for a cluster-randomised controlled trial. Trials 2024; 25:46. [PMID: 38218938 PMCID: PMC10790253 DOI: 10.1186/s13063-023-07782-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 11/06/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Children in Malawi face high rates of malnutrition and are at risk of not reaching their developmental potential. Community-based childcare centres (CBCCs) can be cost-effective platforms for scaling-up early childhood development (ECD) and nutrition social behaviour change (SBC) interventions. However, evidence also suggests potential synergies from coupling nutrition SBC with cash transfers (CT), given that rural households in Malawi face high levels of poverty and recurring extreme lean season food-security shocks. The Maziko trial is aimed at evaluating the effectiveness and cost-effectiveness of using CBCCs and parenting care groups as platforms to improve maternal diets and child nutrition and development by providing nutrition-sensitive SBC and CT intervention packages in communities already receiving a standard of care Government SBC program. METHODS We designed a 3-year cluster-randomised controlled trial in two districts of Malawi, including 156 communities randomised to one of four treatment arms: (1) standard of care (SoC) arm: receiving the standard Government SBC program; (2) SBC arm: receiving the SoC intervention with additional nutrition-sensitive SBC activities to improve nutritious food production, diets, and care practices for young children; (3) low CT arm: SoC plus SBC plus a maternal and child cash transfer ~ 17 USD per month; and (4) high CT arm: SoC plus SBC plus a maternal and child CT ~ 43 USD per month. The trial will enrol pregnant women and children < 2 years of age. The primary outcomes are maternal diet assessed using the mean probability of adequacy and child development assessed using the Malawi Developmental Assessment Tool. Intermediate outcomes along the programme impact pathways will also be measured, including maternal mental health, maternal empowerment, child feeding practices, and child nutritional status. DISCUSSION This is the first study to examine the impact and synergies of combining ECD SBC with nutrition-sensitive SBC and CTs on maternal and child outcomes during the first 1000 days. The findings from this evaluation will inform national ECD and nutrition programmes. TRIAL REGISTRATION ISRCTN ISRCTN53055824. Registered on 7 March 2022.
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Haghparast-Bidgoli H, Harris-Fry H, Kumar A, Pradhan R, Mishra NK, Padhan S, Ojha AK, Mishra SN, Fivian E, James P, Ferguson S, Krishnan S, O'Hearn M, Palmer T, Koniz-Booher P, Danton H, Minovi S, Mohanty S, Rath S, Rath S, Nair N, Tripathy P, Prost A, Allen E, Skordis J, Kadiyala S. Economic Evaluation of Nutrition-Sensitive Agricultural Interventions to Increase Maternal and Child Dietary Diversity and Nutritional Status in Rural Odisha, India. J Nutr 2022; 152:2255-2268. [PMID: 35687367 PMCID: PMC9535442 DOI: 10.1093/jn/nxac132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/01/2021] [Accepted: 06/04/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Economic evaluations of nutrition-sensitive agriculture (NSA) interventions are scarce, limiting assessment of their potential affordability and scalability. OBJECTIVES We conducted cost-consequence analyses of 3 participatory video-based interventions of fortnightly women's group meetings using the following platforms: 1) NSA videos; 2) NSA and nutrition-specific videos; or 3) NSA videos with a nutrition-specific participatory learning and action (PLA) cycle. METHODS Interventions were tested in a 32-mo, 4-arm cluster-randomized controlled trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) in the Keonjhar district, Odisha, India. Impacts were evaluated in children aged 0-23 mo and their mothers. We estimated program costs using data collected prospectively from expenditure records of implementing and technical partners and societal costs using expenditure assessment data collected from households with a child aged 0-23 mo and key informant interviews. Costs were adjusted for inflation, discounted, and converted to 2019 US$. RESULTS Total program costs of each intervention ranged from US$272,121 to US$386,907. Program costs per pregnant woman or mother of a child aged 0-23 mo were US$62 for NSA videos, US$84 for NSA and nutrition-specific videos, and US$78 for NSA videos with PLA (societal costs: US$125, US$143, and US$122, respectively). Substantial shares of total costs were attributable to development and delivery of the videos and PLA (52-69%) and quality assurance (25-41%). Relative to control, minimum dietary diversity was higher in the children who underwent the interventions incorporating nutrition-specific videos and PLA (adjusted RRs: 1.19 and 1.27; 95% CIs: 1.03-1.37 and 1.11, 1.46, respectively). Relative to control, minimum dietary diversity in mothers was higher in those who underwent NSA video (1.21 [1.01, 1.45]) and NSA with PLA (1.30 [1.10, 1.53]) interventions. CONCLUSION NSA videos with PLA can increase both maternal and child dietary diversity and have the lowest cost per unit increase in diet diversity. Building on investments made in developing UPAVAN, cost-efficiency at scale could be increased with less intensive monitoring, reduced startup costs, and integration within existing government programs. This trial was registered at clinicaltrials.gov as ISRCTN65922679.
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Affiliation(s)
| | - Helen Harris-Fry
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Naba Kishore Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapada, Odisha, India
| | - Shibananth Padhan
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapada, Odisha, India
| | | | - Sailendra Narayan Mishra
- Voluntary Association for Rural Reconstruction and Appropriate Technology (VARRAT), Kendrapada, Odisha, India
| | - Emily Fivian
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Philip James
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Sneha Krishnan
- Jindal School of Environment and Sustainability, OP Jindal Global University and ETCH Consultancy Services, Mumbai, Maharashtra, India
| | - Meghan O'Hearn
- Tufts University Friedman School of Nutrition Science and Policy, Boston, MA, USA
| | - Tom Palmer
- University College London, Institute for Global Health, London, United Kingdom
| | | | - Heather Danton
- SI Research & Training Institute, Inc. Arlington, VA, USA
| | - Sandee Minovi
- SI Research & Training Institute, Inc. Arlington, VA, USA
| | | | | | | | | | | | - Audrey Prost
- University College London, Institute for Global Health, London, United Kingdom
| | - Elizabeth Allen
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jolene Skordis
- University College London, Institute for Global Health, London, United Kingdom
| | - Suneetha Kadiyala
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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