Cost-Effectiveness of Nutrition Interventions in Mozambique

COST-EFFECTIVENESS ANALYSIS OF
NUTRITION INTERVENTIONS IN
MOZAMBIQUE
Leadership in Public Financial Management II

(LPFM II)
November, 2018
This publication was produced by Nathan Associates Inc. for review by the United States Agency
for International Development.
COST-EFFECTIVENESS ANALYSIS OF
NUTRITION INTERVENTIONS IN
MOZAMBIQUE
Leadership in Public Financial Management II
(LPFM II)
DISCLAIMER
This document is made possible by the support of the American people through the United States
Agency for International Development (USAID). Its contents are the sole responsibility of the author
or authors and do not necessarily reflect the views of USAID or the United States government.
III
TABLE OF CONTENTS
Acronyms v
Executive Summary 1
Summary Results for CEA Study for Mozambique 3
Introduction 4
The Need for Improved Nutrition in Mozambique 4
The Objectives and Approach of this CEA study 6
CEA Methodology 1
What is Cost-Effectiveness Analysis? 1
What are Recommended Nutrition Interventions? 1
What Nutrition Interventions Are Included in This Study? 3
What Steps Are Taken in A CEA? 4
The CEA Model 4
Data Collection 5
Costing Estimates 5
CEA Results 7
What Are the Key Considerations and Overall Limitations of this CEA? 7
Key Findings on CEA Program interventions 8
Intervention No. 1. Social + Behavioral Change Communication (SBCC)+ Feeding Practices
in Diarrhea 9
Intervention No. 2. Prevention of Malaria IPTp/ITN for Malaria in Pregnancy 11
Intervention No. 3. WASH – Water Access 13
Intervention No. 4. WASH – Rural Sanitation 15
Intervention No. 5. Micronutrient Supplementation 18
Intervention No. 6. School Feeding Program 20
Intervention No. 7. Increased Availability of Natural Nutritious Food 22
Intervention No. 8. Social Protection 24
Summary of Findings and Recommendations 26
A. All the 8 nutrition programs or interventions are comparable in cost according to
WHO CEA standards 26
B. Optimal combinations of interventions should be developed and costed and there
needs to be better integration across programs 27
C. To ensure sustainability, nutrition programs need to have financing strategies 29
D. There is a need for further capacity building and building of data collection processes
30
Bibliography 32
Annex A: Organizations Consulted 35
IV
Annex B: CEA Data Collection Template 36

Annex C: Sensitivity Analysis For SBCC and IPTp Malaria 36
Annex D: LiST Methodology 38
Annex E: 2016 Global Health Estimates Summary Tables 40
Annex F: Review of Literature and Comparative Findings 41
Annex G: CEA Costing Training (Train the Trainers), Preliminary Results Presentation,
April 2018 43
Annex H: CEA of Nutrition Interventions, December 2017 Presentation 46
Annex I: CEA of Nutrition Interven tions, March 2018 Presentation 53
Annex I: CEA of Nutrition Interven tions, April 2018 Presentation 57
V
ACRONYMS
ADPP Ajuda de Desenvolvimento de Povo para Povo (Development Aid from
People to People)
CEA Cost Effectiveness Analysis
CIP International Potato Center
CLTS Community Lead Total Sanitation
DALY Disability-Adjusted Life Year
EFSP Emergency Food Security Programs
EP Office of Economic Policy
ESAN Estratégia de Segurança Alimentar e Nutricional (National Strategy for
Food Security and Nutrition)
GoM Government of Mozambique
INAS Instituto Nacional da Acção Social (National Institute for Social Action)
IPTp Intermittent preventive treatment in pregnancy
ITN Insecticide Treated Nets
LiST Lives Saved Tool
LPFM II Leadership in Public Financial Management II
MCSP Maternal and Child Survival Program
MISAU Ministério da Saúde (Ministry of Health)
MT Metric ton
NGO Nongovernmental organization
PAMRDC Plano de Acção Multissectorial para a Redução da Desnutrição Crónica
(Multisectoral Action Plan for the Reduction of Chronic Undernutrition
in Mozambique)
PASD Programa de Apoio Social Directo (Direct Social Action Program)
PESA-ASR Plano Estratégico de Água e Saneamento Rural (Strategic Plan for Rural
Water and Sanitation)
PFM Public financial management
PRONAE Projecto de Alimentação Escolar (National School Feeding Programme)
SBCC Social and Behavior Change Communication
SETSAN Secretariado Técnico de Segurança Alimentar e Nutricional (Technical
Secretariat for Food Security and Nutrition)
USAID United States Agency for International Development
USAID/E3 United States Agency for International Development Bureau for
Economic Growth, Education and Environment
USG United States Government
VISTA Viable Sweetpotato Technology in Africa
WFP World Food Programme
1
EXECUTIVE SUMMARY
Mozambique is a low-income developing country facing a high burden of malnutrition
and undernutrition. The level of stunting among children under age five exceeds 40
percent, and other indexes of malnutrition remain at concerning levels. The long-term
impact of undernutrition, especially in children, is severe: it results in low human capital
development, diminished learning ability, low productivity, and high mortality and
morbidity.
There is strong interest among government and other development agencies to reduce
malnutrition and related health issues in Mozambique. However, resources are scarce;
hence, there is an urgent need to find ways to optimize investments on nutrition
interventions. Therefore, USAID Mozambique, in consultation with the government of
Mozambique, decided to commission a cost-effectiveness analysis (CEA) to inform the
government agency SETSAN (Technical Secretariat for Food Security and Nutrition)’s
investment decisions on nutrition interventions. USAID had discussions on the CEAs
with the World Food Program (WFP) team in country in order to complement the
WFP’s Fill the Nutrient GAP analysis to help inform SETSAN multisectoral nutrition
strategy.
This study was prepared by the Duke Center for International Development, with
Nathan Associates, and consists of a CEA for eight selected nutrition interventions.
WFP provided office space for Nathan's consultant at WFP offices for almost all the
duration of this CEA work.
The interventions were analyzed using an economic technique, cost-effectiveness

analysis, which assesses the cost of investments to achieve desired objectives measured
in non-monetary terms. The methodology allows alternative projects to be compared as
approaches to achieve the same desired objectives, such as the reduction of stunting or
reducing disability adjusted life years (see pg. 8 for definition). For each selected
intervention, the results are discussed and compared to regional and international
standards.
Key Findings and Recommendations
In general, the results of these analyses show cost-effectiveness ratios that are
comparable to results for similar programs in other countries in the region and beyond.
In summary:
● The eight selected nutrition interventions are drawn from the many interventions
ongoing in Mozambique. They correspond to interventions listed by organisations
including The Lancet and other global health publications, on the most effective
interventions to combat malnutrition. The selection however was influenced
both by SETSAN/GOM’s areas of interest and the availability of data over the
time in which the assessment could be conducted.
2
● For the interventions analyzed in this report, program/project results show cost-
effectiveness in line with international experience. The actual costs seen for any
particular district obviously will vary, and figures reflect estimates for the whole
of Mozambique based on the costing data available. (The summary results are
presented below.)
● We took a multi perspective approach to attempt to integrate nutrition and

fortification of food programs, social protection programs, and maternal and
child nutrition focused interventions. There are also important links to school
feeding (to maintain any gains in malnutrition reduction) and water-supply and
sanitation.
● Since interventions are determined within a budget constraint, they need to take
account of synergies between them and have well developed financing strategies.
Combinations of interventions must be selected from within a budget constraint,
and decisions on expansion or new interventions must be made with an eye on
where Government’s and implementers start from. At the same time, integration
across programs (e.g., sharing resources) can lead to cost efficiencies beyond
what is seen from measurement of a program alone.
● A systematic collection and sharing of information on interventions is needed, and must

include data on relevant costs, the number of beneficiaries, and real impacts for the
individuals and populations targeted. An agency such as SETSAN requires a full
inventory and dataset for the programs or projects that have a functional
relation to nutrition indexes in Mozambique. Conducting the CEA has meant
gathering data and doing the analysis in a more detailed way for different kinds of
interventions, and finding out many times that the relevant data and information
was not available.
● There is a need to do this type of analysis in country on an ongoing basis. This study is
a first attempt to push the analytical frontier for economic and social analysis for
nutrition interventions in Mozambique. This needs to be done on an ongoing
basis and expanded.
● More human capacity building is required to continue the strengthening of local

capacity to analyze, formulate, and monitor optimal policies for nutrition interventions,
as emphasized in the CEA analysis and training workshops conducted in 2018 in
Maputo. The discussion of relevant international and local experience, the
comparative cost per effect, and the feasibility of choosing and expanding the
best interventions are all shown in presentations found in Annexes G through I.
● SETSAN requires the highest level of support from Mozambique policymakers for both
institutional and process strengthening and for human capital development through
training and hiring. This would support SETSAN’s mandate to coordinate all policy
and implementation efforts for nutrition-related public programs in the country.
Moreover, although data platforms and software access has been provided to
SETSAN by some donors, continued attention and support is required.
● The Nutrition Strategy for Food Security and Nutrition (ESAN III) (to be formulated,
discussed, and presented by the end of November 2018) would be enhanced by the
3
results from this study. Cost-effectiveness ratios will indicate which interventions
are more efficient in achieving malnutrition reduction. The ratios are an input
into the optimization process to achieve the greatest possible results given
financial constraints. The strategy formulation will use packages of interventions
to maximize synergies among interventions.
SUMMARY RESULTS FOR CEA STUDY FOR MOZAMBIQUE
Sensitivity Benchmark based

Analysis (Cost per on Comparisons
DALY Averted) (Cost per Daly
Averted)
Intervention Cost per Min Max Min Max Countries
DALY Comparison
averted
Social + Behavioral $6.61 $5.48 $11.24 $1.00 $10.00 Global
Change
Communication
(SBCC)+ Feeding
Practices in Diarrhea
$88.74 $52.95 $106.49 $40.00 $90.00 Low and
Middle Income
Countries
IPTp/ITN for Malaria in
Pregnancy
$1,320.17 $968.12 $1,452.18 $3,000.00 $4,000.00 Low and
Middle Income
WASH – Water Supply Countries
$75.11 $52.58 $105.16 $11.25 $270.00 Developing
WASH – Sanitation
countries
(CLTS)
Micronutrient $70.32 $41.90 $126.58 $95.00 $236.00 DRC (2015)
Supplementation (i.e., Mali (2015)
Vitamin A, Iron, Folic Nigeria (2014)
Acid, Iodine, Zinc, and Togo (2015)
Micronutrient Powder)
School Feeding $75.49 $47.18 $211.39 $20.00 $34.00 Global
Program
Increased Availability of $10.66 $7.11 $16.08 $15.00 $20.00 Mozambique
Natural Nutritious and Uganda
Foods
Social Protection $250.96 $115.59 $360.41 $383.00 $2,764.00 Pakistan

4
INTRODUCTION
The high incidence and impacts of malnutrition—that is, stunting, wasting, and
malnourishment—represent a serious problem for Mozambique. In fact, the data for the
past decade show that about 40 percent of children under age five are stunted owing to
childhood malnutrition. Given that this country’s population is young and that the
incidence of stunting remains high, the long-term, negative dual impacts of stunting are
staggering because child mortality and life-long disability create welfare losses for both
the household and the economy.
The Government of Mozambique (GOM) and the donor community have a strong
interest in addressing food and nutrition issues and in finding effective ways to reduce
malnutrition. With the high needs due to poverty in the country, and limited resources
from the public sector and donors, development agencies are coordinating to find cost
effective ways to solve these problems and address basic needs.
One approach to assess and compare alternative development interventions or
programs, especially in the social sector, is cost-effectiveness analysis (CEA). This
approach seeks to determine, among alternative options, which intervention (or set of
interventions) can achieve a comparable outcome at a lower cost. This analytical
approach to support strategic decisions for reducing malnutrition has been used in
different parts of the world; however, it has not been effectively developed for
Mozambique.
In late 2017 and part of 2018, LPFM II conducted a CEA for eight nutrition interventions
in Mozambique. This report discusses the approach used, the methodology applied, and
the results of the analysis.
THE NEED FOR IMPROVED NUTRITION IN MOZAMBIQUE
Mozambique is a low-income developing country in Sub-Saharan Africa that has emerged

from a history of violent conflict. Research shows that countries in and emerging from
conflict tend to have lower socioeconomic conditions (FSIN 2017). Data from the
Mozambique nutrition profile points to high levels of child mortality and to child
malnutrition and undernutrition in the country. Vicious cycles of poverty are further
fueled by situations such as famines and food shortages, surges in food prices, and the
resulting protests or riots like those that occurred in Mozambique in the early 2000s.
Indicators of the state of poverty and social needs in the country are shown in Table 1.
The prevalence of undernutrition among young children has remained a serious concern
and has not changed significantly during the last decade (see Table 2).
5
Table 1 – Indicators of Poverty and Social Needs in Mozambique (2016)
Source: World Bank and UNDP country reports

https://data.worldbank.org/country/mozambique
http://hdr.undp.org/sites/default/files/2016_human_development_report.pdf
Table 2 – Nutrition Data for Mozambique, 2003 and 2011
Note: This Nutrition Profile reflects the most recent data available; some data has not been updated since
2011.
6
THE OBJECTIVES AND APPROACH OF THIS CEA STUDY
The goal of this research was to make a positive contribution to strengthening the
formulation of food and nutrition policy and its implementation for programs in
Mozambique. This was achieved through a series of context-specific cost-effectiveness
analyses (CEA) for nutrition interventions, used to inform potential policy options to
improve nutrition outcomes for Mozambique. The results of these CEAs,
complemented with additional analysis (e.g. the Fill the Nutrient Gap study), will be used
to inform the Government of Mozambique’s Multisectoral Action Plan for the Reduction
of Chronic Undernutrition (PAMRDC). The study can also be a building block to
provide some evidence to inform the upcoming National Strategy for Food Security and
Nutrition (ESAN III).
The report “Fill the Nutrient Gap” (FNG) takes a national and local level approach to
explore key nutrition gaps and their social and private costs, as well as the conditions
and effectiveness of possible interventions and options that could make nutritious diets
more available. This includes the supply side of food production and accessibility for the
most vulnerable families in Mozambique. The analysis was developed by WFP with some
support from UNICEF and IFPRI under the coordination of SETSAN and in partnership
with civil society, government, and private sector stakeholders.
In contrast to the broader and larger FNG Study presented by WFP, the CEA Analysis
is more modest and initially targeted just four to six public sector nutrition
interventions. SETSAN is the coordinating authority in the Government of
Mozambique, under the Ministry of Agriculture. SETSAN oversees nutrition
coordination with all relevant government and non-government entities and donors.
In addition to conducting quantitative research by applying the cost-effectiveness model
(detailed in the next section), qualitative research was conducted via field research and
stakeholder collaboration, as follows:
● A combination of three trips to Maputo, Mozambique, were included as part of

the CEA Analysis.
● Meetings and data gathering were conducted with +20 organizations.
● A costing training was conducted during the second in-country visit. Training
included topics such as CEA explanation, costing data scenarios, costing
models/approaches.
● A presentation of preliminary results was made during the third in-country visit.
● A train-the-trainers session was conducted during the third in-country visit.
Training topics included CEA concepts and MS Excel exercises on net present
value (NPV), discount rates, sensitivity analysis, cost-effectiveness ratios (CERs),
stunting cases averted, DALYs, and $/DALY averted.
7
The process for the development of this report is outlined below:
1st In-Country Visit

Identification of
Meetings with Final List of Interventions
Preliminary Initial Data Gathering
Stakeholders / Template by SETSAN
Interventions (Dec-Jan 2017)
for Data Gathering (Feb 2018)
(Nov 2017)
(Dec 2017)
2nd In-Country Visit 3rd In-Country Visit

Meetings with Data Gathering and Data Presentation of Data Gathering and Data
Stakeholders / Validation Preliminary Results/ Validation
Ingredients Cost Training (Mar-Apr 2018) Train-the-Trainers on CEA (May - June 2018)
(Mar 2018) (Apr 2018)
Final Report
(Jun 2018)
COLLABORATING ORGANIZATIONS FOR THIS STUDY
The GOM has set up a specialized national agency, SETSAN (Technical Secretariat for
Food Security and Nutrition), to address the problem of malnutrition. A major concern
for the agency is addressing the trends and levels in undernutrition in the population,
especially among mothers and small children.
This report was the result of a very close collaboration with SETSAN, World Food
Program (WFP), and other development partners, as part of increased efforts to
improve capacity and technical capability for collecting and analyzing nutrition-related
data for monitoring and evaluation of nutrition programs, and for more effective
formulation of nutrition policies.
USAID, through the Office of Economic Policy (EP) and the USAID/Mozambique
mission, is committed to promote evidence-based decision-making, to use policy analysis
approaches, and to strengthen monitoring and evaluation systems to inform project
design to increase the impact of its development work. The aim of USAID in supporting
this study is the generation of analysis that can support policy- and decision-making on
nutrition initiatives to optimize scarce resources and achieve improvements in nutrition
levels in Mozambique.
While EP has a strong record in conducting and promoting the use of cost-benefit
analysis at USAID, cost-effectiveness analysis is a newer addition to their toolkit. Over
the past six years, over 85 cost-benefit analyses have been completed for projects in 30
USAID countries.
Other development agencies working in Mozambique agreed to provide data and other
support in the conduct of the study. The WFP offices in Mozambique and Rome shared
their studies on the cost effectiveness of nutrition interventions. Additionally, with a
funding contribution from USAID/Mozambique, WFP supported a workshop for this
project as well as a two-day training workshop for officials of SETSAN and other
8
relevant agencies on CEA analysis for policy formulation. Other agencies and NGOs
include UNICEF, GAIN, PATH, and the UN FAO. A list of the agencies consulted is
included in Annex A, and workshop presentations are found in Annexes G, H, and I.
1
CEA METHODOLOGY
WHAT IS COST-EFFECTIVENESS ANALYSIS?
Cost-effectiveness analysis (CEA) is an economic tool used for comparing alternative

interventions to determine which intervention can achieve a desired outcome at the
lower cost. CEA is often used to identify improvements to existing programs or to
assess potential new programs. CEA is done by estimating the expected or measured
costs of implementing a project and comparing the cost to an agreed-upon social
outcome.
CEAs are used to model sectors in which the benefits from desired outcomes are not
easily quantified in monetary terms, such as in public health and education, and thus
cannot be easily analyzed with cost-benefit analysis. CEA is uniquely suited to inform
decision-making about which interventions to select, given the simple unit of
comparison (cost per outcome) and ease of understanding by policymakers. For
example, policymakers may ask: What is the least costly way of providing nutrition to
poor children and mothers? Or, what is the least costly way to reduce the incidence of
anemia?
One widely used metric for measuring the impact of nutrition and other health
interventions is the disability-adjusted life year (DALY). The World Health Organization
describes this measure as follows:
“[O]ne DALY can be thought of as one lost year of "healthy" life. The sum of these DALYs
across the population, or the burden of disease, can be thought of as a measurement of the
gap between current health status and an ideal health situation where the entire population
lives to an advanced age, free of disease and disability.”
— World Health Organization
Website, definition of metrics 1
WHAT ARE THE RECOMMENDED NUTRITION INTERVENTIONS?
The literature on the implications of the burden of malnutrition all point to the serious
nature of the problem, given that malnutrition is responsible for almost half of all child
deaths in the world (World Health Organization, 2018). This research also strongly
indicates that the environment and informed caring influence the status of children’s
health and nutrition. Evidence shows that a multi-sectoral approach involving health,
social assistance, and education, among others, is the only way to prevent malnutrition
(Marini et al. 2017). Countries such as Peru followed a multiyear and multi-sectoral
approach to tackling the nutrition problems. There has been much progress in the
1 Ref: http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/
2
world to improve nutrition intake and health in general. As the World Bank (2016)
notes:
In spite of severe economic setbacks, many developing countries have made impressive
progress. More than two-thirds of the people in developing countries now eat iodized
salt, combating the iodine deficiency and anemia that affect about 3.5 billion people,
especially women and children in some 100 nations. About 450 million children a year
now receive vitamin A capsules, tackling the deficiency that causes blindness and
increases child mortality. New ways have been found to promote and support
breastfeeding, and breastfeeding rates are being maintained in many countries and
increased in some. Mass immunization and promotion of oral rehydration to reduce
deaths from diarrhea have also done much to improve nutrition.
— World Bank, 2016
Investing in Nutrition
International experts in the fields of health, food and nutrition, and development studies
have prepared recommendations and several generic estimates of the desirability of
different nutrition interventions. The Lancet, a global health journal, in 2013 listed the
following as the top 10 nutrition interventions in terms of health and nutrition impacts:
● Maternal balanced energy-protein supplements
● Breastfeeding promotion
● Maternal calcium supplements
● Complementary feeding education (food-secure areas) and food (food-insecure
areas)
● Management of moderate-acute malnutrition (MAM)
● Maternal multiple micronutrient supplements
● Therapeutic feeding for severe-acute malnutrition (SAM)
● Universal salt iodization
● Vitamin A for prevention of illness
● Zinc for prevention of diarrhea
Source: Bhutta et al. 2013
Another source of international comparison for most optimal development and health
interventions comes from the results of the Copenhagen Consensus, in which a panel of
international experts (including many Nobel laureates in economics) was asked to find
and justify the best allocation of resources for a total of $75 billion for the world’s most
urgent needs — an allocation that could be disbursed over four years.
The Copenhagen Consensus has prioritized interventions within its budget of $75 billion
over four years. Interventions to reduce undernutrition in preschoolers were identified
as the first priority. Many other projects were also identified; these were linked to the
reduction of malnutrition, the improvement of health indices of children and mothers,
and better agricultural productivity.
The list of projects identified and the dollar amount allocated per year are presented in
Table 3.
3
Table 3 – Interventions Prioritized by Copenhagen Consensus
Amount per
Solution Year (US$
billions)
Bundled Interventions to Reduce Undernutrition in Pre-Schoolers 3
Subsidy for Malaria Combination Treatment 0.3
Expanded Childhood Immunization Coverage 1
Deworming of Schoolchildren 0.3
Expanding Tuberculosis Treatment 1.5
R&D to Increase Yield Enhancements 2
Investing in Effective Early Warning Systems 1
Strengthening Surgical Capacity 3
Hepatitis B Immunization 0.12
Acute Heart Attack Low-Cost Drugs 0.2
Salt Reduction Campaign 1
Geo-Engineering R&D 1
Conditional Cash Transfers for School Attendance* 1
Accelerated HIV Vaccine R&D 0.1
Information Campaign on Benefits From Schooling* 1.34
Borehole and Public Hand Pump Intervention 1.89
TOTAL 18.75
Source: Copenhagen Consensus, 2012
WHAT NUTRITION INTERVENTIONS ARE INCLUDED IN THIS

STUDY?
During discussions with SETSAN and USAID in December 2017 and February 2018, the
highest priority interventions to be included in the CEA analysis were identified and
prioritized. These interventions correspond closely with the ideal set of interventions
outlined in the previous section.
The list of the 16 original interventions of interest, as determined initially by SETSAN, is
shown in Table 4, which represents the final interventions for analysis agreed-upon by
SETSAN and USAID in February 2018.
Table 4 – Original Nutritional Interventions List Defined by SETSAN
No. Intervention Organization

Social + Behavioral Change Communication UNICEF, GAIN, PATH, FAO,
1 (SBCC)+ Feeding practices in diarrhea SETSAN
WASH + Deworming + Zinc therapy for diarrhea
IPTp/ITN for malaria in pregnancy PATH, UNICEF, GAIN,
2 Malaria prophylaxis in children SETSAN
Micronutrient supplementation (i.e. Vitamin A,
3 iron, folic acid, iodine, zinc, MNPs ) UNICEF, GAIN, PATH
4
4 School Feeding Program UNICEF, FAO & WFP

5 Fortification UNICEF, WFP & PATH
6 Increased availability of Natural nutritious foods UNICEF, GAIN, FAO
7 Social Protection UNICEF, SETSAN, PATH
8 Increase agricultural practices PATH, FAO
Prevention of early pregnancy + Nutrition
9 interventions for adolescent girls GAIN, SETSAN
11 Maternal delivery homes WFP
12 General Food Distribution WFP
13 Biofortification FAO
14 Food for asset WFP
Complementary foods (fortified and unfortified)
16 for children 6-23 months SETSAN
In subsequent meetings, this list was narrowed down to eight potential interventions,
based on likely data availability and the time constraints of the analysis. These are shown
in Table 5. Eventually, based on the availability of information on costing, the list was
adapted further to the set of interventions set out in the opening of the Key Findings on
CEA Program Interventions.
Table 5 – Interventions Defined by SETSAN

No. Intervention Organization
Social + Behavioral Change Communication UNICEF, GAIN, PATH, FAO,
1 (SBCC)+ Feeding practices in diarrhea SETSAN
WASH + Deworming + Zinc therapy for diarrhea
IPTp/ITN for malaria in pregnancy PATH, UNICEF, GAIN,
2 Malaria prophylaxis in children SETSAN
Micronutrient supplementation (i.e. Vitamin A,
3 iron, folic acid, iodine, zinc, MNPs ) UNICEF, GAIN, PATH
4 School Feeding Program UNICEF, FAO & WFP
5 Increased availability of Natural nutritious foods UNICEF, GAIN, FAO
6 Social Protection UNICEF, SETSAN, PATH
Prevention of early pregnancy + Nutrition
7 interventions for adolescent girls GAIN, SETSAN
Complementary foods (fortified and unfortified)
8 for children 6-23 months SETSAN
WHAT STEPS ARE TAKEN IN A CEA?
The CEA Model

Cost-effectiveness ratios (CER) are used to summarize complex programs in terms of a
simple ratio of costs to impacts. The sensitivity analysis of key variables for two of the
interventions is included in this model as well (see Annex C). A more detailed model
was developed (using MS Excel) for each intervention to estimate the complete costing
and the key inputs and outputs, as shown here.
5
𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉 𝑜𝑜𝑜𝑜 𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝑖𝑖

𝐶𝐶𝐶𝐶𝑖𝑖 =
𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉 𝑜𝑜𝑜𝑜 𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝐸𝑖𝑖
To obtain the discounted values of costs and effects, an estimated 10 percent real
discount rate (the rate used to discount future flows to the present value -i.e., to
determine the current value of future money) for the calculations was applied. 2
Data Collection
Once the nutrition interventions were selected, data collection had to be undertaken
through discussion with key nutrition item providers. This is a challenge in Mozambique
since, as mentioned earlier, there are neither any organized CEA studies that have been
undertaken, nor a systematic collection of the relevant data by any agency.
A template for data gathering was developed to capture costing estimates and outcomes
for nutrition interventions (see Annex B).
Costing Estimates
For the costing analysis, an ingredient approach was used, as shown in Table 6.
The “ingredients method” is one way of collecting cost data for cost-effectiveness analysis. It
involves specifying and gathering cost and quantity information for all the ingredients
necessary to replicate a program, at a sufficient level of detail, to allow for replicability and
analysis of cost drivers if needed. For more information about this method, see Dhaliwal et al.
(2013).
Table 6 – Ingredients Approach to Cost Estimating
Ingredient Intervention
Program Includes staff hired to work throughout implementation of

administration intervention, costs of facilities, and any overhead costs incurred
Targeting costs Includes any costs incurred to target, identify, and raise awareness
of program among potential participants
Staff training Includes the costs of training staff responsible for implementing the
program
User training Includes any costs incurred to train participants or beneficiaries
2
The discount ra te used ca n ra nge between 2 percent and 10 percent per year. See Splett (1996). For the base case,
a n economic discount rate of 10 percent was used. The s ource for this example was a computation based on the
AFDB Soci o Economic Database, 1960-2019, s hown on the at COMSTAT Da ta Hub webpage, at
http://comstat.comesa.int/wiqcbkg/afdb-socio-economic-database-1960-2019?tsId=1322790.
6
Implementation Includes all costs directly associated with implementation of

costs (direct costs) intervention, such as the cost of items distributed to participants or
of staff who worked solely on implementation activities
Monitoring costs Includes any costs incurred owing to oversight, monitoring, or

tracking program participants and staff
Source: Dhaliwal et al. (2013) and J-PAL (Costing Guidelines)
Various events were organized to ensure stakeholder understanding of the ingredients

costing approach. For instance, an in-person training on costing analysis was conducted
with government entities, implementing agencies, and NGOs to understand data
availability and to begin the collection of data (Annex F).
In addition, in-person meetings with different stakeholders were conducted for data
collection and data validation. During these meetings (held from December 2017 to June
2018), preliminary information was gathered, and data provided by organizations was
reviewed and discussed. This process often involved multiple iterations of reporting by
implementers to ensure comprehensive, accurate data (See Annex B).
Estimation of Outcomes
The Estimated Disability-Adjusted Life Year (DALY) was used to compare outcomes
across all intervention types. This has become the most widely used measure within
health cost-effectiveness analysis, as it can be applied across various health and nutrition
programs for comparative analysis.
To undertake this CEA analysis, estimated values of DALYs by cause, sex, and age were
retrieved from the World Health Organization (WHO). In addition, this CEA used the
LiST (Lives Saved Tool) 3 to estimate the impact of interventions on nutrition outcomes.
The model estimates the impact of scaling up health and nutrition interventions on
stillbirths and on maternal, newborn, and child health. LiST was specially used to model
nutrition outcomes (e.g., stunting). 4 The LiST methodology is explained in Annex D. This
study used validated reference materials as guidance4 in the conversion norms from
inputs to reduction in factors like stunting or DALYs. For each of the interventions, an
intermediate outcome (e.g., reduction in stunting, reduction of anemia, increase in
attendance due to reduced malnutrition) was estimated based on results from similar
interventions elsewhere. These intermediate outcomes were used to calculate a level of
reduction in DALYs for a cross-intervention comparison, using WHO Global Health
Estimates data (for summary tables, see Annex E). 5
3
Li nkages between Li ST a nd other analytic tools allow users to modify va riables including demography, HIV/AIDS
progra mming, a nd fa mily planning determinants. LiST i s part of Spectrum, an integrated s uite of policy modules. For
more i nformation, visit http://livessavedtool.org/.
4
The a ccompanying database for Li ST includes national levels of coverage for health, nutrition, water, sanitation,
a nd hygiene i nterventions; mortality ra tes a nd ca use of death distributions; a nd data on key ri sk fa ctors such as
s tunting, wasting, adverse birth outcomes, disease prevalence, a nd micronutrient deficiencies.
5
The WHO Gl obal Health Estimates provi de a comprehensive and comparable assessment of mortality a nd l oss of
hea lth owing to diseases a nd i njuries for a ll regions of the world. For more i nformation, see s ummary conversion
ta bl es and other global health estimates a nd i nformation on the WHO Health Statistics a nd Information Sys tems
pa ge, at http://www.who.int/healthinfo/global_burden_disease/en/.
7
Intended Results
The goal of this CEA is to determine the cost per DALY averted for each of the
nutrition interventions selected in consultation with SETSAN and development partners.
Economic analysis involves comparing the costs of alternatives or estimating the cost
per unit of program outcome. The cost-effectiveness ratios calculated in this study are
used to assemble a strategy or program, with combinations of interventions. The goal is
to achieve the highest impact at the lowest cost to work within the public sector
budgets (feasibility of the overall program).
WHAT ARE THE KEY CONSIDERATIONS AND OVERALL LIMITATIONS

OF THIS CEA?
There are several limitations and considerations to consider that impact the data
availability and collection under this study, including:
● Sufficiently disaggregated data unavailable for robust CEA. For some
interventions, disaggregated data is not available. For example, for interventions such
as “Prevention of early pregnancy + nutrition interventions for adolescent girls” and
“Complementary foods (fortified and unfortified) for children age 6–23 months” do
not have enough available data to be included in this analysis.
● Data collection is an iterative process that requires time and validation to
refine data quality. Information collected for this study has been provided by few
organizations in Mozambique, after several visits and calls. While this does not
directly limit the application of the findings, the labor intensity of the collection limits
the scope and repetition of this kind of work, without a regular process for data
reporting by agencies/implementers.
● Secondary data was used to complement the analysis since outcome
information is not available for some interventions. This is limited by the
degree to which every program collects outcome information, and as a result
required the use of outcome information from interventions carried out elsewhere
(see Key Findings for information of sources of outcome information for each
intervention).
● Comparison with the cost effectiveness of similar interventions in other
countries should be made with caution because context and characteristics for
each intervention and country are unique. Nevertheless, the comparative discussions
are very useful to gain a better understanding of which interventions are working
better than others. This is a caution for the analysis of outcome information: as
outcome data is not available for many of the interventions in Mozambique,
comparative interventions in other countries have been used to estimate effects.
8
KEY FINDINGS ON CEA PROGRAM

INTERVENTIONS
The cost-effectiveness analysis (CEA) conducted for these eight program interventions
selected by SETSAN is presented in this section. It includes an intervention overview
and a discussion of the cost analysis, the data outcome, and the results of the analysis.
No. Intervention
Social + Behavioral Change Communication (SBCC)+ Feeding

1 Practices in Diarrhea
2 IPTp/ITN for Malaria in Pregnancy
3 WASH – Water Supply
4 WASH – Sanitation
Micronutrient Supplementation (i.e., Vitamin A, Iron, Folic Acid,

5 Iodine, Zinc, and Micronutrient Powders)
6 School Feeding Program
7 Increased Availability of Natural Nutritious Foods
8 Social Protection
9
Intervention No. 1. Social + Behavioral Change Communication (SBCC)+

Feeding Practices in Diarrhea
SBCC intervention in this analysis includes culinary demonstrations and interpersonal

communication sessions primarily on maternal and infant/young child nutrition practices. For
this, the Maternal and Child Survival Program (MCSP) uses the Ministry of Health IYCF (infant
and young child feeding practices) counseling package, which also includes feeding children
during sickness (e.g., diarrhea). 6 7
Cost Data. Information used for this analysis is provided by the MCSP in Mozambique. This
includes data for Sofala and Nampula provinces from October 2015 to March 2018. The present
value of total costs for three years of this project, reaching almost 760,000 beneficiaries, is
$1.445 million.
Outcome Data. The Lancet’s 2008 maternal and child undernutrition series noted that a mix of
both optimal, complementary feeding practices along with other supporting strategies (e.g.
counselling about nutrition, food supplements, conditional cash transfers, or a combination of
these) “in food-insecure households could result in a 17% relative reduction in the prevalence of
stunting at 24 months.” 8 The initial parameter reduction is used as an approximation, as we do
not have experimental results in Mozambique. To take care of other elements, we approximate
the analysis with a range of possible effectiveness from 10% to 20%, to obtain the cost
effectiveness ratios.
Results. Total costs were divided by the DALYs averted results in the average cost-
effectiveness ratio (CER) in $ per DALY averted for the SBCC + Feeding Practices in Diarrhea
intervention. The cost per DALY averted owing to this intervention, is $6.61 placing the SBCC
+ Feeding Practices in Diarrhea among the most cost-effective interventions. According to the
World Health Organization (WHO), interventions that cost below $25 per DALY averted are
categorized as “excellent” (Hornik, Naugle, and Trevors 2015). SBCC intervention in
Mozambique falls into this category.
Key Finding: Based on sub-Saharan African studies using the List Saved Tool
(LiST), the cost of DALY averted by applying SBCC is between $1-$10 (Head
et al. 2015).
This DALY cost includes mass media in the context of the food system to reach
poor rural audiences.
6
MCSP Project i n Mozambique. 2018.
7
MCSP i s a multipartner flagship program supporting USAID’s priority goal of preventing child and maternal deaths.
8
See Section 3.3, “Evi dence of Effective SBCC Approaches to Improve Complementary Feeding Pra ctices,” in
La ms tein et al. (2014).
10
Table 7 – CEA Analysis for SBCC Intervention + Feeding Practices in Diarrhea, Discounting
Rate 10%
Discounting Rate 10%
5% 60% 35%
Year 1 Year 2 Year 3
1. Social + Behavioural Change
Communication (SBCC)+ Feeding Oct 2016- Sept
Outcome practices in diarrhoea Oct 2015-Sept 2016 2017 Oct17-Mar18*
% of stunting reduction 17%
Costs
Program Adm $ 724,266.17 $ 36,213.31 $ 434,559.70 $ 253,493.16
Targeting costs $ - $ - $ - $ -
Staff Training $ 14,700.00 $ 735.00 $ 8,820.00 $ 5,145.00
User Training $ 22,806.98 $ 1,140.35 $ 13,684.19 $ 7,982.44
Implementation costs $ 713,719.52 $ 35,685.98 $ 428,231.71 $ 249,801.83
Monitoring costs $ 157,790.19 $ 7,889.51 $ 94,674.11 $ 55,226.57
TOTAL COSTS $ 1,633,282.86 $ 81,664.14 $ 979,969.72 $ 571,649.00
Number of Beneficiaries 759,351 0 182,004 577,347

Cost Per Unit $2.15
Present Value Costs $1,313,621

Present Value Effect $584,185.88
Stunting Cases Averted 99,312

Cost per Stunting Averted $13.23
Cost per DALY Averted $ 6.61
Sensitivity of Costs/Dalys to Reduction in Stunting

Discount rate
Cost per DALY Averted $ 6.61 4% 6% 8% 10%
% of stunting reduction 10% 10.95 11.05 11.15 11.24
12% 9.13 9.21 9.29 9.37
14% 7.82 7.89 7.96 8.03
16% 6.84 6.91 6.97 7.03
17% 6.44 6.50 6.56 6.61
20% 5.48 5.52 5.57 5.62
11
Intervention No. 2. Prevention of Malaria IPTp/ITN 9 for Malaria in

Pregnancy
Malaria has been the leading cause of death for children under age five in Mozambique.
According to the Mozambique National Institute of Health (INS), deaths caused by malaria
represented 33% in 2009. In some areas, 90 percent of children under this age are infected with
the malaria parasite (Dutta et al. 2014). (IPTp) coverage among pregnant women was just 36
percent in 2012(ibid). Current rates of IPTp coverage in the country remain low; 22.4 percent
of women between ages 15–49 received three or more doses of IPTp during their last
pregnancy (MISAU, INE and ICF International 2015).
Cost Data. Information used for this analysis is provided by MCSP. This includes data for the
provinces in Sofala and Nampula from October 2015 to March 2018. The total costs over a
three-year period is $4 million to cover 241,000 beneficiaries.
Outcome Data. The significant effects of the intermittent preventive treatment for pregnant
women (IPTp) intervention may potentially affect health and nutrition outcomes by reducing the
burden of infectious diseases (Bhutta et al. 2013). According to The Lancet, evidence from a
systematic review of seven randomized controlled trials in developing countries in West Africa,
shows that antimalarial treatments reduced low birthweight by 43 percent (RR 0·57, 95 percent
CI 0·46–0·72) (ibid). Evidence from a study in Bangladesh also shows that the prevalence of
malnutrition was markedly higher in children with low birthweight than those with normal birth-
weights (stunting: 51% versus 39%; wasting: 25% versus 14%; and underweight: 52% versus 33%)
(Rahman et al. 2016).
Results. Analysis shows that after using the estimates for DALY by cause from the third round
of WHO Global Health Estimates (GHE), the cost per DALY averted is $88.74 placing IPTp for
malaria in pregnancy intervention in the “good” category based on WHO thresholds. For this
intervention, the cost per DALY averted falls in the range of interventions for adults costing less
than $100 per DALY averted. The cost per DALY averted for IPTp for Malaria in Pregnancy in
Africa ranges from $40 to $90 (Horton et al. 2017).
It is noteworthy that the intervention used for this analysis included the number of pregnant
women who received IPT2 and IPT4 for malaria under direct observation. Comparison with
other interventions should be made with caution because of the different elements that can be
included in this type of intervention. The cost per DALY averted for one specific intervention in
Africa is $59, which includes a combination of ACT (artemisinin-based combination therapy),
IPTp (intermittent preventive therapy for pregnant women), and ITNs (insecticide-treated nets)
at 95 percent coverage. If IRS (indoor residual spraying) is added, the cost per DALY averted is
$96. Context, coverage, and elements of the intervention are characteristics that makes each
intervention unique.
Key Finding: Using the LiST model, the analysis shows that increasing the
coverage of IPTp from 36 percent to 48 percent, the cases of stunting averted
increase dramatically from 50 percent to 80 percent during a 10-year period
(Figure 1).
9 IPTp: Intermittent Preventive Treatment of malaria in pregnancy; ITN: Insecticide Treated Nets
12
Table 8 – CEA Analysis for IPTp/ITN in Pregnancy, Discounting Rate 10%

5% 60% 35%
Year 1 Year 2 Year 3
2. IPTp/ITN for malaria in
pregnancy Oct 2016- Sept
Outcome Oct 2015-Sept 2016 2017 Oct17-Mar18*
Reduction of Low Birth Weight 43% 0 62,573.17 41,024.15
Reduction of Stunting (%) 12% 0 7,508.78 4,922.90
INGREDIENT COSTS
Program Adm $ 1,279,715.89 $ 63,985.79 $ 767,829.53 $ 447,900.56
Targeting costs $ - $ - $ - $ -
Staff Training $ 15,000.00 $ 750.00 $ 9,000.00 $ 5,250.00
User Training $ 38,011.63 $ 1,900.58 $ 22,806.98 $ 13,304.07
Implementation costs $ 3,366,497.93 $ 168,324.90 $ 2,019,898.76 $ 1,178,274.28
Monitoring costs $ 383,718.84 $ 19,185.94 $ 230,231.31 $ 134,301.59
TOTAL COSTS $ 5,082,944.29 $ 254,147.21 $ 3,049,766.57 $ 1,779,030.50
Number of Beneficiaries (*) 240,924 0 145,519 95,405

Cost Per Unit $21.10

Present Value Effect 191,943
Stunting Cases Averted (PV) 9,904

Cost per Stunting Averted $ 177.49
Cost per DALY Averted $ 88.74
Discount rate
% of stunting reduction 10% 105.89 106.09 106.29 106.49
12% 88.24 88.41 88.58 88.74
14% 75.64 75.78 75.92 76.07
16% 66.18 66.31 66.43 66.56
17% 62.29 62.41 62.53 62.64
20% 52.95 53.05 53.15 53.25
Figure I – Stunting Cases Averted by IPTp (Age 0–59 Months)
IPTp (at 36%

constant)
IPTp (% increase
to 48% coverage
in 2018)
Source: Authors’ projections, using the LiST model.

13
Intervention No. 3. WASH – Water Access
In recent years, the government of Mozambique has significantly reformed its water sector. A
Rural Water Supply and Sanitation Strategic Plan 2006–2015 (PESA-ASR) was launched, which
would enable Mozambique to reach the Millennium Development Goals (MDG) target of 70
percent coverage for rural water supply and 50 percent coverage of rural sanitation at national
level, respectively. 10
Cost Data. Information used for this analysis is provided by UNICEF in Mozambique. This
includes data for the costs of rural water supply provision, hand pumps, borehole drilling,
inspection, and training of water committees. The government will assume costs that include
those for government planning and certification and for UNICEF staffing and monitoring. Costs
and results are based on an EU budget proposal in seven districts. The present value for the
costs of covering 105,000 project beneficiaries is $3.4 million.
Outcome Data. Evidence from WHO shows that a modest reduction in diarrhea (e.g., 11%–16%)
can be achieved by improving basic access to water (WHO 2014).
Results. The cost per DALY averted is $1,320.17, as shown by the analysis in Table 9. This high
ratio is a result of a moderate reduction in diarrhea. The health benefit is limited because these
drinking water sources may be microbially contaminated (ibid.). However, this cost per DALY
averted is still lower than the range of cost per DALY averted for water supply in low-income
countries (about $4,000) (Horton et al. 2017). It is noteworthy that globally, there is still little
evidence on the impact of water supply intervention. Therefore, this analysis should be used
with caution.
Key Finding: Globally, the cost per DALY averted by the provision of urban
and rural water supply is considered one of the least cost-effective
interventions because the costs per DALY averted are above $1,000 (ibid.).
10
Technical and Financial File (TFF) Water Supply a nd Management Contributing to Food Security i n Gaza Province.
(2011).
14
Table 9 – CEA Analysis for Water Supply, Discounting Rate of 10%

Discount rate
Cost per DALY Averted $ 1,320.17 4% 6% 8% 10%
% of diarreal diseases reduction 10% 1,452.18 1,452.18 1,452.18 1,452.18
11% 1,320.17 1,320.17 1,320.17 1,320.17
12% 1,210.15 1,210.15 1,210.15 1,210.15
13% 1,117.06 1,117.06 1,117.06 1,117.06
14% 1,037.27 1,037.27 1,037.27 1,037.27
15% 968.12 968.12 968.12 968.12
15
Intervention No. 4. WASH – Rural Sanitation
The promotion of rural sanitation in this project would involve the community 11 —that is, the
Community Lead Total Sanitation (CLTS) with a private-sector party included in this analysis.
Cost Data. UNICEF in Mozambique provided the information used for this analysis. Costs
included are software; training delivered by UNICEF; planning, and certification by government
and UNICEF staff; and monitoring costs. No hardware costs are included as this is the
responsibility of the community. Cost and results are based on program interventions in eight
districts in the provinces of Tete and Manica for 2017, and results are in accordance with
government reports. The present value of the aforementioned set of costs is $286,000 to cover
140,000 beneficiaries.
Outcome Data. Evidence from WHO shows that a diarrheal reduction of 28 percent could be
achieved by shifting from a baseline of unimproved sanitation to improved sanitation (including
sewer facilities). When sewerage connections are excluded from the analysis, the health gains
are smaller (but still significant), with an expected reduction in disease risk of 16 percent (ibid.).
To calculate CEA for this intervention, a 28 percent of diarrheal reduction is used.
Results. Estimates of DALYs attributable to diarrheal disease were used for this analysis (Troeger
et al. 2017). Analysis for the cost per DALY averted for the Community Lead Total Sanitation
(CLTS) intervention is $75.11 (as shown in Table 10). This finding placed this intervention in the
range of interventions for adults costing less than $100 per DALY averted.
Key Finding: According to 2014 Joint Monitoring Programme data, only 11

percent of the rural population has access to improved sanitation facilities (Prat
et al. 2015). Using LiST model, the CEA analysis shows that increasing the
coverage of improved rural sanitation facilities from 11 percent to the national
goal of 50 percent, the number of stunting cases averted increases by about
150 percent (Figure 2).
11
Rural sanitation refers to the construction of latrines to allow people living i n a newly created open defecation-
free community.
16
Table 10 – CEA for Sanitation Intervention, Discounting Rate of 10%

Discount rate
% of diarreal diseases reduction 20% 105.16 105.16 105.16 105.16
24% 87.63 87.63 87.63 87.63
28% 75.11 75.11 75.11 75.11
32% 65.72 65.72 65.72 65.72
36% 58.42 58.42 58.42 58.42
40% 52.58 52.58 52.58 52.58
In addition, a forecast analysis was performed using LiST model. This additional analysis shows
the positive impact of increasing the coverage of improved rural sanitation facilities — that is,
the use of latrines or toilets — from 11 percent to the national goal of 50 percent. The number
of stunting cases averted increases by about 150 percent by 2030, as shown below in Figure 2.
17
Figure 2 – Improved Sanitation Impact on Stunting
Source: Authors projection using the LiST model

18
Intervention No. 5. Micronutrient Supplementation
The CEA analysis of the Micronutrient Supplementation intervention includes efforts to support
(1) supplementation with Vitamin A and iron-folic acid and (2) point-of-use fortification with
micronutrient powders. The beneficiaries of this intervention are pregnant women who
received 90 iron-folic acid supplements.
Cost Data. Information used for this analysis is provided by the MCSP in Mozambique. This
includes data for the provinces in Sofala and Nampula from October 2015 to March 2018. The
present value of costs for three years of service is $682,000 to cover 170,000 beneficiaries.
Outcome Data. Evidence from a study in Vietnam and similar programs elsewhere shows that
supplementation with iron-folic acid contributes to an 18-percent reduction in the prevalence of
anemia in treated women (Casey et al. 2017). Additionally, evidence shows that the cost per
DALY using folic acid fortification is $14.90 (Hoddinott 2018).
Results. DALY estimate for iron–folic acid supplementation is calculated for DALYs averted
among pregnant women.
Key Finding: The cost per DALY averted as a result of this intervention is
$70.32, placing iron-folic acid supplementation in the “good” category based on
WHO thresholds.
Table 11 – CEA for Iron-Folic Acid Supplementation, Discounting Rate of !0%

19

Discount rate
% of anemia reduction 10% 125.69 125.99 126.28 126.58
14% 89.78 89.99 90.20 90.41
18% 69.83 69.99 70.16 70.32
22% 57.13 57.27 57.40 57.54
26% 48.34 48.46 48.57 48.68
30% 41.90 42.00 42.09 42.19
20
Intervention No. 6. School Feeding Program
The 2012–2016 Food for Education project, in Mozambique, is a comprehensive school-feeding

project with child health, nutrition education, water and sanitation components, complemented
by a major teacher-training program component. 12 The project was implemented in the four
districts of Maputo Province (Moamba, Magude, Manhiça, and Matutuine) through a daily meal;
the development of school gardens; the provision of a safe, adequate school water supply; and
the implementation of a deworming campaign. The project was implemented by Planet Aid
International and its local partner Ajuda de Desenvolvimento de Povo para o Povo (ADPP), in
partnership with the World Initiative for Soy in Human Health program (WISHH) of the
American Soybean Association. The number of daily school meals (breakfast, snack, lunch)
provided to school-age children as a result of this program was 33,365,663. Moreover, the
number of school-age children receiving daily school meals (breakfast, snack, lunch) as a result of
this program was 209,752.
Cost Data. Information used for this analysis is provided by ADPP for the school feeding program
Food for Knowledge. Cost data includes the provision of school meals and administrative costs.
The present value of the costs to cover 210,000 beneficiaries in Mozambique over five years
provision was $2,215,000.
Evidence from other school feeding programs shows that the cost range for such programs is
from $28 per child/year to $63 per child/year (Galloway 2009).
Source: Galloway. 2009.

Outcome Data. Based on the data provided by ADPP, attendance increased from year to year,
beginning at project implementation. The total increase in regular attendance between 2013 and
2015 was 23.8 percent (29 percent for boys and 18.6 percent for girls).
Evidence from six school feeding programs show that the costs of school feeding are higher than
the costs of deworming, iron supplementation, and malaria prevention (less than $4 per
child/year). This may mean that the cost per outcome for these other school health and
nutrition interventions are lower (ibid.). According to Galloway, the cost for an extra day of
attendance in Gambia, Kenya, Lesotho, and Malawi was less than $10 per student (ibid.).
Galloway also mentions that the cost per extra kilogram of weight ranged from US$38 to
US$252 (ibid).
Results. The cost per DALY averted as a result of this intervention is $75.49.
Key Finding: Student enrollment increased 9 percent in target schools as a

result of the implementation of the school feeding program Food for
Knowledge.
12
ADPP. School Feeding Program Food for Knowledge. Final Eva luation Report
21
Table 12 – CEA for School Feeding Program, Discounting Rate of 10%

Year 1 Year 2 Year 3 Year 4 Year 5
Outcome 4. School Feeding FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Effectiveness 0.25
Costs
Provision of School Meals $ 2,275,163 $ 517,830 $ 726,538 $ 481,633 $ 473,340 $ 75,822
Sub-Total $ 2,275,163 $ 517,830 $ 726,538 $ 481,633 $ 473,340 $ 75,822
Administrative Costs
Prof Services $ 536,484 $ 5,124 $ 111,823 $ 237,772 $ (148,475) $ 330,240
Office - US HQ $ 141,331 $ 29,204 $ 35,769 $ 36,157 $ (1,895) $ 42,096
Travel $ 41,123 $ 11,932 $ 5,283 $ - $ 2,620 $ 21,288
Benefits $ 18,370 $ 2,578 $ 6,990 $ 5,222 $ 2,251 $ 1,329
Salaries $ 524,757 $ 152,115 $ 125,671 $ 112,725 $ 109,946 $ 24,300
Administration ICR $ 114,838 $ 19,291 $ 27,411 $ 37,620 $ 5,325 $ 25,191
Sub-Total $ 1,376,903 $ 220,244 $ 312,947 $ 429,496 $ (30,228) $ 444,444
TOTAL COSTS $ 3,652,066 $ 738,074 $ 1,039,485 $ 911,129 $ 443,112 $ 520,266
Number of Beneficiaries (*) 209,752 24,342 37,070 69,114 79,226 79,226

Cost Per Unit $17.41

Present Value Beneficiaries $207,997
Costs/Unit/Year 10.65
Cost/malnutrition averted $46.29
Number of DALYs 334,000
Cost per DALY Averted 75.49
(*) Number of school-aged children receiving daily school meals (breakfast, snack, lunch) as a result of USDA assistance
Sensitivity of Costs/Dalys to Effectiveness and Dureation of School Feeding Programs

Discount rate
% of stunting reduction 10% 211 203 196 189
15% 141 136 131 126
20% 106 102 98 94
25% 85 81 78 75
30% 70 68 65 63
35% 60 58 56 54
40% 53 51 49 47
22
Intervention No. 7. Increased Availability of Natural Nutritious Food
Viable Sweet Potato Technology in Africa (VISTA) is a three-year project launched by the
International Potato Center, an organization that aims to contribute to improved nutrition, food
security, and incomes among smallholder farming families. This is accomplished through
increased production and expanded consumption of nutritious orange-fleshed sweet potato
(OFSP) varieties, especially by those most at risk of vitamin A deficiency: children under the age
of five and pregnant and lactating women (Zano 2015). The project is implemented in the
provinces of Zambezia (Gurué and High Molocué) and Nampula (Meconta, Monapo, Murrupula,
and Nampula-Rapale).
Cost Data. Information used for this analysis of the VISTA project is provided by the
International Potato Center. Cost data includes program and administrative costs. The present
value of total costs is $11 million, covering 1,890,000 beneficiaries.
Outcome Data. Evidence from a community-level intervention in a very resource-poor area of
Mozambique (e.g., the Towards Sustainable Nutrition Improvement Project) shows that a 15-
percent decline in the prevalence of vitamin A deficiency was attributable to an integrated
agriculture intervention that included the introduction of OFSP (Low et al. 2007). Evidence from
other OFSP studies show that average costs per target beneficiary were $86/household in
Mozambique and $56/household in Uganda.
Results. The cost per DALY averted owing to this intervention is $10.66.
Key Finding: Evidence from other OFSPs shows that in terms of vitamin A
benefit, interventions in Africa cost $15–$20 per disability-adjusted life years
(DALYs) saved (HarvestPlus 2012). The VISTA project cost per DALY is below
this range, placing this intervention among the most cost-effective
interventions.
23
Table 13 – CEA for Increased Availability of Natural Nutritious Food, Discounting Rate of
10%
Year 1 Year 2
5. Increased Availability of Natural Phase II (Sep 2016-
Outcome Nutritious Food Phase I (2014-2016) 2021)
Reduction of Vitamin A Deficiency 52,877.25 230,625.00
Percent 15%
INGREDIENT COSTS
Program Adm $ 7,834,858.00 $ 817,994.00 $ 7,016,864.00
Targeting costs $ 169,817.22 $ 76,700.00 $ 93,117.22
Staff Training $ 157,385.97 $ 55,155.00 $ 102,230.97
User Training $ 186,872.48 $ 54,250.00 $ 132,622.48
Implementation costs $ 3,397,266.77 $ 108,689.00 $ 3,288,577.77
Monitoring costs $ 503,800.00 $ 96,325.00 $ 407,475.00
TOTAL COSTS $ 12,250,000.43 $ 1,209,113.00 $ 11,040,887.43
Number of Beneficiaries (*) 1,890,015 352,515 1,537,500

Cost Per Unit $6.48

Costs/Unit 42.84
Cost per DALY Averted $10.66
Discount rate
Cost per DALY Averted $10.66 4% 6% 8% 10%
% of anemia reduction 10.0% 16.08 16.05 16.02 16.00
12.5% 12.86 12.84 12.82 12.80
15.0% 10.72 10.70 10.68 10.66
17.5% 9.19 9.17 9.16 9.14
20.0% 8.04 8.03 8.01 8.00
22.5% 7.15 7.13 7.12 7.11
24
Intervention No. 8. Social Protection
The government of Mozambique established the National Institute of Social Action (INAS),
which implements programs aimed at people in need and living in situations of vulnerability.
Among INAS interventions, they operate Basic Social Protection Programs, the Basic Social
Subsidy (PSSB), Social Support Direct (PASD), Social Services of Social Action (PSSAS), and
Productive Social Action (PASP).
● Basic Social Subsidy (PSSB). Consists of monthly monetary transfer, directed on a regular
and indefinite basis to groups of family households headed by individuals incapacitated
for work. Inability can come from old age, chronic illness and/or disability.
● Social Support Direct (PASD). Based on the transfer of benefits in kind and/or payment for
services that are designed to deal with situations of shocks that aggravate the degree of
vulnerability of needy PAs. This program is subdivided as follows:
− PASD-A (Prolonged Support). Provides a basic food kit for poor households whose
members are acutely malnourished and for families headed by children and / or
members of working age temporarily to work.
− PASD-B (Substitute for Breast Milk). Supplies breast milk replacement kit for
children (1) under 24 months living in vulnerable families due to the death of the
mother and (2) needing breast milk.
− PASD-C (Point Support). Provides in-kind cash grants of a different nature to
vulnerable households or individuals facing shock situations that aggravate their
vulnerability.
● Social Services of Social Action (PSSAS). Ensures the guarantee of institutional care in
nurseries, old age support centers, open centers, and transit centers. This program is
responsible for providing the guidance and family reunification of the most vulnerable
and disadvantaged groups who have lost or are marginalized by their families.
● Productive Social Action (PASP). Consists of supporting groups of households in poverty,
with at least one member of working age and capable of working. This component is
included in the provision of public services, in exchange for the monthly monetary
allocation.
Cost Data. Information used for this analysis was obtained from the annual reports provided by
the National Institute of Social Action (INAS).
Outcome Data. Evidence from studies from Africa countries show that the cost per DALY
averted through the implementation of food baskets and cash transfers range from $181 to
$504. 13
Results. A Gross National Income (GNI) per capita function was used for the calculation of the
DALYs (Sterck et al., 2018). They looked at the relationship between DALYs due to non-
communicable diseases and GNI, and found a non-linear, natural logarithmic, relationship (with
R2 equal to 0.48). This function was used to get the DALYs averted 14 . The analysis shows that
the Cost per DALY averted is $250.96 which falls in the range of the studies conducted in
Africa.
A multi-sectoral perspective on food assistance and cash transfers for nutrition in the context of
cost effectiveness to reduce DALYs (within health sector programs in Tanzania, Zambia Ethiopia
13
Remme. 2017. Social Protection and Cost-Effectiveness.
25
and South Africa), shows an average for the 5 countries of $337/DALY 15 averted, with a range
of values of $181 to $504 16 . These are examples of the ranges of values that can be obtained
empirically, which will need further study to obtain more precise estimates of CE parameters
and results.
Key Finding: Cost per DALY averted for social protection in this analysis is
very sensitive in relation to the effectiveness of the program. If the
effectiveness of the program increase is 20 percent, the cost per DALY
averted decrease from $250.96 to $209.14 (Table 15).
Table 14 – CEA for Social Protection, Discounting Rate of 10%
Table 15 – Sensitivity Analysis of Costs/DALYs to Stunting Reduction, Discounting Rates 4%

- 10%
15 Remme, Michelle, Melisa Martinez-Alvarez, Anna Vassall. Cost-Effectiveness Threshold s in Global

Health: Taking a Multisectoral Perspective. Value in Health 20. 2017
16 Remme, Michelle. Are cash and food transfers cost-effective HIV strategies?. Abidjan, December 2017
26
SUMMARY OF FINDINGS AND

RECOMMENDATIONS
The use of Cost-Effectiveness Analysis can be very useful to policy makers and donors
who design, fund, and manage nutrition programs and projects in Mozambique. The
country has a very limited budget (the total health budget for Mozambique amounts to
approximately $800 million) to address a high incidence of stunting and malnutrition
among children in its population of about 28 million people. Efficient programing and
allocation of resources, therefore, is required to achieve optimal returns measured in
the reduction of malnutrition and/or equivalents in lives saved.
Below are the four main findings from our research and the CEA studies we undertook
from end 2017 to April 2018.
A. Many of the 8 nutrition programs or interventions are comparable in

cost according to WHO CEA standards
Among the 8 nutrition intervention programs we studied, there are marked differences
in terms of cost effectiveness, yet most of the 8 interventions included in this study have
a cost per DALY averted of below $100. According to the World Health Organization,
interventions that cost below $100 per DALY averted are good and those that cost
below $25 are excellent.
Among the projects, those ranking among the most cost-effective interventions in this
study are the following: (1) Social + Behavioral Change Communication (SBCC) +
Feeding Practices in Diarrhea, and (7) Increased Availability of Natural Nutritious Foods.
In general, the results of these CEAs show ratios comparable to results reported in
several other studies.
Table 16 – Cost per DALY Averted for Mozambique Interventions (in $)
No. Intervention Cost per DALY

Averted
($)
Social + Behavioral Change Communication $6.61

1 (SBCC)+ Feeding Practices in Diarrhea
2 IPTp/ITN for Malaria in Pregnancy $88.74
3 WASH – Water Supply $1,320.17
4 WASH – Sanitation (CLTS) $75.11

27
Micronutrient Supplementation (i.e., Vitamin A, $70.32

Iron, Folic Acid, Iodine, Zinc, and Micronutrient
5 Powder)
6 School Feeding Program $75.49
7 Increased Availability of Natural Nutritious Foods $10.66
8 Social Protection $250.96
Overall, for the programs that reported data in Mozambique, the results are showing a
comparable performance based on WHO thresholds.
What the analysis also shows is that there are effective programs that can be
undertaken or expanded with relative low cost outlays and yet have significant impacts.
This should be of interest to the policy makers and donors as these interventions can be
initiated or expanded relatively soon.
B. Optimal combinations of interventions should be developed and

costed and there needs to be better integration across programs
1) Combinations of interventions must be selected from within a budget

constraint, and decisions on expansion/new interventions, must be
made with an eye on where Governments and implementers start
from.
Governments must select from different packages of interventions, and it is worth
noting that interventions starting from nothing are likely to have differing cost-
effectiveness ratios to those representing an expansion of activity.
For example, in the below diagram (Figure 3) we can see that the cost effectiveness
ratio of a2 is 25.45. However, the cost effectiveness ratio of moving from a1 to a2 is
lower (i.e. (140-120)/(5.5-1) and comes to 4.4. This would make an expansion of the
intervention from a1 to a2 more cost effective than new investment in b1. However it is
worth noting it is only more incrementally cost effective because the investment in a1
has occurred/is occurring, and may not be the most cost effective path (which would in
fact be c). So potentially a government which moved from a budget constraint of 120 to
220 could use this analysis to inform where to direct that extra 100 in resources, and
ultimately decide to expand a1 to a2, and invest in c1 as well; rather than an investment
in b1.
28
Figure 3 – Costs and benefits of three sets of mutually exclusive interventions
200 Interventio Cost Benefit Cost

a3 a4 n s s Effectiveness
180
c4 a1 120 1 120
160
b3 a2 140 5.5 25.45
140 a2
a3 170 3 56.67
120 a1 b1 b2 c3
100 a4 190 7 27.14
Costs
80 b1 100 12 8.33
c2
60 b2 120 17 7.06
c1
40 b3 150 20 7.5
20
c1 50 22 2.27
0
c2 70 24.5 2.86
0 10 20 30 40
c3 120 29 4.14
Health Outcomes c4 170 31 5.48
(Source: WHO Manuals)
Note: The graph above has two dimensions. On the horizontal, we measure nutrition impacts (such as
reduction of stunting), in the vertical axis we measure costs or resources. Each dot represents one
possible intervention, within groups of mutually exclusive interventions, with c1 for example representing
a CE Ratio of 50/22 or 2.3/unit of reduction in stunting. Along the “package C” or across packages, we
would build a potential strategy that needs to be optimized and compared with other efficient alternatives.
The lines on the diagram above show the cost effectiveness of each intervention. The slope of the lines
between the interventions and the origin (e.g 0 to b2) represent the average cost-effectiveness; the lines
between interventions (e.g. a2 to a4) represent the incremental cost-effectiveness.
When observing the CE ratios in Figure 3, we can see that the slope of the rays for the
more cost-effective interventions would be flatter. In our own analysis interventions
like Intervention 7 (Increased Availability of Natural Nutritious Food) and Intervention 1
(Social + Behavioral Change Communication (SBCC) + Feeding Practices in Diarrhea)
would follow this pattern. On the graph, these interventions would be associated with
the “C” type of interventions (“C” means here a flatter slope, as the nutrition impact is
large on the horizontal axis compared to the cost on the vertical axis). However, we are
only analyzing at one point in time, for one scale of the intervention.
The steeper rays, however, are representing interventions where fixed costs are higher
such as for water supply and for some forms of social protection. These interventions
would be associated more with the “A” type of interventions (“A” means here a steeper
or more pronounced slope, as the nutrition impact is modest on the horizontal axis
compared to the high cost on the vertical axis).
At the national level, SETSAN, in coordination with other agencies, can help develop a
nutrition strategy that optimizes nutrition impact within given resources or budget
limits.
2) Integration across programs can allow for cost savings and greater
cost-effectiveness
29
While some interventions may be cost effective alone, if they are combined with others
that are perhaps less cost effective alone, the resulting combination could have even
more significant long-term nutrition and health impacts. These synergies, and shared
costs, must be researched further with the health and nutrition specialists working
closely with their economist counterparts.
Effective strategies could build more constituents for complementary programs. Some
interventions are already established and have a constituency — for example, some cash
transfer programs or school feeding programs (often, these are in the midrange of cost
effectiveness). However, the coverage of other nutrition interventions can be limited, as
the Fill the Nutrient Gap Analysis study also shows (for further discussion, see the Fill
the Nutrient Gap and CEA Analyses section). If synergies can develop (for example,
geographically based, even if they cut across programs) these should be explored, and
can enable the expansion of one program type building off the investment in another.
More detailed cost effectiveness analysis needs to be done jointly with deeper
nutritional/health analysis and administrative capacity on these kinds of combinations.
C. To ensure sustainability, nutrition programs need to have financing

strategies
To achieve more effect outcomes and maximize benefits, a range of financing sources
should be utilized, including Government (both own revenues and borrowed funds),
private, donor, and charity. The improve of health outcomes can and should be
considered an investment into human capital; and as a result even financing through
lending should be considered. Additionally, consideration on the level of Government
(e.g. national or local) to provide the financing must be a key part of the discussion
alongside analysis of the financial controls at the selected levels to ensure funds reach
the intended recipient.
Deep discussion on this area is beyond the scope of this paper, but work has been done
by Action Contre la Faim as part of their “Aid for Nutrition” series, highlighting some
potential innovative financing methods from donors (Emerging Financing Mechanisms:
Where is the value for nutrition, 2017 17 ).
In order to highlight the scale of need, we looked at the potential funding requirements
for two key programs. The estimates below show the cost to achieve full coverage:
School Feeding Programs:

CE Ratio: 75.49 $/DALY
Scale Up Funding Requirement: $41.5 million/year
The current coverage in the reported program is 209,752 school age children. The cost
per child/year is $17.41. According to UN population statistics, there are between 6 and
7 million school age children in Mozambique. If targeting about 40 percent of these
considered at risk of not meeting nutrition levels, then there would be about 2.6 million
17Ref: https://www.actioncontrelafaim.org/wp-
content/uploads/2017/09/emergingfinancingmechanismsfornutition_V2.pdf
30
children to cover, of which a fraction is being currently covered. To close the gap (scale
up), we would need about $41.5 million, calculated at $(2,600,000-209,752) * 17.41.
This example shows how much more resources would be needed to achieve a full
coverage of the children in need (almost perfect targeting).
Preventive Treatment of Malaria for Pregnant Women:
CE Ratio: 88.74$/DALY
Scale Up Funding Requirement: $20.7 million/year
The current coverage in the reported program is about 120,000 women per year. From
UN population statistics and given the birth rates, about 1.1 million women are
estimated as being currently pregnant. The cost per expectant mother/year is $21.10. If
the aim were to expand a similar treatment to all mothers, the additional resources,
using a linear extrapolation, would be $20.7 million, calculated at $(1,100,000 – 120,000)
* 21.10. Again, this is an example of how much more resources would be needed to
achieve full coverage of expectant mothers (almost perfect targeting).
Total resources to prevent stunting:

Funding Requirement: $500 million/year
The Fill the Nutrient Gap Analysis Report of 2018 reports that about 2 million children
are affected by chronic malnutrition. Using a conservative estimate that we would be
able to spend $250 per child, the amount needed for this purpose would be about $500
million/year.
The WHO Data on “Estimated DALYs ('000) by cause, sex and WHO Member State
(1), 2015” includes a total DALY impact from Diarrhea and Nutrition Deficiency of
(DALYs/1,000 beneficiaries: 1,232 for diarrhea, 1,478 for malaria, and 596 for
malnutrition) adds up to 3,306 DALYs for Mozambique. Also, it is known that a
combined package of interventions would cost on average $150/DALY averted. With
the goal of reducing the DALYs from these causes to almost zero, the implied costs
would be 3,306*150*1000 = $496 million, in the same order of magnitude of the
previous calculation.
D. There is a need for further capacity building and building of data

collection processes
During the preparation and presentations of this study, some workshops for capacity
building purposes were delivered. GOM and SETSAN need to have a systematic
approach to determining skill needs, to support recruiting efforts, and offering training
to existing staff. Being part of the Scaling Up Nutrition (SUN) coalition allows
Mozambique to tap international resources for this purpose.
In addition to individual capacity building efforts and certification, a systematic review of
the institutional processes of coordination for the formulation and implementation of
nutrition strategies and programs needs to be strengthened in the short term.
31
32
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35
ANNEX A: ORGANIZATIONS
CONSULTED
The organizations listed below were consulted, provided information for this study, or attended
meetings and trainings related to the CEA in Mozambique.
No. Organization Name No. Organization Name
15 National Directorate of Water Supply and

1 ADPP
Sanitation
2 DFID 16 National Institute of Social Action (INAS)
3 European Union 17 National Institute of Statistics (INE)
4 GAIN 18 Netherlands, Embassy of
5 IDEPA 19 PATH
6 International Potato Center 20 Save the Children
7 JAM 21 SETSAN
Japan International 22 UNFP

8 Cooperation Agency (JICA)
9 MASA 23 UNICEF
10 Ministry of Health (MISAU) 24 Universidad Eduardo Mondlane (Maputo)
Ministry of Industry and 25 USAID

11 Commerce (MIC)
Ministry of Science and 26 Water Aid

Technology and Higher
12 Education (ISCIZA)
Ministry of Youth and Sports 27 World Bank

13 (MJD)
14 MMR 28 World Food Programme (WFP)

36
ANNEX B: CEA DATA

COLLECTION TEMPLATE
ANNEX C: SENSITIVITY ANALYSIS

FOR SBCC AND IPTP MALARIA
37
38
ANNEX D: LIST METHODOLOGY

The LiST module produces estimates of global health impact by modeling outcomes such as:
• Neonatal and child mortality
• Maternal mortality
• Stillbirths
• Birth outcomes (preterm, small-for-gestational-age, low birth weight)
• Nutrition outcomes (stunting, wasting, anemia)
The framework of LiST is based upon:
• Demography details, either read directly from demographic projections produced by the
United Nations Population Division or derived from national or subnational demographic
estimates
• Cause of death information for neonates, children under five, mothers, and stillbirths, from
country-specific WHO profiles or estimated by using local data sources
• Coverage levels for a variety of key health interventions that affect child and maternal mortality
• Health status indicators for a national or subnational setting
• Effectiveness estimates for neonatal, child, and maternal interventions from the latest scientific
reviews and literature
Impact is calculated based on: •
• Change in coverage
• Effectiveness of the intervention
• Affected fraction
DATA SOURCES:
COUNTRY SPECIFIC DATA GLOBAL DATA
Population data and trends Intervention effectiveness data
• Default: UN Population Division • Default: Systematic reviews,
1950- 2050 (DemProj) metaanalyses, Delphi estimation,
• User-entered data RCTs
• User-entered data
Cause of death structure
• Default: WHO/UNICEF/CHERG
(2015)
Intervention coverage
• Default: DHS/MICS/JMP/WHO-
UNICEF
Mortality rates
• Default: IGME -
www.childmortality.org
39
LiST Stunting Baseline:
LiST Coverage Set-Up:
LiST Projection:
40
ANNEX E: 2016 GLOBAL HEALTH

ESTIMATES SUMMARY TABLES
Mozambique Estimated
Cause for Intervention DALYs (in 000s)
DALYs DALY
All Ages s DALYs
Ages Ages
0-4 5-14
Nutritional deficiencies
596.4 262.8 165.3
1 Protein-energy malnutrition 190.3 118.6 51.5
2 Iodine deficiency 16.7 1.1 4.0
3 Vitamin A deficiency 1.0 0.2 0.3
4 Iron-deficiency anaemia 383.9 141.3 108.6
5 Other nutritional deficiencies 4.5 1.6 0.9
Infectious and parasitic diseases
7,600.2 2,857.9 1,212.0
1 HIV/AIDS 2,606.0 383.1 238.1
2 Diarrhoeal diseases 1,232.1 662.0 233.9
Source: http://www.who.int/healthinfo/global_burden_disease/en/
41
ANNEX F: REVIEW OF LITERATURE AND COMPARATIVE

FINDINGS
This table summarizes some core studies/publication reviewed and presented during stakeholder meetings and trainings. These studies were also used to
compare some of the outcomes and results in the CEA Analysis.
Review Topic Short Title Review Topic
Nutrition Specific - Cost and benefits of investing Global School Feeding - School feeding costs
Interventions in DRC, in 10 packages of Lancet Sourcebook - Lessons from 14 countries
Mali, Nigeria, Togo interventions
(2014) - DALYs comparison in Africa
- Cost per stunting case averted
in Africa
- Cost-effectiveness comparison
Estratégia Nacional de - Social protection programs World Bank (2017). - Critical success factors in
Segurança Social - Coverage Standing Tall (Peru) overcoming
Básica (ENSSB) (2016- stunting crisis
2024) - Smarter policies: focus on
evidence, incentives, and
results
42
Plano Estratégico do - Health costs World Health - Cost-effectiveness

Sector Saúde (2014– - Intervention coverage Organization. CHOICE - DALY
2019) - Nutrition program costs - Thresholds by Africa region
J-PAL Costing - Guidance for gathering costs World Health - DALYs by cause in
Guidelines - Ingredients approach Organization. Global Mozambique
Health Estimates (GHE). - Cost per DALY averted
(2015)
The Lancet (2013) - Cost analysis - World Health - Cost-benefit analysis –

Evidence-based - Effect of packages of Organization. (2003). methods
interventions interventions WHO Guide to Cost- - Health care rationing –
Effectiveness Analysis economics
- Evidence from emerging
interventions - Health priorities –
- LiST economics
- Models, econometric
43
ANNEX G: CEA COSTING TRAINING (TRAIN THE

TRAINERS), PRELIMINARY RESULTS PRESENTATION, APRIL
2018
The study of cost effectiveness of nutrition interventions was conducted with consultation from World Food Programme
(WFP) Mozambique and Rome. WFP played a critical role in supporting the presentation workshop for the CEA
Study in April 2018 and for the two-day training workshop on CEA analysis for policy formulation for several
officials of SETSAN and other agencies.
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ANNEX H: CEA OF NUTRITION INTERVENTIONS,

DECEMBER 2017 PRESENTATION
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ANNEX I: CEA OF NUTRITION INTERVENTIONS, MARCH

2018 PRESENTATION
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ANNEX I: CEA OF NUTRITION INTERVENTIONS, APRIL

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2018 PRESENTATION
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Cost-Effectiveness of Nutrition Interventions in Mozambique

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Cost-Effectiveness of Nutrition Interventions in Mozambique

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COST-EFFECTIVENESS ANALYSIS OF

Leadership in Public Financial Management II

Annex B: CEA Data Collection Template 36

The interventions were analyzed using an economic technique, cost-effectiveness

Key Findings and Recommendations

● We took a multi perspective approach to attempt to integrate nutrition and

● A systematic collection and sharing of information on interventions is needed, and must

● More human capacity building is required to continue the strengthening of local

SUMMARY RESULTS FOR CEA STUDY FOR MOZAMBIQUE

Sensitivity Benchmark based

Social Protection $250.96 $115.59 $360.41 $383.00 $2,764.00 Pakistan

THE NEED FOR IMPROVED NUTRITION IN MOZAMBIQUE

Mozambique is a low-income developing country in Sub-Saharan Africa that has emerged

Table 1 – Indicators of Poverty and Social Needs in Mozambique (2016)

Source: World Bank and UNDP country reports

Table 2 – Nutrition Data for Mozambique, 2003 and 2011

THE OBJECTIVES AND APPROACH OF THIS CEA STUDY

● A combination of three trips to Maputo, Mozambique, were included as part of

The process for the development of this report is outlined below:

1st In-Country Visit

2nd In-Country Visit 3rd In-Country Visit

COLLABORATING ORGANIZATIONS FOR THIS STUDY

Cost-effectiveness analysis (CEA) is an economic tool used for comparing alternative

WHAT ARE THE RECOMMENDED NUTRITION INTERVENTIONS?

Source: Bhutta et al. 2013

Table 3 – Interventions Prioritized by Copenhagen Consensus

WHAT NUTRITION INTERVENTIONS ARE INCLUDED IN THIS

Table 4 – Original Nutritional Interventions List Defined by SETSAN

No. Intervention Organization

4 School Feeding Program UNICEF, FAO & WFP

Table 5 – Interventions Defined by SETSAN

WHAT STEPS ARE TAKEN IN A CEA?

The CEA Model

𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉𝑉 𝑜𝑜𝑜𝑜 𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝐶𝑖𝑖

Table 6 – Ingredients Approach to Cost Estimating

Program Includes staff hired to work throughout implementation of

User training Includes any costs incurred to train participants or beneficiaries

Implementation Includes all costs directly associated with implementation of

Monitoring costs Includes any costs incurred owing to oversight, monitoring, or

Source: Dhaliwal et al. (2013) and J-PAL (Costing Guidelines)

Various events were organized to ensure stakeholder understanding of the ingredients

WHAT ARE THE KEY CONSIDERATIONS AND OVERALL LIMITATIONS

KEY FINDINGS ON CEA PROGRAM

Social + Behavioral Change Communication (SBCC)+ Feeding

2 IPTp/ITN for Malaria in Pregnancy

3 WASH – Water Supply

Micronutrient Supplementation (i.e., Vitamin A, Iron, Folic Acid,

6 School Feeding Program

7 Increased Availability of Natural Nutritious Foods

Intervention No. 1. Social + Behavioral Change Communication (SBCC)+

SBCC intervention in this analysis includes culinary demonstrations and interpersonal

Number of Beneficiaries 759,351 0 182,004 577,347

Present Value Costs $1,313,621

Stunting Cases Averted 99,312

Sensitivity of Costs/Dalys to Reduction in Stunting

Intervention No. 2. Prevention of Malaria IPTp/ITN 9 for Malaria in

Table 8 – CEA Analysis for IPTp/ITN in Pregnancy, Discounting Rate 10%

Discounting Rate 10%

Number of Beneficiaries (*) 240,924 0 145,519 95,405

Present Value Costs $4,088,123

Stunting Cases Averted (PV) 9,904

Figure I – Stunting Cases Averted by IPTp (Age 0–59 Months)