Haïti Priorise: Nutrition, Stone

The Problem

Anemia and micronutrient deficiencies affect a large proportion of the population in Haiti. An estimated 21% of children born in the last 3 years in Haiti had low birth weight, although birth weight was reported in only 26% of births. According to the most recent survey, 49% of women of reproductive age and 65% of preschool children were anemic.

Pregnant women and young children are most vulnerable to micronutrient malnutrition, due to their increased nutrient requirements, the small amounts of foods they consume, and the fact that deficiencies during this life stage can lead to life-long disabilities.

Anemia in pregnancy is associated with an increased risk of infant mortality, preterm delivery, and low birth weight.

The Solutions

Calcium and Micronutrients to Pregnant Women
Flour Fortification
Micronutrients to Children 6-24 months

Summary Table of the BCR

Interventions	Benefit (in gourdes)	Cost (in gourdes)	BCR
Calcium and micronutrients to pregnant women	79.8 billion	7.6 billion	10
Wheat flour fortification with iron and folic acid	7.9 billion	331.3 million	24
Micronutrient powders to children 6-24 months of age	1.2 billion	157.3 million	8

Benefits, Costs, and BCR

Calcium and Micronutrients to Pregnant Women

Anemia in pregnancy is associated with an increased risk of infant mortality, preterm delivery, and low birth weight. Supplementation with multiple micronutrient capsules substantially reduces those risks. Furthermore, women consuming diets low in calcium may be at greater risk of pre-eclampsia or eclampsia, which increases the risk of maternal mortality. The World Health Organization recommends calcium supplementation for women during pregnancy to mitigate that risk.

Costs

Costs include: 1) costs for supplement procurement, transport, and storage; 2) costs for health care time to manage the additional supplement distribution efforts; and 3) training, coordination and supervision. A cost is assumed of $0.0575/tablet for micronutrients and $0.015/tablet for Calcium.

Benefits

Totals:

15,212 deaths averted over 12 years, or fully scaled about 1400 deaths per year
431,771 years of disability averted over 12 years, or fully scaled about 40,000 years of disability averted per year
7.9 billion gourdes of future productivity 'gained' over 12 years or fully scaled about 740m gourdes gained per year.

Breakdown:

18,816 cases of anemia averted over 12 years for pregnant women. Fully scaled, about 1,800 cases of anaemia avoided p.a. for pregnant women
2492 maternal deaths due to pre-eclampsia avoided over 12 years, or fully scaled 235 deaths per year.
200,000 newborns over 12 years who will not be of low birth weight (LBW) or fully scaled, 19,000 LBW babies avoided p.a. This outcome means:

4276 stillbirths avoided over 12 years or, fully scaled about 400 stillbirths avoided per year;
2 years of disability over the lifetime avoided, per avoided LBW;
7.5% greater earnings potential over the lifetime, per avoided LBW. This is approx 40,000 gourdes over the working age from 16 to 60 (expressed as net present value at 5%)

120,591 pre-term births avoided over 12 years or fully scaled, about 11,400 pre term births avoided p.a. This outcome means that:

8441 new born deaths avoided over 12 years or fully scaled, about 800 pre term deaths avoided each year.
928 births with severe or moderate impairment averted, or fully scaled about 88 each year.

Flour Fortification

For both pregnant women and young children, fortification of staple food products, such as wheat flour, with iron and folic acid may offer benefits with regard to anemia reduction while also reducing the risk of neural tube defects.

Costs

The largest mill in Haiti was estimated in 2011 to have a production capacity of 80-85% of national demand. Although fortification is mandatory in Haiti, it appears that this flour is not fortified.

It is assumed that setup costs would be provided to the primary mill and two potential smaller mills as required for a new program: dosing equipment, internal monitoring equipment, and miller training.

In addition, costs are included for meetings and trainings to reformulate the norms to include folic acid in the premix (current policy specifies iron, but not folic acid). An additional consideration in this process will be the price of flour and related products, and the potential need to raise prices to cover the cost of premix.

Premix cost estimates range from US$1.5-2.9, excluding shipping costs. A premix cost of $2.65 per metric ton of wheat milled is assumed, increased by 50% to $4 per metric ton, to account for shipping, taxes, and premix loss.

Benefits

1,321 total newborn deaths from anencephaly and spina bifida averted over 12 years, due to optimal folic acid consumption by women during pregnancy. Fully scaled, approx 150 newborn deaths avoided per year.
869,727 cases of anemia averted over 12 years for women of reproductive age. Fully scaled, about 100,000 anemia cases averted each year for women of reproductive age.
562,596 cases of anemia averted over 12 years for pre-school aged children. Fully scaled, about 60,000 cases of anemia avoided each year for pre-school aged children.
927,886 cases of anemia averted over 12 years for school-aged children. Fully scaled, about 100,000 anemia cases averted each year for school-aged children.

Micronutrients to Children 6-24 months

Among children, micronutrient deficiencies can also lead to anemia, increased susceptibility to infection, and higher mortality risk. Provision of micronutrient powders has been found to significantly reduce the risks of anemia. Micronutrient powders consist of small sachets (~1 gram) containing a powdered micronutrient mixture.

Costs

The costs of providing 2 courses of MNP per year to children 6-23 months of age through health centers and rally posts. Three primary types of costs are estimated: 1) recurring costs for MNP procurement and storage, and 2) recurring costs for distribution by health workers, and 3) training and startup costs.

The cost of the MNP sachets themselves are $0.017 per sachet. Together, the costs of MNP procurement, shipping, and storage represent over 90% of estimated total program costs (in this “passive distribution” scenario in which MNP are distributed to caregivers of children who attend health centers and rally posts); the cost of the MNP alone (120 sachets per child per year) represents more than 2/3 of total program costs.

The cost of health worker time to distribute MNP was estimated as the number of additional health workers needed annually to add the distribution of MNP to other health worker responsibilities. It is assumed that each program contact (MNP distribution twice per year per child reached) requires 15 minutes to instruct the caregiver on the use of the product and that annual health worker salary is 4,830 Gourdes.

Benefits

Around 417,690 cases of anemia will be averted over 12 years for pre-school aged children. Fully scaled, about 62,000 cases of anemia will be avoided each year.