An Economic Model for Optimizing Effective Coverage of MN interventions: A Case Study of Cameroon.

Objectives: Micronutrient (MN) interventions are generally undertaken at national scale. New spatially disaggregated data on MN deficiencies in Cameroon suggest that subnational strategies may be more efficient, but methods to choose among alternative interventions are needed. We developed a tool to plan and manage sub-national MN interventions for Cameroon. Methods: Data from a nationally representative multi-stage cluster survey were used to determine the spatial distribution of MN deficiencies among population sub-groups at greatest risk. Macroregion-specific data (North, South, Douala/Yaoundé) on food intake were used to predict the effects of alternative MN intervention strategies on the prevalence of inadequate MN intake and absorption. MN supplements, fortified and biofortified foods, deworming and behavioral change communication to promote breastfeeding are among the interventions examined. Costs of alternative interventions were prepared. The costs and nutritional benefits of alternative interventions are included in an economic optimization model that chooses the best combination of MN interventions to ensure adequate MN intake, at regional level, over a ten-year planning horizon, given funding and other constraints. Results: Preliminary results indicate large spatial differences in MN deficiencies, e.g., estimated prevalence of vitamin A deficiency varied from ~62% (North region) to ~22% (Northwest region). Consumption of VA-rich foods and fortifiable foods also varies spatially. Hence, program efficiency may be enhanced by adopting targeted sub-national MN intervention strategies. Conclusions: Given spatial patterns in MN deficiencies, diet-driven effectiveness of alternative MN interventions, and costs of these interventions, sub-national MN interventions may offer efficiency gains that exceed the costs of planning and implementing them.

Effects of Alternative Spatial Distribution Schemes on Household Access Costs of Lipid-based Nutrient Supplements: Case Study in Rural Burkina Faso.

Objectives: Identifying cost-effective strategies for delivering efficacious nutrient supplements is a policy challenge, especially in rural areas. This paper examines the effects of alternative distribution outlet schemes on transportation costs of 3,146 households in the Dandé health clinic catchment area (1,600 sq. km), Burkina Faso, site of the International Lipid-Based Nutrient Supplements Zinc research project. Methods: Spatially referenced data on households, hospitals, clinics and markets, and on the road networks that link them, are combined with the motorized transportation fare structure to construct a distance-based transportation cost overlay. This overlay is then used to estimate the householdspecific, one-way transportation costs under alternative lipid-based nutrient supplement (LNS) distribution outlet schemes. Results: If the full-service Bobo Dioulasso Hospital is the only outlet, average transportation cost is US$ 1.96 and varies widely across households. Including the local Dandé Hospital in the distribution network reduces the average transportation cost to US$ 1.16; the spatial distribution of household access costs changes. Extending the network to include all health centers reduces average transportation cost to US$ 0.60. Adding markets as distribution outlets does not further reduce average transportation costs. Conclusions: Full-service hospital-based (only) distribution is the most costly LNS distribution scheme to households. Extending the network of outlets to include all hospitals, health centers and clinics reduces average households access costs by nearly 70%; doing so shifts the cost burden from households to other entities charged with managing this larger outlet network. At this site, involving retail outlets offers no household transportation costs savings.

Willingness-to-Pay for LNS Products: Evidence from the iLiNS Studies.

Objectives: Households’ stated willingness-to-pay (WTP) for small-quantity lipid-based nutrient supplements (LNS) influence the economic viability of retail outlets for these products, and will guide public policy action when WTP falls short of LNS production/distribution costs. This presentation provides evidence on WTP for LNS products tested in the context of the International Lipid-Based Nutrient Supplements (iLiNS) Project in Malawi, Ghana and Burkina Faso. Methods: Field-based contingent valuation methods provide estimates of WTP for LNS for pregnant/lactating women (LNS-P&L) and for children 6-24 mo of age (LNS-child), and for their traditional alternatives. Experimental auctions provide incentive-compatible estimates of WTP for LNS-P&L (Ghana) and for LNS-child (Burkina Faso). Results: Average hypothetical WTP at baseline for LNS-child (one 20g sachet) was approximately US$0.39 (Ghana), US$0.23 (Burkina Faso) and US$0.20 (Malawi-DOSE). Average hypothetical WTP at baseline for LNS-P&L (one 20g sachet) was approximately US$0.61 (Ghana) and US$0.17 (Malawi-DYAD). Average experimental WTP for LNS-P&L (20g sachet) was, respectively, approximately US$0.25 (Ghana) and US$0.12 (Burkina Faso). Several household characteristics that could be used for programmatic targeting, e.g., number of children under five years of age, were associated with WTP. Conclusions: Hypothetical WTP is positive for the vast majority of respondents in all study areas and average WTP is above estimated average national production costs for all LNS products; hence, LNS products may be commercially viable. However, large proportions of respondents reported WTP below average production costs (e.g., approximately 6% of respondents reported zero WTP in the Ghana baseline) signalling the need to consider publically assisted mechanisms for reaching resource-poor households.

The Cost of Home Delivery Schemes for Lipid-based Nutrient Supplement Products: A Policy Experiment from Rural Malawi.

Objectives: Public policy makers may play a role in promoting products demonstrated to be efficacious. Home delivery reduces households’ out-of-pocket costs of accessing these products; however, home delivery may be expensive, especially in rural areas. This paper provides evidence based on a home-delivery scheme undertaken by the International Lipid-Based Nutrient Supplements (iLiNS-DOSE) Project in rural Malawi. Methods: Estimates of home delivery costs for lipid-based nutrient supplements (LNS), including product procurement, transportation, staffing and storage costs, are based on those faced by the iLiNS-DOSE Project. A cost model was developed and used to run a hypothetical five-year policy experiment to provide LNS to 60% of the approximately 12,000 young children aged 6-24 months. LNS is delivered bi-weekly to all children in the targeted age bracket; older early-enrollees and young late-enrollees would not receive the full 18-month intervention. Results: Total cost of the hypothetical five-year intervention would be approximately US$3.3m. Cost per treated-child is US$69; cost per fully-treated-child is US$89. 63% and 21% of the total cost is attributable to product purchases and personnel costs, respectively. Conclusions: Home delivery of LNS products brings the private costs of procuring them to zero. However, the cost of procurement, storage and weekly home delivery of these products, shouldered by the public sector in our example, can be large relative to other product delivery mechanisms. Changes to intervention protocol (target population, frequency of delivery, etc.) will affect costs. The expected health and other benefits associated with each proposed intervention strategy should be compared to these costs to set priorities.

Adherence to Intake Recommendations of Lipidbased Nutrient Supplements (LNS) and Iron/Folic Acid (IFA) among Pregnant and Lactating Women (PLW) in a Community Health Program Setting.

Objectives: Limited knowledge exists on sustained adherence to small quantity LNS for PLW and how this compares to other prenatal supplements, particularly in programmatic settings. We aimed to address these gaps. Methods: A random subsample of women (n=360) from an ongoing LNS effectiveness trial were selected for home interviews about use and preferences of LNS or IFA. Purposively selected women (n=16) and key informants (n=18) participated in in-depth interviews about perceptions and acceptability of LNS. Results: Prevalence of high-adherers (≥70%) based on self-reported supplement consumption was 67%, 68%, 81%, 87% and 71% among LNS recipients during pregnancy, early and late lactation and IFA recipients during pregnancy and early lactation, respectively (P=0.044). Programmatic factors (e.g. distribution and visits by program staff) were significantly associated with reported high adherence in all groups. Among LNS recipients, overall supplement acceptability score was positively associated (odds ratio (OR): 2.94; P<0.0010) and reports of previous stillbirths were negatively associated (OR: 0.12; P=0.0054) with reported high-adherence. In in-depth interviews, women reported benefits of taking LNS to both themselves and their infants, but some faced barriers to consumption such as aversion to LNS odor and taste during pregnancy, forgetfulness, and disruptions in supply. Conclusions: Adherence to LNS was sustained throughout the physiological periods at levels comparable to other supplementation programs. To achieve high adherence, these results suggest that maternal supplementation programs should focus on programmatic barriers and consider counseling on reminder techniques. Odor and taste acceptability of LNS, particularly during pregnancy, may also need to be addressed.

Comparison of Methods to Assess Adherence to Small-quantity Lipid Based Nutrient Supplements (SQ-LNS) and Dispersible Tablets among Young Burkinabe Children Participating in a Community-based Intervention Trial.

Objectives: Adherence to supplementation provided during an intervention trial can affect study outcomes. We compared different approaches for estimating adherence to SQ-LNS and dispersible tablets in a randomized clinical trial in Burkina Faso to evaluate concordance among results and factors associated with reported non-adherence. Methods: 2453 children (9-18 mo) were randomly assigned to receive daily 20 g SQ-LNS with varying contents of zinc and a dispersible tablet (0 or 5mg zinc). During weekly home visits, reported adherence to SQ-LNS and tablets was collected through caregiver interview and disappearance rate was calculated based on unused packages. In a randomly selected subgroup (n=192), 12-h home observations were completed when children were 11 and 16 mo of age, to assess supplement consumption. Results: Average daily reported SQ-LNS and tablet adherence was 97%±6%. SQ-LNS and tablet disappearance rate also showed high weekly adherence (98%±5%). By contrast, home observation found that only 68% and 58% of children at 11 and 16-mo, respectively, received SQLNS during the observation periods (Rho=0.06, P=0.294 reported vs. observed), and fewer (36 and 28%) received a tablet at 11 and 16-mo (Rho=0.11, P=0.05). Fever, diarrhea, malaria, vomiting and loss of appetite reduced significantly reported consumption of SQ-LNS and, to a lesser extent, tablet (P<0.0001). Conclusions: Discrepancies among observed and reported results suggest possible overreporting of adherence to products and/or that consumption occurs outside the 12h home observation period. Child morbidity may change child acceptance or caregiver perceptions regarding the suitability of supplementation. Better methods are needed to assess adherence in community supplementation trials.

Impact of Small-quantity Lipid-based Nutrient Supplements on Infant and Young Child Feeding Practices.

Objectives: Lipid-based nutrient supplements (LNS) are energy-dense and could change infant and young child feeding (IYCF) practices by changing caregiver perceptions of needs and/or child appetite and demand for breast milk and local complementary foods. We hypothesized that LNS (10-40g/day) would not have significant impacts on IYCF practices. Methods: Infants in three randomized controlled trials were assigned to receive either LNS from 9- 18 mo (Burkina Faso) or 6-18 mo (Ghana and Malawi) or a delayed intervention (DI). All caregivers were given brief didactic messages promoting continued breastfeeding and diverse diets at first distribution of LNS; messages were repeated periodically in Ghana and Malawi (all groups) and not repeated systematically in Burkina Faso. IYCF practices were assessed at 18 mo by caregiver recall of the preceding day and week. Results: The reported prevalence of continued breastfeeding did not vary by intervention group in any site, and was 97%, 74%, and 89% in Burkina Faso, Ghana, and Malawi. Reported frequency of breastfeeding yesterday also did not vary. The proportion of infants meeting the WHO recommendation for minimum dietary diversity (4+ food groups) did not differ by intervention group and was 37%, 75%, and 68% in Burkina Faso, Ghana and Malawi. In Burkina Faso, infants in the LNS group were more likely to meet the WHO recommendation for number of meals/snacks yesterday (79%, vs. 66% in DI group). Conclusions: Provision of LNS did not change most IYCF practices but increased frequency of feeding in one site.

Small-quantity Lipid-based Nutrient Supplements, Together with Malaria and Diarrhea Treatment, Improve Growth and Development in Young Burkinabe Children.

Objectives: Small-quantity lipid-based nutrient supplement (SQ-LNS) is a promising home fortification product to supplement young children's diets, but the optimal zinc level to include is uncertain. We assessed growth and development in young Burkinabe children who received SQLNS without or with varied amounts of zinc. Methods: In a partially masked, placebo-controlled, randomized trial, 34 communities were assigned to immediate (II) or non-intervention (NI). 2469 eligible II children were randomly assigned to 1 of 4 groups to receive 20 g LNS/d containing 0, 5 or 10 mg of zinc (and placebo tablet) or LNS without zinc and 5 mg zinc tablet from 9-18 mo of age, along with treatment of malaria and diarrhea. Children in NI (n=797) received neither SQ-LNS, tablets nor morbidity treatment. At 9 and 18 mo, length, weight, and mid-upper arm circumference (MUAC) were measured in all children. In a randomly selected subgroup, motor, language, and personal-social development was assessed at 18 mo (n=747 II; n=376 DI). Results: Reported adherence was 97±5% for SQ-LNS and tablets. Length, weight, MUAC and developmental scores were significantly greater at 18 mo in children who received SQ-LNS and morbidity treatment (p<0.001) compared to NI, but did not differ by II group. Stunting prevalence at 18 mo was 39% in children in NI and significantly reduced to 24-33% in children in the II groups (p<0.0001). Conclusions: Providing daily 20 g LNS with or without zinc along with malaria and diarrhea treatment significantly improved growth and motor, language, and personal-social development in young children.

Cost-Effectiveness of Zinc Supplementation for the Prevention or Treatment of Diarrhea among Young Children in Rural Burkina Faso.

Objectives: Zinc supplements may decrease incidence of diarrhea among young children at risk of zinc deficiency. We estimated the cost-effectiveness of three approaches for delivery of preventive and therapeutic zinc supplements in rural Burkina Faso. Methods: Cost estimates were derived from data collected during a community-based randomized zinc trial, information on ongoing child-health days to distribute public health services, and an indepth study of the current health care system. Diarrhea incidence reduction is based on intent-totreat analysis of zinc trial data. Activity-based costing using an ingredients approach accounts for the costs of mutually exclusive inputs related to defined program activities for each approach. Cost-effectiveness is analyzed and compared across an intermittent preventive zinc (IPZ) approach (quarterly delivery of 10-days of 10 mg/d supplements to childrens’ homes), and a therapeutic approach (10-days of 20 mg/d supplements delivered during an ill-child consultation at a local clinic (TZ-CSPS) or via community-based health worker (TZ-CHW)). We assume 81.6% of children are reached with IPZ and .06% and 52% of diarrhea cases treated with TZ-CSPS and TZCHW, respectively. Results: Estimated annual program cost per additional child reached is $3.52 (IPZ), $3.49 (TZCSPS) and $17.59 (TZ-CHW). Cost per death averted in the first program-year is estimated to be $3164 (IPZ), $7363 (TZ-CSPS), and $14068 (TZ-CHW), assuming a diarrhea case fatality rate of 0.3% and 2.64 episodes of diarrhea/child/year. Estimated cases of diarrhea averted per year are 11.5% (IPZ), 0.9% (TZ-CSPS), and 8.2%(TZ-CHW). Conclusions: IPZ is the most cost-effective approach for a zinc program among our study population.