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Table 3 Intervention unit costs

From: Ending malnutrition in all its forms requires scaling up proven nutrition interventions and much more: a 129-country analysis

Unit costs

Intervention

Global average

[Between countries: median; IQR and range between countries]

Low income country (LC), lower-middle income country (LMC) and upper-middle income country (UMC) averages

Sources and notes for calculating commodity and human resource cost components. Commodity costs have been marked up to include supply chain costsa. All costs have been inflated to 2017 US$.

Cash transfers (unconditional)

US$351.41

[Between countries: median=US$286.06; IQR=US$103.97-521.91; range=US$23.74-1182.46]

LC average=US$63.22, LMC average=US$230.15, UMC average=US$653.16

Cost per child per annum. Estimated as 10% of per capita GDP.

Delayed umbilical cord clamping

US$2.03

[Between countries: median=US$1.1; IQR=US$0.38-2.79; range=US$0.03-12.85]

LC average=US$0.4, LMC average=US$1.4, UMC average=US$3.6

Cost per birth. Assumes 5 minutes of specific health provider time per caseb and nurses/midwives receive training every 5 yearsc.

Infant and young child feeding education

US$8.12

[Between countries: median=US$6.63; IQR=US$2.49-12; range=US$0.66-27.03]

LC average=US$1.6, LMC average=US$5.4, UMC average=US$15

Cost per child per annum. Country-specific estimates calculated by scaling the cost interval from Shekar et al. investment framework for nutrition [24] according to the range of per capita GDP for the 129 countries. i.e., the lowest cost estimate from Shekar et al. is assumed to be for the country with the lowest GDP per capita, the highest cost estimate for the country with the highest GDP per capita, and cost estimates for each country in between are scaled according to where their GDP per capita falls in the range between the lowest and highest values.

Immediate initiation of breastfeeding

US$21.71

[Between countries: median=US$11.88; IQR=US$3.29-28.26; range=US$0.31-143.79]

LC average=US$3.9, LMC average=US$14.5, UMC average=US$40.1

Cost per preterm birth. Assumes 60 minutes of specific health provider time per preterm birth + and nurses/midwives receive training every 5 yearsc.

Lipid-based nutrition supplements

US$23.71

[Between countries: median=US$23.28; IQR=US$22.58-24.22; range=US$21.46-29.75] LC average=US$25.3, LMC average=US$23.1, UMC average=US$23.3

Cost per annum. Commodity costs (US$10, assuming 1/3 sachets/day for 100 days at US$45 for 150 SQ-LNS sachets of 92g9) + 18 minutes of specific health provider time per annum (assumed to be the same as for micronutrient powders) [74].

Oral rehydration solution + Zinc

US$2.06

[Between countries: median=US$2; IQR=US$1.91-2.16; range=US$1.72-2.69]

LC average=US$2, LMC average=US$1.9, UMC average=US$2.2

Cost per diarrhoea episode. Commodity costs (US$0.77 [74]) + 10 minutes of specific health provider time per case of diarrhoea [74].

Public provision of complementary foods

US$104.48

[Between countries: median=US$94.96; IQR=US$68.46-129.3; range=US$56.78-225.46] LC average=US$62.5, LMC average=US$86.8, UMC average=US$148.4

Cost per child per annum. Country-specific estimates calculated by scaling the cost interval from Shekar et al. investment framework for nutrition (2017) [24] as for IYCF education.

Treatment of SAM

US$246.99

[Between countries: median=US$221.47; IQR=US$187.37-288.85; range=US$86.91-972.69]

LC average=US$185.8, LMC average=US$246.3, UMC average=US$288

Cost per case. Commodity costs (US$44.60 for material costs on averaged, and assuming complicated cases require an average of 14 days, inpatient care was costed according to regional estimates from WHO-CHOICE unit costs of patient services [75]) + 200 minutes of specific health provider time per case of SAM on averaged. All treatment assumptions are based upon Bhutta et al. (2013)12.

Vitamin A supplementation

US$1.36

[Between countries: median=US$1.13; IQR=US$0.57-1.89; range=US$0.33-4.01]

LC average=US$0.5, LMC average=US$1, UMC average=US$2.3

Cost per child per annum. Commodity costs (US$0.10 [74]) + 18 minutes of specific health provider time per annum from the OneHealth tool [74].

Balanced energy-protein supplementation

US$54.01

[Between countries: median=US$49.84; IQR=US$38.23-64.89; range=US$33.11-107.02] LC average=US$35.6, LMC average=US$46.3, UMC average=US$73.3

Cost per pregnancy. Country-specific estimates calculated by scaling the cost range from Shekar et al. investment framework for nutrition [24] as for IYCF education intervention above.

Calcium supplementation

US$42.51

[Between countries: median=US$40.65; IQR=US$39.94-44.62; range=US$39.44-54.75] LC average=US$46.8, LMC average=US$41.9, UMC average=US$40.3

Cost per pregnancy. Commodity costs (US$18.60, assuming 1.5g/day for 6 months15 at US$0.02/0.3g tablet [76]) + 8 minutes total health provider time per pregnancy [74].

Iron and folic acid supplementation for pregnant women

US$13.78

[Between countries: median=US$13.56; IQR=US$13.07-14.17; range=US$12.57-17.44] LC average=US$14.8, LMC average=US$13.5, UMC average=US$13.4

Cost per pregnancy. Commodity costs (US$5.88 [76]) for 1 tablet per day for 6 months + 8 minutes of specific health provider time per pregnancy [74]. Assumes supplied through community health facilities.

Iron and folic acid supplementation for women of reproductive age

US$1.45

[Between countries: median=US$1.31; IQR=US$1.16-1.63; range=US$1.02-2.58]

LC average=US$1.1, LMC average=US$1.3, UMC average=US$1.8

Cost per woman per annum. Commodity costs (US$0.42 [76]) for 1 tablet per week for 3 months + 8 minutes of specific health provider time per pregnancy [74]. Assumes supplied through community health facilities.

Intermittent preventative treatment of malaria during pregnancy

US$0.66

[Between countries: median=US$0.6; IQR=US$0.29-0.96; range=US$0.18-1.54]

LC average=US$0.2, LMC average=US$0.4, UMC average=US$1

Cost per pregnancy. Commodity costs (US$0.06 [74]) + 8 minutes specific health provider time per pregnancy [74].

Intervention only applies to countries with malaria risk.

Multiple micronutrient supplementation

US$19.72

[Between countries: median=US$19.34; IQR=US$18.64-20.45; range=US18.11-25.16]

LC average=US$21.46, LMC average=US$19.33, UMC average=US$18.94

Cost per pregnancy. WHO regional commodity costs (US$5.52-7.21 [10]) + 8 minutes of specific health provider time per pregnancy [74]

Iron and folic acid fortification (wheat, maize or rice)

US$0.37

 

Cost per person per annum. Global estimate for wheat flour from Shekar et al. investment framework for nutrition [24] and Horton (2006) [77].

Iron and iodine fortification of salt

US$0.14

 

Cost per annum. Global estimate from Bhutta et al (2013) [10].

Long-lasting insecticide-treated bed nets

US$4.57

[Between countries: median=US$4.51; IQR=US$4.28-4.73; range=US$4-5.71]

LC average=US$4.9, LMC average=US$4.5, UMC average=US$4.4

Cost per person per annum. Commodity costs (US$5.26/3 years [76]) + 5 minutes personnel time for delivery [10]. Long-lasting insecticide-treated bed nets are assumed to last 3 years, so the purchasing cost is

$13.05 [$12.37, IQR: $12.10-13.82, range: $11.82-16.88]

Intervention only applies to countries with malaria risk.

  1. Abbreviations: DHS Demographic and Health Survey, GDP gross domestic product, IQR inter-quartile range, IYCF infant and young child feeding, LC low income country, LiST Lives Saved Tool, LMC lower-middle income country, MAM moderate acute malnutrition, OR odds ratio, ORS oral rehydration solution, RRR relative risk ratio, SGA small for gestational age, SAM severe acute malnutrition SQ-LNS small quantity lipid nutrient supplement paste, UMC upper-middle income country, WHO-CHOICE World Health Organization CHOosing Interventions that are Cost-Effective
  2. aCountry-specific supply chain costs were estimated similarly to Stenberg and colleagues’ [78], who grouped 73 countries into five categories based on “Logistics System Condition”, and estimated a mark-up percentage to apply to commodities for countries in each group. Additional countries in this study were allocated into the five groups by determining an approximate range of GDP per capita for each group (higher GDP per capita is assumed to be associated with better logistics system conditions)
  3. b Hourly (and per minute) wages for staff time estimated for each country by taking per capita GDP, and dividing by an assumed 48 weeks worked per year, and 38 hours worked per week
  4. cTraining was assumed to cost US$300 per session, with a session educating 10 nurses/midwives every five years. The annual cost per nurse/midwife (US$6) was translated to a per-birth cost by estimating the number of births per nurse/midwife per year: the total number of births1 divided by the estimated number of nurses/midwives in the country2
  5. dAll patients are assumed to receive amoxicillin for 5 days (1.5 x 250mg/day at US$0.02/250mg [76]); 15% of cases are assumed to be complicated, requiring inpatient care and receiving 7 days of F-75 therapeutic milk (700mL/day with approximately 2.5L reconstituted milk per 400g carton at US$61.20 per case of 24 cartons [79]). Furthermore, half of complicated cases are assumed to require an additional 14 days of inpatient care and F-100 therapeutic milk (1.4L/day with approximately 2.1L reconstituted milk per 400g carton at US$70.50 per case of 24 cartons [79]). All uncomplicated cases and half of complicated cases also receive 15kg of RUTF over 8 weeks (US$45 for 150 LNS sachets of approximately 100g [75]). For accounting personnel time, uncomplicated cases plus half of complicated cases are assumed to require 10 minutes/week for 8 weeks, and all complicated cases require 60 minutes/day for an average of 14 days
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