ObjectiveTo assess the efficacy of ready-to-use therapeutic food (RUTF), centrally produced RUTF (RUTF-C) or locally prepared RUTF (RUTF-L) for home-based management of uncomplicated severe acute malnutrition (SAM) compared with micronutrient-enriched (augmented) energy-dense home-prepared foods (A-HPF, the comparison group).MethodsIn an individually randomised multicentre trial, we enrolled 906 children aged 6–59 months with uncomplicated SAM. The children enrolled were randomised to receive RUTF-C, RUTF-L or A-HPF. We provided foods, counselling and feeding support until recovery or 16 weeks, whichever was earlier and measured outcomes weekly (treatment phase). We subsequently facilitated access to government nutrition services and measured outcomes once 16 weeks later (sustenance phase). The primary outcome was recovery during treatment phase (weight-for-height ≥−2 SD and absence of oedema of feet).ResultsRecovery rates with RUTF-L, RUTF-C and A-HPF were 56.9%, 47.5% and 42.8%, respectively. The adjusted OR was 1.71 (95% CI 1.20 to 2.43; p=0.003) for RUTF-L and 1.28 (95% CI 0.90 to 1.82; p=0.164) for RUTF-C compared with A-HPF. Weight gain in the RUTF-L group was higher than in the A-HPF group (adjusted difference 0.90 g/kg/day, 95% CI 0.30 to 1.50; p=0.003). Time to recovery was shorter in both RUTF groups. Morbidity was high and similar across groups. At the end of the study, the proportion of children with weight-for-height Z-score (WHZ) >−2 was similar (adjusted OR 1.12, 95% CI 0.74 to 1.95; p=0.464), higher for moderate malnutrition (WHZ<−2 and ≥−3; adjusted OR 1.46, 95% CI 1.02 to 2.08; p=0.039), and lower for those with SAM (adjusted OR 0.58, 95% CI 0.40 to 0.85; p=0.005) in the RUTF-L when compared with the A-HPF group.ConclusionsThis first randomised trial comparing options for home management of uncomplicated SAM confirms that RUTF-L is more efficacious than A-HPF at home. Recovery rates were lower than in African studies, despite longer treatment and greater support for feeding.Trial registration numberNCT01705769; Pre-results.

Trial designThree feeding regimens—centrally produced ready-to-use therapeutic food, locally produced ready-to-use therapeutic food, and augmented, energy-dense, home-prepared food—were provided in a community setting for children with severe acute malnutrition (SAM) in the age group of 6–59 months in an individually randomised multicentre trial that enrolled 906 children. Foods, counselling, feeding support and treatment for mild illnesses were provided until recovery or 16 weeks.MethodsCosts were estimated for 371 children enrolled in Delhi in a semiurban location after active survey and identification, enrolment, diagnosis and treatment for mild illnesses, and finally treatment with one of the three regimens, both under the research and government setting. Direct costs were estimated for human resources using a price times quantity approach, based on their salaries and average time taken for each activity. The cost per week per child for food, medicines and other consumables was estimated based on the total expenditure over the period and children covered. Indirect costs for programme management including training, transport, non-consumables, infrastructure and equipment were estimated per week per child based on total expenditures for research study and making suitable adjustments for estimations under government setting.ResultsNo significant difference in costs was found across the three regimens per covered or per treated child. The average cost per treated child in the government setting was estimated at US$56 (<3500 rupees).ConclusionHome-based management of SAM with a locally produced ready-to-use therapeutic food is feasible, acceptable, affordable and very cost-effective in terms of the disability-adjusted life years saved and gross national income per capita of the country. The treatment of SAM at home needs serious attention and integration into the existing health system, along with actions to prevent SAM.Trial registration numberNCT01705769; Pre-results.

Improving investments in primary health care has become a mounting priority in the context of Universal Health Coverage and India’s National Health Policy 2017 goal to provide cost-effective care. The paper uses the India National Health Accounts, health care providers and health care functions classifications, to allocate current health expenditures (CHE) to primary, secondary and tertiary (PST) care and analyse the trends and composition of PST expenditures between 2013–2014 and 2016–2017. Findings reveal that 45.2% of CHE was spent on primary care in 2016–2017. The government spends 52% of its CHE for primary care. Private spending on primary care has declined from 44% to 41% during the study period. Disaggregate analysis shows that 41% of primary care expenditures were on medicines, 29% on curative care and 15% on preventive care services. About 32% of primary care expenditures were spent at government facilities/providers as compared to 10% at private facilities/doctors. Private sector share of secondary care (38%) and tertiary care (75%) reinforces the role of private sector in providing secondary and tertiary care services. In cognisance of national and international goals, an additional investment of 0.7% of gross domestic product or additional US$11 (₹754) per capita would be required in primary care.

Aim To estimate incremental costs of an implementation model for scaling up Kangaroo Mother Care (KMC) for neonates with birthweight <2000 g. Methods Seven sites across Ethiopia and India collected data for 2018–19 to calculate incremental recurrent costs (of health worker time, supplies, and operations) and start‐up costs for KMC scale up. The costs were estimated per live newborn <2000 g eligible for KMC identified in the study population. Results Scaling up KMC in study districts required average incremental costs of US$59 (95% CI US$ 52–67) in Ethiopia and US$72 (95% CI US$ 41–103) in India per eligible newborn in the population. Most of these costs were recurrent; the annualised start‐up costs per eligible newborn ranged from 12%–25% of total costs in Ethiopia and 9%–16% in India. The major cost driver was human resources, followed by initial and recurrent training, supplies, and communications costs. Incremental infrastructure costs were only 2%–6% of total costs in both countries. Most of the costs were for activities at the KMC implementing facility, accounting for 79%–88% of the total costs in Ethiopia and 89%–93% of those in India. Conclusion The costs for successful scale up of KMC seem affordable but must be included in programme budgets.