Cost-effectiveness Analysis for 
Integrated Social and Behavior Change 
Programming by the Resilience in the 
Sahel Enhanced II Program in the 
Maradi and Zinder Regions of Niger
TECHNICAL REPORT
MAY 2023
Acknowledgments
We would like to say thank you to the Resilience Food Security Activities in Niger which include Hamzari (led by Care), Girma (led by Catholic Relief 
Services), and Wadata (led by Save the Children) for their collaboration in this activity.
Breakthrough RESEARCH is made possible by the generous support of the 
American people through the United States Agency for International 
Development (USAID) under the terms of cooperative agreement no. 
AID-OAA-A-17-00018. The contents of this document are the sole 
responsibility of the Breakthrough RESEARCH and Population Council and 
do not necessarily reflect the views of USAID or the United States 
Government.
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Suggested Citation
Avenir Health. 2021. "Cost-effectiveness analysis for integrated 
social and behavior change programming by the Resilience in the 
Sahel Enhanced II program in the Maradi and Zinder regions of 
Niger," Breakthrough RESEARCH Technical Report. Washington, 
DC: Population Council.
Contact
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breakthroughactionandresearch.org
Cost-effectiveness Analysis for Integrated 
Social and Behavior Change Programming 
by the Resilience in the Sahel Enhanced II 
Program in the Maradi and Zinder Regions 
of Niger
TECHNICAL REPORT MAY 2023
Avenir Health
BREAKTHROUGH RESEARCH | MAY 2023 i
ANC antenatal care
CCP Johns Hopkins University Center for Communication Programs
DALY disability-adjusted life year
FP family planning
GDP gross domestic product
ICER incremental cost-effectiveness ratio
IPC interpersonal communication
LiST Lives Saved Tool
mCPR modern contraceptive prevalence
MNCH maternal, neonatal and child health
MWRA married/in union women of reproductive age
RFSA Resilience Food Security Assistance
RISE II Resilience in the Sahell II
SBC social and behavior change
USAID United States Agency for International Development
USD United States dollar
WASH water, sanitation, and hygiene
YLD years of life lived with disability
YLL years of life lost to death
Acronyms
ii COST-EFFECTIVENESS ANALYSIS FOR INTEGRATED SBC PROGRAMMING BY THE RISE II PROGRAM IN NIGER
Table of Contents
ACRONYMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Estimate impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Calculate cost-effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Cost-effectiveness.................................................................................... 11
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Key findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
APPENDIX A: ORGANIZATIONAL CHART AND SBC ACTIVITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
APPENDIX B: ADDITIONAL SBC EXPENDITURE DETAILS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
BREAKTHROUGH RESEARCH | MAY 2023 iii
iv COST-EFFECTIVENESS ANALYSIS FOR INTEGRATED SBC PROGRAMMING BY THE RISE II PROGRAM IN NIGER
EXECUTIVE SUMMARY
Background
The United States Agency for International Development 
(USAID) funds programs that work with the govern￾ment and partners to improve health and development 
outcomes in Niger, including the Resilience in the Sahel 
II (RISE II) initiative. RISE II builds on prior efforts to 
improve priority health behaviors related to maternal, 
newborn and child health (MNCH), family planning (FP), 
nutrition, and water, sanitation and hygiene (WASH) 
through a multi-sectoral integrated social and behavior 
change (SBC) approach in the Maradi and Zinder regions 
of Niger (USAID 2018). The Breakthrough ACTION project 
is supporting the RISE II initiative via capacity building, 
leveraging their expertise in SBC design, and supporting 
the launch of a national campaign. Three Resilience Food 
Security Assistance (RFSA) partners are leading the imple￾mentation of SBC activities, including radio programming, 
interpersonal communication (IPC), community aware￾ness raising and community engagement interventions, 
and provider behavior change initiatives. 
Breakthrough RESEARCH conducted an evaluation of 
the RISE II initiative by examining the SBC costs and the 
impact of SBC activities on priority health outcomes. The 
impact analysis utilizes three repeated cross-sectional 
surveys: a baseline survey in April and May 2021, a 
midline survey in April and May 2022, and a final survey 
scheduled to be available in March 2023. This report 
combines the expenditures from the project initiation 
through April 2022 to match the timeframe of the total 
costs with the impact data collected at midline. Using 
these inputs, the primary research question addressed in 
this analysis is what is the cost-effectiveness of RISE II at 
midline? A second research question is what increase in 
health outcomes is necessary to yield cost-effective results 
by the end of programming activities?
Methods
To evaluate the cost-effectiveness of RISE II SBC interven￾tions, it is necessary to calculate the incremental cost-ef￾fectiveness ratio, or ICER. An ICER examines the total 
costs associated with SBC interventions divided by the 
total impact following three main steps: 1) estimate the 
impact of SBC interventions on priority health outcomes, 
2) estimate the SBC-related costs, and 3) calculate the 
ICER.
The baseline and midline surveys are used to assess 
impact at midline. While the RISE II initiative is multisec￾toral and has more components than just SBC, including 
agricultural and microfinancing, the health outcomes are 
expected to be largely linked to the SBC programming. 
Because the SBC interventions cross multiple health 
areas, a common impact measure is needed. As such, a 
linear deterministic causal model called the Lives Saved
Tool (LiST) was used to examine how changes in popu￾lation coverage of specific interventions translate into 
the number of lives saved over a specified time period 
based on changes in priority health outcomes: modern 
contraceptive prevalence, antenatal care attendance, 
facility-based births, and handwashing. LiST scenarios 
were developed to estimate the number of lives saved 
attributable to the RISE II program at midline (2022), 
which were then translated into disability-adjusted 
life years (DALYs) averted using the GBD Results Tool
for Niger. Two further sets of hypothetical scenarios 
were also examined: 1) a 25% improvement scenario 
explored what the impact would be if the outcomes in 
the intervention group increased by 25% from the 2022 
value by 2025 compared to a control group in which the 
outcomes remained constant at their 2022 levels through 
2025 and 2) 25% + breastfeeding scenario examined the 
same hypothetical 25% increase between 2022 and 2025 
for the intervention area but also included increases in 
breastfeeding outcomes, which were not adequately 
measured in the Breakthrough RESEARCH surveys, 
although SBC interventions were provided in these areas.
The first phase of SBC expenditures covered project 
initiation through September 2021 and were summarized 
in a prior Breakthrough RESEARCH report. The second 
phase captured SBC expenditures from October 2021 
through September 2022. When aggregating expendi￾tures across time periods, the total expenditures were 
adjusted to 2022 United States dollars using the United
States gross domestic product (GDP) deflator. Since 
implementation of SBC activities began gradually in mid￾2020, the prior start-up costs in 2019 and the first half of 
2020 were amortized over the life of RISE II to 2025. Total 
expenditures were calculated at midline (April 2022). To 
estimate SBC expenditures to 2025 for the hypothetical 
BR E A K THROUGH R ESE A RCH | M AY 2023 1 
scenarios, the monthly average spend from January 2021 
to September 2022 was used to project expenditures 
going forward through June 2025 at a constant rate. 
Service delivery costs associated with changes in the 
behavioral health outcomes were also estimated using 
the LiST costing module. 
Once the impacts and costs were obtained, the ICER 
was calculated. For the RISE II study, the total costs 
are divided by the total DALYs averted to estimate the 
cost per DALY averted. This ICER was then compared 
to Niger’s GDP per capita to assess cost-effectiveness. 
According to World Health Organization’s guidelines, 
health interventions with a cost per DALY averted that 
are less than one times the GDP per capita are consid￾ered “highly cost-effective” and those between one and 
three times the GDP per capita are “cost-effective”. To 
ensure comparability with the costs, the GDP per capita 
was adjusted to 2022 United States dollar using the US 
GDP deflator, resulting in a value of $631.93. As such, the 
cost per DALY averted needs to be below $632 for the 
SBC investments to be considered “highly cost-effective” 
and below $1,896 to be “cost-effective”.
Results
At midline, an estimated four lives were saved due to 
the RISE II initiative, yielding 122 DALYs averted. When 
combined with the estimated costs of approximately $5.7 
million at midline, the resulting cost per DALY averted 
is $47,005 and thus over the threshold of $1,896 and 
deemed not cost-effective.
Far more DALYs averted are generated in the two 
hypothetical scenarios that extend to 2025. The 25% 
improvement scenario yields a total of 4,835 DALYs 
averted and the 25% + breastfeeding scenario generates 
12,131 DALYs averted. When combined with an estimated 
SBC cost of $19.9 million by 2025, the cost per DALY 
averted is $4,111 for the 25% improvement scenario and 
$1,597 for the 25% + breastfeeding scenario. While the 
25% improvement scenario is still above the cost-effec￾tive threshold, the 25% + breastfeeding scenario is below 
the threshold and therefore considered cost-effective.
Discussion
This study is one of the first to examine the cost-effec￾tiveness of integrated SBC programming. We present 
three key findings that shed light on whether SBC 
interventions are or could be cost-effective. First, the 
ICER using the results from the midline scenario
of $47,005 per DALY averted is not cost-effective. 
Given the brief time span between the baseline and 
the midline, this result is not surprising as more time is 
typically needed for SBC programming to shift underly￾ing intermediate determinants, which can then later be 
detectable as changes in health behavioral outcomes. 
For these reasons, looking ahead to future studies, one 
recommendation is that researchers use project midline 
to explore other relevant costing questions, but not focus 
on midline cost-effectiveness.
A second major finding from this analysis is that cost￾effectiveness of the RISE II SBC program is achievable if
substantial positive changes in health outcomes occur
by project endline. The 25% + breastfeeding scenario is 
below the cost-effective threshold for Niger. While a 25% 
increase in outcomes due to SBC interventions is sub￾stantial, it is not beyond the bounds of what is feasible. 
A similar survey of the outcomes in 2025 would reveal 
whether this level of change occurred for the key out￾comes in this analysis. 
The third key finding is the importance of capturing all
relevant outcomes in an impact measure for cost-ef￾fectiveness analysis. In this projection, the inclusion of 
the breastfeeding outcomes is critical for achieving the 
cost-effectiveness threshold. For integrated SBC overall, 
missing the inclusion of a priority health behavior from 
the impact denominator is problematic for the analysis 
because it under-estimates important health gains. This 
is particularly challenging for multisectoral programs like 
RISE II, where improvements in agricultural yields and 
reducing early marriage have known economic benefits 
but these benefits do not map to health outcomes that 
can be mapped into DALYs averted. For integrated SBC 
projects that cross different sectors, other approaches 
such as a benefit cost-ratio analysis, will likely yield more 
complete and thus more favorable results, but they are 
also more difficult to conduct. 
As with all modeling studies, the analysis relies on various 
data inputs and assumptions in assessing both the 
impacts and the SBC costs. This analysis also assumes 
that the changes in the health indicators are due to SBC 
programming and not the other RISE II activities, such as 
direct food aid and agricultural support. Despite these 
limitations, while a one-year time frame is premature 
for yielding useful cost-effectiveness results, the hypo￾thetical scenarios included in this analysis indicate that 
if substantial gains are made in key health outcomes, 
2 COST-EFFECTIVENESS ANALYSIS FOR INTEGRATED SBC PROGRAMMING BY THE RISE II PROGRAM IN NIGER
cost-effectiveness could be achieved by project end, 
although these scenarios are, of course, speculative. 
Looking forward, more research is needed to examine 
the cost-effectiveness of integrated SBC and further 
exploration on what types of integrated programming 
are most cost-effective. 
BR E A K THROUGH R ESE A RCH | FEBRUA RY 2021 3 
BACKGROUND
Niger faces multiple health and development challenges, 
including high rates of malnutrition, mortality, fertility, 
and chronic food insecurity (USAID 2022, UNICEF 2018). 
Additionally, a historical pattern of severe droughts 
and recurring environmental shocks and stressors have 
undermined development progress (USAID 2018). In 
response, the United States Agency for International 
Development (USAID) funds programs that work with the 
government and partners to improve health and devel￾opment outcomes in Niger, including the Resilience in the 
Sahel II (RISE II) initiative, which aims through multisec￾toral programming to build on prior efforts to improve 
priority health behaviors related to maternal, newborn 
and child health (MNCH), family planning (FP), nutrition, 
and water, sanitation and hygiene (WASH) through an 
integrated social and behavior change (SBC) approach in 
the Maradi and Zinder regions of Niger (USAID 2018). 
The Breakthrough ACTION project, led by Johns Hopkins 
University Center for Communication Programs (CCP), 
with partners Save the Children, ideas42 and Viamo, 
is supporting the RISE II initiative via capacity building, 
leveraging their expertise in SBC design, and supporting 
the launch of the Garkuwar Al’Umma campaign (which 
means “Shield of the Community” in Hausa). Garkuwar 
Al’Umma, launched in December 2022, is a nationwide 
campaign that aims to unify and promote a range 
of health behaviors under one flagship brand. Three 
Resilience Food Security Assistance (RFSA) partners are 
leading the implementation of SBC activities, with the 
Hamzari project led by CARE, the Girma project led by 
Catholic Relief Services, and the Wadata project led by 
Save the Children. Each of the RFSAs are implementing 
radio programming, interpersonal communication (IPC), 
and community awareness raising and community 
engagement interventions. Additionally, Girma conducts 
text messaging around nutrition and health, while both 
Girma and Wadata have implemented provider behavior 
change initiatives focused on community health workers. 
See Appendix A for further details on the organizational 
structure and included SBC activities.
Breakthrough RESEARCH conducted an evaluation of 
the RISE II initiative by examining the cost and impact 
of SBC activities on priority health behaviors and out￾comes in Niger. The original cost-effectiveness study 
design planned to pair the total SBC expenditures for 
RISE II with the total health impact estimated at the final 
Breakthrough RESEARCH survey. However, since the final 
survey data were not available in the needed time frame 
to conduct this analysis, this report reviews the cost-ef￾fectiveness at midline and will examine hypothetical 
scenarios of cost-effectiveness through 2025 when RISE II 
concludes. Table 1 details the analysis time frame. 
Breakthrough ACTION began planning their SBC activities 
in late 2019 and RFSA SBC activities were delayed and 
then incrementally started in mid-2020 but limited due 
to the COVID-19 pandemic and its restrictions on social 
contacts. Breakthrough RESEARCH’s baseline survey was 
conducted in April and May 2021 and the midline survey 
was conducted in April and May 2022. Data from the final 
Breakthrough RESEARCH survey was not available until 
early March 2023 and is thus not included in this report. 
An initial cost report analyzed the SBC program expen￾ditures from project initiation in late 2018 to September 
2021 (Avenir Health 2022). This report combines the 
expenditures from the initial report with subsequent 
expenditures from October 2021 through April 2022 to 
match the timeframe of the total costs with the impact 
data collected at midline. Using these inputs, the primary 
research question addressed in this analysis is what is 
the cost-effectiveness of RISE II at midline? While it is 
interesting to explore this question, a one-year change 
for an SBC initiative is unlikely to yield cost-effective 
results because more time is typically needed to gen￾erate impact on health outcomes. As such, a secondary 
research question is what increase in health outcomes 
is necessary to yield cost-effective results by the end of 
programming activities?
4 COST-EFFECTIVENESS ANALYSIS FOR INTEGRATED SBC PROGRAMMING BY THE RISE II PROGRAM IN NIGER
TABLE 1 TIME FRAME FOR RISE II PROGRAMMING AND BREAKTHROUGH RESEARCH’S EVALUATION
TIME FRAME (QUARTER) RISE II DESIGN 
PHASE
RISE II SBC DESIGN 
PHASE
RISE II INTEGRATED 
SBC ACTIVITIES
BREAKTHROUGH 
RESEARCH 
EVALUATION
April – June 2019
July – September 2019
October – December 2019
January – March 2020
April – June 2020
July – September 2020 *
October – December 2020
January – March 2021 Baseline
April – June 2021
July – September 2021
October – December 2021
January – March 2022
April – June 2022 Midline
July – September 2022
October – December 2022
January – March 2023 Final
April – June 2023
July – September 2023
October – December 2023
January – March 2024
April – June 2024
July – September 2024
October – December 2024
January – March 2025
April – June 2025 RISE II project endline
*SBC interventions began rolling out gradually during this time period.
BR E A K THROUGH R ESE A RCH | M AY 2023 5 
METHODS
To evaluate the cost-effectiveness of RISE II SBC inter￾ventions, it is necessary to calculate the incremental
cost-effectiveness ratio, or ICER. An ICER examines the 
total costs associated with SBC interventions divided by 
the total impact, following three main steps: 1) estimate 
the impact of SBC interventions on priority health out￾comes, 2) estimate the SBC-related costs, and 3) calculate 
the ICER. 
Estimate impact
The foundation for the impact analysis is the Break￾through RESEARCH RISE II evaluation study, which is a 
repeated cross-sectional study designed to assess the 
impact of RISE II SBC programming. The baseline, mid￾line, and final surveys target married/in union women of 
reproductive age (15–49 years) and assess the ideational 
factors and behavioral outcomes associated with priority 
health areas. The baseline study conducted in April 2021 
surveyed 1,354 married/in union women of reproduc￾tive age (MWRA) between 15 and 49 years in the RISE II 
programming intervention areas and another 1,355 were 
interviewed in control areas in the region (i.e., not where 
RISE II is operating (Dougherty et al. 2022)). At midline, 
1,342 were interviewed in the intervention and 1,384 
were interviewed in the control areas (forthcoming). 
While the RISE II initiative is multisectoral and has more 
components than just SBC, including agricultural and 
microfinancing, the health outcomes assessed in this 
analysis are related to health services utilization and 
are expected to be largely linked to the SBC program￾ming in RISE II that is focused on addressing barriers 
to health care-seeking. Because the SBC interventions 
cross multiple health areas, a common impact measure 
is needed. As such, a linear deterministic causal model 
called the Lives Saved Tool (LiST) was used to examine 
how changes in population coverage of specific inter￾ventions translate into the number of lives saved over 
a specified time period. LiST was initially developed in 
2003 to estimate the impact of clinical, hospital, and 
community-based interventions on mortality for children 
under five years and later expanded to include maternal 
impacts (Walker et al. 2013). As an example, Figure 1 
shows an example of pathways that map how improve￾ments in handwashing influences risk factors and causes 
of death in LiST.
Table 2 details five health behavioral outcomes 
addressed by RISE II SBC programming that are included 
in LiST and the corresponding baseline and midline values 
for the intervention and control areas, as well as the 
percentage point changes from baseline to midline. Some 
indicators dropped, potentially due to health service and 
disruptions from COVID-19. Three indicators showed sta￾tistically significant changes from baseline to midline at 
p<0.05. In the intervention area, the use of at least four 
antenatal care (ANC) visits dropped by 9.9 percentage 
FIGURE 1 LIST PATHWAYS FOR HANDWASHING INFLUENCING NEONATAL AND CHILD MORTALITY
Source: www.listvisualizer.org
6 COST-EFFECTIVENESS ANALYSIS FOR INTEGRATED SBC PROGRAMMING BY THE RISE II PROGRAM IN NIGER
points but dropped even more in control areas (14.6 per￾centage points). The control area also saw a statistically 
significant drop in women having one ANC visit during 
their pregnancy (4.1 percentage points). The percent 
of households living with a handwashing facility on the 
premises that has soap and water available dropped 5.8 
percentage points in intervention areas compared to a 
1.4 percentage point drop in control areas.
While improving breastfeeding outcomes was another 
key behavior addressed by the RISE II initiative, it should 
be noted that they are not captured in Table 2 due to 
an inaccurately deployed skip pattern in the baseline 
survey that resulted in missing information of the age for 
children needed for these indicators.a
The values shown in Table 2 were used to generate a 
series of LiST scenarios that can be used to examine the 
number of lives saved that can be attributed to the RISE II 
initiative. To begin, default national-level population data 
from Niger were adjusted to reflect the RISE II initiative 
reach based on project documentation. Next, the follow￾ing LiST files were created:
1. An intervention baseline file that uses the baseline 
intervention survey values for each of the above 
behavioral health outcomes in years 2021 and 2022.
a
Due to COVID-19, the Washington, DC-based study team was unable to 
travel and participate with the Niger-based team in the training and study 
tool piloting. As a result, it was more challenging to provide close over￾sight and ensure that the paper-based study tool was accurately deployed 
on the mobile application. The skip pattern was corrected in the midline 
survey and a comparison of midline and the final survey will be available 
in the final evaluation manuscript.
2. A control baseline file that uses the baseline control 
survey values for each of the outcomes in 2021 and 
2022.
3. An intervention scaled file that uses the baseline 
survey values for the intervention areas in 2021 and 
the midline values for 2022. 
4. A control scaled file that uses the baseline survey 
values for the control areas 2021 and the midline 
values for 2022. 
The number of lives saved were then calculated based on 
modeled deaths averted at midline. To calculate maternal 
lives saved, the number of deaths from the scaled-up file 
capturing changes over time in the intervention areas 
is subtracted from the baseline file for the same area 
(Equation 1). The same calculation is made for the control 
areas (Equation 2). 
Due to underlying population dynamics, the best 
approach for calculating the number of lives saved based 
on changes in the behavioral health outcomes differs 
TABLE 2 HEALTH BEHAVIORAL OUTCOMES IN RISE II INTERVENTION AND CONTROL AREAS FROM
 BASELINE (2021) TO MIDLINE (2022)
INTERVENTION CONTROL
HEALTH 
OUTCOMES
BASELINE 
2021
MIDLINE 
2022
% PT 
CHANGE
BASELINE 
2021
MIDLINE 
2022
% PT 
CHANGE
Modern contraceptive prevalence (mCPR) among 
all women
25.3 24.9 -0.4 21.0 19.5 -1.5
% women who report at least 1 ANC visit during 
their pregnancy
89.3 89.4 0.1 87.0 82.9 -4.1*
% women who report at least 4 ANC visit during 
their pregnancy
56.7 46.8 -9.9*** 50.4 35.8 -14.6***
% children born in a health facility 55.9 58.1 2.2 56.1 57.2 1.1
% of households living with a handwashing facility 
on the premises that has soap and water available
15.7 9.9 -5.8** 10.6 9.2 -1.4
*Statistically significant change at p<0.05, **p<0.01, ***p<0.001
Equation 1: Maternal deaths averted at midline based
 on intervention results (2022)
 
 = – 
BASELINE/INTERVENTION
(Maternal deaths)
SCALED/INTERVENTION
(Maternal deaths)
Lives
saved
Equation 2: Maternal deaths averted at midline based
 on control results (2022)
 
 = – BASELINE/CONTROL
(Maternal deaths)
SCALED/CONTROL
(Maternal deaths)
Lives
saved
BR E A K THROUGH R ESE A RCH | M AY 2023 7 
for mothers and children. For children, the number of 
lives saved were estimated for each intervention in the 
scaled-up file in the LiST results. Then, to estimate the 
number of lives saved at midline attributable to RISE II, 
the number of lives saved in the files using the control 
values were subtracted from the lives saved using the 
intervention values (Equation 3). 
The number of lives saved generated from this equation 
was translated into disability-adjusted life years (DALYs) 
averted using data obtained from the GBD Results Tool
for Niger. Total “DALYs averted” are comprised of the 
years of life lost to death (YLL) and the years of life lived 
with disability (YLD). For each relevant cause of death, 
the total deaths and total DALYs were obtained for Niger 
to calculate the number of DALYs per death, which were 
then applied to the lives saved attributable to the RISE II 
initiative. For example, an increase in the proportion of 
facility-based births results in saving newborn lives and 
there are approximately 90 DALYs averted associated 
with saving a newborn life due to interventions reducing 
childbirth complications. Following standard practices for 
cost-effectiveness evaluation, future DALYs averted were 
discounted at 3% (IDSI 2022). 
Acknowledging that substantial behavior changes are 
unlikely to occur in the year between baseline and 
midline survey due to the SBC activities, two further sets 
of hypothetical scenarios were examined. First, a 25% 
improvement scenario explored what the impact would 
be if the outcomes in the intervention group increased 
by 25% by 2025 compared to a control group where the 
outcomes remained constant at their 2022 levels through 
2025. Second, a 25% + breastfeeding scenario exam￾ined the same hypothetical 25% increase between 2022 
and 2025 for the intervention area and also included 
hypothetical increases of 25% by 2025 in breastfeeding 
outcomes, which were not adequately measured in 
the Breakthrough RESEARCH surveys, although SBC 
interventions were provided in these areas. Baseline 
breastfeeding health outcomes were obtained from a 
2021 population-based survey, relying on the average 
percentages for Maradi and Zinder (INS 2022). Table 3
details the values included in the scenarios, where the 
values incrementally increase to a 25% increase by 2025 
in the intervention scenario, and the 2022 values from 
the midline survey remain constant through 2025 in the 
control scenarios.
Similar to the midline impact calculation, the number 
of lives saved for the two hypothetical scenarios were 
captured by subtracting the lives saved from the control 
scenarios from the lives saved in the intervention scenar￾ios (Equation 4).
TABLE 3 HEALTH OUTCOMES VALUES USED IN THE TWO HYPOTHETICAL IMPACT SCENARIOS
OUTCOMES 2021 2022 2023* 2024* 2025*
25% hypothetical scenario
mCPR 25.3 24.9 27.0 29.1 31.1
ANC 1 89.3 89.4 91.3 93.1 95.0**
ANC 4 56.7 46.8 50.7 54.6 58.5
Facility-based birth 55.9 58.1 62.9 67.8 72.6
Handwashing 15.7 9.9 10.7 11.6 12.4
25% (above) + breastfeeding (below) scenario-only
Early initiation breastfeeding*** 68.0 72.3 76.5 80.8 85.0
Exclusive breastfeeding (1 month)*** 23.8 25.3 26.8 28.3 29.8
Exclusive breastfeeding (under 6 months)*** 14.0 14.9 15.8 16.6 17.5
Any breastfeeding (6–12 months)*** 97.0 97.3 97.5 97.8 98.0
Any breastfeeding (13–24 months)*** 76.0 80.8 85.5 90.3 95.0*
*Hypothetical values; **Max value capped at 95%; ***Baseline values from INS 2022 study for Maradi and Zinder.
Equation 3: Estimated lives saved due to RISE II
 initiative at midline (2022)
 
 = – INTERVENTION
(Maternal lives +
Child lives)
CONTROL 
(Maternal lives +
Child lives)
Lives
saved
8 COST-EFFECTIVENESS ANALYSIS FOR INTEGRATED SBC PROGRAMMING BY THE RISE II PROGRAM IN NIGER
Estimate costs
The costing component of this analysis follows Break￾through RESEARCH’s Guidelines for Costing of Social
and Behavior Change Health Interventions, which 
include 17 principles of design, data collection, analysis, 
and presentation for SBC costing studies (Rosen, Plosky 
and Bollinger 2019). SBC expenditures were collected in 
two phases. The first phase collected SBC expenditures 
from the project initiation in 2018 through September 
2021 and were summarized in Breakthrough RESEARCH’s 
initial cost report, which explored the allocation of 
expenditures in different categories (e.g., personnel, 
travel, indirect) (Avenir Health 2022). The second phase 
captured SBC expenditures from October 2021 through 
September 2022. Data requests for the second tranche 
of SBC expenditures began in October 2022, with follow 
up conducted through January 2023. For CCP, transaction 
data were made available, while total expenditures were 
submitted by the other partners where transaction data 
were not available.b
When aggregating expenditures across time periods, the 
total expenditures were adjusted to 2022 United States 
dollars (USD) using the United States gross domestic
product (GDP) deflator. The CCP transaction data 
detailed SBC expenditures by date. We used the propor￾tion of the annual expenditures spent each month by CCP 
to estimate the monthly RFSA expenditures by applying 
that proportion to the annual reported expenditures for 
each RFSA. Since implementation of SBC activities began 
gradually in mid-2020, the prior start-up costs in 2019 
and the first half of 2020 were amortized over the life of 
the RISE II project, where the RFSAs plan to continue the 
SBC activities to 2025. Total expenditures were calculated 
at midline (April 2022) and the SBC expenditures per per￾son in the intervention areas were also calculated using 
the intervention area population estimate of 548,474, 
based on provided census data.
b
Transaction data detail specific expenditures, such as office utilities, and 
the associated date, amount, and other details.
To calculate SBC expenditures beyond midline, to be 
used in the hypothetical 25% and 25%+breastfeeding 
scenarios that extend out to 2025, the monthly average 
spend from January 2021 to September 2022 was used 
to project expenditures going forward through June 2025 
at a constant rate. Expenditures for 2023 through 2025 
were discounted at 3%, following standard practice for 
cost-effectiveness evaluations (IDSI 2022).
In addition to SBC expenditures, there are service 
delivery costs associated with changes in the behavioral 
health outcomes. For example, increases in mCPR will 
result in additional commodity costs. LiST contains a 
costing module that estimates the total intervention 
costs associated with health behavior outcomes modeled 
in the application using default values (Bollinger et al. 
2017). The total intervention costs were estimated for 
each scenario and the additional service delivery costs 
associated with changes in health outcomes were added 
to SBC expenditures for a more complete assessment of 
the associated costs related to RISE II. 
Calculate cost-effectiveness
Once the impacts and costs were obtained, the ICER 
was calculated. For the RISE II study, the total costs (SBC 
expenditures and additional service delivery costs) are 
divided by the DALYs averted attributed to the SBC pro￾gram to estimate the cost per DALY averted (Equation 5). 
This ICER was then compared to Niger’s GDP per capita 
to assess cost-effectiveness. According to World Health 
Organization’s guidelines, health interventions with a 
cost per DALY averted that are less than one times the 
GDP per capita are considered “highly cost-effective” and 
those between one and three times the GDP per capita 
are “cost-effective” (WHO 2001). For Niger, the most 
recent estimate for GDP per capita is $590.60 in 2021 
(World Bank 2021). To ensure comparability with the 
costs, the GDP per capita was adjusted to 2022 United 
States dollar (USD) using the US GDP deflator, resulting 
in a value of $631.93. As such, the cost per DALY averted 
needs to be below $632 for the SBC investments to be 
considered “highly cost-effective” and below $1,896 to 
be “cost-effective.”
Equation 4: Estimating potential lives saved at endline
 due to RISE II initiative using hypothetical
 scenarios
 
 = – INTERVENTION
(Maternal lives +
Child lives)
CONTROL 
(Maternal lives +
Child lives)
Lives saved
endline
(2022–2025)
Equation 5: Cost per DALY averted 
SBC expenditures + additional
service delivery costs
Intervention DALYs averted –
Control DALYs averted
Incremental
cost-effectiveness
ratio (ICER)
=
BR E A K THROUGH R ESE A RCH | M AY 2023 9 
RESULTS
Impact
The number of lives saved generated by the scenarios 
measuring impact at midline are shown in Table 4, where 
negative numbers represent lives lost due to a lower per￾centage of the population exhibiting the health behavior 
from 2021 and 2022. For example, the slight decrease in 
the mCPR between 2021 and 2022 resulted in one life 
lost in the intervention scenario and three lives lost in the 
control scenario. Overall, however, there is a net total of 
2 additional lives saved when the value from the control 
area scenario is subtracted from the value from the 
intervention area scenario (e.g., -1 life saved in interven￾tion minus -3 lives saved in control = 2 net lives saved in 
intervention area). Compared to the control, a year of 
life is lost in the intervention area due to the reduction 
in handwashing with soap. The other health interven￾tions all show lives saved as estimated by LiST due to the 
increase in facility-assisted births and include clean birth 
environment, immediate drying and additional stimula￾tion, thermal protection, clean cord care, and neonatal 
resuscitation. In sum, there were a total of four additional 
lives saved in the intervention areas, yielding 122 net 
DALYs averted.c
Far more DALYs averted are generated in the two hypo￾thetical scenarios that extend to 2025, as shown in Figure 
c
When restricting the changes in LiST to outcomes with statistically signifi￾cant changes, the intervention resulted in zero lives saved.
1. The first scenario, where RISE II is assumed to result in 
a 25% improvement in the existing health outcomes by 
2025, yields a total of 4,835 DALYs averted. The majority 
of DALYs averted are related to childbirth and due to 
improvements in facility-based birth and maternal lives 
saved due to contraception. The second scenario, which 
adds improvements in the breastfeeding outcomes not 
captured in the midline scenario or first hypothetical sce￾nario, increases the total DALYs averted to 12,131 DALYs 
averted, a gain of approximately 7,300 DALYs.
TABLE 4 LIVES SAVED AND DALYS AVERTED AT MIDLINE (2022) 
INTERVENTION CONTROL ADDITIONAL LIVES 
SAVED (INTERVENTION
- CONTROL)
DALYS 
AVERTED
Maternal
Contraception -1 -3 2 59
Child
Clean birth environment 1 0 1 32
Immediate drying and additional stimulation 1 0 1 32
Thermal protection 1 1 0 0
Clean cord care 1 1 0 0
Neonatal resuscitation 1 0 1 32
Hand washing with soap -1 0 -1 -32
TOTAL 3 -1 4 122
FIGURE 1 DALYS AVERTED FOR MIDLINE AND
 HYPOTHETICAL SCENARIOS TO 2025
Maternal Pregnancy Childbirth
0
2000
4000
6000
8000
10000
12000
25% + 
breastfeeding
25% 
improvement
Midline
Breastfeeding
12,131 
4,385
122
DALYs averted
10 COST-EFFECTIVENESS ANALYSIS FOR INTEGR ATED SBC PROGR AMMING BY THE RISE II PROGR AM IN NIGER
Cost
The total SBC expenditures from project initiation 
through the midline survey in April 2022, with design 
costs appropriately amortized, amount to $5.7 million 
(2022 USD). This translates to $10.46 per person reached 
in the RISE II intervention areas. There were uncertainties 
around the estimated SBC budgets for 2023 through 
2025 for some partners. As such, for our projections 
to 2025, we estimated future SBC expenditures on the 
current level of spending to align with the assumptions 
regarding the impact projections. Based on this assump￾tion, the total SBC expenditures increase to $19.9 million 
(2022 USD). 
Table 5 details the SBC expenditures, additional service 
delivery costs, and resulting total costs for each of the 
three scenarios. Note that the additional service delivery 
costs between the intervention and control scenarios 
at midline are minimal at approximately $5,000, which 
is less than 0.1% of the total costs. For the two hypo￾thetical scenarios, the additional service delivery costs 
increase to over $127,000 but are still less than 1% of 
the total costs. Note that no additional service delivery 
costs are expected for the addition of breastfeeding and 
complementary feeding since these interventions are 
not typically associated with additional service delivery 
costs. See Appendix B for more details on the SBC 
expenditures.
Cost-effectiveness
Combining the impact and cost estimates results in 
a “cost per DALY averted” calculated for each of the 
three scenarios: midline, 25% improvement, and 25% 
improvement + breastfeeding (see Table 6). The midline 
ICER is $47,005d
 per DALY averted, which is far above 
Niger’s threshold for cost-effectiveness at $1,896. When 
considering the hypothetical scenario that increases the 
health outcome impact by 25% in the year 2025, the ICER 
improves substantially to $4,111 per DALY averted, but 
this would still be considered not cost-effective. How￾ever, when the potential breastfeeding feeding outcomes 
that could not be captured at midline are included, 
with the additional DALYs averted now included, the 
ICER becomes $1,638, which is below the threshold for 
cost-effectiveness and thus investments in SBC under this 
scenario would be considered cost-effective. 
TABLE 6 COST-EFFECTIVENESS RESULTS 
 COMPARED TO GDP PER CAPITA
 THRESHOLDS*
SCENARIO ICER: COST PER 
DALY AVERTED
COST-EFFECTIVENESS
DETERMINATION
Midline $47,005 Not cost-effective
25% 
improvement
$4,111 Not cost-effective
25% + 
breastfeeding
$1,638 Cost-effective
*An ICER below $1,896 is cost-effective and below $632 is highly cost-ef￾fective, based on the GDP per capita in Niger
c
When restricting impact to outcomes with statistically significant 
changes, there are no additional lives saved and thus no DALYs averted. As 
such the cost per DALY averted cannot be calculated.
TABLE 5 SBC EXPENDITURES AND ADDITIONAL 
 SERVICE DELIVERY COSTS, BY SCENARIO
SCENARIO SBC 
EXPENDITURES
$
ADDITIONAL 
SERVICE 
DELIVERY 
COSTS
$
TOTAL 
COSTS
$
Midline 5,735,490 5,019 5,740,509 
25% 
improvement 19,747,881 127,404 19,875,285 
25% + 
breastfeeding 19,747,881 127,404 19,875,285
BR E A K THROUGH R ESE A RCH | M AY 2023 11 
DISCUSSION
Key findings
This study is one of the first to examine the cost-effec￾tiveness of integrated SBC programming. We present 
three key findings that shed light on whether SBC 
interventions are or could be cost-effective in Niger. First, 
the ICER using the results from the midline scenario
of $47,005 per DALY averted is not cost-effective, and 
in fact is much higher than the cost-effective threshold 
of $1,896. Originally, the cost-effectiveness analysis was 
intended to be based on the final survey at the conclu￾sion of Breakthrough RESEARCH’s activities; however, 
the midline survey was used due to time constraints. The 
disappointing ICER is not surprising given the time span 
between the baseline and midline, which is insufficient to 
feasibly observe changes to many of the health outcome 
indicators that would be influenced by SBC programming. 
For example, for a measurable increase in antenatal 
care seeking to be observed, women would need to be 
exposed to the SBC content, be or become pregnant, and 
newly attend antenatal care to see an increase in this 
outcome variable. As such, the number of women who 
could potentially change their behaviors in a one-year 
time frame is limited. Furthermore, RFSA programming 
related to COVID-19 likely influenced some of the mea￾sured outcomes from baseline to midline. Note the per￾centage of households living with a handwashing facility 
dropped from 15.7% in 2021 to 9.9% in 2022. This drop 
is perhaps due to an artificially high level of handwashing 
in the early stage of the pandemic, between the onset 
of the pandemic in 2020 to 2021, and then later waned 
in 2022. This metric dropped also in the control area, 
although to a lesser extent. For these reasons, looking 
forward to future studies, one recommendation is that 
researchers use project midline to explore other relevant 
costing questions at project midline, such as the primary 
cost drivers of the interventions or calculating unit costs, 
but not focus on midline cost-effectiveness.
A second major finding from this analysis is that cost￾effectiveness of the RISE II SBC program is achievable if
substantial positive changes in health outcomes occur
by project endline. The 25% + breastfeeding scenario 
is below the cost-effective threshold for Niger. While 
a 25% increase in outcomes due to SBC interventions 
is substantial, it is not beyond the bounds of what has 
been seen in the literature (Saggurti et al. 2018, Fidele 
et al. 2012). It may be more challenging to reach these 
levels of increases in some health behaviors than others. 
For example, a 25% increase in mCPR would be a very 
substantial gain, as opposed to breastfeeding indica￾tors, which have shown stronger relationships with SBC 
interventions (Rosen et al. 2019, Avenir Health 2023). A 
similar survey of the outcomes at endline in 2025 would 
reveal whether this level of change occurred for the key 
outcomes in this analysis. Note that when a 20% increase 
was used across all outcomes, the results were no longer 
cost-effective.
The third key finding is the importance of capturing all
relevant outcomes in an impact measure for cost-ef￾fectiveness analysis. In this projection, the inclusion of 
the breastfeeding outcomes is critical for achieving the 
cost-effectiveness threshold (without it, a 25% increase in 
all other outcomes results in SBC investments that would 
not be considered cost-effective at project endline). For 
RISE II, the breastfeeding improvements are unknown 
at present due to complications in the data collection 
at baseline due to COVID-19, although SBC messaging 
on breastfeeding did occur. However, prior research has 
shown that investments in SBC interventions encouraging 
breastfeeding can be highly cost-effective (Avenir Health 
2023). For integrated SBC overall, missing the inclusion of 
a priority health behavior from the impact denominator 
is problematic for the analysis because it underestimates 
important health gains. After the baseline survey was 
conducted, the RISE II initiative also included SBC malaria 
interventions as well, which have also been found to be 
highly cost-effective (Avenir Health 2021) and would have 
likely favorably influenced the results but without base￾line data these could not be captured in this analysis. A 
bigger challenge emerges for multisectoral programs like 
RISE II, where work in other sectors and outcomes, such 
as improving agricultural yields and reducing early mar￾riage have known economic benefits, but these benefits 
do not map to health outcomes like those modeled here 
(UNFPA 2022). Future studies on the cost-effectiveness 
of integrated SBC in health should take care in assessing 
what outcomes can be mapped to a common denomina￾tor and ensuring those data are adequately captured. For 
integrated SBC projects that cross different sectors, other 
approaches such as a benefit cost-ratio analysis, will likely 
yield more complete and thus more favorable results, but 
they are also more difficult to conduct. 
12 COST-EFFECTIVENESS ANALYSIS FOR INTEGR ATED SBC PROGR AMMING BY THE RISE II PROGR AM IN NIGER
Limitations
As with all modeling studies, the analysis relies on various 
data inputs and assumptions. The expenditure analy￾sis made several assumptions in allocating above-site 
expenditures and distributing costs over the project time 
period. On the impact side, as noted in the methods 
section, most of the percentage changes seen between 
baseline and midline outcomes were not statistically 
significant, likely due to the short timeframe between 
the two surveys. Some of the changes seen between 
these two time periods were also potentially influenced 
by other extenuating circumstances, such as changes in 
governmental policies and environmental conditions, 
although these occurred in both the intervention and 
control areas. Additionally, this analysis assumes that the 
changes in the health indicators are due to SBC program￾ming and not the other RISE II activities, such as direct 
food aid and agricultural support.
Conclusions
While a one-year time frame is premature for yielding 
useful cost-effectiveness results, the hypothetical sce￾narios included in this analysis indicate that if substantial 
gains are made in key health outcomes, cost-effective￾ness could be achieved by project end, although these 
scenarios are, of course, speculative. Looking forward, 
more research is needed to examine the cost-effective￾ness of integrated SBC and further exploration on what 
types of integrated programming are most cost-effective. 
BR E A K THROUGH R ESE A RCH | M AY 2023 13 
REFERENCES
Avenir Health. 2021. “The business case for social and 
behavior change for malaria with applications for Côte 
d’Ivoire and Tanzania,” Breakthrough RESEARCH Technical 
Report. Washington, DC: Population Council.
Avenir Health. 2022. “Initial expenditure report for 
integrated social and behavior change programming by 
the Resilience in the Sahel II program in the Maradi and 
Zinder regions of Niger.” January.
Avenir Health. 2023. “The business case for social and 
behavior change for breastfeeding and complementary 
feeding,” Breakthrough RESEARCH Technical Report. 
Washington, DC: Population Council.
Bollinger, L.A. et al. 2017. “Lives Saved Tool (LiST) costing: 
a module to examine costs and prioritize interven￾tions,” BMC Public Health 17 (Suppl 4), 782. https://doi.
org/10.1186/s12889-017-4738-1.
Dougherty, Leanne, Lynn Abu Turk, Nrupa Jani, and 
Chaibou Dadi. 2022. “Evaluation of RISE II integrated 
social and behavior change activities in Niger: Baseline 
report,” Breakthrough RESEARCH Technical Report. 
Washington, DC: Population Council.
Fidele, N. et al. 2012. “Designing and implementing an 
innovative SMS-based alert system (RapidSMS-MCH) to 
monitor pregnancy and reduce maternal and child deaths 
in Rwanda,” Pan African Medical Journal 13:31. 
iDSI reference case for economic evalua￾tion. Accessed February 28, 2022 at: https://
www.idsihealth.org/resource-items/ 
idsi-reference-case-for-economic-evaluation/.
Institut National de la Statistique (INS) et Utica 
International. 2022. Enquête Nationale sur la Fécondité 
et la Mortalité des Enfants de Moins de Cinq Ans au Niger 
2021. Niamey, Niger et Columbia, Maryland, USA : INS et 
Utica International.
Rosen, James E., Willyanne DeCormier Plosky, and Lori 
Bollinger. 2019. Guidelines for Costing of Social and 
Behavior Change Health Interventions. Breakthrough 
RESEARCH. Washington DC: Population Council.
Rosen, James E. et al. 2019. The Business Case for 
Investing in Social and Behavior Change for Family 
Planning. Breakthrough RESEARCH. Washington DC: 
Population Council.
Saggurti, N. et al. 2018. “Effect of health intervention 
integration within women’s self-help groups on collec￾tivization and healthy practices around reproductive, 
maternal, neonatal and child health in rural India,” PLoS 
One. 13(8): e0202562. 
United Nations Population Fund. 2022. “Investing in three 
transformative results: Realizing powerful returns.” New 
York: UNFPA.
UNICEF. 2018. “Maternal and newborn health disparities: 
Niger.” Accessed September 27, 2022 at: Maternal and 
Newborn Health Disparities country profiles—UNICEF 
DATA.
USAID. 2018. “Resilience in the Sahel Enhanced 
(RISE) II technical approach working paper.” Available 
at: https://2017-2020.usaid.gov/documents/1860/
usaid-resilience-sahel-enhanced-rise-ii-technical-ap￾proach-working-paper. Accessed August 28, 2020.
USAID. 2022. “Health, Niger.” Accessed September 27, 
2022 at: Health | Niger | U.S. Agency for International 
Development (usaid.gov).
14 COST-EFFECTIVENESS ANALYSIS FOR INTEGR ATED SBC PROGR AMMING BY THE RISE II PROGR AM IN NIGER
APPENDIX A
ORGANIZATIONAL CHART AND SBC ACTIVITIES
FIGURE A1 PARTNERS FOR RISE II IN NIGER
TABLE A1 PLANNED SBC ACTIVITIES BY RFSA
SBC 
INTERVENTION
GIRMA
CATHOLIC RELIEF SERVICES
HAMZARI
CARE
WADATA
SAVE THE CHILDREN
Mass media Radio Radio Radio
SMS SMS messaging around nutri￾tion/health
IPC Several group IPC interventions 
focused on grandmothers, 
mothers, youth, and household 
visits
Household visits on child well￾ness, peer educator groups, 
group IPC for pregnant women, 
mothers, and husbands
Several group IPC interventions 
focused on youth, mothers, and 
husbands
Community 
awareness raising
Video viewings and other com￾munity events
Awareness raising talks, cultural 
troops, cooking demonstrations, 
video screenings
Messaging through religious 
leader sermons
Community 
engagement
Engagement with traditional 
chiefs and religious leaders, and 
community dialogues 
Community stakeholder engage￾ment 
Peer-led community forums, 
engagement with community 
influencers
Provider behavior 
change
Work with community health 
workers
Enhance trust and communi￾cation with community health 
workers
Other SBC activities Several activities related to 
literacy, agriculture, financial 
literacy, sanitation, leadership 
and governance, and emergency 
planning
Several activities related to 
agriculture, gender 
Several activities related to food 
security, agriculture, economic 
development, emergency plan￾ning and community infrastruc￾ture that have implications for 
health
BREAKTHROUGH ACTION NIGER
Johns Hopkins CCP, Save the Children, ideas42, Viamo
GIRMA
Catholic 
Relief 
Services
HAMZARI
CARE
WADATA
Save the 
Children
BR E A K THROUGH R ESE A RCH | M AY 2023 15 
APPENDIX B
ADDITIONAL SBC EXPENDITURE DETAILS
The total SBC expenditures examined for the analysis included actual SBC expenditure data from the program incep￾tion—starting in September 2018 through September 2022. For the cost-effectiveness analysis, the expenditures were 
adjusted to amortize the start-up design costs over the life of the project (to 2025) and were adjusted to 2022 USD 
to match the impact analyses. Additionally, the midline costing scenario included expenditures and service delivery 
costs up to May 2021, while the hypothetical projected scenarios were estimated to 2025 based on average monthly 
expenditures.
Returning to the actual SBC expenditures (not amortized or adjusted for inflation), the total SBC expenditures were 
estimated at $7.2 million for the initial data collection period of September 2018–September 2021 and an additional 
$3.8 million for the subsequent data collection period of October 2021–September 2022, for a total of $11.1 million 
from project initiation through September 2022. 
Figure B1 below shows the changing composition of expenditures between the initial and subsequent data collection 
period. In both time periods, the majority of the expenditures were allocated to personnel, totaling 63% in the initial 
period and 55% in the subsequent period. This allocation is consistent with many of the planned SBC activities, such as 
community SBC engagement, which is highly personnel intensive. 
One key shift between the two data collection periods is a change in the proportion of expenditures focused on direct 
non-personnel SBC expenditures, such as media costs and information, education, and communication materials, 
which increased from 12% during the initial period to 34% in the subsequent period. This shift reflects the move to full 
implementation of activities in the subsequent phase. Capital and headquarter operation expenditures remained low 
during both time periods. Future costing efforts at project endline in 2025 may reveal additional shifts in expenditure 
allocation that are informative for future budgeting and planning purposes.
FIGURE B1 ALLOCATION OF RISE II SBC EXPENDITURES
Niger 
personnel
Niger 
operations
HQ 
personnel
HQ 
operations
12%
Direct SBC
(non-personnel
Capital
2%
4%
22%
18%
41% 34%
1%
13% 2%
21%
34%
Initial period (September 2018–September 2021) Subsequent period (October 2021–September 2022)
16 COST-EFFECTIVENESS ANALYSIS FOR INTEGR ATED SBC PROGR AMMING BY THE RISE II PROGR AM IN NIGER
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