John L. Fiedler

The costs and effectiveness of three vitamin A interventions in Guatemala

The purpose of the study presented in this paper was to estimate, using secondary sources of data, the cost and effectiveness of three programs to combat vitamin A deficiency in Guatemala-the national sugar fortification program, a targeted capsules distribution program and the promotion of home food production combined with nutrition education and to draw conclusions concerning priorities for Guatemala. Data on the costs and coverage were collected from implementing agencies in Guatemala. Coverage data were converted into a common set of impact indicators. Sensitivity analyses were conducted on variables whose precise value was uncertain. Potential impacts of improvements in program performance operations were also explored. The analysis found the cost per high-risk person achieving adequate vitamin A to be US

Household Consumption and Expenditures Surveys (HCES): A primer for food and nutrition analysts in low- and middle-income countries

0.98 for fortification, US

Still waiting for Godot? Improving Household Consumption and Expenditures Surveys (HCES) to enable more evidence-based nutrition policies

1.68-1.86 for capsule distribution and US

A strategic approach to the unfinished fortification agenda: Feasibility, costs, and cost-effectiveness analysis of fortification programs in 48 countries

3.10-4.16 for food production/education. Fortification is the most efficient option if vitamin A levels in sugar are maintained at reasonable levels. Where fortified sugar is not consumed and vitamin A deficiency is highly prevalent, small-scale, targeted, complementary interventions such as capsules and food production education may be appropriate for sustained broader impacts.

Estimating micronutrient intakes from Household Consumption and Expenditures Surveys (HCES): an example from Bangladesh.

Background The dearth of 24-hour recall and observed-weighed food record data—what most nutritionists regard as the gold standard source of food consumption data—has long been an obstacle to evidence-based food and nutrition policy. There have been a steadily growing number of studies using household food acquisition and consumption data from a variety of multipurpose, nationally representative household surveys as a proxy measure to overcome this fundamental information gap. Objective To describe the key characteristics of these increasingly available Household Consumption and Expenditures Surveys (HCES) in order to help familiarize food and nutrition analysts with the strengths and shortcomings of these data and thus encourage their use in low- and middle-income countries; and to identify common shortcomings that can be readily addressed in the near term in a country-by-country approach, as new HCES are fielded, thereby beginning a process of improving the potential of these surveys as sources of useful data for better understanding food- and nutrition-related issues. Methods Common characteristics of key food and nutrition information that is available in HCES and some basic common steps in processing HCES data for food and nutrition analyses are described. Results The common characteristics of these surveys are documented, and their usefulness in addressing major food and nutrition issues, as well as their short-comings, is demonstrated. Conclusions Despite their limitations, the use of HCES data constitutes a generally unexploited opportunity to address the food consumption information gap by using survey data that most countries are already routinely collecting.

Household income and expenditure surveys: a tool for accelerating the development of evidence-based fortification programs.

Background The constrained evidence base of food and nutrition policy-making compromises nutrition programs. Nutrition policy-making must do better than relying exclusively on Food and Agriculture Organization Food Balance Sheets. The strategy of relying on observed-weighed food record or 24-hour recall surveys has not proven practical either; they remain few in number, generally not nationally representative, and of dubious external validity. Although Household Consumption and Expenditures Surveys (HCES) have shortcomings, they are increasingly being used to address this information gap. Objective To promote dialog within the nutrition community, and between it and the greater community of HCES stakeholders, in order to identify their shared agenda and develop a strategy to improve HCES for analyzing food and nutrition issues. Methods The diverse origins and objectives of HCES are described, the evolution of their use in addressing food and nutrition issues is traced, and their shortcomings are identified. Results The causes, relative importance, some potential solutions, and the strategic implications of three distinct categories of shortcomings are discussed. Elements of a possible approach and process for strengthening the surveys are outlined, including identifying best practices, developing guidelines and more rigorously analyzing the tradeoffs involved in common, key survey design and implementation decisions. Conclusions To date, the nutrition communitys role in most HCES has been as a passive user of secondary data. The nutrition community must become more involved in the design, implementation, and analysis of HCES by identifying criteria for prioritizing countries, establishing assessment criteria, applying the criteria in retrospective assessments, identifying key shortcomings, and recommending alternatives to ameliorate the short-comings. Several trends suggest that this is a propitious time for improving the relevance and reliability of HCES.

Indian Social Safety Net Programs as Platforms for Introducing Wheat Flour Fortification: A Case Study of Gujarat, India:

Background Food fortification is a promising strategy for combating micronutrient deficiencies, which plague one-third of the worlds population. Which foods to fortify, with which micronutrients, and in which countries remain essential questions that to date have not been addressed at the global level. Objective To provide a tool for international agencies to identify and organize the next phase of the unfinished global fortification agenda by prioritizing roughly 250 potential interventions in 48 priority countries. By explicitly defining the structure and operations of the fortification interventions in a detailed and transparent manner, and incorporating a substantial amount of country-specific data, the study also provides a potentially useful starting point for policy discussions in each of the 48 countries, which—it is hoped—will help to catalyze the development of public–private partnerships and accelerate the introduction of fortification and reduction of micronutrient deficiencies. Methods Forty-eight high-priority countries were identified, and the feasibility of fortifying vegetable oil and sugar with vitamin A and fortifying wheat flour and maize flour with two alternative multiple micronutrient formulations was assessed. One hundred twenty-two country-, food-, and fortification formulation–specific interventions were assessed to be feasible, and the costs of each intervention were estimated. Assuming a 30% reduction in the micronutrient deficiencies of the persons consuming the food, the number of disability-adjusted life years (DALYs) saved by each of the programs was estimated. Results The cost per DALY saved was calculated for each of the 122 interventions, and the interventions were rank-ordered by cost-effectiveness. It is estimated that the 60 most cost-effective interventions would carry a 10-year price tag of US

A Program Needs-Driven Approach to Selecting Dietary Assessment Methods for Decision-Making in Food Fortification Programs

1 billion and have costs per DALY saved ranging from US

Relative Costs of 24-Hour Recall and Household Consumption and Expenditures Surveys for Nutrition Analysis

1 to US

Managing the vitamin A program portfolio: a case study of Zambia, 2013-2042.

134. The single “best bet” intervention—i.e., the most cost-effective intervention—in each of the 48 countries was identified. Conclusions This study provides a detailed, transparent, evidence-based approach to defining and estimating the costs and cost-effectiveness of the unfinished global fortification agenda in the 48 priority countries. Other considerations in designing a strategic approach to the unfinished global fortification agenda are also discussed.