Impact of stakeholder perspectives on cost-effectiveness estimates of four specialized nutritious foods for preventing stunting and wasting in children 6-23 months in Burkina Faso

Abstract

Background: Multiple specialized nutritious food options are programmed for supplementation in humanitarian and development settings. However, comparative cost-effectiveness evidence is lacking, let alone incorporation of perspectives from uncompensated stakeholders. A Burkina Faso trial evaluated the cost-effectiveness of Corn Soy Blend Plus w/ oil (CSB+ w/oil, reference arm), Corn Soy Whey Blend w/oil (CSWB w/oil), Super Cereal Plus (SC+), and Ready-to-Use Supplementary Food (RUSF) in reducing stunting and wasting among children 6-23 months old. This paper presents cost-effectiveness findings from multiple stakeholders' perspectives, including caregivers and program volunteers.

Methods: An activity-based costing with ingredients approach was used to summarize cost of the 18-month-long blanket supplementary feeding for each enrolled child (in 2018 USD). Time data were collected using self-reported and observational instruments. Cost-effectiveness relative to CSB+ w/oil assessed incremental cost per enrolled child against incremental outcomes: prevalence of stunting at 23 months of age and number of months of wasting. Two combined perspectives were compared: program (donor, implementer, and volunteer) versus program and caregiver (adding caregiver).

Results: A total of 6112 children were enrolled. While similar effectiveness was found in three arms (CSWB w/oil was less effective), costs differed. Product cost and caregiver time to prepare study foods were major drivers of cross-arm cost differences from the respective combined perspective. The two major drivers were used to construct uncertainty ranges of cost per enrolled child from program and caregiver perspective: $317 ($279- $355) in CSB+ w/oil, $350 ($327- $373) in CSWB w/oil, $387 ($371- $403) in RUSF, and $434 ($365- $503) in SC+. Cost from program and caregiver perspective was a substantial increase from program perspective. CSB+ w/oil was most cost-effective in reducing stunting and wasting, and this main finding was robust to changing perspectives and all corresponding sensitivity analyses when uncompensated time was valued at minimum wage ($0.36/h). The break-even point for uncompensated time valuation is >$0.84/h, where RUSF became the most cost-effective from the program and caregiver perspective. Relative cost-effectiveness rankings among the other three arms depended on choice of perspectives, and were sensitive to values assigned to product cost, international freight cost, opportunity cost of time, and outcomes of a hypothetical control. Volunteer opportunity cost did not affect arm comparisons, but lack of compensation resulted in negative financial consequences for caregivers.

Conclusions: Evaluating cost-effectiveness by incorporating uncompensated stakeholders provided crucial implementation insights around nutrition products and programming.

Trial registration: Trial registration number: NCT02071563. Name of registry: ClinicalTrials.gov URL of registry: https://ichgcp.net/clinical-trials-registry/NCT02071563?type=Intr&cond=Malnutrition&cntry=BF&draw=2&rank=9 Date of registration: February 26, 2014. Date of enrollment of first participant: July 2014.

Keywords: Caregiver; Cost-effectiveness; Infant and young children; Opportunity cost; Stunting; Supplementary feeding; Wasting; West Africa.

Conflict of interest statement

The authors declare that they no competing interests.

Figures

Fig. 1

Five costing perspectives and corresponding stakeholders

Fig. 2

Cost-effectiveness analysis methods to compare across arms

Fig. 3

Cost per metric ton compared across products, breakdown by cost components

Fig. 4

Cost per monthly ration compared across arms, breakdown by cost components

Fig. 5

Cost per enrolled child compared across arms, breakdown by cost components

Fig. 6

Caregiver opportunity cost per monthly ration compared across arms, breakdown by caregiver activities attributable to study foods. Hourly value of time at $0.36/h

Fig. 7

Total cost per enrolled child across arms: program perspective versus caregiver perspective. Hourly value of time at $0.36/h

Fig. 8

Incremental cost-effectiveness plane for stunting averted compared to CSB+ w/ oil, base-case scenario with uncertainty ranges: a program perspective; b program and caregiver perspective. Both axes were constructed comparing each of the SC+, RUSF, and CSWB w/oil arms to the reference arm CSB+ w/oil. Vertical uncertainty ranges for incremental costs from program perspective were constructed based on 1 standard deviation above and below the mean realistic product costs. Vertical uncertainty ranges for incremental costs from program and caregiver perspective additionally incorporated uncertainty in caregiver opportunity cost (1 standard deviation above and below mean adjusted study food preparation time per meal for the three flour-based arms). Horizontal uncertainty ranges for adjusted incremental effectiveness were constructed based on 95% confidence intervals around the adjusted marginal means estimated from the stunting statistical model that excluded LTFU. *p < 0.001. Data label: (point estimate on incremental effectiveness, point estimate on incremental cost)

Fig. 9

Incremental cost-effectiveness plane for wasting averted compared to CSB+ w/ oil, base case scenario with uncertainty ranges: a program perspective; b program and caregiver perspective. Both axes were both constructed comparing each of the SC+, RUSF, and CSWB w/oil arms to the reference arm CSB+ w/oil. Vertical uncertainty ranges for incremental costs from program perspective were constructed based on 1 standard deviation above and below the mean realistic product costs. Vertical uncertainty ranges for incremental costs from program and caregiver perspective additionally incorporated uncertainty in caregiver opportunity cost (1 standard deviation above and below mean adjusted study food preparation time per meal for the three flour-based arms). Horizontal uncertainty ranges for adjusted incremental effectiveness were constructed based on 95% confidence intervals around the adjusted marginal means estimated from the wasting statistical model that included LTFU. *p = 0.02. Data label: (point estimate on incremental effectiveness, point estimate on incremental cost)

Fig. 10

Realistic versus study-incurred product cost per metric ton. Mean and Standard Deviation (SD) of realistic prices for all products except CSWB were calculated using USAID FY14–16 three-yearhistorical data. The realistic price for CSWB was a single value without a range as it was a quote estimated at hypothetical procurement scale of >500MT provided directly by a major food aid supplier in US

Fig. 11

Realistic versus study-incurred international freight cost per metric ton. Realistic prices for all foods were single-value estimates as they were quotes per 20′ container provided by a major freight forwarder for USAID