Optima Nutrition: Maximizing Efficiency of Nutrition Investments in Tajikistan
Preliminary analysis on the allocative efficiency of nutrition investments in Tajikistan reveals the potential impact of Optima Nutrition in optimizing resource allocation for various interventions. The tool aims to enhance the cost-effectiveness and effectiveness of public health investments in nutrition-specific interventions, ultimately improving key nutrition outcomes such as stunting and anemia. By strategically allocating resources across different nutrition activities, Optima Nutrition seeks to achieve optimal health benefits with the available public health budget.
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Nutrition Allocative Efficiency of Nutrition Investments in Tajikistan: A Preliminary Analysis Jakub Kakietek, Mayram Kironova, Farrukh Egamov, Mutriba Latypova .
Presentation Objectives Optima Nutrition presentation of the tool A preliminary application of Optima Nutrition in Tajikistan Discussion and the next steps
Why Optima Nutrition? Estimating the costs Cost effectiveness analyses Benefit-cost analyses Cost per DALY 12 29 216 44 264 43 Intervention Annual Public Sector Cost of Scaling-up Nutrition-specific Interventions (USD million) $1 invested = $22 returns IYCN Vitamin A supplementation Therapeutic Zinc suppl./ORS Micronutrient powders Deworming Iron-folic acid supplementation Iron fortification of staple foods Salt iodization Public provision of complementary food CMAM for SAM $200 153 125 $150 101 79 $100 61 138 46 110 34 85 25 $50 19 64 15 46 31 19 10 15 4 15 0 15 15 15 15 15 15 15 15 3,256 $0 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 169 Current cost Additional costs Total ANNUAL PUBLIC INVESTMENT BENEFITS Cost-effectiveness map: Regions with the lowest cost per case of stunting averted 25% 31% 38% 6% $0.01 Consumables Other inputs Transport Human resources Program cost (.87,1] (.745,.87] (.65,.745] [0,.65] One key question we could not answer: what is the optimal allocation of resources across interventions?
Thinking of Efficiency Technical efficiency maximizing outputs at given cost. Better Nutrition $ Intervention A Different nutrition interventions Allocative efficiency maximizing outputs by allocating resources across different activities Different health programs Different sectors $ 4
What Optima Nutrition Does: For different funding levels, how should resources be allocated across a mix of nutrition interventions and what impact is achievable? Overall public health budget available for nutrition Which investment combination leads to optimal outcomes? $ Balanced energy protein supplementation Multiple micronutrient supplementation Prophylactic Zinc supplements Public food provision Complementary feeding education Breastfeeding promotion Vitamin A supplements for the right peoplein theright placesat theright timein theright ways
How Optima Nutrition Works: 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) Cost Coverage Impact (health, nutrition) Optimization
Optimization: consider just two dimensions Objective function: e.g. number of stunted children Funding to Program B Funding to Program A Apply an optimization algorithm to calculate best resource allocation
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 data Health and nutrition status data Coverage of the interventions included in the analyses Unit cost data Data sources: Government sources (official surveys, data from MoHSP) Supplemental data from partners
Data: Interventions Women Intervention Impact Modern family planning methods Number of births Magnesium supplementation for eclampsia Maternal mortality Magnesium supplementation for pre-eclampsia Maternal mortality Calcium supplementation Maternal mortality Iron supplementation for pregnant women Maternal mortality
Data: Interventions Children Intervention Infant and young child feeding counseling (in health facilities) Micronutrient powder supplementation for children Oral rehydration solution for treatment or diarrhea Oral rehydration solution and zinc for treatment of diarrhea Treatment of severe acute malnutrition (SAM) Child mortality Impact Child mortality, linear growth (HAZ) Child mortality, anemia Child mortality Child mortality Vitamin A supplementation Child mortality, diarrhea incidence
Data: Interventions General Population Intervention Impact Child anemia, WRA anemia, child morality (FA s impact on neural tube defects) Child anemia, WRA anemia, child morality (FA s impact on neural tube defects) Iron and folic acid (IFA) fortification of maize flour Iron and folic acid (IFA) fortification of wheat flour
Data: Intervention Coverage and Cost Intervention Coverage Cost (US$) Modern family planning methods 29% 8.40 Magnesium supplementation for eclampsia 74% 20.70 Magnesium supplementation for pre-eclampsia 74% 20.70 Calcium supplementation 0% 3.58 Iron supplementation for pregnant women 45% 6.38 Infant and young child feeding counseling (in health facilities) 67% 8.00 Micronutrient powder supplementation for children 45% 5.73 Oral rehydration solution for treatment or diarrhea 73% 1.67 Oral rehydration solution and zinc for treatment of diarrhea 15% 2.37 Treatment of severe acute malnutrition (SAP) 25% 135 Vitamin A supplementation 76% 1.31 Iron and folic acid (IFA) fortification of maize flour 0% 0.30 Iron and folic acid (IFA) fortification of wheat flour 0% 0.30
Data: Estimated Current Expenditure Approximated annual expenditure on nutrition-specific interventions USD 50.5 million 60% - treatment of SAM 3 interventions currently not funded (but new fortification regulations just adopted) Intervention Current (USD M) Modern family planning methods 1.27 Magnesium supplementation for eclampsia 4.8 Magnesium supplementation for pre-eclampsia 4.8 Calcium supplementation 0 Iron supplementation for pregnant women 0.83 Infant and young child feeding counseling (in health facilities) 3.65 Micronutrient powder supplementation for children 2.55 Oral rehydration solution for treatment or diarrhea 0.17 Oral rehydration solution and zinc for treatment of diarrhea 0.05 Treatment of severe acute malnutrition (SAP) 31.95 Vitamin A supplementation 0.98 Iron and folic acid (IFA) fortification of maize flour 0 Iron and folic acid (IFA) fortification of wheat flour 0 TOTAL 50.53
Preliminary analyses Analysis question: How to allocate a budget of additional resources, with a possibility of re-allocating current budget, to maximize impact? Additional resources: Additional U$ 10M per year Can 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.
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 allocation Optima 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).
Scenarios - coverage Intervention Current Business as usual Optimized Modern family planning methods 29% 35% 95% Magnesium supplementation for eclampsia 74% 88% 95% Magnesium supplementation for pre-eclampsia 74% 88% 95% Calcium supplementation 0% 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 diarrhea 15% 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%
Scenarios - Impact Outcome Business as usual Optimized funding Optimized funding versus Business as usual Number of alive, non-stunted children turning age 5 726 1,050 45% Prevalence of stunting in children -0.4% -0.7% 66% Prevalence of anaemia in children Prevalence of anaemia in pregnant women -0.6% -3.4% 470% -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.
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 fortification Preventing interventions for children under the age of 5 Caveats: More accurate data on the actual expenditure on nutrition interventions is needed Validation of the coverage data (e.g. is 65% really covered by quality IYCF)? Additional analyses needed at the sub-national level
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
Acknowledgements: The team would like to thank the Optima Working Group chaired Dr. Saida Umarzadova for their support and guidance during the analysis project The 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.
THANK YOU FOR YOUR ATTENTION QUESTIONS?
Minimize the number of stunted children Minimize the number of stunted children Intervention Cost (U$ M) Coverage 0% 20% 40% 60% 80% Calcium supplementation $0 0% Calcium supplementation 0% Family planning $6,165,829 95% Family planning 66% IFA fortification of maize $0 0% IFA fortification of maize 0% IFA fortification of wheat flour IFAS for pregnant women (health facility) $0 0% IFA fortification of wheat flour 0% IFAS for pregnant women (health facility) 0% $827,694 45% IYCF 1 28% IYCF 1 $7,801,383 95% Mg for eclampsia Mg for eclampsia $4,800,104 74% 0% Mg for pre-eclampsia $4,800,104 74% Mg for pre-eclampsia 0% Micronutrient powders $2,546,524 45% Micronutrient powders 0% Oral rehydration salts $170,809 73% Oral rehydration salts 0% Treatment of SAM $31,953,923 25% Treatment of SAM 0% Vitamin A supplementation $1,940,471 95% Vitamin A supplementation 19% Zinc for treatment + ORS $49,809 15% Zinc for treatment + ORS 0%
Minimize number of child deaths Intervention Cost (U$ M) Coverage Minimize the number of deaths -100%-50% 0% 50% 100%150% Calcium supplementation $0 0% Calcium supplementation 0% Family planning $4,264,852 95% Family planning 66% IFA fortification of maize $0 0% IFA fortification of maize 0% IFA fortification of wheat flour IFAS for pregnant women (health facility) $391,413 95% IFA fortification of wheat 95% IFAS for pregnant -45% $0 0% IYCF 1 IYCF 1 28% $5,240,828 95% Mg for eclampsia -74% Mg for eclampsia $0 0% Mg for pre-eclampsia -74% Mg for pre-eclampsia $0 0% Micronutrient powders -45% Micronutrient powders $0 0% Oral rehydration salts 22% Oral rehydration salts $224,699 95% Treatment of SAM 14% Treatment of SAM $49,270,227 39% Vitamin A 19% Vitamin A supplementation $1,349,186 95% Zinc for treatment + ORS 80% Zinc for treatment + ORS $315,447 95%
