Assessing the cost-effectiveness of interventions within a humanitarian organisation

Methodological choices for an economic evaluation of a combined psychosocial and nutrition treatment intervention for children with severe acute malnutrition: The FUSAM trial in Nepal

As a public health burden, severe acute malnutrition (SAM) among children has been increasingly studied to determine the optimal combination of treatment approaches. Among the new approaches is the addition of early childhood development sessions to standard nutrition-based treatment for SAM which can enhance both nutrition and development outcomes among young children. However, few studies demonstrate the relationship between the costs of such combined programs and the benefits accrued to the children and their caregivers. This article describes our experience of designing and conducting an economic evaluation alongside a cluster randomized controlled trial assessing a combined nutrition and psychosocial intervention for the treatment of SAM in children aged 6-24 months in Nepal. We present key lessons learned regarding methodological choices, the challenges of field data collection, as well as study adjustment when data analysis did not unfold as anticipated. With the view to transparency, this manuscript provides some clarifications on the evaluation processes for funders and policy makers on what economic evaluations entail and what information they convey for the purpose of supporting policy decision-making around limited resource allocation.

Framework for determining the optimal course of action when efficiency and affordability measures differ by perspective in cost-effectiveness analysis-with an illustrative case of HIV treatment in Mozambique

BACKGROUND

Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients' costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity.

METHODS

We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed.

RESULTS

In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique's annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country's annual average for out-of-pocket health expenditures.

CONCLUSION

Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.

How is the implementation of empirical research results documented in conflict-affected settings? Findings from a scoping review of peer-reviewed literature

Implementation science scholars argue that knowing 'what works' in public health is insufficient to change practices, without understanding 'how', 'where' and 'why' something works. In the peer reviewed literature on conflict-affected settings, challenges to produce research, make decisions informed by evidence, or deliver services are documented, but what about the understanding of 'how', 'where' and 'why' changes occur? We explored these questions through a scoping review of peer-reviewed literature based on core dimensions of the Extended Normalization Process Theory. We selected papers that provided data on how something might work (who is involved and how?), where (in what organizational arrangements or contexts?) and why (what was done?). We searched the Global Health, Medline, Embase databases. We screened 2054 abstracts and 128 full texts. We included 22 papers (of which 15 related to mental health interventions) and analysed them thematically. We had the results revised critically by co-authors experienced in operational research in conflict-affected settings. Using an implementation science lens, we found that: (a) implementing actors are often engaged after research is produced to discuss feasibility; (b) new interventions or delivery modalities need to be flexible; (c) disruptions affect how research findings can lead to sustained practices; (d) strong leadership and stable resources are crucial for frontline actors; (e) creating a safe learning space to discuss challenges is difficult; (f) feasibility in such settings needs to be balanced. Lastly, communities and frontline actors need to be engaged as early as possible in the research process. We used our findings to adapt the Extended Normalization Process Theory for operational research in settings affected by conflicts. Other theories used by researchers to document the implementation processes need to be studied further.

The impact of livestock interventions on nutritional outcomes of children younger than 5 years old and women in Africa: a systematic review and meta-analysis

Background

Nutrition-sensitive livestock interventions have the potential to improve the nutrition of communities that are dependent on livestock for their livelihoods by increasing the availability and access to animal-source foods. These interventions can also boost household income, improving purchasing power for other foods, as well as enhance determinants of health. However, there is a lack of synthesized empirical evidence of the impact and effect of livestock interventions on diets and human nutritional status in Africa.

Objective

To review evidence of the effectiveness of nutrition-sensitive livestock interventions in improving diets and nutritional status in children younger than 5 years old and in pregnant and lactating women.

Methods

Following PRISMA guidelines, we conducted a systematic review and meta-analysis of published studies reporting on the effect of livestock interventions on maternal and child nutrition in Africa. Data were extracted, synthesized, and summarized qualitatively. Key outcomes were presented in summary tables alongside a narrative summary. Estimation of pooled effects was undertaken for experimental studies with nutritional outcomes of consumption of animal-source foods (ASFs) and minimum dietary diversity (MDD). Fixed effects regression models and pooled effect sizes were computed and reported as odds ratios (ORs) together with their 95% confidence intervals (CI).

Results

After the screening, 29 research papers were included in the review, and of these, only 4 were included in the meta-analysis. We found that nutrition-sensitive livestock interventions have a significant positive impact on the consumption of ASFs for children < 5 years (OR = 5.39; 95% CI: 4.43-6.56) and on the likelihood of meeting minimum dietary diversity (OR = 1.89; 95% CI: 1.51-2.37). Additionally, the impact of livestock interventions on stunting, wasting, and being underweight varied depending on the type of intervention and duration of the program/intervention implementation. Therefore, because of this heterogeneity in reporting metrics, the pooled estimates could not be computed.

Conclusion

Nutrition-sensitive livestock interventions showed a positive effect in increasing the consumption of ASFs, leading to improved dietary diversity. However, the quality of the evidence is low, and therefore, more randomized controlled studies with consistent and similar reporting metrics are needed to increase the evidence base on how nutrition-sensitive livestock interventions affect child growth outcomes.

A multi-country, prospective cohort study to evaluate the economic implications of relapse among children recovered from severe acute malnutrition: a study protocol

Background

Community-based management of acute malnutrition (CMAM) is an effective intervention at recovering children from severe acute malnutrition (SAM) and preventing mortality. However, there is growing evidence that for many children recovery is not sustained post-discharge. This study will assess the economic implications of relapse by calculating the average cost of treating a case of SAM that relapses after initial CMAM treatment compared to the cost of a case that remains recovered for 6 months post-discharge.

Methods

This protocol outlines the methods for a cost-efficiency analysis to assess cost per episode of treatment for acute malnutrition for children enrolled in CMAM programs for initial SAM treatment in Mali, Somalia and South Sudan. Cost data will be collected and analyzed on a monthly basis for each CMAM service component (outpatient treatment program for SAM, supplementary feeding program for moderate acute malnutrition, and inpatient stabilization care for SAM with medical complications). Financial data will be extracted from expenditure records from institutional accounting systems where possible. Where these are not present, cost data will be collected via interview and review of financial documents. Staff time allocation interviews will be conducted. This data will be applied to quantify personnel costs, to apportion costs that are shared between programs and to exclude staff time spent on research activities.

Discussion

This study will provide the first estimates to address the limited evidence on the economic implications of SAM relapse in CMAM programs. Data from this economic analysis will help raise awareness and provide actionable data for the global nutrition community to address the financial burden of relapse. Estimating the cost of relapse in three countries representing different geographic and operational contexts will help in generalizing these results.

Trial registration

Registration # IORG0007116, Date of registration: 06/09/2020. This study is not registered as a clinical trial as it is observational research and does not include an intervention. The study has received the required ethical approvals as outlined in the declarations.

What is the Price of Conservation? A Review of the Status Quo and Recommendations for Improving Cost Reporting

Wildlife conservation is severely limited by funding. Therefore, to maximize biodiversity outcomes, assessing financial costs of interventions is as important as assessing effectiveness. We reviewed the reporting of costs in studies testing the effectiveness of conservation interventions: 13.3% of the studies provided numeric costs, and 8.8% reported total costs. Even fewer studies broke down these totals into constituent costs, making it difficult to assess the relevance of costs to different contexts. Cost reporting differed between continents and the taxa or habitats targeted by interventions, with higher cost reporting in parts of the Global South. A further analysis of data focused on mammals identified that interventions related to agriculture, invasive species, transport, and residential development reported costs more frequently. We identify opportunities for conservationists to improve future practice through encouraging systematic reporting and collation of intervention costs, using economic evaluation tools, and increasing understanding and skills in finance and economics.

Evaluation of the cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by lady health workers as compared to an outpatient therapeutic feeding programme in Sindh Province, Pakistan

BACKGROUND

Due to the limited evidence of the cost-effectiveness of Community Health Workers (CHW) delivering treatment for severe acute malnutrition (SAM), there is a need to better understand the costs incurred by both implementing institutions and beneficiary households. This study assessed the costs and cost-effectiveness of treatment for cases of SAM without complications delivered by government-employed Lady Health Workers (LHWs) and complemented with non-governmental organisation (NGO) delivered outpatient facility-based care compared with NGO delivered outpatient facility-based care only alongside a two-arm randomised controlled trial conducted in Sindh Province, Pakistan.

METHODS

An activity-based cost model was used, employing a societal perspective to include costs incurred by beneficiaries and the wider community. Costs were estimated through accounting records, interviews and informal group discussions. Cost-effectiveness was assessed for each arm relative to no intervention, and incrementally between the two interventions, providing information on both absolute and relative costs and effects.

RESULTS

The cost per child recovered in outpatient facility-based care was similar to LHW-delivered care, at 363 USD and 382 USD respectively. An additional 146 USD was spent per additional child recovered by outpatient facilities compared to LHWs. Results of sensitivity analyses indicated considerable uncertainty in which strategy was most cost-effective due to small differences in cost and recovery rates between arms. The cost to the beneficiary household of outpatient facility-based care was double that of LHW-delivered care.

CONCLUSIONS

Outpatient facility-based care was found to be slightly more cost-effective compared to LHW-delivered care, despite the potential for cost-effectiveness of CHWs managing SAM being demonstrated in other settings. The similarity of cost-effectiveness outcomes between the two models resulted in uncertainty as to which strategy was the most cost-effective. Similarity of costs and effectiveness between models suggests that whether it is appropriate to engage LHWs in substituting or complementing outpatient facilities may depend on population needs, including coverage and accessibility of existing services, rather than be purely a consideration of cost. Future research should assess the cost-effectiveness of LHW-delivered care when delivered solely by the government.

TRIAL REGISTRATION

NCT03043352 , ClinicalTrials.gov. Retrospectively registered.

Costs and cost-efficiency of a mobile cash transfer to prevent child undernutrition during the lean season in Burkina Faso: a mixed methods analysis from the MAM'Out randomized controlled trial

Background

This study assessed the costs and cost-efficiency of a mobile cash transfer implemented in Tapoa Province, Burkina Faso in the MAM’Out randomized controlled trial from June 2013 to December 2014, using mixed methods and taking a societal perspective by including costs to implementing partners and beneficiary households.

Methods

Data were collected via interviews with implementing staff from the humanitarian agency and the private partner delivering the mobile money, focus group discussions with beneficiaries, and review of accounting databases. Costs were analyzed by input category and activity-based cost centers. cost-efficiency was analyzed by cost-transfer ratios (CTR) and cost per beneficiary. Qualitative analysis was conducted to identify themes related to implementing electronic cash transfers, and barriers to efficient implementation.

Results

The CTR was 0.82 from a societal perspective, within the same range as other humanitarian transfer programs; however the intervention did not achieve the same degree of cost-efficiency as other mobile transfer programs specifically. Challenges in coordination between humanitarian and private partners resulted in long wait times for beneficiaries, particularly in the first year of implementation. Sensitivity analyses indicated a potential 6% reduction in CTR through reducing beneficiary wait time by one-half. Actors reported that coordination challenges improved during the project, therefore inefficiencies likely would be resolved, and cost-efficiency improved, as the program passed the pilot phase.

Conclusions

Despite the time required to establish trusting relationships among actors, and to set up a network of cash points in remote areas, this analysis showed that mobile transfers hold promise as a cost-efficient method of delivering cash in this setting. Implementation by local government would likely reduce costs greatly compared to those found in this study context, and improve cost-efficiency especially by subsidizing expansion of mobile money network coverage and increasing cash distribution points in remote areas which are unprofitable for private partners.