Amy Margolies, Economic Evaluation of an Early Childhood Development Center-Based Agriculture and Nutrition Intervention in Malawi
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Amy Margolies POLICY SEMINAR Using Malawi’s Community-Based Childcare Centers to Implement an Agriculture and Nutrition Intervention Co-organized by IFPRI, the University of Washington led SEEMS nutrition project, and the CGIAR Research Program on Agriculture for Improved Nutrition and Health (A4NH)
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Amy Margolies, Economic Evaluation of an Early Childhood Development Center-Based Agriculture and Nutrition Intervention in Malawi
- 1. GELLI A, KEMP CG, MARGOLIES A, LEVIN C, TWALIBU A, KATUNDU M Economic evaluation of an early childhood development center– based agriculture and nutrition intervention in Malawi
- 2. Study Objectives Estimate intervention cost Cost-efficiency What is the cost-effectiveness of this intervention? Cost effectiveness analysis Calculate return on investment for the intervention Benefit-cost analysis
- 3. • SEEMS approach: top-down expenditure analysis and bottom-up microcosting approach • Retrofitted cost data to SEEMS framework and standard codes • Valued opportunity cost for government, volunteers and beneficiaries • Developed allocation rules for shared costs • Total costs and cost-efficiency • Total intervention cost divided by number of target population reached. Methodological approach
- 4. • Cost-effectiveness: • Premature deaths estimated using the Lives Saved Tool • Stunting cases averted • Disability-Adjusted Life Years (DALYs) averted estimated incorporating premature mortality and disability due to stunting • Benefit-cost analysis: • Mortality • Lifetime productivity • Agricultural production • Sensitivity analyses explored other Value of a Statistical Life (VSL) calculations and discount rates Methods: Economic Evaluation
- 6. Water, Sanitation & Hygiene Agriculture Production of nutrient-rich foods Consumption of nutrient- rich foods Intake of macro- & micro-nutrients Dietary Diversity Health and Nutrition ↑ use of maternal health services Exclusive breastfeeding Micronutrient deficiencies Anemia & hemoglobin Death averted Under/over-weight Stunting Wasting Low birthweight Illness averted Water quality Water storage ↓ Distance of water source to home ↓ Girls’ school dropout post-puberty ↓ Danger/Shame with open defecation ↓ Enteropathy ↑ cognitive function ↑ Water security ↓ Parasite load Livelihoods Women’s empowerment ↓ Poverty household income access to assets Protection from shocks Food expenditure Food security Legend CEA
- 7. Water, Sanitation & Hygiene Agriculture Production of nutrient-rich foods Consumption of nutrient- rich foods Intake of macro- & micro-nutrients Dietary Diversity Health and Nutrition ↑ use of maternal health services Exclusive breastfeeding Micronutrient deficiencies Anemia & hemoglobin Death averted Under/over-weight Stunting Wasting Low birthweight Illness averted Water quality Water storage ↓ Distance of water source to home ↓ Girls’ school dropout post-puberty ↓ Danger/Shame with open defecation ↓ Enteropathy ↑ cognitive function ↑ Water security ↓ Parasite load Livelihoods Women’s empowerment ↓ Poverty household income access to assets Protection from shocks Food expenditure Food security Legend CEA CUA - DALYs
- 8. Water, Sanitation & Hygiene Agriculture Production of nutrient-rich foods Consumption of nutrient- rich foods Intake of macro- & micro-nutrients Dietary Diversity Health and Nutrition ↑ use of maternal health services Exclusive breastfeeding Micronutrient deficiencies Anemia & hemoglobin Death averted Under/over-weight Stunting Wasting Low birthweight Illness averted Water quality Water storage ↓ Distance of water source to home ↓ Girls’ school dropout post-puberty ↓ Danger/Shame with open defecation ↓ Enteropathy ↑ cognitive function ↑ Water security ↓ Parasite load Livelihoods Women’s empowerment ↓ Poverty household income access to assets Protection from shocks Food expenditure Food security Legend CCA CEA BCA
- 10. Results: Cost-Efficiency Total Cost Population Cost/reached $186,832 Pre-School Children: 1,017 $182 per child Beneficiaries: 4,806 $39 per beneficiary Households: 900 $206 per household
- 11. Cost NEEP-IE intervention cost (not NET) $186,832 Results: Cost-Effectiveness Incremental Cost Effectiveness Ratio (ICER) Estimates Stunting $569 $/case of stunting averted Death $15,569 $/death averted DALY (standard LE) $488 $/DALY averted DALY (Malawi LE) $514 $/DALY averted Outcomes Stunting cases averted 329 Deaths averted 12 DALYs averted (standard LE) 382 DALYS averted (Malawi LE) 363
- 12. Results: Benefit Cost Analysis Base Low High Benefits $1,055,864 $529,775 $3,547,220 • Deaths Averted $345,009 $345,009 $2,342,400 • Lifetime Productivity $609,826 $121,435 $1,085,523 • Agricultural Production $101,028 $63,330 $119,297 Costs $186,832 • Program $147,917 • Community contribution $38,915 Net benefits $869,033 $342,944 $3,360,388 Benefit-cost ratio 5.7 2.8 19.0 Sensitivity analyses: • VSL calculation (US VSL extrapolation, age/life expectancy adjusted, US ratio, OECD ratio) • Discount rate (3%, 5%, 12%)
- 13. Intervention Country Sectors Benefit-Cost Ratio Source Essential nutrition- specific interventions 17 countries Nutrition, health 18 (3.6 – 48) Hoddinott et al 2013 NEEP (Integrated nutrition/ECD) Malawi Nutrition, agriculture, education 5.7 (2.8 – 19) Gelli et al 2019 Essential nutrition- specific interventions Haiti Nutrition, health 5.2 (2 – 8.4) Wong & Radin 2019 School feeding Nepal Nutrition, education 5.2 (3.1 – 8.6) WFP & MasterCard 2018 Rural sanitation project India WASH 2.5 – 5 Weiss et al 2018 Community-led total sanitation Hypothetical Sub- Saharan Africa WASH 1.6 (1.2 – 2) Radin et al 2019 Integrated nutrition and ECD Nicaragua Nutrition, education 1.5 (1.3-2.3) Lopez Boo et al 2014 Discussion
- 15. Results: Cost-Outcomes Cost Beneficiaries Effects Original Standardized Cost-outcome $186,831 4,807 Change in production diversity score 0.71 units 0.52 SD $75/SD increase Change in production variety score 2.14 units 0.51 SD $76/SD increase Change in diet adequacy (MPA) 5 p.p. 0.34 SD $114/SD increase Change in individual dietary diversity score (IDDS) 0.37 units 0.23 SD $169/SD increase Change in household dietary diversity score (HDDS) 0.36 units 0.17 SD $229/SD increase
Editor's Notes
- SEEMS; Strengthening Economic Evaluation for Multisectoral Strategies University of Washington – Carol Levin and Chris Kemp
- -SEEMS used a standardized framework which I wont go into for time constraints (mapping activities to framework and standardized cost categories) -Financial vs economic costs -Collect qualitative data to capture opportunity costs using semi-structured interviews & focus groups
- -Valued three benefits streams - mortality, productivity, agricultural production (these are fairly standard valuations) -Reference Case Guidelines for Benefit-Cost Analysis in Global Health and Development
- -impact pathways of the program – overall, the goal was to try and value all the different outcomes -How to cost the activities and to cost the community based activities which are opportunity costs (economic) and impacts - -emphasizing multiple outcomes and impacts, several bc is complex intervention - this is a methodological challenge for costing
- -only looking at some outcomes – hard to look across all possible outcomes from a multirsectoral program, one of the challenges of the SEEMS project Range of outcomes measured Some that will be modeled Here are the outcomes that went into evaluating cost-effectiveness Stunting Several others are omitted What did we gain from BCA? What did we never capture from CEA and BCA? What do we gain from CCA?
- Range of outcomes measured Here are the outcomes that went into evaluating cost-effectiveness Stunting Several others are omitted
- -Here are the outcomes that went into evaluating cost-effectiveness -METHODS CHALLENGE – only the ones we could value were here, still others we couldn’t figure out
- -SEEMS approach allows us to break down by activity and identify cost drivers by different program components -Almost half cost devoted to training and 16% actually provided by the community (provision of meals) – importance of community contributions -Costs by input type: Personnel as largest investment of cost (40%), highlight that supplies (farm inputs such as seeds) composed 16% -One quarter of costs for start up, ¾ were recurrent costs to maintain the program
- - How much does it cost to avert one more case of stunting? (Average incremental cost associated with 1 additional unit of the measure of effect) -MOST OF THIS IS DETERMINED BY STUNTING which is a limitation -defined by the difference in cost between two possible interventions, divided by the difference in their effect -The ICER can be used as a decision rule in resource allocation. If a decision-maker is able to establish a willingness to pay value for the outcome of interest, it is possible to adopt this value as a threshold. -DALYs: sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition (DALY=YLL+YLD). -The YLL basically correspond to the number of deaths multiplied by the standard life expectancy at the age at which death occurs. The basic formula for YLL (without yet including other social preferences discussed below), is the following for a given cause, age and sex: YLL= N (# deaths)*LE (standard life exp at age death in years)
- -Modeled 3 different cases: base, low and high -Using different values of a statistical life and different discount rates -The way to account for the time value of money is to discount the flow of revenues and costs and evaluate them based on their present value.
- Fits in the upper range of similar interventions that are considered cost effective
- -For example, gives a sense of cost per unit outcomes, many different results and can value them. -Less complex interventions might only have one outcomes or two to value, here we have many