Understanding the costs and cost-efficiencies of preventing stunting combining standard of care, nutrition supplementation and cash transfer interventions in Southern Angola: an analysis of implementation data from the MuCCUA cluster randomised trial.

Abstract

To advance stunting reduction efforts, robust cost evidence on multisectoral interventions is essential for optimising resources and achieving outcomes efficiently. This study objective was to estimate the cost and cost-efficiency of three multisector interventions that combined standard of care (SOC), SOC plus cash transfers (SOC+CT) and SOC plus nutritional supplementation (SOC+NS) with small quantity lipid-based nutrient supplements (SQ-LNS) complemented with a family food ration (FFR) to prevent stunting in Southern Angola. Cost-effectiveness will be estimated in a future study. Interventions were nested within the Mother and Child Chronic Undernutrition in Angola (MuCCUA) trial and costs estimated after 1 year of implementation. Using a mixed-methods approach, we estimated financial and economic costs from institutional and societal perspectives. Activity-based costing and the ingredients approach were used to capture and calculate total institutional costs and opportunity costs incurred by participants. Cost-efficiency of each intervention was calculated as cost per participant reached. Costs were adjusted for inflation and reported in 2024 USD. Through the first 12-month implementation period, MuCCUA interventions covered 1423 pregnant women and their children. Total institutional costs by intervention arms were: US$190 408 for SOC (n=463), US$414 946 for SOC+CT (n=479) and US$515 799 for SOC+NS (n=481). Total monthly costs per participant reached were US$12.85, US$27.07 and US$33.51, respectively, for SOC, SOC+CT and SOC+NS (societal costs: US$13.48, US$28.26, US$34.56). Personnel (73%) and staff training (24%) drove most costs in SOC, whereas supplies-cash transfers (32%) in SOC+CT and SQ-LNS with FFR (35%) in SOC+NS-were the largest expenses. Intervention costs were higher in the SOC+CT and SOC+NS arms driven by inputs and recurrent distributions of cash transfers and nutrition supplies and lower in the SOC driven by personnel and training. Cost-efficiency could be increased by increasing the implementation period, so that start-up costs are spread over a long period of time. Disaggregated costing enhances understanding of resource use in complex programmes, supporting operational planning and budgeting, and will inform forthcoming cost-effectiveness analyses once outcome data become available. NCT05571280.