Cost-effectiveness of subnational targeting of small-quantity lipid-based nutrient supplementation: A simulation model in Nigeria, Ethiopia, and Pakistan

Introduction: Small-quantity lipid-based nutrient supplementation (SQ-LNS) is an intervention that provides supplemental nutrition to young children and has significant impacts on mortality, nutrition, and developmental outcomes. The World Health Organization recommends the use of SQ-LNS in certain targeted contexts, but evidence on the cost-effectiveness of SQ-LNS targeting approaches is limited. Methods: We utilized an individual-based simulation model to estimate the cost-effectiveness of SQ-LNS within first-level administrative divisions in Ethiopia, Nigeria, and Pakistan. We estimated the cost-effectiveness of subnational targeting strategies including threshold- and priority-based targeting algorithms with several indicators across child mortality, nutrition, and complementary feeding measures. Results: Subnational targeting according to wasting, stunting, and anemia thresholds was on average more cost-effective than untargeted strategies for all locations. Incremental cost-effectiveness ratios for these targeted and untargeted strategies respectively were $363 (95% uncertainty interval, UI: 243, 666) per disability-adjusted life year (DALY) averted and $458 (95% UI: 291, 863) in Ethiopia, $135 (95% UI: 74.2, 305) and $227 (95% UI: 124, 513) in Nigeria, and $474 (95% UI: 329, 718) and $544 (95% UI: 366, 878) to in Pakistan. Priority-based targeting using a composite ranking measure across mortality, wasting, and stunting burdens offered the greatest cost-effectiveness of any strategy assessed, achieving 7.0% (UI: 4.4, 12) and 4.6% (UI: 1.4, 7.3) more DALYs averted for the same cost as the threshold-based targeting approach in Nigeria and Ethiopia and equal impact in Pakistan. Conclusions: Subnational targeting of SQ-LNS can significantly improve cost-effectiveness relative to untargeted scale-up strategies. Several targeting strategies and indicators may be used to improve cost-effectiveness, with highest performance seen with a priority-based algorithm using a composite ranking measure across child mortality, wasting, and stunting burdens. Subnational targeting according to such measures should be considered in the implementation of SQ-LNS programs in accordance with existing guidelines.