Nutrition Allocative Efficiency of Nutrition Investments in Tajikistan: - PowerPoint Presentation

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Nutrition

Allocative Efficiency of Nutrition Investments in Tajikistan:

A Preliminary Analysis

Jakub Kakietek,

Mayram

Kironova, Farrukh Egamov, Mutriba Latypova

Финансовая поддержка для проведения этой работы была оказана Правительством Японии через Японский трастовый фонд по расширению инвестиций в здоровое питание.

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Presentation Objectives

Optima Nutrition – presentation of the tool

A preliminary application of Optima Nutrition in Tajikistan

Discussion and the next steps

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Why Optima Nutrition?

Estimating the costs

Cost effectiveness analyses

Benefit-cost analysesCost-effectiveness map: Regions with the lowest cost per case of stunting averted

$1 invested = $22 returns

Intervention

Cost per DALY

IYCN12Vitamin A supplementation29

Therapeutic Zinc suppl./ORS

216

Micronutrient powders

44

Deworming

264

Iron-folic acid supplementation

43

Iron fortification of staple foods

 

Salt iodization

 

Public provision of complementary food

3,256

CMAM for SAM

169

One key question we could not answer: what is

the optimal allocation

of resources across interventions?

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Thinking of Efficiency

Technical efficiency – maximizing outputs at given

cost.

4Intervention A

Allocative efficiency

– maximizing outputs by allocating resources across different

activities

$

Different health programs

Different nutrition interventions

Different sectors

$

Better Nutrition

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$

Overall public

health budget

available for nutrition

Which investment

combination

leads

to

optimal

outcomes?

What Optima Nutrition Does:

Balanced energy protein supplementation

Breastfeeding promotion

Vitamin A supplements

Multiple micronutrient supplementation

Complementary

feeding education

Prophylactic Zinc supplements

Public food provision

For different funding levels, how should resources be allocated across a mix of nutrition interventions and what impact is achievable?

for the

right people

in the

right places

at the

right time

in the

right ways

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Optimization

Cost

Coverage

Impact (health, nutrition)

Underlying model is a

reproduction of the

LiST

framework

Tracks under-5 population over a time period (e.g. 2016-2030)

Tracks risk factors that contribute to malnutrition and mortality

Key nutrition outcomes include: stunting, wasting,

anemia

, breastfeeding

Estimates the impact under a given (e.g. status quo) allocation.

Estimates the impact under the optimal allocation (one that maximizes a specific outcome or set of outcomes)

How Optima Nutrition Works:

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Objective function: e.g. number of stunted children

Optimization:

consider just two dimensions

Funding to

Program A

Funding to

Program B

Apply an optimization algorithm to

calculate best resource allocation

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Optima Nutrition: Application in Tajikistan

One of the first ever applications of the took

Initial presentation of the tool to the national nutrition stakeholders in early 2019

Data collection:Basic demographic and socio-economic dataHealth and nutrition status dataCoverage of the interventions included in the analyses

Unit cost dataData sources:Government sources (official surveys, data from MoHSP)Supplemental data from partners

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Data: Interventions – Women

Intervention

Impact

Modern family planning methodsNumber of birthsMagnesium supplementation for eclampsiaMaternal mortalityMagnesium supplementation for pre-eclampsiaMaternal mortalityCalcium supplementation

Maternal mortality

Iron supplementation for pregnant womenMaternal mortality

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Data: Interventions – Children

Intervention

Impact

Infant and young child feeding counseling (in health facilities)Child mortality, linear growth (HAZ)Micronutrient powder supplementation for childrenChild mortality, anemiaOral rehydration solution for treatment or diarrheaChild mortalityOral rehydration solution and zinc for treatment of diarrhea

Child mortality

Treatment of severe acute malnutrition (SAM)Child mortality

Vitamin A supplementation

Child mortality, diarrhea incidence

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Data: Interventions – General Population

Intervention

Impact

Iron and folic acid (IFA) fortification of maize flourChild anemia, WRA anemia, child morality (FA’s impact on neural tube defects)Iron and folic acid (IFA) fortification of wheat flourChild anemia, WRA anemia, child morality (FA’s impact on neural tube defects)

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Data: Intervention Coverage and Cost

Intervention

Coverage

Cost (US$)Modern family planning methods29%8.40Magnesium supplementation for eclampsia74%20.70Magnesium supplementation for pre-eclampsia

74%20.70

Calcium supplementation0%

3.58

Iron supplementation for pregnant women45%6.38Infant and young child feeding counseling (in health facilities)67%

8.00

Micronutrient powder supplementation for children

45%

5.73

Oral rehydration solution for treatment or diarrhea

73%

1.67

Oral rehydration solution and zinc for treatment of diarrhea

15%

2.37

Treatment of severe acute malnutrition (SAP)

25%

135

Vitamin A supplementation

76%

1.31Iron and folic acid (IFA) fortification of maize flour0%0.30Iron and folic acid (IFA) fortification of wheat flour0%0.30

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Data: Estimated Current Expenditure

Intervention

Current (USD M)

Modern family planning methods1.27Magnesium supplementation for eclampsia4.8Magnesium supplementation for pre-eclampsia

4.8

Calcium supplementation0

Iron supplementation for pregnant women

0.83Infant and young child feeding counseling (in health facilities)3.65

Micronutrient powder supplementation for children

2.55

Oral rehydration solution for treatment or diarrhea

0.17

Oral rehydration solution and zinc for treatment of diarrhea

0.05

Treatment of severe acute malnutrition (SAP)

31.95

Vitamin A supplementation

0.98

Iron and folic acid (IFA) fortification of maize flour

0

Iron and folic acid (IFA) fortification of wheat flour

0

TOTAL

50.53

Approximated annual expenditure on nutrition-specific interventions –

USD 50.5 million

60%

- treatment of SAM

3

interventions currently not funded (but new fortification regulations just adopted)

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Preliminary analyses

Analysis question: How to allocate a budget of

additional resources

, with a possibility of re-allocating current budget, to maximize impact? Additional resources:Additional U$ 10M per yearCan reallocate the exiting budget

Impact: A combination of reduced: number of stunted children, number of children suffering from anemia, number of child deaths, number of maternal deaths, number of pregnant women suffering form anemia.

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Scenarios

Three scenarios are analyzed:

Baseline – no additional funding

Business as usual – additional funding (USD 10M) allocated proportionally to the currently funded interventions:USD 10m (additional funding) = 19.6% of the current estimated expenditure (USD 50.5M); therefore, the coverage of each intervention is expanded by 19.6% (not percentage points)

Optima allocationOptima Nutrition software can allocate all funding (the currently spent USD 50.5M and the additional USD 10M) in such a way to achieve the best impact for the complex objective (minimize the number of stunted and anemic children, minimize the number of child deaths, minimize the number of anemic pregnant women, minimize the number of maternal deaths).

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Scenarios - coverage

Intervention

Current

Business as usualOptimizedModern family planning methods29%35%95%Magnesium supplementation for eclampsia74%

88%95%

Magnesium supplementation for pre-eclampsia74%

88%

95%Calcium supplementation0%0%95%Iron supplementation for pregnant women

45%

54%

95%

Infant and young child feeding counseling (in health facilities)

67%

80%

95%

Micronutrient powder supplementation for children

45%

54%

95%

Oral rehydration solution for treatment or diarrhea

73%

87%

0%

Oral rehydration solution and zinc for treatment of diarrhea15%18%0%Treatment of severe acute malnutrition (SAM)25%30%

0%

Vitamin A supplementation

76%

91%

95%

Iron and folic acid (IFA) fortification of maize flour

0%

0%

0%

Iron and folic acid (IFA) fortification of wheat flour

0%

0%

95%

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Scenarios - Impact

Outcome

Business as usual

Optimized fundingOptimized funding versus Business as usualNumber of alive, non-stunted children turning age 57261,05045%Prevalence of stunting in children-0.4%-0.7%

66%

Prevalence of anaemia in children-0.6%

-3.4%

470%Prevalence of anaemia in pregnant women-1.6%-9.2%460%Child mortality rate

-0.2

0.3

-260%

Maternal mortality rate

-2.4

-5.1

116%

Optimized funding annually prevents about

320 cases of stunting

,

49 child deaths

,

760 maternal deaths

, and

25,000 of anemia cases in pregnant women

above the business as usual scenario at the same cost.

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Conclusions and caveats (so far):

Improving allocative efficiency of nutrition investments can lead to a greater impact.

Shifting funding to more cost-effective interventions can improve key outcomes including stunting prevalence, anemia prevalence, maternal and child mortality, without incurring additional costs.

For the joint objective presented above, the priorities for financing include:Nutrition interventions preventing maternal mortality

IFA food fortificationPreventing interventions for children under the age of 5Caveats: More accurate data on the actual expenditure on nutrition interventions is neededValidation of the coverage data (e.g. is 65% really covered by quality IYCF)?

Additional analyses needed at the sub-national level

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Next Steps:

EWG validates input data at the national level;

Discussions with the EWG to refine and validate the outcomes and the results at the national level;

Geospatial analyses – optimized allocations across different intervention AND across different oblast’Presentation of results and training on the Optima Nutrition tool

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Acknowledgements:

The team would like to thank the Optima Working Group chaired Dr.

Saida

Umarzadova for their support and guidance during the analysis projectThe team would also like to thank the all the agencies and technical partners who have shared the data used in the analysis.Thank you for your continuous collaboration.

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Thank you for your attention

Questions?

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Minimize the number of stunted children

Intervention

Cost (U$ M)

Coverage Calcium supplementation$00%Family planning$6,165,82995%IFA fortification of maize$0

0%

IFA fortification of wheat flour$0

0%

IFAS for pregnant women (health facility)$827,69445%IYCF 1$7,801,38395%

Mg for eclampsia

$4,800,104

74%

Mg for pre-eclampsia

$4,800,104

74%

Micronutrient powders

$2,546,524

45%

Oral rehydration salts

$170,809

73%

Treatment of SAM

$31,953,923

25%

Vitamin A supplementation$1,940,47195%Zinc for treatment + ORS$49,80915%

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Minimize number of child deaths

Intervention

Cost (U$ M)

Coverage Calcium supplementation$00%Family planning$4,264,85295%IFA fortification of maize$0

0%

IFA fortification of wheat flour$391,413

95%

IFAS for pregnant women (health facility)$00%IYCF 1$5,240,82895%

Mg for eclampsia

$0

0%

Mg for pre-eclampsia

$0

0%

Micronutrient powders

$0

0%

Oral rehydration salts

$224,699

95%

Treatment of SAM

$49,270,227

39%

Vitamin A supplementation$1,349,18695%Zinc for treatment + ORS$315,44795%