In general, the methodology described in Scaling Up Nutrition: What Will it Cost? (Horton et al., 2009) was followed to calculate the annual cost of scaling up the key micronutrient interventions in each of the 68 countries. It should be noted that these are rough estimates based on available reported data and do not reflect the nuances of each country.
Ten nutrition interventions were identified in Scaling Up Nutrition (SUN); for the country profiles we focused on seven of the ten interventions that relate specifically to micronutrient deficiencies. The additional costs of scaling up these seven interventions were included in the estimated total costs cited in the profiles:
- Vitamin A supplementation for children 6-59 months of age
- Therapeutic zinc supplements as part of diarrhea management for children 6-59 months of age
- Multiple micronutrient powders for in-home fortification of complementary food for children 6-23 months of age
- Deworming medication for pre-school aged children
- Iron-folic acid supplementation for pregnant women
- Iron fortification of staple foods
- Salt iodization for the general population
Every effort was made to obtain estimates on current coverage rates for each of the interventions. The “uncovered” target population was then approximated and the additional cost of providing the interventions to this group was calculated. The goal coverage rate was assumed to be 100% of the target population for each intervention.
It is important to emphasize that these estimates do NOT incorporate existing investments in nutrition which account for current coverage levels. Furthermore, the calculations have not factored in a number of relevant factors such as the difference in costs due to regional variability within a country, delivery mechanism etc.
The following considerations were taken into account:
Population numbers: The 2009 UNICEF State of the World’s Children (SOWC) was used as the primary reference to obtain population statistics. This document reports the estimated total population in the country as well as the number of children under five years of age. It was estimated that 11% of the under-five population was between 0 and 6 months of age, 89% was between 6 and 59 months of age, 40% was between 0 and 23 months of age, and 80% was between 12 and 59 months of age. The total number of live births (per year) was used as a rough proxy for the number of pregnant women per year, recognizing that this does not take into account multiple or still births.
Prevalence of undernutrition: SOWC was also used as the primary reference for rates of stunting, wasting, and underweight among children under five. Rates of undernutrition in this report were primarily obtained from the WHO Global Database on Child Growth and Malnutrition, which catalogues data from Demographic and Health Surveys (DHS) and other national surveys. If data were missing for rates of underweight, Repositioning Nutrition as Central to Development was used as a secondary source. For the sake of simplicity, it was assumed that the rate of underweight among children 6-23 months of age would be the same as the reported rate among children under five years of age. (In reality, however, the rate would likely be higher in the 6-23 month-old subgroup.)
Salt iodization: Coverage rates of household salt iodization were obtained from SOWC. If data were missing, the Micronutrient Initiative’s Investing in the Future report was used as a secondary source.
Vitamin A supplementation: The data on vitamin A supplementation coverage rates are relatively sparse. SOWC was used as the first source of data for the proportion of children 6-59 months of age that receive “full” coverage (i.e. two doses per year, approximately 6 months apart). The Micronutrient Initiative’s Investing in the Future report was used as a secondary source in the case of missing data. Finally, as a last resort the 2004 UNICEF/MI Vitamin and Mineral Deficiencies: A Global Progress Report was relied upon, which reports the percent of children receiving at least one dose of vitamin A per year. There are a few countries which target vitamin A supplementation to specific subgroups; the cost of scaling up vitamin A supplementation was not calculated in these cases.
Deworming: The WHO Preventive Chemotherapy and Transmission Databank was used to obtain estimates of the number of preschool-aged children that should be targeted to receive preventive chemotherapy against intestinal parasites as well as current coverage rates. The most current year of reported data was used. However, if a country did not have any reported coverage rates, a coverage rate of zero was applied in order to be as generous with the cost calculations as possible. Table 3 in Hall et al. (2010) was referred to determine the number of recommended rounds of chemotherapy that targeted children should receive each year. This is based on the WHO recommendation of one round in countries where the prevalence of any soil-transmitted helminth is ≥20% and two rounds per year where the prevalence if ≥ 50%.
Iron-folic acid supplementation of pregnant women: Coverage of antenatal services, as reported in the WHO Statistical Information System, was used as a proxy for coverage of iron-folic acid supplementation of pregnant women. If antenatal coverage data were not available for a country, the median coverage level for the region was applied.
Multimicronutrient powders: As outlined in SUN, the target population for multimicronutrient powders is children 6-23 months of age who are not being covered by supplementary food for moderate malnutrition or receiving treatment for severe acute malnutrition (SAM). To provide a rough estimate of the size of the subgroup, the number of children 6-23 months of age with a weight-for-age z-score (WAZ) < -2 was subtracted from the total number of children 6-23 months of age.
Zinc supplementation for the management of diarrhea: This intervention includes 10-14 days of zinc supplementation for the management of diarrhea. The target population is assumed to be all children 6-59 months of age. The cost estimate of US$1/child/year allows for 2-3 rounds of treatment per year. Current coverage rates were assumed to be negligible in all countries.
Iron fortification of staples: This intervention is a population-level intervention, so the target population was assumed to be the total number of people in the country. Data on the proportion of the population in each country with potential access to fortified flour was obtained from the Flour Fortification Initiative website. The size of the uncovered population was calculated as the difference between the total population and the number of people with potential access. If data were not available for a country, current coverage levels were considered to be negligible.
Unit cost of each intervention: The following table shows the unit cost of each intervention:
Vitamin A supplementation
US$1.20 per child 6-59 months of age
Assumes two supplements per year, includes costs associated with distribution
Therapeutic zinc for the management of diarrhea
US$1 per child per 6-59 months of age
Allows for 2-3 rounds of zinc supplementation per child per year
US$3.60 per child 6-23 months of age
Assumes each child will receive 60 sachets, as per current recommendations. Includes cost of delivery. Target population does not include children receiving complementary food for prevention/treatment of moderate malnutrition or children receiving treatment for SAM.
US$0.25 per round of chemotherapy per child 12-59 months of age
Iron-folic acid supplementation of pregnant women
US$2.00 per pregnancy
Number of pregnant women based on number of live births per year
Iron fortification of staple foods
US$0.20 per person per year
Universal salt iodization
US$0.05 per person per year
Regional Cost Multipliers: A multiplication factor was applied to all micronutrient interventions except for iron fortification and salt iodization, where costs are often fixed externally. The multiplication factor accounts for regional differences in salary and distribution costs for interventions which are typically delivered via community-level services.
Flour Fortification Initiative. Country data and practices.
Hall A, Horton S, de Silva N. 2010. The cost and cost-effectiveness of mass treatment for intestinal nematode worm infections using different treatment thresholds. Draft.
Horton S, Shekar M, McDonald C, Mahal A, Brooks JK. 2009. Scaling Up Nutrition: What Will it Cost? Washington, DC: World Bank.
Micronutrient Initiative. 2009. Investing in the future: a united call to action on vitamin and mineral deficiencies. Ottawa.
UNICEF and the Micronutrient Initiative. 2004. Vitamin and mineral deficiency: a global progress report.
UNICEF. 2009. The State of the World’s Children 2009. New York, NY: United Nations.
World Bank. 2006. Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action. Washington, DC: World Bank.
World Health Organization. Nutrition Landscape Information System.
World Health Organization. Preventive chemotherapy and transmission databank.
World Health Organization. Statistical Information System.
This methodology was carried out and described by Christine McDonald, March-April 2010.