Cost-effectiveness of community vegetable gardens for people living with HIV in Zimbabwe

The Economic Burden of Severe Acute Malnutrition with Complications: A Cost Analysis for Inpatient Children Aged 6 to 59 Months in Northern Senegal

Severe acute malnutrition (SAM) is a high-fatality condition that affected 13.7 million children under five years of age worldwide in 2022, with complicated cases requiring extensive inpatient stay with an accompanying caregiver. Our objective was to assess the costs of inpatient treatment for complicated SAM in children aged 6 to 59 months in Northern Senegal and identify cost predictors. We performed a retrospective cost analysis, including 140 children hospitalized from January to December 2020 in five SAM inpatient treatment facilities. We adopted a societal perspective, including direct medical and non-medical costs and indirect costs. We extracted patients' sociodemographic and clinical data from medical records and conducted semi-structured interviews with healthcare staff to capture information on time allocation and care management. A multivariable generalized linear model with gamma family and a log link was used to investigate the factors associated with direct costs. Costs are expressed in 2020 international USD using purchasing power parity. Mean length of stay was 5.3 (SD = 3.2) days and diarrhoea was the cause of the admission in 55.7% of cases. Mean total cost was USD 431.9 (SD = 203.9), with personnel being the largest cost item (33% of the total). Households' out-of-pocket expenses represented 45.3% of total costs and amounted to USD 195.6 (SD = 103.6). Costs were significantly associated with gender (20.3% lower in boys), diarrhoea (27% increase), anaemia (49.4% increase), inpatient death (44.9% decrease), and type of facility (26% higher in hospitals vs. health centre). Our study highlights the financial burden of complicated SAM in Senegal in particular for families. This underscores the need for tailored prevention and social policies to protect families from the disease's financial burden and improve treatment adherence, both in Senegal and similar contexts.

Perceived Impacts of Urban Gardens and Peer Nutritional Counseling for People Living With HIV in the Dominican Republic

OBJECTIVE

Explore participants' perceptions of urban gardens and peer nutritional counseling intervention for people with HIV and food insecurity on antiretroviral therapy in the Dominican Republic.

METHODS

Semistructured endline interviews (n = 21) with intervention participants about their perceptions of diet, health, and quality of life. A codebook was applied to verbatim transcripts, and coded data were analyzed using matrices to identify themes.

RESULTS

Participants were mostly Dominican (86%; 14% Haitian); 57% were men; the mean age was 45 years. The most salient experiences described by intervention participants were improved dietary quality and diversity, improved food security, and saving money. Participants also emphasized improved social interactions, mental health, and emotional well-being.

CONCLUSIONS AND IMPLICATIONS

Urban gardens and peer nutritional counseling may improve participants' diet and psychosocial well-being. Nutrition programs with marginalized populations may need to improve access to healthy foods and build camaraderie and linkages to programs addressing structural factors.

Economic Evaluation of Nutrition-Sensitive Agricultural Interventions to Increase Maternal and Child Dietary Diversity and Nutritional Status in Rural Odisha, India

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.

Measurement of benefits in economic evaluations of nutrition interventions in low- and middle-income countries: A systematic review

Economic evaluation of nutrition interventions that compares the costs to benefits is essential to priority-setting. However, there are unique challenges to synthesizing the findings of multi-sectoral nutrition interventions due to the diversity of potential benefits and the methodological differences among sectors in measuring them. This systematic review summarises literature on the interventions, sectors, benefit terminology and benefit types included in cost-effectiveness, cost-utility and benefit-cost analyses (CEA, CUA and BCA, respectively) of nutrition interventions in low- and middle-income countries. A systematic search of five databases published from January 2010 to September 2019 with expert consultation yielded 2794 studies, of which 93 met all inclusion criteria. Eighty-seven per cent of the included studies included interventions delivered from only one sector, with almost half from the health sector (43%), followed by food/agriculture (27%), water, sanitation and hygiene (WASH) (10%), and social protection (8%). Only 9% of studies assessed programmes involving more than one sector (health, food/agriculture, social protection and/or WASH). Eighty-one per cent of studies used more than one term to refer to intervention benefits. The included studies calculated 128 economic evaluation ratios (57 CEAs, 39 CUAs and 32 BCAs), and the benefits they included varied by sector. Nearly 60% measured a single benefit category, most frequently nutritional status improvements; other health benefits, cognitive/education gains, dietary diversity, food security, knowledge/attitudes/practices and income were included in less than 10% of all ratios. Additional economic evaluation of non-health and multi-sector interventions, and incorporation of benefits beyond nutritional improvements (including cost savings) in future economic evaluations is recommended.

When Communities Pull Their Weight: The Economic Costs of an Integrated Agriculture and Nutrition Home-Grown Preschool Meal Intervention in Malawi

Background:

Community-based preschool meals can provide an effective platform for implementing integrated agriculture and nutrition programs. However, there is little evidence on the costs and cost-efficiency of implementing these types of multisectoral interventions.

Objectives:

Assess the economic costs and cost-efficiency of implementing an effective integrated nutrition-sensitive intervention through a preschool platform in Malawi, including community-level contributions.

Methods:

The Strengthening Economic Evaluation for Multisectoral Strategies for Nutrition (SEEMS-Nutrition) framework and methods were applied to assess financial and economic costs of the intervention. A mixed-methods approach was used to measure and allocate costs for program activities and inputs using financial expenditure data combined with micro-costing. All costs were allocated to input and expenditure categories using the SEEMS-Nutrition framework. To facilitate comparisons with existing school meals programs, activities were also mapped against a standardized school feeding supply chain framework.

Results:

The total annualized cost of the program was US$197 377, inclusive of both financial and economic costs. The annual economic cost of the program ranged from US$160 per preschool child to US$41 per beneficiary. The principal drivers of cost by program activity were training (46%), school meals provision (19%), monitoring and evaluation (12%), and establishing and running community groups (6.5%). Notably, community contributions accounted for 25% and were driven by food donations and volunteer labor.

Conclusions:

Cost per beneficiary estimates of implementing an integrated agriculture–nutrition intervention through an early childhood development platform compare favorably with similar interventions. Further research is needed that applies a standardized economic evaluation framework to such multisectoral interventions.

Community gardens and wellbeing amongst vulnerable populations: a thematic review

The aim of the thematic review is to document the effects of community gardens on wellbeing amongst vulnerable populations. We searched for articles published between 1980 and 2017 in major databases resulting in the inclusion of 51 articles. Vulnerable populations included, amongst others, ethnic minorities and refugees, socioeconomically disadvantaged neighbourhoods or low-income or food insecure families. Our findings suggest that community garden participation may have a positive impact on physical health, such as reducing body weight and hypertension, and increasing physical activity and food knowledge. However, findings relating to community gardens and their potential to enhance food security were inconsistent. Furthermore we found that community gardens can have a positive influence both at the individual level (i.e. self-esteem, independence, personal control, etc.), particularly for refugees; the relational and social level (i.e. relationships, social connections, community and neighbourhood). Community garden participation have the potential to enhance wellbeing amongst vulnerable populations. However, two articles in our review presented potential food safety concerns related to community gardens, indicating that, particularly in urban settings, attention must be given to minimizing potential food safety concerns, e.g. by using raised garden beds. Based on this review, we recommend that further research and evaluation on non-US-based community gardens is carried out, as community gardens are practiced globally but there is little research to document the effects of community gardens on wellbeing amongst vulnerable populations outside of the USA.

What is the cost of integration? Evidence from an integrated health and agriculture project to improve nutrition outcomes in Western Kenya

Integrated nutrition and agricultural interventions have the potential to improve the efficiency and effectiveness of investments in food security and nutrition. This article aimed to estimate the costs of an integrated agriculture and health intervention (Mama SASHA) focused on the promotion of orange-fleshed sweet potato (OFSP) production and consumption in Western Kenya. Programme activities included nutrition education and distribution of vouchers for OFSP vines during antenatal care and postnatal care (PNC) visits. We used expenditures and activity-based costing to estimate the financial costs during programme implementation (2011-13). Cost data were collected from monthly expense reports and interviews with staff members from all implementing organizations. Financial costs totalled US$507 809 for the project period. Recruiting and retaining women over the duration of their pregnancy and postpartum period required significant resources. Mama SASHA reached 3281 pregnant women at a cost of US$155 per beneficiary. Including both pregnant women and infants who attended PNC services with their mothers, the cost was US$110 per beneficiary. Joint planning, co-ordination and training across sectors drove 27% of programme costs. This study found that the average cost per beneficiary to implement an integrated agriculture, health and nutrition programme was substantial. Planning and implementing less intensive integrated interventions may be possible, and economies of scale may reduce overall costs. Empirical estimates of costs by components are critical for future planning and scaling up of integrated programmes.

Assessing the cost-effectiveness of interventions within a humanitarian organisation

Cost-effectiveness analysis is increasingly relevant in humanitarian action. The cost of response has increased exponentially in the past decade, alongside concurrent donor budget restrictions. However, there remains limited comprehension and application of these methods in this field. This paper documents methods developed for use within Action Against Hunger, an international humanitarian organisation, in response to a lack of understanding of this topic within the humanitarian community and limited evidence of the cost-effectiveness of humanitarian action. These methods encompass costs to both implementing institutions and participating communities. Activity-based cost analyses are conducted to assess resources per programme activity. Cost-effectiveness is evaluated using successful programme outcomes, and uncertainty is appraised via sensitivity analysis. This paper aims to advance knowledge, stimulate discussion, and promote the adoption of cost-effectiveness methods for building the evidence base for humanitarian action, including consideration of community costs, to enable analytical outputs that are useful for managers and policymakers alike.

Mycotoxin management in a developing country context: A critical review of strategies aimed at decreasing dietary exposure to mycotoxins in Zimbabwe

Mycotoxins are unavoidable environmental contaminants, which are found throughout the food chain, particularly in cereals. Mycotoxin management is not effective in developing countries, such as Zimbabwe, due to resource constraints, yet human health risk is evident. Various practical mitigation strategies that can be employed to decrease human dietary exposure to mycotoxins as a means of preliminary steps towards risk management are discussed. These strategies were stratified into two categories. First, crop/commodity-centred strategies, mainly the pre-harvest actions of cultivar selection, bio-control, as well as good agricultural practices (GAP), and the post-harvest actions including timeous harvesting, appropriate drying and storage technologies, are elaborated making use of hazard analysis critical control points (HACCP) principles. The role of legislation is also explored as a crop/commodity centred mitigation strategy. Second, human-centred strategies anchored on dietary diversity and the use of socio-cultural approaches as a direct means of reducing mycotoxin exposure are discussed. Finally, an integrated science-based mycotoxin management strategy, encompassing targeted legislation on mycotoxins, consumer education and information sharing, human and institutional capacity building, training and financing, is suggested in addition to GAP, as a means of reducing human health risk associated with mycotoxin exposure in Zimbabwe.HighlightsFarm-to-fork HACCP-based mycotoxin managementHuman-centred mycotoxin management approaches are keyAgronomy, technology and legislation critical in reducing mycotoxin exposure.

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.

Syndemics and the biosocial conception of health

The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.

Bibliometric trends of health economic evaluation in Sub-Saharan Africa

BACKGROUND

Collaboration between Sub-Saharan African researchers is important for the generation and transfer of health technology assessment (HTA) evidence, in order to support priority-setting in health. The objective of this analysis was to evaluate collaboration patterns between countries.

METHODS

We conducted a rapid evidence assessment that included a random sample of health economic evaluations carried out in 20 countries (Angola, Botswana, Congo, Lesotho, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa, Swaziland, Tanzania, Zambia, Zimbabwe, Ghana, Kenya, Nigeria, Ethiopia, Uganda). We conducted bibliometric network analysis based on all first authors with a Sub-Saharan African academic affiliation and their co-authored publications ("network-articles"). Then we produced a connection map of collaboration patterns among Sub-Saharan African researchers, reflecting the number of network-articles and the country of affiliation of the main co-authors.

RESULTS

The sample of 119 economic evaluations mostly related to treatments of communicable diseases, in particular HIV/AIDS (42/119, 35.29 %) and malaria (26/119, 21.85 %). The 39 first authors from Sub-Saharan African institutions together co-authored 729 network-articles. The network analysis showed weak collaboration between health economic researchers in Sub-Saharan Africa, with researchers being more likely to collaborate with Europe and North America than with other African countries. South Africa stood out as producing the highest number of health economic evaluations and collaborations.

CONCLUSIONS

The development and evaluation of HTA research networks in Sub-Saharan Africa should be supported, with South Africa central to any such efforts. Organizations and institutions from high income countries interested in supporting priority setting in Sub-Saharan Africa should include promoting collaboration as part of their agendas, in order to take advantage of the potential transferability of results and methods of the available health economic analyses in Africa and internationally.