Intervention Costs and Cost-Effectiveness
Multiple strategies exist for preventing malnutrition in young children in the short and long term. This section considers the costs and cost-effectiveness of these interventions for preventing malnutrition or deaths attributable to each nutritional problem. Table 28.4 presents a compendium of cost information, including, where possible, the costs of preventing a child death or saving a DALY.
[Table .]
Horton and others (1996) use data from Brazil, Honduras, and Mexico to estimate the costs and cost-effectiveness of hospital-based programs to promote breastfeeding. Using standard costing methods, they examine the costs of breast-feeding promotion activities in each program and the additional inputs, as well as the savings. Savings accrued from the removal of infant formula where it was currently used. Using data on infant feeding practices and morbidity and mortality from Brazil, they estimated the costs of the programs per birth, per diarrhea case averted, and per death averted. As table 28.4 shows, the costs of such programs range from US$0.30 to US$0.40 per child, and from US$100 to US$200 per death averted, making them comparable in cost-effectiveness to measles and rotavirus vaccination. Assuming that deaths would otherwise have occurred around age one, and using average Latin American life expectancy at that age, yields a cost per DALY gained of only US$3 to US$7.
In many community-based strategies, multiple organizations work through a variety of communication channels to promote exclusive breastfeeding. Two studies in Ghana and Madagascar provide costs estimates for such programs (Chee, Makinen, and Sakagawa 2002; Chee and others 2003). The programs cost US$4 to US$16 per child, and given the effect on mothers' practices, the cost ranged from US$5 to US$58 per adopter of exclusive breastfeeding. In Ghana, an estimated 883 deaths were averted, yielding a program cost of US$7.80 per DALY gained or US$203 per death prevented. The range of costs within each program depended on the baseline prevalence of the behavior, the population density, and the characteristics of the implementing organizations themselves. Programs will be more cost-effective when the baseline prevalence is lower; the population density is higher; and the organizations involved are focused, highly motivated, and well organized.
Less information is available on the costs of community-based nutrition programs to prevent growth faltering, to control morbidity, and to improve survival. The costs of a program in Mali (Ross, Loening, and Mbele 1987), which included promotion of breastfeeding, counseling, and education on optimal child feeding; prevention of diarrheal disease; and growth monitoring, were estimated to be US$282 per death averted and US$11 per DALY gained. This estimate is consistent with others that nutrition programs cost US$2 to US$10 per child, depending on the intensity of nutrition counseling, including Fiedler's (2003) study of the Integrated Community Child Care Program in Honduras, which had an estimated cost of US$4 per child. (For a fuller analysis of such programs, including contextual and programmatic characteristics that affect outcomes, see chapter 56.)
In the past five years, investigators have undertaken several cost analyses of national programs to distribute vitamin A capsules. Two reports from Ghana and Zambia are particularly informative (Rassas, Hottor, and others 2004; Rassas, Nakamba, and others 2004). As table 28.4 shows, such programs cost US$0.90 to US$1.23 per child, with the costs per death averted ranging from US$162 to US$277. (Deaths from micronutrient deficiencies are assumed to occur between ages one and five, and estimates of cost per DALY ranging from US$6 to US$11 reflect this range, as well as region-specific life expectancies at those ages.) These costs are comparable with estimates of a vitamin A program in Nepal that cost US$1.25 per child and US$327 per death averted (Fiedler 2000). Ching and others (2000) examine the costs of incorporating vitamin A capsule distribution into immunization campaigns in 50 countries in 1998 and 1999. Their analysis finds that the total costs per death averted ranged from about US$150 to US$600, with the incremental costs for vitamin A distribution amounting to only about US$30 to US$150 per death averted. The costs per death averted depended on the country setting, the program's coverage, the delivery of vitamin A (one or two doses), and the underlying level of mortality. The incremental cost per DALY gained could be as low as US$1 or as high as US$6.
Fewer examples of vitamin A fortification programs are available, with the only clear example being sugar fortification in Central America. In 1994, estimates indicated that a program in Guatemala cost US$0.17 per child, and US$1,000 per death averted. Counting only the losses from mortality, the cost of saving a DALY was US$33 to US$35. However, for each death prevented, there were probably several cases of eye damage prevented and of improved general health; thus, taking full account of nonfatal effects would reduce the cost per DALY somewhat.
Iron supplementation is more costly than distribution of vitamin A capsules, as it involves a daily supplement over an extended period. Estimates indicate that such programs cost US$3.17 to US$5.30 per child. Numerous cost estimates are available for iron fortification programs, because these programs have been the principal strategy to prevent and control iron deficiency anemia. Such programs have traditionally cost US$0.09 to US$1.00 per child, depending on the country and the vehicle for fortification. These estimates are based on elemental iron as the fortifier. Even though this is the cheapest form available, critics have questioned the bioavailability of elemental iron, and many researchers now advocate using other forms of iron.
Iodine fortification programs cost little, about US$0.02 to US$0.05 per child. Iodized oil injections are more costly at US$0.80 to US$2.75 per beneficiary, but these programs may be recommended for settings where people consume little commercialized and easily fortified food.
Currently, no examples of zinc intervention programs are available from which to estimate cost-effectiveness. However, Robberstad and others' (2004) simulation analysis examines the potential costs and cost-effectiveness of providing zinc as an adjunct to oral hydration salts in treating diarrhea in young children. Providing zinc as part of case management carries an estimated incremental cost of US$0.47 per treatment, ranging from US$0.33 to US$0.62. Given the relationship between zinc provision and mortality risk, this addition to current management programs would cost, on average, US$2,100 per death adverted and US$73 per DALY gained.
Despite the enormity of the nutritional problems, the associated loss of DALYS, and the existence of programs to combat malnutrition, surprisingly little data on the costs or cost-effectiveness of nutritional programs are available. This problem represents a serious gap in information for health planning, implementation, and advocacy. Nonetheless, considerable evidence indicates that when programs to promote breastfeeding or child growth or to correct micronutrient deficiencies are delivered to populations with a relatively high prevalence of malnutrition, the cost per participating child is usually so low that deaths can be averted at a cost per DALY that is less than US$100, and often less than US$10, even in regions with low life expectancy. Few health interventions are comparably cost-effective.
