Cost-effectiveness of a market-based home fortification of food with micronutrient powder programme in Bangladesh

Impact of market-based home fortification with micronutrient powder on childhood anemia in Bangladesh: a modified stepped wedge design

Background

Anemia poses a significant public health problem, affecting 1.6 billion people and contributing to the loss of 68.4 million disability-adjusted life years. We assessed the impact of a market-based home fortification program with micronutrient powder (MNP) called Pushtikona-5 implemented by Bangladesh Rural Advancement Committee (BRAC) on the prevalence of anemia among children aged 6-59 months in Bangladesh.

Methods

We used a modified stepped wedged design and conducted three baseline, two midline, and three endline surveys to evaluate the Pushtikona-5 program implemented through three BRAC program platforms. We interviewed children's caregivers, and collected finger-prick blood samples from children to measure hemoglobin concentration. We also collected data on coverage of Pushtikona-5 and infant and young child feeding (IYCF) practices. We performed bivariate and multivariable analysis and calculated adjusted risk ratios (ARRs) to assess the effect of program outcomes.

Results

A total of 16,936 households were surveyed. The prevalence of anemia was 46.6% at baseline, dropping to 32.1% at midline and 31.2% at endline. These represented adjusted relative reductions of 34% at midline (RR 0.66, 95%CI 0.62 to 0.71, value of p <0.001) and 32% at endline (RR 0.68, 95%CI 0.64 to 0.71, value of p <0.001) relative to baseline. Regarding MNP coverage, at baseline, 43.5% of caregivers surveyed had heard about MNP; 24.3% of children had ever consumed food with MNP, and only 1.8% had consumed three or more sachets in the 7 days preceding the survey. These increased to 63.0, 36.9, and 4.6%, respectively, at midline and 90.6, 68.9, and 11.5%, respectively, at endline.

Conclusion

These results show evidence of a reduction in the prevalence of anemia and an improvement in coverage. This study provides important evidence of the feasibility and potential for impact of linking market-based MNP distribution with IYCF promotion through community level health workers.

Barriers to and Facilitators of the Implementation of a Micronutrient Powder Program for Children: A Systematic Review Based on the Consolidated Framework for Implementation Research

BACKGROUND

As one of the most cost-effective investments for improving child nutrition, micronutrient powder (MNP) has been widely used in many countries to underpin the Sustainable Development Goals, yet challenges remain regarding its implementation on a large scale. However, few studies have explored the factors that facilitate or impede the implementation process using implementation science theories and frameworks. To address this gap, we adopted the Consolidated Framework of Implementation Research (CFIR) and conducted a systematic review of studies on the implementation barriers to and facilitators of MNP interventions.

METHOD

Five publication databases, including EMBASE, Medline, PubMed, Web of Science, and Scopus, were searched for studies on the influencing factors of MNP interventions. Based on the CFIR framework, the facilitators and barriers for the MNP program implementation reported in the included studies were extracted and synthesized by five domains: intervention characteristics, outer setting, inner setting, individual characteristics, and process.

RESULTS

A total of 50 articles were eligible for synthesis. The majority of the studies were conducted in lower-middle-income countries (52%) through the free delivery model (78%). The inner setting construct was the most prominently reported factor influencing implementation, specifically including available resources (e.g., irregular or insufficient MNP supply), structural characteristics (e.g., public-driven community-based approach), and access to information and knowledge (e.g., lack of training for primary-level workers). The facilitators of the engagement of private sectors, external guidelines, and regular program monitoring were also highlighted. On the contrary, monotonous tastes and occasional side effects impede intervention implementation. Additionally, we found that the inner setting had an interrelation with other contributing factors in the MNP program implementation.

CONCLUSION

Our results suggest that MNP program implementation was prominently influenced by the available resources, organizational structure, and knowledge of both providers and users. Mobilizing local MNP suppliers, engaging public-driven free models in conjunction with market-based channels, and strengthening the training for primary-level health workers could facilitate MNP interventions.

Costs and cost-effectiveness of treatment setting for children with wasting, oedema and growth failure/faltering: A systematic review

This systematic review aimed to address the existing evidence gaps, and guide policy decisions on the settings within which to treat infants <12 months of age with growth faltering/failure, and infants and children aged <60 months with moderate wasting or severe wasting and/or bilateral pitting oedema. Twelve electronic databases were searched for studies published before 10 December 2021. The searches yielded 16,709 records from which 31 studies were eligible and included in the review. Three studies were judged as low quality, whilst 14 were moderate and the remaining 14 were high quality. We identified very few cost and cost-effectiveness analyses for most of the models of care with the certainty of evidence being judged at very low or low. However, there were 17 cost and 6 cost-effectiveness analyses for the initiation of treatment in outpatient settings for severe wasting and/or bilateral pitting oedema in infants and children <60 months of age. From this evidence, the costs appear lowest for initiating treatment in community settings, followed by initiating treatment in community and transferring to outpatient settings, initiating treatment in outpatients then transferring to community settings, initiating treatment in outpatient settings, and lastly initiating treatment in inpatient settings. In addition, the evidence suggested that initiation of treatment in outpatient settings is highly cost-effective when compared to doing nothing or no programme implementation scenarios, using country-specific WHO GDP per capita thresholds. The incremental cost-effectiveness ratios ranged from $20 to $145 per DALY averted from a provider perspective, and $68 to $161 per DALY averted from a societal perspective. However, the certainty of the evidence was judged as moderate because of comparisons to do nothing/ no programme scenarios which potentially limits the applicability of the evidence in real-world settings. There is therefore a need for evidence that compare the different available alternatives.

Cost-effectiveness of universal iron supplementation and iron-containing micronutrient powders for anemia among young children in rural Bangladesh: analysis of a randomized, placebo-controlled trial

BACKGROUND

Universal provision of iron supplements or iron-containing multiple micronutrient powders (MNPs) is widely used to prevent anemia in young children in low- and middle-income countries. The BRISC (Benefits and Risks of Iron Interventions in Children) trial compared iron supplements and MNPs with placebo in children <2 y old in rural Bangladesh.

OBJECTIVES

We aimed to assess the cost-effectiveness of iron supplements or iron-containing MNPs among young children in rural Bangladesh.

METHODS

We did a cost-effectiveness analysis of MNPs and iron supplements using the BRISC trial outcomes and resource use data, and programmatic data from the literature. Health care costs were assessed from a health system perspective. We calculated incremental cost-effectiveness ratios (ICERs) in terms of US$ per disability-adjusted life-year (DALY) averted. To explore uncertainty, we constructed cost-effectiveness acceptability curves using bootstrapped data over a range of cost-effectiveness thresholds. One- and 2-way sensitivity analyses tested the impact of varying key parameter values on our results.

RESULTS

Provision of MNPs was estimated to avert 0.0031 (95% CI: 0.0022, 0.0041) DALYs/child, whereas iron supplements averted 0.0039 (95% CI: 0.0030, 0.0048) DALYs/child, over 1 y compared with no intervention. Incremental mean costs were $0.75 (95% CI: 0.73, 0.77) for MNPs compared with no intervention and $0.64 ($0.62, $0.67) for iron supplements compared with no intervention. Iron supplementation dominated MNPs because it was cheaper and averted more DALYs. Iron supplementation had an ICER of $1645 ($1333, $2153) per DALY averted compared with no intervention, and had a 0% probability of being the optimal strategy at cost-effectiveness thresholds of $200 (reflecting health opportunity costs in Bangladesh) and $985 [half of gross domestic product (GDP) per capita] per DALY averted. Scenario and sensitivity analyses supported the base case findings.

CONCLUSIONS

These findings do not support universal iron supplementation or micronutrient powders as a cost-effective intervention for young children in rural Bangladesh.This trial was registered at anzctr.org.au as ACTRN1261700066038 and trialsearch.who.int as U1111-1196-1125.

A Social Business Model of Early Intervention and Rehabilitation for People with Disability in Rural Bangladesh

Background: Despite the high burden of childhood disability in low-and middle-income countries (LMICs), the opportunity for early intervention and rehabilitation is very limited. Studies have found that community-based rehabilitation service is effective for children with cerebral palsy (CP); however, such services are not readily available in LMICs, and services run by non-profit organisations on external funding are often not sustainable. In this study, we report the lesson learnt in establishing a social business model of early intervention and rehabilitation services for children with CP and adults with disabilities in a rural subdistrict of Bangladesh. Methods: Case study of a rural early intervention and rehabilitation centre (i.e., the model centre) implemented between May 2018 and September 2019. An economic evaluation incorporating gross margin analysis along with descriptive statistics was performed to assess the social business potentials of the model centre. Results: The establishment of this model centre cost ~5955 USD with an average monthly running cost of ~994 USD. During the 17 months study period, 7038 therapy sessions (average eight sessions per patient) were offered to 862 patients with musculoskeletal and neurological disorders. The most common clinical presentations were low back pain (35.6%; n = 307). Six percent (n = 52) of the attendees were children with CP (mean (SD) age 6.3 (4.0) years; 35.7% (n = 19) were female), who received 1392 sessions, on average 27 sessions per child. The centre reached the break-even point at the 13th month and remained profitable for the next 4 months of the study period. An average session fee of 2.2 USD resulted in a gross margin of -1458 USD and 1940 USD in 2018 and 2019, respectively. Revenue to cost ratios for the 2 years were 0.27:1 and 0.51:1 while average rates of return were −41.4% and 10.1%, respectively. Sensitivity analysis revealed that session numbers including 5000, 6000, 7000, 8000, 9000, and 10,000 were required to break even at the session fees of 3.0, 2.50, 2.0, 2.0, 1.5, and 1.5 USD, respectively. Conclusion: Our social business model of an early intervention and rehabilitation service provides evidence of enhancing access to services for children with CP as well as adults with disabilities while ensuring the sustainability of the services in rural Bangladesh.

Caregiver perceived barriers to the use of micronutrient powder for children aged 6-59 months in Bangladesh

Background

The effectiveness of micronutrient powder (MNP) on the health outcome of children is yet to be proved. Although studies identified the barriers to the use of MNP the underlying factors related to the barriers to the use of MNP are still unexplored. We examined the underlying factors associated with the barriers reported by the caregivers of the children aged 6–59 months in Bangladesh.

Methods

We analyzed pooled data of 3, 634 caregiver-child dyads extracted from eight cross-sectional surveys. The surveys were conducted as part of an evaluation of the Maternal, Infant and Young Children Nutrition programme (phase 2) in Bangladesh. We performed univariate analysis to find the barriers reported by the caregivers of the children. We identified the underlying factors related to the reported barriers by performing multiple logistic regression analysis.

Results

The mostly reported barrier was perceived lack of need for MNP among the caregivers of the children (39.9%), followed by lack of awareness of the product (21.7%) and cost of the product (18.1%). Caregivers of older children (adjusted odds ratio (aOR): 1.69; 95% CI: 1.43, 2.00) and caregivers who maintained good infant and young child feeding practices (aOR: 1.32; 95% CI: 1.12, 1.57) perceived more lack of need for MNP. Caregivers of the female children (aOR: 0.79; 95% CI: 0.63, 0.98) were less likely to report that their children disliked MNP compared to the caregivers of the male children.

Conclusion

Programmes intended to effectively promote MNP among the caregivers of children aged 6–59 months should carefully consider the factors that could underlie the barriers to the use of MNP.

Comparing costs and cost-efficiency of platforms for micronutrient powder (MNP) delivery to children in rural Uganda

Micronutrient powder (MNP) can reduce iron deficiency in young children, which has been well established in efficacy trials. However, the cost of different delivery platforms has not been determined. We calculated the cost and cost-efficiency of distributed MNP through community-based mechanisms and in health facilities in a primarily rural district in Uganda. An endline survey (n = 1072) identified reach and adherence. During the 9-month pilot, 37,458 (community platform) and 12,390 (facility platform) packets of MNP were distributed. Each packet consisted of 30 MNP sachets. In 2016, total costs were $277,082 (community platform, $0.24/sachet) and $221,568 (facility platform, $0.59/sachet). The cost per child reached was lower in the community platform ($53.24) than the facility platform ($65.97). The cost per child adhering to a protocol was $58.08 (community platform) and $72.69 (facility platform). The estimated cost of scaling up the community platform pilot to the district level over 3 years to cover approximately 17,890 children was $1.23 million (scale-up integrated into a partner agency program) to $1.62 million (government scale-up scenario). Unlike previous estimates, these included opportunity costs. Community-based MNP delivery costs were greater, yet more cost-efficient per child reached and adhering to protocol than facility-based delivery. However, total costs for untargeted MNP delivery under program settings are potentially prohibitive.

Implementation science in nutrition: a summary and synthesis

Objective:

This paper aimed to summarise and critically synthesise the key findings of the articles included in the supplement entitled ‘Nutrition Implementation Science: The Experience of a Large-Scale Home Fortification in Bangladesh’.

Design:

Commentary, summary and synthesis.

Settings:

Low- and middle-income country.

Results:

The supplement included six articles, including this summary paper. The second article presented an implementation science framework that facilitated conceptualising and evaluating the home-fortification programme in Bangladesh implemented by the Bangladesh Rural Advancement Committee (BRAC). The framework encompasses five components: identifying an ‘effective’ intervention; scaling-up and implementation fidelity; course corrections during implementation and assessing the implementation’s effectiveness; promoting sustainability of interventions and consideration of a concurrent evaluation to identify ‘effective’ interventions and to assess the process and outcome indicators of implementation. The other four articles in this supplement addressed the different components of the framework. For example, the third article addressed the implementation fidelity of a home-fortification programme, and the fourth article described the use of concurrent evaluation to course correct the implementation plan that resulted in improved implementation fidelity. The fifth article explained the outcome of course correction in the programme coverage, and the sixth article described the cost-effectiveness of the BRAC home-fortification programme.

Conclusions:

Overall, the supplement provides a comprehensive understanding of nutrition implementation science, which is very new in the field. The lessons learned in this supplement may enhance the capacity of researchers, policymakers and key stakeholders in the nutrition field to scale up new nutrition interventions and sustain them until malnutrition is alleviated.