Political and economic dynamics of nutrition and health: A
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  Intro animation:

Political and economic dynamics of nutrition and health studies at ANH2020

 

Session recording:

ANH2020: Political and economic dynamics of nutrition and health A

 

Speakers and presentations:

  • Session chair: Carol Levin, University of Washington
    @UW
  • Aisha Twalibu, International Food Policy Research Institute (IFPRI)
    @IFPRI
    Economic evaluation of an early childhood development (ECD) centre–based agriculture and nutrition intervention in Malawi
    Presentation | Slides
  • Andrea Warren, University of South Carolina
    @UofSC @DFC_Program
    Stakeholder engagement strategies for policy and programmatic uptake: Lessons from the Drivers of Food Choice Competitive Grants Program
    Presentation | Slides
  • Giang Thai, International Food Policy Research Institute (IFPRI)
    @IFPRI
    The economic costs of a multisectoral nutrition program implemented through a credit platform in Bangladesh
    PresentationSlides
  • Noora-Lisa Aberman, International Food Policy Research Institute (IFPRI)
    @IFPRI
    Leveraging food systems for diets in rural Ghana
    Presentation | Slides

Abstracts:

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

Aisha Twalibu1

Aulo Gelli1

Christopher G. Kemp2

Amy Margolies1

Carol Levin2

Mangani Katundu3
1 International Food Policy Research Institute (IFPRI)
2 University of Washington
3 Chancellor College, University of Malawi

Introduction

Malnutrition is a leading cause of premature death and disability among children in Malawi and other low-income countries. Agricultural programs and other nutrition-sensitive interventions have demonstrated promising effectiveness in increasing the uptake of healthy foods and improving dietary quality among vulnerable children and families. Integration of these programs into other sectors (e.g., health, education) and platforms may have synergistic effects, improving feasibility and effectiveness by leveraging available resources. Evidence on the cost and cost-effectiveness of multi-sector, integrated, nutrition-sensitive programs is limited globally, though such evidence will be critical to motivating future investment in and long-term sustainment of these programs.

Methods

We costed the integrated, ECD-based intervention using a combination of bottom-up micro-costing and top-down expenditure analysis. Costing adopted a societal perspective with a 12-month time horizon. Effectiveness estimates were derived from a longitudinal cluster-randomized controlled trial. Intervention costs and statistically significant changes in measured outcomes were compared. Premature deaths and cases of child stunting averted in the intervention communities were estimated using the Lived Saved Tool. We estimated DALYs averted and increases in lifetime productivity benefits in the same communities. We also estimated increases in household agricultural productivity and increases in community-level socioeconomic equity. We valued these benefits using methods recommended by the Reference Case Guidelines for Benefit-Cost Analysis in Global Health and Development. For our base case analysis, we transferred the US-based value of a statistical life (VSL) to Malawi using an income elasticity of 1.5, and we used a 5% discount rate. Sensitivity analyses explored other VSL calculations and discount rates. We valued increases in socioeconomic equity using methods proposed by Alderman et al 2015. We combined overall costs and benefits into benefit-cost ratios and estimates of net benefit.

Findings

The intervention was estimated to cost $186,832, or $569 per case of stunting averted, $15,569 per death averted, and $488 per DALY averted. Thus, the intervention averted an estimated 12 deaths at a cost of $186,832, or $488 per DALY averted. Net benefit estimates ranged from $ 342,944 to $ 3,360,388 (base case = $869,033), and benefit-cost ratios ranged from 2.8 to 19.0 (base case = 5.7).

Conclusion

This study suggests that ECD-integrated nutrition and agriculture interventions may be an efficient use of financial resources in Malawi and similar contexts.

References

Ruel MT, Alderman H. Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet [Internet]. 2013 Aug 10 [cited 2013 Oct 18];382(9891):536–51. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23746780
Alderman H, Fernald L. The Nexus Between Nutrition and Early Childhood Development. Annu Rev Nutr [Internet]. 2017 Aug 21;37(1):447–76. Available from: https://doi.org/10.1146/annurev-nutr-071816-064627
Black MM, Walker SP, Fernald LCH, Andersen CT, DiGirolamo AM, Lu C, et al. Early childhood development coming of age: science through the life course. Lancet [Internet]. 2017 Jan 7 [cited 2017 Sep 25];389(10064):77–90. Available from: http://www.sciencedirect.com/science/article/pii/S0140673616313897?showa...
Heckman JJ. Skill formation and the economics of investing in disadvantaged children. Science (80- ). 2006;312(5782):1900–2.
Engle PL, Black MM, Behrman JR, Cabral de Mello M, Gertler PJ, Kapiriri L, et al. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. Lancet. 2007;369(9557):229–42.
Ruel MT, Quisumbing AR, Balagamwala M. Nutrition-sensitive agriculture: What have we learned so far? Glob Food Sec [Internet]. 2018 Feb 1 [cited 2018 Feb 19]; Available from: https://www.sciencedirect.com/science/article/pii/S221191241730127X
National Statistical Office. Malawi Demographic and Health Survey. Natl Stat Off DHS Progr [Internet]. 2017;1–658. Available from: http://dhsprogram.com/pubs/pdf/FR319/FR319.pdf
Government of Malawi. The Malawi Vulnerability Assessment Committee (MVAC) National Food Security Forecast, April 2015 to March 2016. Lilongwe, Malawi; 2015.
UNICEF. Malawi humanitarian situation report. Lilongwe, Malawi;
Darmon N, Ferguson E, Briend A. Linear and nonlinear programming to optimize the nutrient density of a population’s diet: an example based on diets of preschool children in rural Malawi. Am J Clin Nutr [Internet]. 2002 Feb 1;75(2):245–53. Available from: http://ajcn.nutrition.org/content/75/2/245.abstract
Ferguson EL, Gibson RS, Opare‐Obisaw C, Osei‐Opare F, Lamba C, Ounpuu S. Seasonal food consumption patterns and dietary diversity of rural preschool Ghanaian and Malawian children. Ecol Food Nutr [Internet]. 1993 Apr 1;29(3):219–34. Available from: https://doi.org/10.1080/03670244.1993.9991307
Bailey RL, West Jr. KP, Black RE. The Epidemiology of Global Micronutrient Deficiencies. Ann Nutr Metab [Internet]. 2015;66(suppl 2(Suppl. 2):22–33. Available from: https://www.karger.com/DOI/10.1159/000371618
Neuman MJ, McConnell C, Kholowa F. From Early Childhood Development Policy to Sustainability: The Fragility of Community-Based Childcare Services in Malawi. Int J Early Child [Internet]. 2014;46(1):81–99. Available from: http://dx.doi.org/10.1007/s13158-014-0101-1
Gelli A, Margolies A, Santacroce M, Sproule K, Theis S, Roschnik N, et al. Improving child nutrition and development through community-based childcare centres in Malawi ? The NEEP-IE study: study protocol for a randomised controlled trial. Trials [Internet]. 2017;18(1):284. Available from: http://trialsjournal.biomedcentral.com/articles/10.1186/s13063-017-2003-7
Gelli A, Margolies A, Santacroce M, Roschnik N, Twalibu A, Katundu M, et al. Using a Community-Based Early Childhood Development Center as a Platform to Promote Production and Consumption Diversity Increases Children’s Dietary Intake and Reduces Stunting in Malawi: A Cluster-Randomized Trial. J Nutr [Internet]. 2018;148(10):1587–97. Available from: https://academic.oup.com/jn/advance-article-abstract/doi/10.1093/jn/nxy1...

Stakeholder engagement strategies for policy and programmatic uptake: Lessons from the Drivers of Food Choice Competitive Grants Program

Andrea M. Warren1

Shilpa Constantinides1

Christine E. Blake1

Edward A. Frongillo1


1University of South Carolina

Introduction

The current landscape of research and practice in multisectoral nutrition is fast-paced and complex. Stakeholder engagement strategies help to ensure relevancy of research efforts, but are challenging to embed within research programs. The aim of this study is to draw upon experiences of stakeholder engagement in food choice research to advance knowledge about best practices. Specifically, what were the stakeholder engagement strategies that researchers developed? How did these strategies help researchers meet their goals for research uptake?

Methods

The Drivers of Food Choice Competitive Grants Program aimed to understand food choice in low- and middle-income-countries. All funded proposals were required to include strategies for multilevel and multisectoral stakeholder engagement tailored to their diverse research contexts across 10 low- and middle-income countries. Data were derived from a document review of funded proposals and reports, and semi-structured interviews with the principle investigators of each of 15 projects (n=15). Interviews focused on researchers’ experiences identifying stakeholders and developing and implementing engagement strategies. Interviews were transcribed and uploaded into NVIVO 12. This effort constitutes a thematic survey, wherein data are coded and analyzed using an inductive approach and the results are relatively “near” to the data in presentation and interpretation (Thomas, 2011; Sandelowski and Barroso, 2003). The lead author analyzed interviews thematically using an a priori code list and led discussion of themes and patterns through peer review with co-authors.

Findings

Grantees developed and implemented a wide range of strategies that varied in terms of level of collaboration sought. “Uni-directional” strategies were researcher-driven and largely informational. These strategies required little to no collaboration with the target stakeholder, and included one-way communication strategies such as emails, newsletters, meetings or workshops to inform about the research, press releases, technical briefs, newspaper articles, and public engagement efforts such as short documentaries. “Bi-directional” strategies required some degree of collaboration with stakeholders, and commonly took the form of workshops at which feedback on stakeholder identification, research questions, methods, results, and/or recommendations was sought (Jolibert and Wesselink, 2012). Grantees used unidirectional strategies to increase stakeholder buy-in and generate demand for results, which aided in promoting the use of evidence for decision-making. Bi-directional approaches were typically more integral to the production of knowledge, and grantees deployed them to seek input on framing research significance, interpreting results, and finalizing recommendations. Grantees thought that bi-directional engagement enhanced the immediate relevance of the research. Grantees developed more and less intensive strategies that involved both bi-and uni-directional engagement, depending on goals for uptake.

Conclusion

This research sheds light on the role of stakeholder engagement in advancing multisectoral nutrition. Findings may aid researchers in constructing engagement strategies that are responsive to diverse research programs and goals within complex multisectoral nutrition landscapes in LMIC. Future research programs should document stakeholder engagement processes, which will yield substantial insight into translational and implementation processes as well as methods to assess impacts and enhance efficacy of stakeholder engagement strategies.

References

Jolibert, C., & Wesselink, A. (2012). Research impacts and impact on research in biodiversity conservation: The influence of stakeholder engagement. Environmental science & policy, 22, 100-111.
Sandelowski, M., & Barroso, J. (2003). Classifying the findings in qualitative studies. Qualitative health research, 13(7), 905-923.
Thomas, D. R. (2006). A general inductive approach for analyzing qualitative evaluation data. American journal of evaluation, 27(2), 237-246.

The economic costs of a multisectoral nutrition program implemented through a credit platform in Bangladesh 

Giang Thai1

Amy Margolies2

Nasrin Sultana3

Aulo Gelli3

Carol Levin4

1International Food Policy Research Institute

2Consultant, International Food Policy Research Institute 

3International Food Policy Research Institute

4University of Washington

Introduction

Undernutrition in young children and their mothers is a persistent problem in Bangladesh. The prevalence of stunting under 5 is 36%, with children in rural areas are more likely to be stunted. Additionally, 19% of ever-married women are also undernourished. Nutrition-sensitive agriculture programs show promise for addressing rural undernutrition in mothers and children. However, questions remain on the relative costs of these interventions. This study calculates the economic costs of BRAC’s Targeting and Re-aligning Agriculture to Improve Nutrition (TRAIN) program, a four-arm intervention with an additive design based on a credit platform to support women’s income generation.  

Methods

The methodology is based on a standardized approach developed through the Strengthening Economic Evaluation for Multisectoral Strategies for Nutrition (SEEMS) consortium. The framework utilizes a four-step approach to incorporate data from a typology of multisectoral nutrition programs with generic program impact pathways. Step 1 identifies categories of interventions across sectors, Step 2 maps impact pathways to program activities and outcomes, Step 3 classifies activities, costs and inputs along the impact pathways and Step 4 considers outputs and outcomes with each activity on the pathway. This process combines the activity-based costing-ingredients method (ABC-I) with expenditure data and qualitative data collection to estimate time allocation and opportunity costs. Quantitative and qualitative data were collected retrospectively from beneficiaries, staff and frontline workers. We leveraged existing secondary data from project expense reports, an RCT and process evaluation to feed into the economic evaluation. In addition, we collected primary qualitative data through semi-structured interviews and focus group discussions with frontline workers, field organizers and district managers. Financial expenditure data and economic costs were combined to calculate the incremental costs of the program. Costs were also disaggregated by treatment arm.

Findings

The total incremental cost of the TRAIN program was $462,580.87, which included both economic and financial costs over the period of February 2017-April 2018. Our analysis identified the main cost drivers of the program by activity type. Home visits, or household counseling for nutrition activities, represented the greatest share of total costs for the intervention (31%). This was followed by community events and extension (13%), distribution of inputs (12%), home visits for agriculture/poultry extension (9%), overhead costs (7%), monitoring and evaluation (6%), frontline worker training (6%) and site supervision (6%). Less than 5% of costs were allocated to planning, management, awareness raising, integration, program installation, procurement and establishing and running community groups. Total costs by input type were led by personnel costs (57%), followed by travel/per diems (16%), supplies (11%), contracted services (8%) and overhead (7%). The incremental cost of the program per household was approximately USD$92, while the cost per beneficiary - considering only the index female of the household and their spouse - was USD$49. Frontline worker out of pocket costs (OOPs) for travel, meals and other costs not covered by the program ranged from USD$92-195 per year.

Conclusion

This economic evaluation identified activity and input-based cost drivers for a complex multisectoral nutrition-sensitive agriculture intervention. The inclusion of financial and economic costs captured both the costs to implementers as well as the opportunity costs to workers and beneficiaries. The relatively high OOP costs suggest potential changes to program design to lessen burdens on participants and frontline workers. There are few cost analyses for comparison, but the cost per beneficiary is lower than an integrated agriculture and health intervention in Kenya (US$ 110 per beneficiary). This standardized approach will permit future cost comparisons with other nutrition-sensitive multisectoral interventions.

References

National Institute of Population Research and Training (NIPORT), Mitra and Associates, ICF International. 2016. Bangladesh Demographic and Health Survey 2014. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT, Mitra and Associates, and ICF International.

Levin, C. E., et al. 2019. What is the cost of integration? Evidence from an integrated health and agriculture project to improve nutrition outcomes in Western Kenya. Health Policy and Planning, 34(9), 646-655.

Leveraging food systems for diets in rural Ghana 

Noora-Lisa Aberman1
Aulo Gelli1
John Agandin1
Doreen Kufoalor1
Jason Donovan2
1IFPRI  
2CIMMYT

Introduction

Global economic and demographic changes are driving food system changes throughout the world. In Ghana, economic growth and development and the early stages of a nutrition transition coincide with pervasive rural food and nutrition insecurity, generating distinctive risks and opportunities for the rural poor. This study applies a mixed-methods multi-disciplinary analytical approach to assess Ghana’s changing food system and the implications for diet choices of the rural poor. We apply a value chains for nutrition (VCN) diagnostic tool to examine multiple food value chains through a nutrition lens, from production to consumption [1].

Methods

Food system considers aspects of the natural world, such as food nutrient content and agricultural production, but is embedded within and influenced by complex and context-specific socio-cultural factors. Food systems analysis can be enhanced by considering this embeddedness, weaving together precise quantitative data with deep qualitative data that explores the diversity of perceptions and viewpoints across the relevant contexts [2]. Food nutrient consumption patterns are derived from analysis of secondary data from nationally-representative surveys. The drivers of diet choices are explored—specifically, the role of socio-cultural norms and food-market environment characteristics—based on 8 community case studies (48 in-depth interviews and 109 market interviews) across 4 regions of Ghana. A critical realist research paradigm supports integration of these different data, in order to assess the relationships between factors under analysis and generate theory-related and context-specific explanations of food systems and diets [3]. Detailed household survey data from a seven-day recall of consumption and expenditures was analyzed to provide a breakdown of per capita food and nutrient consumption shares. Data from IDIs were translated, transcribed, and thematically coded using NVivo 12. Market interviews were collated and summarized by market and by food type.

Findings

We find that seasonality of supply and demand, short local supply chains, and limited infrastructure underlie a subsistence-first approach to farming, amplifying the importance of own-production to diet choices—especially near rural markets and in the north. Market challenges create barriers for food purchase (diets) as well as food sales (livelihoods), wherein the perishability and supply-demand patterns of many important nutritious foods disincentivizes production for consumption and sale. In addition, processed forms of nutritious foods, including industrially and traditionally processed forms, are available throughout the country and help bridge seasonal gaps of some highly preferred nutritious foods. However, some ultra-processed foods are also used as replacements for fresh nutritious foods, representing an emerging challenge of the globalizing food system as well as an opportunity for developing more nutritious local and shelf-stable alternatives. Furthermore, our analysis supports application of a more nuanced conceptualization of market access than the oft-applied measures such as distance, time, and cost to the market. A measure of market access that considers the variety and consistency of food supplied may be able to shed additional light on questions about how to enhance diets through market-based approaches. We see this as an important area for further research and validation.

Conclusion

Demand for increased quantities of nutritious foods can be enhanced, especially the tendency to substitute legumes, seeds, and animal foods with seasonal vegetables. And seasonal production and limited supply chain infrastructure for traditional vegetables (like leafy greens and turkey berry) and preferred fruits are critical for addressing seasonality of healthy diets. Specific policy suggestions include: enhancing nutrition education in community health clinics and in school curricula to increase demand for nutritious foods; addressing seasonal limitations to fresh nutrient rich foods by supporting dry-season production; and exploring innovative storage, packaging, processing and transport solutions to decrease waste of nutrient rich foods.

References

Gelli, Aulo et al. 2015. “Value Chains and Nutrition A Framework to Support the Identification, Design, and Evaluation of Interventions.” IFPRI Discussion Paper. Washington DC.
Bisogni, Carole A., Margaret Connors, Carol M. Devine, and Jeffery Sobal. 2002. “Who We Are and How We Eat : A Qualitative Study Of.” Journal of Nutrition Education and Behavior 34: 128–39.
Shannon-Baker, Peggy. 2016. “Making Paradigms Meaningful in Mixed Methods Research.” Journal of Mixed Methods Research 10(4): 319–34.

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