Economic evaluation of interventions to address undernutrition: a systematic review

Abstract

Strategies to address undernutrition in low- and middle-income countries (LMICs) include various interventions implemented through different sectors of the economy. Our aim is to provide an overview of published economic evaluations of such interventions and to compare and contrast evaluations of interventions in different areas. We reviewed economic evaluations of nutrition interventions in LMICs published since 2015 and/or included in the Tufts Global registry or Disease Control Priorities 3rd edition. We categorized the studies by intervention type (preventive; therapeutic; fortification; delivery platforms), nutritional deficiency addressed and characteristics of the economic evaluation (e.g. type of model, costs and outcomes included). Of the 62 economic evaluations identified, 56 (90%) were cost-effectiveness analyses. Twenty-two (36%) evaluations investigated fortification and 23 (37%) preventive interventions. Forty-three percentage of the evaluations of preventive interventions did not include a model, whereas most of fortification strategies used the same reference model. We identified different trends in cost categories and inclusion of health and non-health outcomes across evaluations in the four different topic areas. To illustrate the implications of such trends for decision-making, we compared a set of studies evaluating alternative strategies to combat zinc deficiency. We showed that the use of ‘off-the-shelf’ models and tools can potentially conceal what outcomes and costs and value judgements are used. Comparing interventions across different areas is fundamental to assist decision-makers in developing their nutrition strategy. Systematic differences in the economic evaluations of interventions delivered within and outside the health sector can undermine the ability to prioritize alternative nutrition strategies.

Economic evaluation of an early childhood development center–based agriculture and nutrition intervention in Malawi

“…The estimates from this study are also in the upper range of similar interventions that are considered cost-effective in the literature (Table 5 ). Detailed comparisons with estimates from the literature are however difficult to interpret because of the different methodologies employed in collecting and analysing the cost data, obtaining estimates on the impact of interventions and valuing the benefits streams of the intervention impacts (Ramponi et al, 2020 ). In this study, the two economic evaluation methods provide comparable evidence that this intervention is good value for money, and has a favorable return on investment.…”

“…First, given the complex determinants of nutrition outcomes, multiple sectors contribute nutrition improvements and many of the interventions and actions to improve nutritional status have secondary benefits related to food security, production diversity, dietary diversity, women's empowerment, and higher educational enrollment that are not fully captured in either cost-effectiveness or benefit-cost analyses. Second, there is no current guidance or specific methods on how to value the full range of benefits and opportunity costs incurred by all stakeholders across sectors (Remme et al, 2017;Ramponi et al, 2020). As a result, the interpretation and comparisons of findings from existing economic evaluations in the literature is challenging for policymakers (Ramponi et al, 2020).…”

“…Second, there is no current guidance or specific methods on how to value the full range of benefits and opportunity costs incurred by all stakeholders across sectors (Remme et al, 2017;Ramponi et al, 2020). As a result, the interpretation and comparisons of findings from existing economic evaluations in the literature is challenging for policymakers (Ramponi et al, 2020). Given these limitations in current approaches, this study aims to explore whether one economic evaluation method or the other might be preferred, and whether cost-effectiveness and benefit cost analysis approaches provide comparable results yielding the same policy conclusion in terms of value for money.…”

“…While the evidence on the effectiveness of nutrition sensitive programs and platforms is growing (Ruel et al, 2018), there is little or no evidence on the costs and cost and benefits of multisectoral strategies that combine both nutrition-specific and nutrition-sensitive interventions. Two recent systematic reviews of economic evaluations focus predominantly on preventive and therapeutic nutrition specific interventions, such as micronutrient supplementation, infant and young child feeding, treatment of moderate and severe acute malnutrition, food fortification, with more limited evidence on nutrition sensitive programs, such biofortification and the use of cash transfers to improve nutritional outcomes (Ramponi et al, 2020;Njuguna et al, 2020). Moreover, there are no standardized methods for aggregating the multiple outcomes along the complex pathways linking activities to impacts of nutrition-sensitive strategies (Ramponi et al, 2020).…”

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

“…With the growing awareness of the importance of economic evaluation evidence for resource allocation, priority setting, scaling of effective solutions and global and national funding decisions, recently there has been a flurry of systematic reviews that shed light on the costs and benefits of interventions to address nutritional deficiencies in global settings. Two recently published systematic reviews of economic evaluations of interventions provide evidence on preventive nutrition interventions, such as supplementation, infant and young child feeding, therapeutic nutrition interventions (interventions to treat undernutrition and micronutrient deficiencies), fortification and cash transfers linked to improved nutritional outcomes (Njuguna et al, 2020; Ramponi et al, 2020). A third recent study by Das et al (2020) provides a systematic review of both the effectiveness and cost‐effectiveness of interventions that manage acute malnutrition in children in LMICs.…”